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So we and we're live. Excellent. Hi everyone. Hi, sorry Rosa. I was just cutting in on you that. Go on. Ok. Um hi. Yeah. Um thanks for joining us for today's session on psych history taking. Um Cath here have made a great powerpoint which will help you remember what to do on your EK. Yeah, come to you. You crack up. Yeah, go for it. So hi everyone. Um as Rima said, I'm Cath. Um I am currently one of the f ones in Princess of Wales in Bridgend. Um I'm gonna be doing a talk on psychiatry history taking. Um, if anyone has any questions, please put them in the um chat. Um or you can email me if you want to, I'll share my email address um in the chat if I can find it. So you can email me if you'd like at at gmail dot dot com. That's how you spell my name. Yeah, good, cool. So yeah you can email me if you want any questions. Feel free. Cool. So I just wanna go through psych history. Um let me just share my screen. No show window I guess. Sorry. I'm trying to work out how to do this? Cool. So Riza, what, what can you guys see? Nothing? I can't see anything great. What about? Oh, there we are. If I do that, it might just go like a bit weird. But can you see my whole screen? No. Oh This has been great, isn't it? That? Yeah. What about now? No, no. Ok. I promise you guys it will be worth it. Just bear with us. so weird. Why is it not working? You present now, right? And then share entire screen. Yeah, I click that and it says share and it's not like and then you need to click on. What do you want to share? Yeah, it's that that entire screen. Yes, that's what I want. Can anyone else see anything? Yeah. Could just write in the group chat um the chart if you can actually see anything or if you just saying like nothing. No, we can't see. OK. Thank you. Um OK. Bear with me out. Let's just try loads of different things, then we'll get that. Um in the meantime, if there are any questions you guys have or anything you're concerned about ice. Um put it on and ice we will go through during the session. I like that. You did that. That was kinda why is I'm so sorry guys. This is not working, is it why is it not working? Um The reason I might have to send it. Oh, sorry guys. Yes. Send it to me and I can sure on Facebook, send it to you on Facebook or whatsapp. So guys bear with us, it will be worth that for actually in the meantime. Um, actually, um, if you guys wanna share anything you're concerned about with psych or Yeah. Yeah. Oh, in general, if you're concerned about anything, um, because this will actually help reassure other people as well. Trust me because we're all at the stage where we think we're the only ones who don't really know how to 1000%. 1000%. All right, let me see if I can get it back up. Now, in the meantime, I'm just gonna keep trying because this is so weird that it's not working. Um, sorry, everybody set up, I guess. Oh, actually what I could do. Um, I've got an idea actually I got it. I got it actually if you want, uh, oh, yeah, go for it and if you can. Yeah, go for it. Yeah, like I said, with this guys, oh, we've picked up some more people in this time. I thought we'd be losing people while I'm just waiting here. But we've actually got more people in now. That's good. Thanks guys. We're just getting the, um, slides up because mine, my computer is having a bit of a hissy fit and not playing ball. So it's a bit annoying, isn't it? Can you see anything? No, what's going on? This is so weird. Why is it? Oh, someone's coming in. My name is I'm from the meal support team. Just noticing you're having an issue. Screen sharing. We are. Yeah. Are you able to help us? Hopefully? Hopefully. So what, what exactly is going on, um, from when you try and share a screen? So I'm pressing a little button that says a little um, rectangle with an arrow going up. I'm pressed share entire screen, share window and share tab and nothing's coming up. So even when you press the share, like the share button, you've selected the screen, nothing's popping up. Yeah, nothing's coming. Are you on an apple or um or you're on a Mac? Oh, ok. So there it might be that your settings, your privacy settings are, don't allow you to screen record across various sites because you're recording. Uh ok. If you go into system settings and then find privacy, um, there should be a screen recording area. You can't do yours either. Can you, I can do it now? Wait. Uh So sorry. Did you say so I'm on my sets? Yeah. And then privacy and security and then you should be able to scroll down and find a screen and system audio recording section and you'll have to allow chrome to uh screen record. Can I go? It's a sensitive content one, I'll do a screen recording. Yes, screening system. Ah ok. Fine, excellent. Will it work though? Let's have a look. Oh, we can see your screen. That's fine. You can, you can do yours. That, that's totally cool. Ok. Yeah. Wait, wait, wait, see if I can do that. Just checking that work for you. Asma can you, is it working for you or asthma? Um, I think it's a bit slow. This is so annoying. Hm. Let's have a look. Well, mine seems to be saying that I can share it might then be an issue with your chrome but because you're able to show your mic and you're able to share your camera, it's more like um let's see if anybody that's listening or watching has any suggestions, please share because that'd be great and just checking your, your sharing uh via chrome and see if I can. Sorry guys. Um Yeah, you can all go get, grab a coffee and come back. Hey guys, I'm back. Sorry. Right. I know what happened there. I pressed the button and then it just went weird. So, um how about if I can you see thing, hang on one sec uh share your screen to screen and then can you see anything? Now, I did briefly see your screen but then it went away. Uh That might have been R oh, right. I see. I think that was rus. Oh, I'm so sorry. Everybody um allowed to share a screen. Yeah. II don't actually know what else to suggest than you were able to get the, the slides up, weren't you er, it's not working now. I, can I check it before any animation I'm just gonna log out and log in. Um, yeah. Go for it. Yeah. That is so weird. Yeah. Sorry. I don't