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Session 9: Clinical Station - part 2



This on-demand teaching session explores various scenarios medical professionals might encounter, focusing especially on aspects of the Mental Health Act and the Mental Capacity Act. Hosted by three researchers from East Midlands and Oxford, this session discusses interview strategies and simulates possible patient encounters with issues such as Moderate Severity Pneumonia and Asthma Exacerbation. Participants will also get guidance on how observations and symptoms guide the determination of a disease’s severity. The hosts share best practices for medication, symptom alleviation, and understanding lab results, and suggestions for additional testing procedures. With demonstrations of thoughtful process for treatment consideration, this session promises to be educational, especially for those honing their diagnostic and patient care skills.
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Join us for the final session of our interview preparation series where we will be covering some further common A-E scenarios with clinical prioritisation and final Q&A to wrap up the interview series

Learning objectives

1. Understand the Mental Health Act and the Mental Capacity Act and how it impacts medical practice and patient care. 2. Identify and manage mental health scenarios using the principles of the Mental Health Act and the Mental Capacity Act. 3. Learn how to conduct a patient history review, especially in cases of acute or severe illness such as pneumonia and asthma. 4. Understand and recognize the clinical signs of anaphylaxis and immediate management as well as subsequent measures to be taken. 5. Gain knowledge of how to manage severe asthma, including the importance of assessing severity, immediate treatment, tests and measures for long-term management.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

You save her. Hi, guys. Sorry, we were informed we weren't live. So, so if you were, if you missed out on all of that, I'll quickly run through it. No, that sound in the beginning, my friend. Oh, great. Sorry guys, Mos has been speaking to us about I for the past 10 minutes. Alright guys. Hi, everyone. Sorry. We're a bit delayed. We'd started the presentation without going live. Um ok, we'll start from the beginning. Today's er, session will outline some of the at scenarios Mental Health Act and the Mental Capacity Act. Here we are, we applied to S FP. This is the last lecture in our series. There will be another one at the start of January just going over some of the offers and er final Qs and A s that you want to talk about. These are the speakers for today. I'll run through them. Julia's not here. She's unwell. My name is Mo. Uh I'm doing research at the East Midlands. Er, youf is also research at East Midlands and Kai is research at Oxford. All right, just to recap for the interview stations. I'm sure you, someone's spoken to you about it already, it'll be some combination of clinical academic or personal or motivational stations. It's best to speak to people who have already, er, applied to the de use. You're applying to and got on offers, cos they'll know best about what to expect here. Usually the interviews last from 15 to 30 minutes. So they're very fast and they usually have 2 to 3 clinical or academic doctors, uh a and on the panel and you apply for the interviews online. Another thing to note is the interview dates vary extensively between the different deaneries. So make sure you know, when your date is also, the interview offers can come out any time from a few days to a few weeks before. So you have, if you haven't heard back yet, don't be uh upset, you might still hear back. Alright, we'll go onto the scenarios and quickly go through them. Ok. Firstly, um so scenario one is a 71 year old patient who's confused and febrile he has consolidation on his chest X ray um and also diagnosed with moderate severity pneumonia treated with IV Comox. The nurse tells you that the patient is developing a rash on his arms and they want you to review the patient before you go into any interview, er sorry, before you go into any station or scenario, make sure you take a brief history. This is the summary of the brief history if however, the patient's really unwell or deteriorating probably not the best time to ask these questions. It will just be suitable to look at the notes or get a handover from the nurse. Make sure you verbalize these things during your interview so that uh the doctors or assessors know that you have a thought process. All right. So this is the at assessment for the patient with the pneumonia. You notice that he has hoarse voice, swollen lips and also wheezing on auscultation. The patient is pale and clammy and also the BP is low. Er, and on full inspection, you notice that there's urticarial rash bilaterally on the arms on the left, you have the life threatening problems. So, if the airways compromised, you get a hoarse voice stridor. If er the breathing is impaired, you'll get increased work of breathing, wheezing fatigue and the oxygen levels will fall. Um, cyanosis is a late presentation of uh anaphylaxis and this typically means that the patient may be on the verge of respiratory arrest and of course, look after low BP as shock is also evidence of anaphylaxis on assessment of disability. The patient may be anxious, sense, impending doom and have reduced consciousness on everything else. You notice some skin and mucosal changes, these tend to occur