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is the volume one from my end. Okay. Yeah, I can hear you. Great. It's very good. Thank you. Yeah. Started recording. So, um yes. Thank you so much for joining Doctor Caroline. I really appreciate it. Um uh, yeah, This will be a really good session, I think for everyone, people are all are very different stages. So some people have just had not any teaching on psychiatry. Some people have had just the teaching. They haven't had any placement yet. And some people have had placements. Um, that might want a bit of revision. So this is just a really good sort of crash course for people to get a guide to initially, for you to just take some history and MSC, So thank you so much. Um and yeah, I hand over to you, and if anyone has any questions, you can put them in the chat. But I've also arranged for time at the end if you just wanna unmet yourself and ask them directly. So that's, um that's actually Yeah. Just let me know. I think you just slide towards yourself or you need to do it. I can just tell you the next slide if that's okay. Okay. All right. Thank you so much. OK, so, um hi, everyone. I've been invited by, um, one of the medical students, Bushra who I worked with cams, um, to do this teaching. Um, So instead of just providing, um, you guys a template of the history, I thought I'd just go through one of my actual cases. As you know, we learned. I think we learn better by example. Um, so, yeah, we'll just go through it, um, if you go to the next slide. So, um, you want to start the history by just describing the patient? Um, So I've We have patient m 25 year old Caucasian male, and he was admitted to the psychiatric. I see you under a section of the mental Health Act due to increasingly suspicious, confrontational, aggressive behavior. And I've highlighted there, um, quote unquote, I can see the devil coming after me. So, um, lots of information just by, um, patient demographics. You you got to mention their age. Um, ethnicity. Um, sex slash gender. Um, if they were admitted, whether they were seen in a community setting in a hospital setting and are they admitted under section of the Mental Health Act. So I'm I'm not very aware. Um, how how much? Um, of medical students know about this, but basically they've been detained, and they really have no choice but to accept psychiatric treatment from from from the psychiatrist. So and then you provide a reason as to why they were admitted. And usually a chief complaint in psychiatry is the exact line. Usually what the patient says. So if if we go down to the next slide, So you want to give a timeline a brief timeline of how the patient, um, how the events led to subsequent admission. So, um, just going through it very briefly. Five days before m. Was admitted, his parents observed him to be sleeping poorly, staying home and missing work. So, um, the reason for his missing work was because he felt that a colleague from work could listen to his thoughts. And then a day after that, he felt that the whole Basingstoke was after him and he kept opening the window in his room as if to escape. So in case that somebody would indeed go after him, he'd he'd have a safety exit and the day after that, Um, the the part. The paranoia, um, were sent to the extent that he thought about protecting himself by making a makeshift hammer and hiding it under his bed. That's that's what prompted. His parents eventually called the Crisis Team, um, where he was started on olanzapine, which is an antipsychotic at night and some as needed, diazepam to help, um, with his agitation. So if you go to the next slide, So a day before his admission, he threw a chair at his father, whom he perceived have been possessed by the devil. And that's what led to another assessment by the crisis team who thought that would benefit to the early intervention psychosis team, which is another. It's a kind of, um, psychiatric service, where if someone has presented with psychotic symptoms for the first time, they try and treat the patient very early so as to increase the chances of recovery. And, of course, you know the best prognosis that one can have, in case you would, you know, really, in case you would deteriorate to having schizophrenia or any other mental illness with with psychosis involved. So the EIP did manage to visit patient M. Who was living with his parents. And they thought that with his current presentation, um, the risks that he presented towards himself and towards other people, they thought that a mental health assessment would be helpful. So this involves, um, two consultant psychiatrists and one, um, independent mental health amend mental health practitioner. So it's a 33 people who would eventually do an even more thorough or intensive interview with patient needed treatment. Otherwise, this would lead to, you know, further risks of deteriorate deteriorating in his mental health and, of course, the risks he presented towards his parents. So he was detained under Section two. That meant that he would be in hospital for a period of at least 30 days for further observation and treatment, and they thought that he would benefit from a from award that is more likely to observe him more closely. And that was a psychiatric. I see your A P Q. So once you So if you go to the next slide, um, after after going through the present events, you wanna explore more about the patient by looking at their past. Has this happened before? So I was mentioning in the present history that he was referred to the early intervention psychosis. So it was giving me an idea that might be happening for the first time. But on looking at his notes, apparently his mental health did deteriorate back in 2017, triggered by seeming similar combination of, um, social factors, which I managed to speak to the father, and he described it as a storm of stressful events. So I think this was a time where, um he was working, he had a degree in finance and he struggled to get a job. Um, and he was working in the co op, so there was a lot of expectations from the family. Um, I believe if I remember correctly, his girlfriend had broken up with him. Um, and he was resorting to cannabis to cope. And eventually that's what led to him developing paranoid thoughts that people were after him. People were out to get him. He appeared to be very thought blocked, which later on I will describe what it means. He was responding to unseen stimuli. Um, so this eventually led to consultation. He and he was prescribed, uh, mirtazapine and citalopram, which which are both antidepressants just to see if that would improve. So in the next slide, you can see that he was actually diagnosed already with the first episode of psychosis back in 2018. So, um and this was this was the only time that we found out because when I spoke again to the parents, this was they had disclosed. So a similar incident happened when they were on holiday patient M attempted to jump from the second floor in their hotel, and he was frightened that people were after him. So again very similar, um, thought that people were going to go after him and as a as a response and in order in order to defend himself, he attempted to attack his mother, and he he would carry a knife and a pair of sisters again for for protection. And interestingly, he was already detained under a section too, um, prior to the current admission. So if you go to the next slide, he was actually already maintained on olanzapine, the previous antipsychotic that the crisis team prescribed, and he was actually taking the antidepressant of citalopram 20 mg a day. So these are fairly low doses and he He was actually being seen by the community mental health team regularly until July 2020. So that's that's quite a long time. Two years? Um, meaning he was, you know, um, taking his meds regularly. There wasn't anything? No, no relapse. Know events that may have led to deterioration. That was until though, the plan, Uh, in July 2020 the the psychiatric doctor who saw him decided to stop olanzapine. Um, Citalopram was continued, but was considered to be stopped in six months. So to me, that meant that he was doing fine for for his antipsychotic to be stopped. Usually it does take years before you start tapering down on