know. Um, why it's doing this because usually it's been absolutely fine. Hm. I don't know if it might have been an update somewhere. Can I check if you've got any animation in your slides at all? Uh, yes. Ok. Ok. Because the, the other option would be to share as a PDF, but that would mess with any animations that you've got in. The animations aren't important. That's fine. Um Let's have a look. I mean, I haven't got it as a PDF but I can change into a PDF. That's not a problem. Um because there is another option which allows you to share a PDF and you'll be able to see the chat as well at the same time as Yeah, let's do that. Let's just do that right. Bear with me guys. I'm gonna say this is a PDF and then uh PDF. There we go. I'm such an old lady when it comes to this. I literally amazed. I actually where it work. So I had to do a PDF. There we go. Um OK. Oh, so I'm currently seeing you can see now. Yes. Oh, ok. Well, let's just crack on then. Ok, you can see it. Um OK. So if you guys can stay on like audio, can you see everything now. Yeah, if I'm doing this you can see everything. Yeah. Yeah. Yeah. I'm so sorry everybody, we are 17 minutes late but I will crack on. So like I said, my name is Cath. Um I'm one of the um f one doctors in Princess of Wales Bridgend. Um again, really sorry for the complications with technology at the start. Um, but hopefully like I said, we'll make it worth it for you. If you have any questions, please put them in the chart. Um Either or myself will get back to you, right? Let's crack on. So psych history. So just to let you know that I put a lot of te text in this um presentation, but don't worry, it's not all important and the nitty gritty things don't worry too much about the important things are things that I'm gonna mention out loud as well. Um I will give you the slides. Um We'll send the slides out after. Um and I put some extra slides in with yellow background. If, if you see a yellow background, that means it's just like things for fy I information that you don't need to necessarily worry about too much. OK, great. Let's crack on then. So these are the kind of things that can come up. Um So depression plus or minor psychosis, bipolar, um schizophrenia, drug induced psychosis, uh generalized anxiety disorder. Um probably not those two phobic anxiety type disorders. PTSD could come up substance, alcohol misuse could definitely come up suicide and self harm very much definitely could come up. Um, eating disorders can also come up. So, for example, in my, uh I think it was my mock. I had um I had a patient with bulimia that was vomiting and had low potassium and we had to treat that cool. So psych history is basically the same as a normal history. I I'm not gonna teach you guys to suck eggs. Um So a complaint, percent complaint uh past medical history, remember to ask about past psych history as well. Um So have they ever been referred to psychiatry before? Have they ever been in CS? So, CS is the children's um mental health um team drug history and allergies. Obviously, family history again, including psych history because some conditions such as schizophrenia are very much heritable. Um social history I put on steroids because there's a lot of things you can ask in social history. You don't necessarily have to ask all the things that I'm going to list shortly, but just be aware of the things that might be pertinent for that particular patient. I put this in red. So please please please, please, if you don't take, if you take anything from today's session, remember to do a risk assessment and screening. So risk assess all patients for self harm and and harm to others as well. So they might have Children just make sure that they're safe um and just make sure that they're, if they're harming themselves to what extent is it just thoughts they're having fleeting thoughts of suicide or self harm? Um Or is it things they've actually acted on also really important to screen for depression mania and psychosis in any patient with any psychiatric condition, always screen for those things. So if someone comes in with depression, screened for mania, screen for psychosis as well, if someone comes in for um even an eating disorder, you ask um about depression, anything, always ask those questions really, really important. And then obviously ice these are the social history things you can ask about. So alcohol and smoking, obviously, relevant drugs, very relevant family can be um important as well, especially if you've got young Children at home, say for example, they've got um a patient's got schizophrenia. Um and they've got young Children at home. Are those Children at risk? We don't know. Um Is there abuse going on at home? We need to find out those things, employment may or may not be important. It's a good thing to ask. Um It's a good thing. So if someone has depression, they're unemployed, it might be one of the good things like actually, it might be good for you to get out, get a job motivation. Obviously, if it's severe depression, that's the last thing they need. So just like read your audience um home life, accommodation streets. So for surfing, so maybe they don't have a fixed abode and they're literally living on the streets or they're in accommodation or they're just living on their friends set, going to different houses back and forth. Finances can be relevant. Um, for example, in mania, maybe they're, um, uh, in debt because they've used so much money, social support. Some people might actually have their own, um, social worker. So it's a good thing to ask about, um, social work and social support as well, any family at home that can help them as well. Um And then prison again, read your audience. It may or may not be appropriate to ask about prison. Have they ever had any um uh criminal offenses in the past? That's what I mean by social history on steroids is that you're asking more things than you would know medical um history, great. These things I just mentioned before. So screening for um depression mania psychosis and any other mental health conditions. So, say if someone comes in for um depression, you might want to ask them about anxiety. Do they become anxious um or get any uh intrusive