in approximately 80% of patients and it's important to keep a look out for them. Usually, nurses will come up to you and tell you these are the first presenting symptoms that the patient has uh, another thing to note is 20% will not have these symptoms or will have mild presentations of these, of these symptoms. They may also have some abdominal issues like vomiting or er, tummy pain. However, this is more rarer, less likely to happen and probably not gonna happen in your interview. All right. So management call for help, stop the meat, stop the fending medication, lie the patient flat and raise their legs Because of course, there, there's a vasodilation effect of the histamine being released during the anaphylaxis shock. Give them iron adrenaline er, in the anterolateral aspect, middle third of the thigh and you repeat this every five minutes and then you move on to your A two E assessment and sorry, not assessment. But at E management, you establish the airway, you give them high flare oxygen, that's 15 L non rebreed mask and you give them an IV fluid bowler to help with the drop in BP. Um, steroids and antihistamines are no longer part of the guidelines, but a lot of doctors still prescribe them out of habit. There's no response. After two doses of adrenaline, you start the refractory Anaphylactic guidelines. Um However, this is senior L. So you're not expected to do this. The most important bloods to take during an anaphylactic shock is mast cell tryptase, which is an enzyme that's found in er basophils and mast cells and th this release along with histamine. So usually you'll see this tryptase level rise at two hours after the after the event and then come back down after 24 hours. So you do blood test at the event two hours after the event and 24 hours after the event to prove that this is an anaphylactic shock. Why these are the refractory anaphylactic guidelines which you don't need to know about. Ok. Next scenario, 28 year old patient with worsening shortness of breath over the last three hours now unable to complete sentences, as you can probably tell by the history which says known asthmatic that this is an ex exacerbation of asthma. Ok. On a, on, at assessment, you see that the patient's talking but unable to complete full sentences. Respirate is 29 raised oxygen sats are low, they're wheezing on auscultation, er, circulation is with a er, they're tachycardic, blood pressure's high cap refill is less than two seconds, the patient's alert and there's no other findings. And then from that, you get the information that you need to determine how severe this asthma is. So usually moderate, moderate, moderate severity asthma, the peak flow rate is still 50 to 75. Uh, but with severe, you start seeing a lower flow rate of 3233 to 50 resp rate is slow, raised and heart rate raised as well and there's inability to complete full sentences and worse than that. You get life threatening asthma where the peak flow falls further. Uh oxygen sats drop further. The patient becomes hypoxic because their uh po two falls below eight. And at this point, you also see the patient becoming fatigued. So they have a silent chest cyanosis, poor respiratory effort. Um they might develop an arrhythmia and also the consciousness level may fall near fatal. Asthma is when this ti is start, starts having a biochemical effect. So you see the PA CO2 rising and this is when the patient may need mechanical ventilation. So this is extremely severe. Ok. And one more thing to mention here is the severity de determines what management you need to get for moderate and severe asthma. For both of them. You will start them off with some salbutamol salbutamol nebs or with spacer and you will also prescribe prednisoLONE. So that's typically what you do for every patient with moderate or severe asthma for severe asthma. You also wanna start considering whether you wanna send this patient to hospital. If the salbutamol nebs are not doing the job, you send them to hospital for life threatening. Even if they have 11 of the criteria of life threatening asthma, you would send them to hospital for our patient. He fits in with a severe asthma picture, but his oxygen stats are are 91%. And if you look into the criteria of life threatening, uh the criteria says SBO two less than 92. So this is a patient with life threatening asthma. So they will be sent to hospital. And if you look on the left, that's the investigations you wanna do. So as you're going through your a three assessment, you investigate as you go. So you measure the peak flow during your breathing assessment, you also take an ABG to of course, assess whether the patient's hypoxic. Um and to figure out what's causing this asthmatic attack, you also wanna consider doing a chest X ray, uh take a sputum sample and also a viral swab. Cos you're trying to figure out what the precipitant of this exacerbation is. And then of course, consider what severity of asthma this is. We wanna do bloods again, you on basic bloods and also blood culture if you're querying an infection IV fluids, if necessary, and antibiotics if necessary. And then blood glucose. As of course, the patient will be working very hard to breathe. So you wanna see what their glucose is looking like. And of course, take a history whether that's from a parent or partner or friend to see what they have been exposed to. Is there exposure to allergen? Is there exposure to any chemicals that might have exacerbated this asthma? And of course, your aim is to prevent this in the future for management. If