this kind of medication. And he was asked to just follow up in 3 to 4 months, unless there are new concerns. So if you go to the next slide, So once you've gathered all, um, the relevant psychiatric, um, events in a patient, you just want to go through the past medical history since, um, a lot of physical health conditions are highly linked with with mental health illnesses, so we couldn't see anything relevant with this medical health. So if you go further, you want to. You want to ask about the family as well, whether they've had any psychiatric illnesses before. So his father was diagnosed with depression in 2010, which was associated with brief psychosis. So the father again appeared to experience similar experiences as his son. But as he explained to me, it wasn't. It wasn't that severe. As patient ended and it didn't happen again. It was only one occurrence with the with the father. Meanwhile, the grandfather had anxiety and depression. So if you go further down to the personal and social history, if you go to the next slide, please. So for the personal and social history Oh, I think I think you're one slide advanced. Chloe, could you back up? There you go. So for usually for me, this kind of the busiest part of the history, because you try and establish a timeline from from when they were born. Um, since sometimes obstetric complications can can lead to certain your developmental conditions that is associated with mental health illnesses as as somebody reaches their adulthood. So he lives at home with the siblings and parents. He's the oldest of four Children he grew up in a religious background. He is currently not in a relationship. As, um in 2017, he has been trying to get back together with his girlfriend, but he has been single since he attended Cardiff University with an accounting degree. And, um, he has been working in co op, um, in the interim, while trying to look for a job in finance. So if you go to the next slide, please, um, you also want to explore any substance or recreation illicit or recreational substance misuse, which is, um, to me, I think one of the most important things in taking a psychiatric history So he doesn't have any known drug and alcohol misuse apart from one occasion of taking ketamine in 2017. And he did say he only uses it recreational E until February 2018, when he decided to quote unquote when he gave himself to Jesus and, you know, leave the life without without that. So if you go through the next slide, So, uh, I was going to ask questions whether I remember that you can ask towards the end, Just checking if everything makes sense. So far, so more or less, that's the those are the main components in a psychiatric history, and again it varies from patient to patient, especially when when I clerked patient's, for example, during on Coal Shifts you I can have two patient to patient Admission's and take Me, for example, two hours to get a history of one patient where asked, if you have, sometimes you can get 4 to 5 admission's, but because they're so known to mental health and they just they relapse and they get discharged and they get admitted again. The history taking becomes like a copy paste. So it really depends on how how well known this patient is known to mental health service. That gives you a picture of how much information you need to gather. Um, so it's also nice when, especially when you're presenting a case, um, whether our our report or just, you know, presenting the case to your to your consultant a timeline of the events just, you know, to paint a good picture of this patient's deterioration. So if you can see on the left that was his first, um, possible precipitant for for for what? For what has led to his current admission, Um, he had challenging life events. He couldn't cope. That prompted a G P review. And there was already a habit of resorting to cannabis, which we know can aggravate, uh, mental health symptoms. And that went on until, um, 2018 of May. He had his first detainment under section, and that was extended to a Section three, meaning that after the 30 days of the section two has lapsed. Another assessment was was done, which needed he needed to be on section a little bit longer. So to me, that tells me the severity or, um, the severity in the nature and the degree of the illness he was having and that just carried on into 2019. Um, finally, in 2020 the olanzapine was discontinued. So if you go to the next slide, please and you can see that the next thing that's happened was in 2021 that's when he had his second episode of psychosis. So that was so actually, when he came to us, we thought he had his first episode when in fact, it was actually a second that it was the discontinuation of his olanzapine at the community, which has led to his relapse. And finally he was treating the PQ. He recovered with medication. Um, it took it, Took us quite a while. He was. He was in hospice, was in the ward for three months where he was eventually deemed fit to be transferred to an acute ward, and then eventually he was sent back to the community. Okay, so that's the history bit. Um, if we go to the next slide, we have the mental state exam. So, um, again, there's there's a lot to cover here, but I think I'm going to just try to say the basics and I'll try to pattern like a normal template with With how I assess my patient patient m with the mental state exam when he first came in. So for the next slide, So for the appearance, Um, of course, we had the demographics with the With the patient profile, you really just want to observe the patient the moment they come in the door to once you talk to them from the clothes that they wear. Is it appropriate for the weather? Um, do you think that they could be a bit disinhibited from the way they dress the way they fix their hair? Are they encamped? Do you think they need a shower? Have they been neglectful of themselves? You want to see how they're walking? Um, if they're confident, are they guarded? Are they hesitating? Are they pacing? Are they anxious? Are they? Are they comfortable to talk to you? And also, you want to see any for any physical health issues That might be, um, patient currently be experiencing because we know a lot of physical health difficulties. Um is associated with depression, and eventually you wanna you wanna check the patient extremities for any scars, Any marks of, um, self harming, such as, um, cutting And, um, you know, probably getting any wounds from their attempt to self harm marks of ligature ng. Um, and finally, um, if you if if you're even more observant, you might be able to see signs of illicit substance use such as, you know, um, if somebody has been injecting uh drugs into their system, you'll you'll be able to see the marks on their on their arms if you go the next slide for their behavior. So very similar to very similar to what? To the appearance. Um, you wanna see. Are they establishing any eye contact with you or the avoidant? Do you think they're not telling you something? Is that because they feel that you might be part of the police, which they're very, um, paranoid about? You want to see their facial expressions as well? Um, are they comfortable to see you? Are they happy to see you? Are they angry to see? Are they upset that they are on section? Are they Are they upset that you know, this is this is where they are At the moment you can see their body language if it's open or closed, you want to see if they're com or if they're calm, but they're easily agitated during the during the interview. Um, yeah, and ultimately your goal is to establish some rapport. So even if even if they're not cooperative, I think it's important that you you hope to manage some rapport with the patient because ultimately that will. That will be the way that that will be what you need eventually for them to accept the treatment. So if you go to the next slide, so describing patient M. So when I first saw him, when I clerked him in. He was sitting on the bed and he was staring at the wall. He was casually dressed. He was barefoot, his hair was disheveled and he appeared tired. So I he was, uh he was very friendly, so he didn't have any problems. Um, speaking to him, his eye contact was initially appropriate. Then I noticed that