thoughts? Anything like CD? Just generally, you don't need to spend a long time and it just think of other conditions and just put it in there. So the exam knows you're thinking about it really, really, really important to ask about risk assessment. Um Oh, sorry to do a risk assessment rather. So I'm pretty sure I don't know, but I'm pretty sure you'll get a mark for asking this. It's really, really, really important. It's as important as like the ice. So Cardiff just love it. Um, for self harm, intentional versus unintentional. What I mean by that is somebody may be intentionally harming themselves. Ie the classic, I say classic. But what we think of as self harm, so cutting, um, cutting wrists or, um, just generally hurting themselves, unintentional could be that maybe they've got schizophrenia and they're having hallucinations. Um And people are telling them, I don't know, you've got a chip in your neck and you need to get that out and they start like literally gouging out their skin or something. It's I doubt they'd give you anything that gory in an ache but just ask, um do you feel safe in general? Do you ever have thoughts of harming yourself to these um voices or do these people that speak to you? Do they ever tell you to hurt yourself um or hurt others? So make sure you ask about that. Um Suicide is a really important thing to ask and some was quite difficult to know how to ask as well. We'll come on to that. Um And then harm to others, as I mentioned, command hallucinations, which you can get in schizophrenia or even just psychosis in general. Um can tell you these thoughts can tell you um you know, you need to, I think I heard one story this wasn't through medicine. It was, I think I was probably watching some sort of Crime youtube video at 4 a.m. But anyway, I think it was something like um a mother was being told that she needs to kill her child. Otherwise the devil was going to kill the child. And it was really, really, really twisted. So make sure you ask about those kind of questions. Ok. So suicide risk assessment. So in the interest of time, I was gonna um ask a question if you guys can, how would you word a question um about asking patients if they're suicidal? So if you can pop in the chart, I've got my um phone in front of me so I can see what you guys are writing. Can you just pop something in the chart? How you would ask someone if they have any suicidal thoughts? I'll give you a few, few uh seconds. If you haven't answered in a few seconds, I will just crack on and give you the answer, but it'd be good to see how you guys answer it. There's no right or wrong reason. Uh sorry, right or wrong way to do this. Um Literally you can ask it in any way as long as it's sensitive. Um OK, I'm not seeing any replies in the group chat, but that's fine. I will just give you the answer. This is, this is how I would say it anyway. So, um how do you feel about the future. Do you feel that life is worth living? Um Have you ever thought about taking your own life the way I would actually word it myself is when people feel really low as you do because sometimes feel that life just isn't worth living anymore. Is this something that you can relate to or to say that you have felt it's a bit more like normalizing it. Not that suicide thoughts are normal. But by saying when people feel as low as you do, they can sometimes feel like this. It makes people think oh other people think this way. So maybe um there are no wrong answers, feel free to answer and you've got questions here. Yeah, absolutely. You spot on there. Um So people can feel a little bit more open to admitting that they do have ideas of suicide because they feel that when you say a lot of other people feel like this, they don't feel so alone. So the six ps um again, in the interest of time, I'm gonna go through these myself. So the six ps of suicide risk assessment. So, um I don't know if any of you guys have heard of this, but they're the six things to think slash ask about when doing suicide risk assessment, which honestly you should probably be doing in most, most psych histories, to be honest. So the six ps planning this impulsivity perception of lethality, preparation, performance precautions and planning don't worry too much about the ins and outs of these essentially. Um, it kind of tells you about the degree of severity of the suicide and how serious they were about it. So, for example, if someone's drunk or intoxicated, um, they may be more likely to be impulsive and then just think. Do you know what, um, sorry to sound crude now, but they might think. Oh, do you know what? I can't do this? I want to kill myself and they attempt suicide? Sorry, that sounds crude. But you get the gist versus someone who's planned it for weeks, maybe. And how long have they been thinking about it? Maybe they've been thinking about it for a day. Maybe they've been thinking about it for a week. Maybe they've just had an argument with their, um, girlfriend or boyfriend, they think. Oh, right. That's it. I'm gonna go and act on it now. So it's a good idea to get adjusted the, the planning with the impulsivity perception without is important. So you can ask the patient, did you think, um, this is if they have tried to commit suicide? You can ask them, did you think this would result in you dying or did you think it would just result in you being harmed? There's a big difference if someone, um, uh, I think generally speaking, if someone hangs them, I'm sorry, this is not a very nice to someone hangs himself that's pretty lethal. And the chances are they probably were doing it in order to, you know, end their life if it's something less lethal, maybe they weren't planning to, to end their life. Maybe they were just trying to induce harm or somehow relieve anxiety in that way. Um, good thing to ask as well is, um, did someone else call the ambulance for you or did you call the ambulance for yourself? Um, because that can kind of give a gist as well. Um Preparations again is important to ask about. So, did you leave a suicide note? Did you um prepare a will beforehand? Did you um organize childcare? Kind of those kind of questions can again, give an indication of how prepared they were