they're hypoxic, give them uh two therapy, you also give them salbutamol 5 mg nebs and you can add ipratropium to that as well. These can be delivered together. So you can just say salbutamol and ipratropium nebs er, delivered every 15 minutes. So you wanna keep that going until the patient starts feeling better and everyone you prescribe prednisoLONE, you give them 40 mg of oral prednisoLONE. And if they can't take anything orally, you can give them HIV, hydrocortisone. And that's typically where the f one role ends after this, it will be senior led. If you think the patient has life threating asthma and they're not getting better, then you may speak to senior about giving them magnesium sulfate. And if that still doesn't do the job, then this really needs senior address. So you, so they can think about whether uh intubation is necessary, er, further medication necessary, whether IV beta uh uh beta S are necessary as well. And of course, because you're giving this patient so much salbutamol, your potassium might start falling as well. So, a good, you know, a good addition to your, er, management might be to say to the interview, is that what I will also assess the potassium levels and replace if necessary? And that'll just be that extra little spot to add to your, er, management plan. All right. That's all from me. Er, apologies for speaking, er, with a blank screen before, er, but I'll pass on to my colleague now to er, go through the rest of the scenarios. Thank you. Hi guys. So uh let's read the story together. So you're asked to see a 78 year old man who feels short of breath, hint, hint and had a funny time only going to the toilet, he's come to the hospital following a fall and has the stands of isolated left sided rib fractures. He will start on epidural for pain relief. So you may already be having to think about what kind of differentials that may be going through your head, especially with shortness of breath. Um And the fact that he's in for surgery, let's get to the next slide, please mark, ok. So free assassination in an at e manner, his airway is patent. He's talking to you. That means his airway is patent. If we look at his breathing, we're gonna look for your listen, measure treat. So that's every, that's what you have to do for every single one of these assessments. So if you're looking and you're feeling and all that stuff, and then once you get to the measurements, you see that his respirate is 22 his sp O2, his oxygen saturation is at 92% and he doesn't have a chronic disease scale, which means he doesn't have a history of CO PD, which would make that, make that 92% normal. And he also has no cough. So immediately what you're gonna do is you're gonna be starting to think about he's uh technique, you know, he's hypoxic. Uh So maybe we wanna think about what's going on in to, to make him that way uh if we move with circulation, again, look for your list and measure treat. Um we can see that his BP is low. So he is hypertensive slightly. He is a bit tachycardic. His heart sounds are present and his cap breathing is ok despite his BP. So again, we have to think about how can we immediately manage these uh measurements before you go on to disability. Once we move on to disability, we see that he's got a G CS of 15. So we're not worried about him neurologically, his glucose 6.3 you know, he's fine. He doesn't have a history of diabetes and his temperature is fine. He's uh he's got people that equally active to light and it does everything else. This is where some of these scenarios which you can't immediately have a differential for in everything else. This is where things get a bit more interesting. This all you have to think about the differentials and what kind of specific things you need to look out for. So when you ask this patient, when you do a secondary survey of his um thorax, you see that he's got pain in his chest, you'll see that his calves are soft, non tender. But recently in his medication, you see that he's has, has had his Epix and stopped because of the epidural and no vte prophylaxis prescribed um for him. So again, that gives you more hints about what we're dealing with here. Um If anybody wants to pop it in the chat, feel free. Um Otherwise let's go to the next slide, please watch. Ok, so we do an E CG as part of all standard workout. We should wanna do an E CG. Um And what can we see on this E CG? Ok. Anybody she wanna pop it in the chart. Do we have, do we have people here? Yeah, we've got some people, anybody you wanna pop in the chat with any things going on? Sinus tachycardia is a viable answer as well. So, um he is tachycardic. As you can see uh something else though, there's something else on the ECG and it's not really necessary to spot that all the time. But what you can see here is on leads V one V two V three, V four kind of uh these are the anterior chest leads, right? If you think about where they go on the ECG O on the chest and you can see there that there is huge T waves, isn't there? Oh, well, two wave inversion, sorry. Um And you can see that they're down sloping like that whereas usually they wouldn't look like this and this can indicate right ventricular strain. Um So that's something to keep in mind as well to look out for. It's one of the more common patterns that we see in this kind of pathology as well as an sinus tachycardia, which we can see from the E CG as well. Fine. So let's go to the next slide. So, what we're looking at here is something called pulmonary embolism. I'm sure you're familiar with it. I'm