he he was just staring towards me. And at the end of the assessment, um, I saw him wink a few times, which eventually led to, um to the interview being stopped. So if you go to the next slide, so as you do as you, um, converse with this patient, you wanna just observe the way that they talk as well. So it's the rate tone and volume. Um, because that would say that would say a lot with how they're feeling at the moment. Um, you want to check if they might be overly sedated by medication, for example, and that can be reflected with how the way they speak. If you have a patient who's bipolar and having a manic episode, then you would find their speech to be pressured, and it would be very, very hard to interrupt. Interrupt them and you also want to check if our they articulate in their speech, Are they making any sense? Is it slurred? Could it possibly be intoxicated? Or is it clear? And is it like, you know, it's It's normal and there's usually it's well, in my experience. So far, it seems to be normal, largely. So for the next slide, Uh, you wanna go into their moods. So again, this is, I think it's also always quite confusing with the mood and affect. So just with the slide, you can just see that, um, the mood is more of a sustained emotion, whereas affect is how how they project that mood, what you're seeing. Um, so, for example, and so if you can see there, there's a subjective and objective mood. So for me, I personally I do have an issue with this because because when you say subjective, you ask them how they're feeling. And if they say I'm okay, but clearly, when they're saying it in a way that they're not okay. So sometimes we we put subjective and put the patient's words, and then we put our objective. But then I think it becomes quite an issue where sometimes we don't tend to believe our patient's because we still we still count on ourselves to do the assessment. So I try to avoid doing this bit subjective objective because it in a way it doesn't quite respect what the patient is actually is actually feeling. So I think it's just a case to case basis. So if you go to the next slide, which is affect so you can see that, um, how how they're reacting to that emotion. So if you have a flat or a blunted affect, um, it just means that you can be speaking to a patient for about an hour. And they just have the same neutral expression or their face or like an emotionless, um, expression on their face and that that happens a lot with patients with depression. Patient's with schizophrenia, and sometimes you can see them to be with a euphoric affect and agitated ethic. And this is seen in patient's with mania or patient's with substance induced psychosis. Um, if if you see somebody who's agitated or somebody who is labile, for example, like clearly, um alternating alternating states, you can see this in, um, for example, bipolar, Um, rapid cycling, bipolar or delusional disorders. Um, because especially paranoid personality disorders as well, because anything that you say to them, it will make them experience panic or paranoia. So they need need a lot of reassurance with that, Um, with the restricted and expansive affect, I think this is just the range of Imo, the range of how they project their emotions during that interview. So you can have you can speak to a patient for just 30 minutes and you can witness them laughing hysterically and sobbing. Really? Um, really intensely. And then they just fluctuate an emotion. So that is an expansive, expansive affect. So if you go to the next slide, So for patient m, he was very articulate. Um, he mostly spoken phrases in between pauses and the normal the tone and volume was normal. The mood was, um, quote unquote, really bad. And he did a thumbs down sign while telling me that. But then next question that I asked him. He just started smiling again and was winking from time to time so you can see that it was an incongruent affect. It wasn't matching with what he reported to be feeling for the next slide. Um, you wanna assess his thoughts? So there's a lot of ways that you can report somebody's thoughts, But just for the for the mental state exam, you wanna see there you wanna observe for their form of thought there content of thought, Um, their possession of thought and their stream of thought. So with a form of thought, you just Dimmock Westchester. Are they asking it in relation to what you're to What your are they answering in relation to what you're asking? So if I If I say that, how are you? Um, the weather is Well, I'll give a a more obvious answer. So if I say how are you feeling? And then he says, um, I'm going to poison your drink So that's that's not that's not in relation to what? To what I asked. So that's That's a thought disordered form or a tangential form. So there's no flow of the conversation because they're always they're always responding away from what you're trying to ask. The content of thought is just it's just what they what they talk about, really like, uh, you want to ask how their how their sleep has been, how the appetite has been do How do they have any thoughts to hurt themselves? And usually, um, I do like to start, um, observing for their thought. Just when you ask, What brings you to hospital or where do you think you're here? Do you think you need to be here? And that's just by asking those few questions you can. You can elicit a lot of information from patient's. They would say that I don't need to be here. Um, it's your choice that you you put me here or I need to go. There's nothing wrong with me. Um, and then if you further explore that, why or if you further explore something that they did, uh towards the member of public, for example, and they start saying, Oh, it's because I saw the devil in them or because they he reminds me of, For example, my father abused me. So just by making full conversation to their present, usually patient's in psychiatry are very open, and they will tell you a lot more than than you than you usually expect for the stream of thought. Um, if you noticed earlier, I said that he appeared thought blocked. So that just means is his train of thought Um normal. Like how it's how how it flows. It's quite similar to the form of thought, but the stream is more like for the long term, like in the long term conversation. So sometimes when a patient starts to, for example, if they describe there, um, history growing up and he starts suddenly talking about religion. Or he starts talking about politics where he starts talking about, um, what he's going to eat next in the middle of in the middle of, you know, his childhood. Then you can say that you know, the stream is incoherent or if somebody's thought block and this is very, very, um, one of the significant symptoms in somebody with schizophrenia Thought block just means that, um, there is something that is blocking their thoughts literally. They're unable to answer you because they're unable to formulate thoughts in their mind, and they can't tell you anything. Um, and if you have a pressure of thoughts, there's too much too many thoughts going on that somebody with mania, for example, they struggle to keep up with their thoughts that they become frustrated, and they tend to respond in a different way. That's why they become agitated. They they start pacing. Or they start to exhibit physical symptoms like sweating and sometimes, um, and you, they will be able to hear it in their voice how they how they try to compose themselves, which is, um, often times they're not unable to. So, yeah, there's a lot that you can elicit for the thoughts, I think for the mental state exam. This is kind of the the Metea's like the heaviest part of the of the assessment and then for the possession of thought. This is this is mostly used for patient's who have schizophrenia or psychotic states. This isn't usually, um, assessed in, for example, mood or personality disorders. It's worth exploring if somebody may have a bit of both, like psychotic depression or manic psychosis. But if it's just pure depression or somebody, for example, with, um, what's a good, for example, a personality disorder? I wouldn't usually ask this anymore. So somebody with schizophrenia you can just ask them, Are your thoughts your own? So that's a general