performance, meaning um was it an isolate, were they isolated or they in company? So if they made sure everyone was out of the house, um and they were alone that shows that they probably were more serious. They wanted, they didn't want to be stopped again, same sort of thing with precautions. Um I planning to do again is really, really, really important to ask if you say if I let you know if you were to go home tonight. Now, do you think you would want to try this again in the ki they're probably not gonna lie. Um In real life generally, people are quite honest. Um But just it's a good thing to ask. So again, B boxes you're probably aware of this already. I think I mentioned this in my last um talk. So B boxes is bedside uh bloods orifice, X ray ecg and special tests. Um So again, I'm gonna put it out there. Does anybody wanna venture some guesses of some things that might be important in a psych um patient? So someone's come in with, I don't know, depression or schizophrenia, hallucinations, psychosis, any investigation that you'd like to do, there's again, like Ro said, there's no right or wrong answers. So just throw anything in the chat. Um Let's have a look. Yes, I love it. That was gonna be my big like message for you all T FT S and I'll come on to that now. Thank you, Shan. That's exactly right. Anything else? Literally anything else? But I like that one mental exam. Yeah. Nice good. Yeah. While, while people are putting more answers in. Yeah. Thank you Ella. While people are putting more answers in, please just chuck them all in. Nothing's too rogue. Just throw it in. Um The reason why I got really excited with T FT S is was basically for any psych history, you can say T FT S thyroid function tests because um if you're hyperthyroid, so high um thyroid hormone, you can become almost psychotic. Um you can become really like manic. Um and also if you've got low um thyroid, you can become very low and lethargic and just low in mood that actually came up in my mock, I think there was a patient who came in with depression and turns out plot twist, they were actually hypothyroid which probably did manifest as depression as well. Um Ace two. Yeah. Uh sorry. Ace Three. Yeah. Mocha. Yeah, that's for kind of like, um, um, what do you call cognitive impairment? Excellent medication reviews. Yeah. Absolutely brilliant. Really, really good, really good. So I'm gonna check some, um, more at night if you please crack on with any more, if you wanna um for the chat. Thank you for um contributing guys diagnostic questionnaires. Just to be honest, they're just good things to mention because it makes the examiner think that you know what you're talking about, which I'm sure you do. So um uh patient hospital questionnaire had this hospital anxiety and depression, I believe be depression and mood disorder questionnaire is for bipolar. Just generally, you don't need to really worry too much about what they involve just if you mention them, that's quite a good thing to do at the bedside. Bloods always, always, always rule out an organic cause. So as Shan said, thank you T FT is brilliant. FBC. They could have an infection, especially elderly patients having an infection can make someone really delirious. Ii met a lady um who had a really good growing infection and she was completely uh lover. She was away with the fairies in the, in the nicest way possible. She was um N FT s so some sort of, um, if they've got, uh, hepatic opathy and anything like that, they can't clear the, the toxins, they can become, um, encephalopathic bone proval, high calcium can, again, can make you a little bit, um, well, it can go either way you can become very low in mood or very, very, um, I think you can become a little bit psychotic as well. I use that word psychotic loosely because clinically they're not actually psychotic but they can appear they're not themselves sort of thing. Uh folate B12, anyone know the reason for, oh, I've written it, confusion screen. Um Yeah, so anyone who's confused, you want to do a folate B12 because kind of that sort of deficiency can make you confused. Um So the reason we do these is again, infection, thyroid, electron Aboral Cushing's anemia, confusion screen diabetes. Diabetes can actually um make you a bit if you're tired and lethargic can make you feel a bit depressed, hypoglycemia, uremia to get off the all that jazz. Uh always, always good to a urine dip. Um because UTI s again, especially in the elderly can make someone really, really, really delirious. Um Another good thing to ask about is a tox screen. So, um if you've got, if you've ingested or inhaled or injected or whatever mode of drug taking you want to do, um It can mimic mania. Uh Another interesting story I met, met a lady who was severely constipated and I've never seen delirium like that ever. She wasn't particularly old, I think she's like fifties or sixties and she was completely and II don't use this word Loy. She was actually so delirious and came across as having an acute psychotic episode, um, able to watch us back. Yeah. Uh, Kaya. Yes, it'll be recorded and you'll be able to see it on medal. Sorry, it was late. That's my fault. Um, actually I wanted to blame my Mac wasn't my fault. Cool. So yeah, you will, you will get access to it. So yeah, think of pr if it's appropriate, obviously don't just mention that for any patient imaging. So again, head scans, if there's an elderly patient who's a bit confused, you want to think of a if they had a bleed or they had a fall recently, chest infection can cause again, any um infection can cause um confusion ecg So the reason I put this in is if they want to start um Citalopram, Haloperidol TCA S, they can cause um changes to your uh QT uh sorry. Qt a little bit of a heads up if you, I've just thought of this now, but this is actually probably a bit of a negative information for you. So if you have a patient with um depression and then they want to start a medication and they say for example, start an SSRI like talopram and they give an ECG and they've gone to Torsades de like, what is this, is this psych, is this cardio? The reason? Probably, I don't know, I wouldn't be able to look and be like that's a long QT but probably it will be