sure you've heard of it. And with the pulmonary embolism, some of the most common signs and symptoms is somebody being hypoxic, somebody being tachycardic, uh somebody having pleuritic chest pain. So, pruritic chest pain means that when they take a deep breath in deep breath out, they've got some pain in their chest and that gets worse with deep breath, deep breaths and deep expiration. Um So what are some of the medications that you want to do is obviously bloods, a full compressive set of bloods. Um You'll also want to take an ABG and A V VG as a general rule of thumb. If your patient is going on oxygen or they're, and they're hypoxic, you wanna do an ABG for them because you wanna see what their oxygen to CO2 to ph uh ratios are, you know, are they a CO2 retainer? Is it a type two respiratory failure or is it a type one respiratory failure? And that'll help you to further manage the patient. Um One of the things that we always send for is an ECG. Um we're doing an a ce assessment and then again, we had a look at the ECG and as we can see, 44% of patients with a pulmonary embolism present with sinus tachycardia 80% of the right bal branch block. And the second most common is right ventricular strain. And what that, how that's shown is at wave inversion, V one to V four plus or minus the inferior leads. Now, the question maybe is why do they have right ventricular strain? And um, if you think about the pathophysiology of what's going on, you've got a embolism in one of the um arteries of the lung and that's where the right ventricle pumps blood to. So if you've got a blockage there, you're gonna have a bit more pressure in the right ventricle. Um And that is essentially gonna show up on the E CG cos the right side of the heart is working harder. Um, commonly in textbooks, you see, you hear about S one Q three T three. You may see that, um, it's not that common. You may see it partially as well. So you may have an S one and AQ three, but not at three. So these are things to look out for. Um, so we've talked about bloods, we've talked about the ABG and V VG and we've talked about the E CG. One of the other things that you wanna do is something called a well score plus or minus ad dimer. Um If we look at the latest nice guidelines, which is what's gonna be assessed in your interviews. Um When you look, when you considering your pulmonary em embolism, the first kind of risk stratification that you have to do is something called a perk score, which is a pulmonary embolism rule out criteria. So, and it's in the name, I guess it's a very short thing. You're looking at things like age, heart rate, the basic saturations and stuff like that. And essentially, if all of the above are absent, the post test probability of pe is less than 2%. So essentially, if they have any other c, if they don't have any other criteria, you can essentially rule out pe OK. Now, let's say you do this PK test. And if you look at the PC test, you can see that this patient has some of the criteria. So the tachycardic with a heart rate above 100 the ox saturation less than 94%. So you're gonna move on from the PT score and this is where you do a two level P well score. And this is what essentially is gonna risk stratify your patient into P likely or P unlikely if the P is likely, which is more than four points. You know, there's gonna be um uh a plan to arrange an immediate C TPA. Um Obviously in the N HSN, nothing is really that immediate. So, um in the meantime, what you do is you start um anticoagulation with a li like he or a Doac a less contraindicated. Um if the P is unlikely four points or less is the one you'd go for Ad Dier. Um And AD dimer is a blood test and that looks at the breakdown of um fibrin. So Fibrin split products and essentially, it's when the clot is being broken down, that generates something called ad dimer. Um So again, the D DIR can also help you. So if the D di comes back high, again, you're gonna go for a C TPA in the end as well. So the only thing that change the world score changes is whether you go for A C TPA immediately um or if you go for ad Dier straight, er first, um obviously, if the D dimer is negative, you can rule out pe consider alter as diagnosis. Now, let's suppose your patient cannot have a C TPA, for example, due to renal function or they're pregnant. One of the things that you can do is a VQ scan, that's a ventilation perfusion scan. So it looks at if there's a mismatch between the ventilation and perfusion and that can also indicate that there's a pulmonary embolism. Um in terms of management, like we discussed, you wanna, you know, thin the blood. So unless they're contraindicated, you have to commence them on a molecular with heparin or olic uh enoxaparin is an example of a heparin. And then an example of a delic is the pa what the patient was, was having before, which is Apixaban. Um So yeah, just to know if they're hematologically ins um instability um If sorry, that I should say if they're hemodynamically unstable, then you have to consider a more immediate management to break the clot. Um Does anyone know what that could be? Ok. No. So it's something like, it's something called like alter plays. Uh So alter Plays is if they're, for example, if you're unstable, you would want to act immediately. Uh And that would be with alter plays. O obviously, if they're stable, then again, we'll look at our air and direct alternative. Um And then what we wanna do further along down the line is something you want you might want to mention is to consider if this pulmonary