statement because it kind of it goes into more specific questions like, Do you think somebody owns your thoughts? Do you think somebody is putting thoughts in your head? Do you think that other Sorry? Do you think that somebody's removing the thoughts in your head? And usually somebody with schizophrenia is very, very likely to respond yes to one of these to one of these symptoms for the next slide? Um, you have thought perception, and this is really, um, to summarize it. It's just asking if are they experiencing any hallucinations in any modality. So hearing, hearing noises or voices seeing things that aren't there smelling, touching things that aren't there and this is again this is quite similar. This is quite significant associated. Significant associate with physical health Um, problems such as? For example, if somebody's intoxicated with alcohol or or cannabis, they tend to hallucinate. Um, at the same time, this is also very, for example, uh, very common in people with schizophrenia. So again, this this helps us to narrow down what is going on. And if this is something, this is something temporary or historical, because you can have somebody who has been hearing voices all their lives, and they're and they're comfortable with that. For example, somebody with schizotypal disorder. You know, people who often live in a fantasy world, for example. But they're not. They're not, um, not the menace to society. They're they're not harm. They're not putting anybody at harm. They're just they're just comfortable with their own world and they can hear voices. And they're finding comfortable with that where if you have somebody who acutely starts to hear voices that he must, For example, he must, um, protect his little brother from his father, who's who's been possessed by a spirit. And he starts following that voice that obviously that is a different problem situation altogether. And that increases the risk. And that will decide how the treatment is. Is determined, if that makes sense. So for patient m feel her the next slide. So when I was speaking to him, um, there was mild tangentiality, um, with his with the way he was speaking, he was occasionally thought block. When I do ask a few questions, he would sometimes just stop. Um, and I would try to prompt him and say, Did you hear what I just said? And it for a few? A few moments, and I have to, like, redirect him back to the conversation. And, um, he did have some abnormal thought perceptions. He thought that the bed lover in his bed were the devil's horns. And interestingly, the nursing staff told me that he was standing on the toilet for several hours a day because quote unquote, the floor is lava. And for his thought content, he definitely had the paranoid and the persecutory delusions that was in his, um, in his history. And he said that the devil is after him and he deserves punishment. And he told me this quote, that unbelief is the most unforgivable sin. And he had a he He felt that God speaks to him and through him. So for the next slide, um, which is cognition? It's just having an awareness. If the patient is, does he know where he is? Does he know who he is? And does he know? Um, the time is he aware that, you know, we are in the year 2022 or in the same same season? Same. So it's kind of a memory test, I guess. But it's just showing that he's not confused or how's his memory? How how his memory is if he could be again intoxicated by illicit substances that can obviously affect that and some. So, as you can see in the slide, um, concentration as well. Uh, you also want to check if their mute are the unresponsive. And, yeah, some visual visual, spatial functioning, but usually with with an MSC in an acute ward. Um, because they're relatively, well, not as severe as in a in a peak, you we usually just ask, um, the time place in person. So for the next slide, um, so patient m he didn't know where he was. Um, he did not know what his mental illness was. So that's inside. If if you know if you know why you're in hospital and, um capacity, he overall that capacity. Um, I probably not discuss this now because it's a whole different kind of. It takes very, uh, short time to assess this, but to explain the principles it will take some time. So I'll just leave that. So for the next, uh, slide, um, risk assessment. So I think again for the mental state exam. If if the thoughts was the most, um the part where you can gather the most evidence for somebody's presentation. However, the risk assessment I think for me is the first thing that that we do. Because that's what that's what determines, you know, the course of treatment for a patient. Um, so for the risk assessment, uh, it's also what differentiates somebody being detained on a section or somebody who can go into hospital. But be an informal patient, meaning they can. They're admitted, but they're free. They're free to go anytime, if you're if you're not on a section. So you always want to check the risk to self and risk to other people or risk from other people. So patient m clearly is at least presents with some moderate risk to self, because he has hurt himself in the past. And he wasn't also, um, taking care of himself. So you are at risk for physical health complications, and clearly there was a risk to others because he was paranoid, that people after him and he was hurting people. Based on his reasoning off, I was just trying to protect myself. So you, at the end of the assessment, you want to kind of summarize the risk assessment, and that's what I put he present as a high risk patient. He is absurd to be fluctuating in mood with unpredictably violent behavior, and he was recently reported to be sexually disinhibited towards stuff. So, um, if you go to the next slide, that's pretty much it. I just put, um, a slide there. So he does have schizophrenia. And, um, just for, you know, some fun facts. If you go to the next slide, it is quite a common, um, mental illness. So those are the numbers? Um, so, yeah, I think that's the That's the end of my my report. If I don't know if we have time, then but I'm happy to answer any questions. And I'm sorry. I'm presenting on my phone at the moment. I had some browser browser issues. That's great. Thank you so much. That was really, really helpful and very useful to have an actual case study, too. Discuss. Thank you. Um, does anyone have any questions? They can put them in the chat. Or you can put Michael and just you don't have to put your camera, so that's terrifying. But if you want, you can question I think I can. So you said that your patient m was lacking insight into his own mental illness To presume this sort of understanding of his mental health history? Probably quite, um, he might have been quite confused about that. You overcome that when taking a history like how do you trust if he says, Oh, yeah. I've had nothing in my past history. How what we're based off of. You mean like, how do we How do we know if we should believe that? Because there's that insight and there's a possibility that going on, So usually what we like to do is we just ask for their permission. Are you happy for us to get in touch with your family or who do you live with? Um, and usually they would be happy to to do that. If if they're not happy to do that, then that again, you know, gives us more. Um, that would, like, raise a flag for me if they were hesitant about something. So I think however they answer, it'll always lead to us. Um, either just getting more information doesn't, uh, there's always how to be from the patient. So you can. And that's what that's how I managed to to get the facts that this is, in fact, a second episode. Because when he first came in, his note said it was the first episode. So when I finally talked to the parents, Um, and even if you're not able to talk to anybody, say they don't have family, there's just nobody. Sometimes, just when you start the treatment weeks, weeks of, you know, treatment passes, they develop insight. And then sometimes they would be the one to bring you the information themselves at some time. So you don't need to get all of it at the first at the first instance. Okay, Cool. Thank you. I got a question in the chat from Sam. You could hope I'm saying your name. Right. Um, saying