something to do with Citalopram causing prolonged QT and then, um, it progressing into Torsades, uh VT and then Torsades. So, um, be a bit mean to give you that. But they, they could do just remember Citalopram prolongs your Q ti think that's the out of the SS Ri s. That's all that does at the most. Cool. And again, as Ella, I think it was Ella that mentioned it. Yeah, mental exam. Um very, very, very unlikely they'll ask you to do that in an ische but you can mention it and lumbar puncture for meningitis cephalitis because they can cause confusion as well. Ok. Management. Um So with medical um we do all surgical actually, sorry, we do conservative medical surgical. Um Then that's what I used to anyway with psych, always, always, always, always do biopsychosocial. That's another thing with card. I just love it. Just biopsychosocial, good things you can kind of mention for everything to be honest, is a leaflet, patient information, leaflet or support groups. Um Again, that's quite holistic. Uh If you're in GP, especially if you're starting someone on an SSRI you wanna do follow up appointments with a GP. Um And you can do psych referrals if you think they're, if you think they're um warranted if it, if it's, um, kind of, I don't wanna say mild depression because there's other things as mild depression. If you're depressed, you are depressed and no one can tell you it's mild. Um, but if it's something that you think can be managed in as an outpatient, then yeah, you don't need to do a psych il but you can do, um, just follow up frequently with the GP sectioning is, um, can be confusing for the sake of you. II kind of think that probably the main way you need to know about it is 52. Um and this is the one that um a doctor can do, but it can't be used in A&E or GP because they're not an inpatient. So you can only do this when they're already an inpatient and you can hold them for up to 72 hours. Um If you think that the patient is at risk themselves um or others and that has to be done by a doctor. Cool. So I put a bit of just to make it a bit more interesting. Um I'm gonna talk about depression now, I'm just gonna go through with, through each um condition. So I'm just get my see if there are any questions on here that I can see. No, if there are questions guys, please put them in, right? So all these people have um live with or have lived with depression. Um It's very, very common and I don't mean to glamorize it by, you know, these are very beautiful, glossy, famous people. It's not that um II I'm sure I can't relate but it's not that glamorous. Um OK, so uh this is the bit I'm gonna ask for some audience participation. What are the, I'll give you a clue. There are three, what are the three core symptoms of depression? Check them in while I get some water because my throat is going dry. Oh, nice. Yeah. Yeah. Excellent. So, um, you're spot on. So these are the questions that you need to ask, um, about for patients. So, have you been feeling low, have been feeling low in mood, um, low in energy just a bit lethargic and have you lost interest in things that you, you used to find interesting? That's like the classic way that is anhedonia. So these are the posh medical words for them, low mood, which it's not really that posh, but aeria and uh anhedonia. Brilliant. Thank you, Shan. Cool. So ask about these, when you're screened for depression, there are some other symptoms as well. So you've got your core symptoms, you've got your cognitive symptoms, biological symptoms and psychotic symptoms. Really important to ask about the biological symptoms. Actually. Um, they're sometimes forgotten, um, things like early morning wakening that's like a classic. Um, they wake up very early as a name suggests, um, any weight changes. So maybe they're eating more, maybe they're eating less. Maybe they just don't have much appetite at the moment. Um, other cognitive symptoms are things that they just can't concentrate. They're just generally feeling very guilty and very hard on themselves. And this is again, suicide ideations that comes into that as well. So, it's important to ask all those questions if you can, again, with depression, you want to ask about, um, symptoms of mania. So, um, which we'll come on to and also, um, symptoms of psychosis as well. Even if it's just a little, little question, like, have you been, um, hearing voices that other people can't seem to hear or have you been seeing things that people, other people don't seem to see? Um, just, just a quick question that then the exam knows. Ok, they're asking for psychotic symptoms, tick. Uh, don't worry too much about that. That's just mild, moderate severe, um, how to classify them. Don't worry too much about that again. Always rule out organic causes, again, thyroid, maybe they're hypothyroid, maybe they're anemic, maybe that's why they've got low energy. Maybe that's why they can't bother to do much because they're too tired. And that explains that if you replace their, um, thyroid or their iron or whatever, they might feel a heck of a lot better. Great. Um And yeah, again, ask for any symptoms of mania. If there is a symptom of mania, then you've got a different diagnosis of bipolar and that changes your management. Uh, and again, please, please, please, please please screen and risk assess i depression. You probably guys already know this. So antidepressants you can give adjuvants like antipsychotics or lithium. Lithium is a mood stabilizer. T um I actually got a chance to see when I was in as 1/4 year medical student and it was so interesting. Um People were being ect t I don't know if that's a verb but they were undergoing ect um essentially against their will. Um Because they had uh I can never say it's stupor. Um So they were like, they just weren't eating and they were just so so low, they couldn't really make that informed decision. They didn't have capacity essentially. So they, they went and an ac that's very, very, very, very, very down the line. Um So don't worry if you don't mention that psycho obviously, therapy, that's gonna be your, your basis. Um Social again, this is the biopsychosocial. You can mention this for anything. Remember, social support groups, self help