could you go over the types of questions you would ask in? I'm assuming history of presenting complaint is what you mean by HPC? Yes. Memory loss and cognitive decline. So what questions you would ask? Okay, All in the history to assess that. Okay. So usually that if that's a memory or cognitive decline, most commonly that presents with old age psychiatry, usually people having with mild cognitive impairment leading to dementia. But again, there are memory problems as well, with with younger people most most presumably, for example, if they were intoxicated with substances. So you can just do a brief. Just ask them who if they know who they are. They know where they are. If they know who I am. Do you know who you're speaking to? Do you know why you're here? And that already gives a lot to begin with. And you can ask simple things like, Do you know what you have for what you have for breakfast this morning? Or do you know where your birthday is? You know, your parents are, um sometimes you also ask for their address because you know their notes will be in front of us if they're unable to. So I think it's just good to ask simple things. But if if the if the history is saying cognitive decline, you want to ask things about, when did it start? And what is the nature of that? Is that like a step by step decline? Or is it just one day they're just unable to to remember they just start wandering places, but usually in old age psychiatry, it's very step by step. Like at first, they struggle with their names, and then eventually they struggle to even take a shower. They struggle to go to the shops to care for themselves. Eventually you dive into things like activities of daily living. So again, it's very It's so there's a lot to ask. But I think I would just start with those simple questions first with the present, and then try to go to the past. I heard that was useful. Somehow, Um, I think if there are any other Great, um, if there's any other questions, questions, uh, no. Sorry. That was yeah, about thinking organic causes. Yeah, for the perceptions. So what kind of blood panels and stuff would you do on someone presenting with psychosis to rule out those courses Causes? Yeah. Yeah. So, um, most, uh, well, you you said blood, but I would probably go for a urine drug screen first, because that's where we detect all of the substances that somebody has taken. I think that would be more reliable for an acute psychotic state. Um, if it was, um, if you're talking about an organic cause. Um, I would also resort to other investigations like a brain scan, because sometimes tumor's can, um, can have can make the patient experience symptoms that is psychotic in nature. Um, but if you're talking, uh, CT or an MRI, Um, so sometimes it's strange, because in my experience, a consultant has ordered both, but ultimately, for which reason why I haven't gotten to that. But I think both are valid. And in terms of bloods, I'm just trying to think, um I think, but it's really more of the the physical physical health that isn't quite in relation to psychosis. Because what I heard about today was a B 12 deficiency or someone saying about how a detailed deficiency resulted in Was it near list ick delusions? What? They were dead? Well, I Yeah, that's a good point. So I would say malnutrition. For example, Um, I would try to see if the patient had any other mental health illness, so I wouldn't say B 12 directly causes a psychosis. It's probably if somebody were not getting enough nutrients, for example, and there's a self neglect and that ultimately becomes it worsens their physical health, and it will. Ultimately, poor physical health leads to depressed mood and depressed mood. Is is a very strong precipitant for further deterioration in mental health. So I'd say it's a chain of events rather than, uh, I'm not sure where you got that, though. I'd be really interested to find out it was second hand for another student that said, I've seen it on. OK, Psychiatric liaison. Oh, interesting. Okay, well, it might be a case report, but so far, these are my two years of training. I haven't haven't had a case yet, and my consultant hasn't mentioned any yet, so Yeah, Thank you. Great. So if there's no other questions, just checking, then I will say thank you so, so much. I really, really appreciate it. There's a really useful slides. Um, and I think, Yeah. Thank you. Yeah. Yeah, there's there's too much in you a lot. I mean, that's sort of why I wanted a lot to cover, but thank you for doing it. And the slides are really clear and really useful and give a pretty good breakdown. So thank you so much. You're very welcome. Uh, thank you. Um, So I think, um, you don't have to stay, Dominic, if you need to head off. I totally appreciate that. So thank you. Um, I think we'll move on to the next section, which is with Glad and Charlotte who are just done their psych placement. And, uh, they're going to have a sort of just brief discussion about what it's like and, um, sort of tips because I think a lot of people who are there currently on their site placement or going might go into it in the next couple of years. It's quite useful to to know what to expect because it can be quite a different experience. I'd say from like being in hospital or even being in g. P. Um, so, yeah, I don't know where that is. But, Charlotte, you can go first if you're happy. Um oh, yeah, Briefly, before that, there's a I'm just gonna post in the chat. There's, um, interesting talk, Ted, talk because we were talking about hallucinations and kind of how people yeah, have different experiences of them. And this is about a lady who did have, has still has it, hallucinations, auditory hallucinations, and she sort of lives with them quite happily so I just thought I'd post that in the chat. So you don't wonder why it was sort of relevant. Yeah, hand over to you guys, and you can just, uh, tell everyone about your experience. Okay, So I am here, by the way. Um, yeah. So I think I'm going to go first, and then Vlad is gonna follow up. Um, so hello, everyone. Um, I think I know most of you who are here. Um, So as Chloe said, Vlad and I have done our psychiatry placements. Um, already. And I'm going to talk to you a little bit about kind of the structure of the placement. And, um, I'm going to talk a little bit about a CCS as well. And then Vlad is gonna talk about CBD s and his general tips and tricks. Um, so in terms of the placement, obviously it's an eight week block like the rest of them. Um, and essentially, it's split up into different weeks. So, um, the first week is kind of like your introductory week. So you have a couple of days, um, at a hotel, Um, where they go through your key sort of skills, Um, and competencies. which, um, we've just covered as well. Um, and they also do some case studies which are really helpful to kind of again sort of dip your toe in. Um, I think as Chloe said, I personally was really nervous before psychiatry because I've never done anything like it before. Um, so the case studies were quite a nice sort of way of, um, yeah, just getting a bit of an idea of what you're going to expect. Um, And then there's also a skills workshop in the in the first week as well, which again, was really stressful. Um, but actually, I came away feeling really, really prepared. Um, and I really enjoyed it on reflection. Um, so yeah, so that's really good. And then, obviously, all placements work on the hub and spoke model. So, um, a lot of what I'm talking about will be for my hub only. So I know that hubs do things. Definitely. Um, so I was with the Winchester hub, and then I was based in the Ramsay community mental health team. Um, so Vlad was with a different hub. So if there's anything that your hub did differently, Vlad, perhaps you can pitch in. Um, but essentially the way that my hub did things was that the first? So after your entry week, we then did two weeks in our sort of original placement. Then we did a two week placements swap. So they swapped us around, and we spent two weeks with another team. Then we had our family week, and then we spent another two weeks back at our original placement. I don't know if your hub did that, Vlad. Yeah. So, um, I was in reading, which was primarily an, uh, inpatient acute