groups, social services, um online self help books, all these things are great things to mention, step wise again, if you're starting someone an SSRI it's really, really, really important to do a follow up in two weeks. Can anyone tell me why it's important to do a follow up in two weeks? Again, I'm gonna ask you guys to put it in the chat. I know it's really annoying when we ask you for things in the chart, but I'm just interested to see if you guys um if you guys are aware of why we need to ask them to come back in two weeks. It's just a chat with them. I mean, it is important to chat because Yeah. Absolutely. Absolutely. Yes, exactly. So um warm patient side effects. So as you said, Shan um increase agitation yet also evidence shows that there is an increased rate of suicide when you start an Yeah, anxi. Yeah, that's absolutely true. Um There is an increased anxiety rate um when you start an SSRI and I'll, I'll go on to why. Personally, I think that is, that's just a personal thing. Um So yeah, there is an increased rate of suicide after you've started an SSRI. Um and I think the reason for that, I'm not sure if I've read this somewhere or heard it somewhere, but if someone's really, really depressed, they have very little by definition, don't have any motivation to do anything. They're very low in energy. As soon as you give them an antidepressant, they've got a bit more oomph for want of a better word. So they are a bit more motivated and then therefore they act on their thoughts a bit more and that's why maybe anxiety comes into as well. They're a bit more um practice with things. And again, psycho referral MHA A is mental assess a mental health assessment. Sorry, mental health Act bipolar. Again, these are some, um, again, don't mean to glamorize. Um, this, these are a couple of few celebrities that, um, have gone through or have or are living with bipolar. So Mariah Carey Jimi Hendrix, Demi Lovato C Jones and kicking. Ok. Again, um, by polar definition, at least one episode of mania or hypomania and a further episode of mania depression. So I remember hearing this once from a nurse or a doctor that if someone presents with just mania, then technical, they've got a diagnosis of bipolar because they will inevitably go on to have depression. I don't know how solid that definition is. But um always ask if someone comes in with depression, always, always, always ask a mania. I know I'm banging on about it, but it's really important. Um Cool. Uh I dig faster you'll see on the other slide. The following slide, it's just a, a little acri to remember the, the features of bipolar, which I won't bore you guys with. Now cos I'm sure you already know it. And then again, you've got hypomania mainly without psychosis and mania with psychosis, which um you can see the next slide again, screened for mania and psychosis in all depression patients. And this is saying if you just look up in your own time, um The differences between the different types of um mania hypomania and the symptoms of mania. My again, I'll whiz through this only because you can read these slides at the end I'm not gonna bore you. So, the, the main thing is really antipsychotics, um, and mood stabilizers, be wary with anti depressants alone because it can induce mania. I think it would. I don't think you'd get marked down for mentioning it because you can give it. But obviously you'd be doing this in conjunction with chatting to a, um, psychiatrist. Lithium is given four weeks after the, um, acute episode is resolved. I think that has something to do with the fact that it takes time for it to work and you need something sort of ancho just to kind of quickly um control things. Uh This is more for your information and more for the pharmacology station. Actually, it is a little bit of a helpful thing that I found useful. I'm not gonna leave you the point here. Er, I'm sorry, but this could come up at a pharmacology station for sure. Uh a lithium um patient on lithium. So the wait a month side effects of lithium actually spell lithium very conveniently. Um as you can see there. Um and lithium toxicity, the symptoms of lithium toxicity again, um will make up a nice word of toxic with the X from Ataxia. So that's another little nugget information for you that you can ask patients about if they're on lithium. Um If you've got an AK I just as a side note, if someone's got an AK um because lithium um is really excreted if you've got an AK it can um cause your lithium levels to go up for obvious reasons because you're not excreting the toxins and the tablets and everything else. So it builds up and then you become hyper lithium IC. Sorry, I'm making up words today. There we go. Ok. Cool psychosis. So, and this is a really important thing to mention that psychosis is not technically a diagnosis. It's an umbrella. It's like a symptom for um it's like a broad umbrella. So again, I'm gonna be really annoying and ask what are the characteristics of psychosis and remember to um screen for psychosis in any patient with psych history. So if anybody could put in the, in the group chat, and this is the last question I'll ask about for group participation. Um And I imagine a lot of you don't maybe not necessarily want to answer. Um And that's totally fine. Um But if somebody can, that'd be great. If not, that's fine because I will just tell you the answers anyway. So in the interest of time, I am just gonna give you the answers. So, oh yeah. Sha oh you and I are friends, aren't we? Yeah, good. I don't, I don't know we've met before, but we're friends now. Thank you. That's my old. Yeah. Awesome. Yeah. Great. Better than mine. So um mine are a lot simpler. You're a lot more clever than me, obviously. So, minor hallucinations, delusions, a formal thought disorder. So, um passive phenomena. Yes. Or hallucination. Yes, delusion. Yes. The three main ones are those three. and just keeping things simple. Those are three. I'd go for cool. So, again, characters, we've done that already. Psychosis means loss of contact with reality. How do you ask about psychosis symptoms? So this is how I would do them. Do you ever feel that you can see or hear things that others don't seem to be able to see or hear? That's