psychiatric units, which was roughly organized into think. There were six words in total, three of which were acute wards to which were old, a psychiatry words. And then you had, like, a psychiatric intensive care unit. Um, and so with every every, uh, spoke will have, um, it's family week on any designated week, so you'll come back to Southampton to do that. But what we did was we each we were paired off into groups, and we were each given, um, or rather assigned, uh, an acute adult unit, uh, in which we spent. I believe it was four weeks. So the majority of our time there and then you spend a week for me. We spent a week in the liaison department that the general Hospital in reading at RVH. Um, and then two weeks, uh, in one of the old age psychiatric units. But again, as Charlotte mentioned, different spokes will have different ways of doing things. And you may find yourself, uh, in the community. More often than not, you may find yourself. I know some students, for example, who are in gospel. Yet I don't necessarily know which hub that belongs to, but they have the opportunity to go to like a medium security unit. Um, which I didn't, um You may spend your time mostly on liaison, so it really depends on where you go. But whatever you do, make sure you're one top tip would be to make sure you take up every opportunity possible, because you'll be able to see patient's on kind of different, uh, different stages of their psychiatric journey, so to speak. Yeah. So, lads, basically just taken over my section and say Thanks, Vlad. Um, but yeah, that's kind of generally what I was going to say is that there are placements everywhere um, all kinds of settings. You'll see patient's right at the start of their journey. So psych liaison all the way through to kind of, like, chronic, long term follow up in the community and also older persons, mental health as well. Um, so there is so much breath, and I think the nice thing with psychiatry is that you have the opportunities to kind of make the most of them. Um, as in you have slightly more time. Um, you know, because it's an eight week block, there's quite a bit of scope to kind of spend a day here, and they're doing other things that aren't within your placement. Um, so that's my biggest tip is kind of make the most of the opportunities available to you if there's something that you want to see. Um, So, for example, I was quite interested in the forensic side of psychiatry, so I organized a day with the forensic unit. Um and yeah, just kind of put yourself out there, ask your team if they you know the way that I got certain email addresses was through connections within the team. So other people had worked in previous units that they know people. And, you know, it's sort of about putting yourself out there and kind of making the most of it. Um, there's lots of opportunities for teaching as well. So I got to go and, um, watch some electroconvulsive therapy, which was really interesting. Um, the only thing that I would say is yes, it's really great to do all of these opportunities, but also make sure that you are sort of getting everything that you need to get done as well, while you're at your placement. So organizing you're a CC s and things like that because for me, where I only had four weeks in my sort of original placement, I was organizing things. And then I suddenly thought, Oh, actually, you know, I do need to spend some time here as well, actually seeing these patient's and getting my CBD s and getting my a ccs done and everything. So that's the caveat. Yes, you've got sort of more opportunity, but also don't spend all your time other places and make the most of what you've got as well. Um, in terms of who you're going to shadow, obviously you've got psychiatrist. You've got trainees And also there are a lot of mental health nurses, especially in my placement within the community. Teens? They're amazing. I really recommend spending time with the nurses. Um, they know everything, and they're amazing. Um, and also psychotherapists as well. So again, in community, especially, they do a lot of sort of outpatient therapy. You can go and spend time with the therapist and see some sort of CBT, DBT all sorts of things. Um, now I'm going to talk about a CCS. So, um, as fourth years, I'm sure you all know what a CCS are within psychiatry, you have to do three of them. Um, it sounds like a lot, but actually, it's not really, um it's the same with other placements. I'm sure you've all done them. Would you mind explaining what a ccs are for people who aren't aware? Because some people, I don't think have any idea. Just Okay, Fair enough. Yeah. So, a quick rundown of what? Our assessment of clinical competence. Essentially, you're performing a skill while being assessed. So usually you'll go with a doctor or a nurse, depending on who you're doing it with, um, they will usually have picked out a patient for you to go and see, and then they'll say, Okay, you've got 15 minutes to do this skill, whatever it might be, Um, there's various sort of marking criteria. Um, so they'll mark you on things like history taking examination, um, your professional behavior, communication skills and that kind of thing. And it's marked, um 126. So it's kind of like below expectations, meeting expectations and then above expectations. Um, and the thing that I would say with this I'm going to come onto talking about, like, my tips and stuff. But this is quite subjective. So um yeah, my tip is, don't get disheartened if you get like a three or four in one thing, because again, over 4th and 5th year, you do. I think it's 18 a ccs or something and buy finals. You get an average of all of the domains, So if you get a three in one and you get a six in another, then it's going to average out. And because it is so subjective, like you will do two a ccs. So, for example, for me, I did one that I thought was okay, but not great and she marked me with sixes. And then there was one that I thought had gone pretty well and he gave me fours. So it's very subjective and you get an average at the end, so don't stress about them. Basically, um, without giving too much away, Uh, there's two main skills as we've kind of come across, um, in psychiatry. So undoubtedly, those two skills are going to come up in your A CCs. Um, and my sort of other main tip really is, especially with mental state exams. Just try and practice practice practice as much as you can. Um, So, for example, if you're sat in a consultation with someone, um, say it's like a, I don't know, like a drugs review or something like a medication review. If you're just sat there, try and do a mental state exam while you're sitting there, you're not doing anything else. And then at the end, ask the practitioner if you can present it to them and see if they'll give you some feedback on it. Um, the only way that you're going to get them down is practicing. Really? Um, and I think that's my biggest tip is just kind of try and practice as much as possible and get stuck in as much as possible. And I think that's everything I have to say on my half Say, Vlad, if you want to carry on Yeah, so just, uh, what I was gonna say about A C C is basically reinforcing Charlotte's point like they are very variable and very subjective. And with psychiatry, especially because the typical a CC in any specialty, they'll ask you to do a history and then an examination and give them you know, your differentials. And then for your main differential, kind of what the treatment, what treatment you would propose. Um, and that all has to be done in 25 to 30 minutes. Thing is, in psychiatry. To take a psychiatric history in 25 minutes is nearly impossible. So every examiner will ask you to do different things essentially, for you're a CC, so they might ask you to, uh, explore a certain part of the patient's past. Or they're presenting complaint. Or why they came into hospital. And then probably alongside that while you're doing that, just take a quick MSC for the examination. But but again. Everything is going to be, uh, quite subjective. And based on what the Examiner says and with, uh, mirroring Charlotte's experiences, I also for one a c c. I got, like, a three overall, and for another, I got a six overall. So just don't don't stress too much about it, because eventually they will average out And, uh, your true, uh, competency, I guess which more often not that not, is what you also reflect on it to be. Will will become evident. Um, So I was gonna talk about CBD s and just to give you a quick rundown of what CBDs actually are. So there are 20 minute presentations, um, of which you will do one, and they're split up, uh, 10 minutes for case presentation section for of it, and then 10 minutes for the discussion. Throughout your placement, you'll have to compile six, uh, CBDs. And then when you have all six, you'll fill out like a summary performer and then on the examination day, which now I think is done online throughout all of the all of the hubs. Um, examiners will pick one of these CBDs for you to present. Um, so As I said, the CBDs have a case presentation and, uh, throughout the six CBDs you right, You have to cover six out of seven possible, uh, uh categories of disease these being and you'll find all of us on blackboard as well. Um, but these categories being drugs and alcohol mood disorders, which includes, like depression, bipolar mania, uh, or develop developmental disorders like a D h D and ASD autism spectrum disorders, anxiety disorders, psychosis disorders, personality disorders and delirium or dementia. And, uh, more often than not, you'll find that this is quite easy to do is there's no, especially in inpatient units. There's not really, um, a single, a patient that will have only one of these. A lot of these will be co comb orbits. So you you just pick and choose so that you have enough enough breath throughout your six CBDs, and then the discussion points that you have to cover each throughout your six CBDs. There's nine of them, so you have to cover all of these, which are formulation, legal aspects, pharmacology, communication, treatment, differential, diagnosis, state, my ethics and prognosis. Um, my recommendation would be so you can have as many discussion points per case as you want, but you'll only have 10 minutes to do this to discuss these things. So I would say, um, around to discussion points per cases is more than enough. Really, Uh, in terms of what you should include in your case presentation. Uh, so you have an intro, which is kind of a quick summary of, um of, uh, the patient himself. You have the history of presenting complaint. You have the background history, which includes family history, personal history, and I think Doctor Kelly Long probably ran you through these, but I'll just list them off quickly. So personal history, social history, uh, past medical history of the patient medication history, uh, past psychiatric history of the patient and then their pre morbid personality. Uh, about that many patient's won't really have a period of pre more morbidity, especially if they have things like personality disorders. So typically, what you're actually looking here for here is their most functional baseline in their life. When were they the most well in their life? You want to talk about the diagnosis they have, uh, you want to have a risk assessment. You want to do a risk assessment on the patient, which I know. Dr Kelly Lung ran through with you. You want to Do you want to present a mental state exam, And then you also want to present a formulation? Uh, the formulation is basically a narrative trying to explore why that particular patient is suffering with this particular condition at this moment in time. So it really takes into account. Um, it's a holistic narrative of the patient's disease. And my tips for these CBDs essentially was one. Make sure you start early because they take a long, long time. They take a long time to do there. A lot of work. Um, so do start early. Don't do what I did and started quite late. It worked out, but don't do it. It really was more, more, more pressure than was needed. Um, you also run the risk of repeating information. So throughout your case presentations, there are a lot of overlapping categories you have to run through. A big way to save time is that you actually organize and re add that your your presentation so that you don't actually repeat, uh, information unnecessarily. Um, in picking your cases um, ward rounds are a great place to find cases and get like a quick overview of them. But do make sure to to try, speak personally with each patient as you will get, uh, kind of unique site insight and and engage with the the, um, case itself. And you'll probably be do a better job of of bringing something else to your presentation that you wouldn't have been able to, uh, by just reading the notes or sitting in on the ward around. Um, First of all, make sure that you're safe in talking to the patient, but don't be afraid to ask what you mean. Mean task. Don't beat around the bush with sensitive issues. Typically, uh, more often than not, patient's will appreciate your frankness. Um, a good A really good thing to do is, uh, to discuss and revise your understanding of of the cases you pick with your supervisors. Uh, particularly because psychiatry is very particular is very like, um, keen on using the correct terminology and accurately describing symptoms symptoms. And I found this, um, one of the more difficult aspects and that you know, what's the pseudo hallucination? What's the hallucination? What's the delusion What's actually part of the thought forming disorders. So make sure you you talk to someone about this because we're not experts. You know, we we were here to learn. Um and, uh, yeah, we're obviously gonna make mistakes. Uh, as Charlotte, I believe mentioned, or Doctor Calley will take the opportunity to to use the collaterally history if you if you have the if you're able to do so, Um and finally, especially with the case presentation, time yourself practice and time yourself, because they are very strict about it being 10 minutes and you will 100% have more information than you can fit in 10 minutes. So time yourself. Make sure, um, you include what's really relevant, especially with regards to your discussion points. Um, in terms of tips for the discussion, pick interesting cases, Uh, and don't be afraid to challenge aspects about the case, even things like the diagnosis. Uh, and while 90% of the time you may be completely wrong, uh, this actually does show that you're engaging with the process and have kind of like an original thought. And many psychiatrists may have different opinions on on the optimal treatment on the kind of the main diagnosis of the patient. As I did mention, um, a lot of these things come as comorbidities, you know, so you won't have patient's who just have, uh, depression. Many patient's with depression will also have, uh, psychosis. You may find patient's who, um, have personality disorders and depression or an anxiety and mania. So, you know, make sure, um, you try to put an original spin to it. If you have things that you look at in the case and you feel this may not be quite right, take it to someone else. Take it to another psychiatrist. Take it too, uh, to your fellow colleagues and and just flushed out. Discuss alternative inter interpretations. Another. Another good discussion point to do this, the formulation itself. Legal aspects are quite good, and in terms of getting, uh, kind of a forum where you can, um, discuss things. Um, Thursday tutorials are a really good opportunity to do so, because on the wards, you know you're going to have you're supervising, supervising psychiatrist, but and your Reg is and your nurses and they may be quite busy. Whereas the Thursday tutorials are basically an entire day where you just have you have someone you can talk to and rebound ideas off of it. More often than not, you'll have psychiatrist consultant surrounding them. Uh, my my late for time is that I think, yeah, just to give people time, just ask some questions because you guys are coming a lot, if that's okay. Yeah. I'm happy because I finished with the CBD s anyways. Amazing. It was really useful. Thank you both so much because there's a lot there that I think people I don't know about Sophie CBDs. And I think, um, and a CCS because you keep doing them throughout your career. That's the thing I didn't realize was I mean, there was like, I like bridges. You still