better than saying. Do you ever see and hear things aren't there? Because that's kind of, you could argue a little bit invalidating that, that you're saying they're not there, but you're seeing them. You're a bit crazy. So just a little bit of a tweak in the way weird things and then delusions. Are you afraid that someone is trying to harm you? And do you feel safe? You know, people are doing or saying things that have special meaning to you? Um There are different types of delusions. I will let you read those in your own time. Preoccupations and overvalued ideas are different to delusions. This is actually quite important. So, delusions are fixed, false beliefs, no matter what you say to them, they are going to be convinced that they are married to King Charles. Nothing you tell them is gonna change their mind. A preoccupation is maybe they're just, it's a strongly held belief, but they can kind of accept that. Ok, maybe, maybe I'm not actually married to him. Obsession thought is a thought that just comes in all the time and it just really debilitating and it, it can be a thought, it can be an image that just keeps coming to the head and even when you try and try and try and block it out, it just keeps coming. Um So those are the differences, there's a subtle difference with psychosis, they are delusional um and they are fixed and there's nothing you can say. Um hallucinations as you guys already know what they are. So I won't uh la the point formal thought disorder is this, I'm not going to lie. This confused me a lot when I was a student, but I found this picture which you might have already seen before really, really, really useful. So this is meant to be a conversation. So getting from A to B. Um So talking about uh the start of the story, I don't know if you can see my cursor, but the A is the start of the story. B is the end of the story. If you've got sers nights move, they're kind of talking about the story and all of a sudden they just go a completely different direction and it's like, where did you get, where, how did you get from there to there? I don't understand. Um Tangent tangential is f so you kind of go completely as the name just go off on tangent and never actually return to the point of the story, which is B um oops, sorry. Um B is what I do but um I'll be saying a story and it'll take me 10 minutes to get in the story, but eventually I will get to the end of the story. I'll just go all around the houses. And so those are examples of formal thought disorder in the way that they're talking. So it's confusing because it's the way they're talking, that's how you assess it. But it's a form of thought disorder because their verbal kind of um their words are a manifestation of what their thoughts are doing. If that makes sense. Cool psychosis. There's nobody uh sorry, schizophrenia, there's no one I could find like celebrity wise with schizophrenia. I'm sure there are um but I couldn't find anyone. So these guys um that's Newton, the physicist, that's Van Gogh. Um And that is John Nash, which is a really good film called Beautiful Mind. Please watch it. It's so so so so good called Beautiful Mind. OK. So schizophrene is a type of psychotic disorder. There are positive and negative symptoms which again, I'm sure you already know and positive are things that we've mentioned. So and that Shawn mentioned as well. So the hallucinations delusions and for thought disorder, negative symptoms are the things that are taken away. So the lack of motivation, the um asocial or antisocial behavior, those are the um negative um symptoms and the most common type of schizophrenia is para schizophrenia. So I would say if you have a schizophrenia station, very likely paranoid. So um ask them about any command hallucinations or derogatory um hallucinations as well. Cool management of schizophrenia and psychotics Cozine. If treatment resistant psycho uh would be the CBT and the social, it would be the support groups, peer groups, all that jazz, you know the drill by now. Cool. Again, this is more for your psych station. Uh Sorry, uh Pharmacologic indications of cloZAPine um are treatment resistance, it's free yet. So failure to respond to other psychotics. Um So the two main side effects of, of cloZAPine that you really, really, really, really, really need to know about are um so it's agranulocytosis neutropenia um and myocarditis which usually presents in the first two months. So ask about chest pain, palpitations, short breath, all that. Cool. That's again, but a sign that's Morphy Farm Station, I'm gonna whizz through these. These are all people who have had um have had or live with any eating disorder. Again, don't mean to glamorize it. These are just examples of people who've had them. So um there's just a few questions you can ask if someone comes in with an eating soda. It is um acronym Scoff which is a little, you could argue a little bit of a uh I don't know. It's a, I guess you won't forget it. Um Just questionnaires, you can ask, I'll let you read those in your own time. These are some clinical features of eating disorders um, that you may want to ask about. Uh, again, I'll let you read those in your own time. Uh Lanugo hair is like very fine downy hair that you can. I think babies have it as well. Um I think, I think the reason behind it is if someone's really, really underweight, it's more underweight than, um, eating disorders that are overweight. So, um, essentially the body temperature is so cold, um, that the body makes, is fine hair to keep warm. I think that's the reason for it. Cool. Um, again, you can read this in your own time but, uh, investigations would involve just normal bloods. Uh, VBG would be important if someone's, um, vomiting as a, as a form of, um, uh, purging, then they might develop a metabolic alkalosis and a low, um, low potassium as well. Dexa scan can be important as well because in low weight, um, you can have thinning of the bones. Um, believe me, this is something that, again, this came up in my, um, my, so these are just signs you can get in, uh, Bolia. So, and they're complications of repeated vomiting is at the top picture shows. So it sounds awful. But the reason you get those Russell sign is it sounds awful, but when people make themselves sick, they get calluses on their knuckles from the teeth it, it's not very nice. Um, I've never seen it myself. Um, but you can see in the picture there then protid, sorry, bilateral protid swelling because of the self ause vomiting and dental erosion. Um, which you can see in the picture there as well. Also people think of purging or compensatory behaviors as, um, vomiting. It's not just vomiting. It can be laxatives exercise and diabetes. Um, patients can also omit their insulin as well. That's as a form of reducing weight like you read doesn't even time alcohol dependence. I didn't know this but um oh, isn't he lovely Zac Efron there. Um He used to have uh alcohol dependence and sort of Daniel Ratcliffe cage questionnaire um asked about these questions. Felt the need to cut down drinking. Have any, have you people annoyed you by criticism guilty about drinking, eye opener. Um Those are just the questions you can ask and the bottom right? There is just a see in med help mental exam which Ella um mentioned earlier. Very, very, very, very, very unlikely to come up in in is but you can mention it and that's what the mental state exam involves right? Last slide. So thank you for bearing with me guys. How many people are still in? We got. Mm Have you got I think, oh, we've got, oh, we've still got everyone. Oh, awesome. That's awesome. Thank you. So yeah, just the tips for psych stations. So remember there's can be an organic cause. Um for delirium dementia, all these things can um can cause confusion. It's not always psych, for example, thyroid, which I got really excited about. Um and electrolytes stroke can cause you a bleed brain bleed meningitis. All these things might, you might think that it's a cation, but actually, it's not just remember that personal disorder um can be another differential um quite a lot actually, that can, that can be a very good differential to give and then other psych conditions as well because they coexist uh management, biopsychosocial memory, conservative management. So follow ups leaflet self help um treat co morbid conditions always um signpost. Um So I'd like to ask you about some experience with some people. Sometimes I don't actually know what that means. Oh yeah, sorry. Oh yeah, sorry. Signpost. Yeah. So um when you're asking questions, you could say um before going ahead and saying like, oh, do you feel suicidal? You can just get say something like signpost them and say, I'm just asking a few questions about. It may seem a little bit intrusive. There's just questions that we have to ask everyone and then they won't feel so targeted. And it's just, that's one thing I would say normalize the situation. So patients sometimes when they have um when they feel as you do, patients sometimes have thoughts they want to XYZ or they have um they can hear people saying things like XYZ normalize things have a rough idea of the sections 52 is one you really need to know about um very risky. Anyway, um paracetamol lower dose is definitely a potential risky that could come up and read up on lithium and cloZAPine and assessing capacity. You guys already know, assessing capacity involves four domains, understanding, retaining the information, weighing up the information and communicating this back. You need to do everything you possibly can in order to fulfill us for if someone's deaf or if someone doesn't speak your language, you do something so they can understand what you're saying. You can't say they haven't got capacity if you haven't tried everything. Cool. So I, before I've actually written on a whiteboard so people can understand I've also used a translation app so that people can understand what you're talking about because you can't just dismiss and say they don't have capacity or they don't have capacity because they don't understand your language. That's why they don't have capacity. If you tried to facilitate that, they would have capacity. Cool. This is the book that I got a lot of my resources from. It is brilliant. Me. Riser and Rona use this when we did our s and it's class, I cannot recommend it highly enough. It's really good. It's where I got all the tables from, by the way in this talk. Um So I would very much recommend that and I'm not affiliated with that book. So I don't get any like money? Cool. Um any questions guys please pop it in the chat. Now I again I'm really sorry for going over. Um it was a bit of a thing in the end but we we got there in the end. So uh have I stopped sharing or can you guys still see it? Yeah, you stopped it. Ok, cool. Thank you so much guys. If you have any questions, please put in the chat or feel free to email me on my email address, which I have shared, I think. Yeah, I have shared it. So um I hope that was somewhat useful for you guys. Um Please I just the feedback for me. So if you could do that, that would be great. Thank you guys. I'm sorry again for the technical issues. Thank you for, for coming. Please fill out the feedback form. That'll be absolutely great. And again, some time despite my throat is so dry though, go run out of water. Oh, ok. Does anyone have any questions we know that there's a very constant heavy session? So this is your time to ask questions or if you want to explain and and don't stress about a psych history. Just remember biopsychosocial be a nice person. Don't be judgmental and remember there's always an organic cause for differential always and you will mo yeah, you will have a psych session. You definitely will. Yeah, absolutely. So um this is quite important. You definitely 1000% will have a psych station. Um, whether it ends up being psych is a different thing, you'll have to take a psych history. Remember, the main thing is risk assessment. Um, and screening those are so, so, so important. Um, biopsychosocial, remember, simple things like, um, um, conservative things like follow up in two weeks or um, group therapy or referral or um, just simple things that are really useful. Cool. Cool. If we haven't got any questions, then I think we can end it there. Ok? All right guys. Any questions? Ok. We're ending the session now. All right. Thanks for coming. Take care. Well done everyone. Bye.