had case presentations to give to their consultant. So it's a really good thing to get into habit of doing them. Well, now, um and so, yeah, if anyone has any like, questions for anyone, feel free. So I don't know whether you guys can see the chat. Yeah. So how would you write to formulation for a diagnosis of dementia? Enjoy that one. I did formulation for a dementia case. Um, So fortunately, the dementia case that I had, she had vascular dementia. So a lot of what I talked about was the kind of risk factors. So, like the vascular risk factors had diabetes. He had high BP, so that's kind of like your predisposing precipitating factors. Um, and then with the formulation as well, it's quite good to look at the patient holistically, Um, which is a really big thing in psychiatry. So, um, you know, how good is there family support? Are they keeping them sort of independent by helping with shopping and, um, like, keeping them in their own home, for example, providing things like memory clocks and and that sort of thing. Um, there are also examples on blackboard as well. So I think there is a formulation example on blackboard. Um, but yeah, it's Yeah, I think I don't have anything else to say. Does that help you show the question person? Charlotte, Not the answering great. Any other questions we've got? I've got just a little section left. I know it's been quite a long session, but I've got, like, five minutes just to go over What? The perspective of the examiners that I thought would be helpful. But if anyone else has any final questions for Blood and Charlotte before we let them go because they've been very helpful and it's a good experience No. OK, well, thank you both so so much. It's really, really valuable, Valuable and a lot of useful tips there that I even will continue to use. Generally, they're very useful. Um, So thank you. And I hope it helped everyone else as well. Um, yeah. Enjoy replacements. Thank you. Thank you both. Cheers. Um, so yeah, So I'm just gonna chat. I know you. Yeah. As I said, you've been on for a while, so it's really good of you to have stayed this long. I just want to chat five minutes because I was invited to what they call it educator's meeting, which is with all nearly all of the examiners and people who run the psychiatry placement for Southampton Uni and I was the only student there because I'm presidente of this psych sock. And so I got invited, which is very nice, if intimidating. And I just thought I'd give you guys a few little feet like tips and things that they fed back to me. Um, that I thought would be useful. Um, and they're pretty obvious things. Um, but the main thing I wanted you guys take away was just how much they do care. And then sometimes it can feel that they don't. But the majority of them, I would say, are very keen that you guys do well and that you get something from the experience. And it's a rewarding and, um, sort of reflective experience for you because this will be the main instance. You know, you'll have of psychiatry training until you become a doctor. So they really want you to take away as much as you can from them. Um, that being said, you know, I think there are some difficulties that some people have because each hub is sort of has a different way of teaching. I think that could be quite tricky for some people because, you know, in my hub, for example, I had really excellent tutorials. It was really well organized, you know, we got given a folder with our timetables. You know, all the forms we needed with They're all the context with their how to get there. What time to get to placement. All that stuff was there. I know for other people, they aren't that lucky. Um So my main thing would be you do have to be somewhat responsible for your own education. You know, if you're lucky enough to be in a really organized space like me, I was in, um, Poole and Dorset trust their really excellent. Um, so I can recommend that if you want to choose that as a hub, but other places might not be, so you need to be maybe a bit proactive. You know, if you get if you've got an A C c. Particularly email the person if you can find out who they are, email the person you're gonna have. You're a CC with Ask them. When are we meeting? What time should I, you know, get there? Could I have even the details of the patient beforehand to look up if you have access to the clinical systems, Um, that's really useful. And that would just give you that. Sort of It will really reflect well on them as well. Sure that you're really proactive, but it just make sure that you're prepared. Um, what you want to do? Um, I said the other thing is it can feel a bit like you're just sort of throwing at the deep end. They don't give you much inherent teaching on how to assess a patient or what schizophrenia or what bipolar is. And that can seem a bit like over. Well, I don't know anything about psychiatry. Really? What? How do you expect me to assess the patient liberate on their front? You may think I haven't thought about this, but it really is deliberate. They want you to learn by talking to patient's. And I would agree that although that's scary, it's the best way to learn, because you get a really good understanding of how it's not like the text books. Actually, in real life you will have lots of different things going on. At the same time, you know, they have, you know, overlapping conditions. They'll have one feature of this illness, but they might not have all the features, and the best way you can learn is by doing and by practicing that with the patient's, and that's why they got on those case. Discussion's at the end for the assessment because they really want you to gain a good knowledge of a patient, really take a really thorough history and assess them because that is the best way you'll you'll learn because there is no, you know, specific format. Unlike physical medicine, a plus B equals. That's why I like psychiatry. But that's why a lot of people do find it quite challenging because you have to sort of re change your, um and that's sent. So that was my main two points. Um, I think the other a lot of people think it's quite an easy placement to just breeze through, but I would say actually it is mostly I think it's particularly as I said, they're really they're very much to support you, But some people did fail this year, and that was, I think, quite surprised for the, uh, mhm psychiatrist running it. Um, and they are looking into it. But just, um if you do feel you are struggling thing do make a point of like reaching out to that because as psychiatrist, I would find the mostly the nicest people to do that to their really understanding. So I actually took um, I didn't do my case based discussion because I got to really bad, like cold, like a flu one after the other at the end of my placement. Glad timing didn't feel prepared. And they were so supportive. They they were like, Yes, absolutely. Loads of people got involved to make sure everyone who needed to know new It's been rearranged, you know, at my own when I have time to do it really are lovely about it. And I think, you know, if you feel you are struggling, just you do need to speak up and you need to take that motivation even if it's just a little thing. Just say, listen, I don't understand this. Can we go through it? You know, just that? Uh, so that's the main point. I just wanted to get across from the sort of educators perspective. Um, but I think that's about it. And if anyone has any questions at all about anything, um, please feel free to our meats and put it in the chaps. Um, but if not, we're thinking of things. Um, the slides and this recording will be available to you, um, shortly and you all should get a certificate of attendance. That's why I'm using a thing called Medal cause it's really best of it. But your portfolio's, um, there's also a little feedback form, so if you have a moment, it takes two minutes to do that. We really appreciate it. Appreciate it for everyone who spoke and organize that, Um but yeah, I don't think there's any questions. In which case I will say thank you so much everyone for coming, coming. And I hope it was you and you learned it. And you feel a bit more prepared for psychiatry and your sight placement. So, yeah, thank you.