embolism is provoked or unprovoked. Uh pulmonary embolisms tend to come from the deep veins um in the legs of DVTs. And obviously, if they're provoked, that could be surgery or pregnancy, you know, hormone hormone replacement therapy, long haul flights, that kind of thing. Uh unprovoked is no major clinical risk factors. Fine. So that's P ES. If we can get to the next slide, please watch. Ok. So scenario four, you speaking with 25 year old Judy regarding her recent admission to the hospital with a chest infection? Now, don't worry, this is not gonna be sepsis. As you're talking, Julie suddenly stops speaking and begins seizing. Please assess Julie. Now, obviously, these kind of this kind of scenario is difficult because when a patient is sees you in front of you is different to when somebody's just reading out the scenario to you and, you know, you really have to think about what kind of steps you'd do and how you'd act. Um So if we go to the next slide, please, OK. So you're not gonna find a lot on at assessment because this patient is actively seizing. Um But if we do go through the airway, for example, you're gonna see some secretions, you're gonna hear some gurgling sounds. Uh When you look at the breathing, you know, you're gonna see that if we are, if you are able to assess the respiratory rate, it'll be 25 let's say. Uh so a bit high and the oxygen saturate is 94. So it's on the low side of things, but it's ok right now as well. You have to remember that these patients don't have to always have comorbidities. They could be young patients in this case. Uh She's a bit psychotic BP has dropped a little bit, temperature's fine. Can't really assess heart cells because the patient is seizing and the cap refill is a bit slow at three seconds. In terms of disability, they're unresponsive. The patient is seizing and you're not gonna quite be able to assess the G CS. But you can imagine that the G CS is not gonna be very high either. Um because the patient is in status. Um One of the most important investigations that you should order when, when having somebody on um with a seizure or syp tous is ABM um hypoglycemia can cause seizures. So that's something to consider as well. Pupils are equal and reactive. Now, if we go to the next slide, we can discuss about what's the first immediate things to do when confronted with a scenario like this. Now, obviously, in this kind of scenario, what you do want to do is keep the patient safe. Um And before you do that, actually, let's start from the beginning, you have to start by calling for help. This is a medical emergency, ok? And this could also be an airway emergency. So what you wanna do is you wanna call double two, double two. and say that this is an airway and medical emergency. If obviously it's pediatrics, if it's a child under 18, then again, you wanna say that as well. Uh and you wanna start timing seizure and this is relevant because this dictates management. Um Second step you want to do is a recovery position, protect the head and don't hold the patient down. Um A lot of people may think that we should hold the patient down so that they don't hurt themselves, but this could actually lead to problems further down the line. So again, recovery position on their side, protect their head with a pillow and let the patient seize if we come to the airway. Again, that is the most important. I regardless if the patient is using or not airway is always a thing that you want to manage first and make sure it's patient. Um So in this case, you have, so we could see secretions and you wanna suture any of those secretions as much as you can. Um Naser found your airway if you're worried and if they um if they are actively seasoned, you want to avoid putting an oropharyngeal airway in and that's because of something called Trismus, which just means that they can bite. Um And so you don't wanna do that and they might not be able to tolerate it anyway. Ok. Any questions about that? Fine. So let's get to breathing. As you may remember, the breathing was fine. The patient was ok. But you'd want to put them on some oxygen anyway, just in case circulation, you wanna make sure that you've got IV access and this will be very important uh when given medications as well. Um And if we assess disability, if the patient was hypoglycemic, then you'd want to give a bonus dose of some dextrose to bring that up. And then what you wanna do is you wanna follow the status epilepticus protocol um and escalate if the seizure does not terminate. So let's go to the next slide. So as you can see, the reason that I said, we just start the timer at the start is because as you on the left, as you can see, as you go down with the timing of the seizure, the management gets more escalated and it, you know, leads you where to go. So the first kind of five minutes be before five minutes, you wanna do your at E um and make sure that the patient is stable after five minutes have passed. This is what you'd count as a continuous generalized seizure activity or as, as epilepticus. And the first line thing that you'd want to do is give IV LORazepam um or IV diazePAM. Again, this could vary from trust to trust. Um But there will be guidelines to follow if you don't have IV access, then the ideal thing is um uh Buco Midazolam or Pr diazePAM. And then this is repeated if the procedure keeps continuing every five minute mark until you get to 15 minutes where you'd have to call the ICU anesthetics and escalate this further. There are some other second line treatments, but again, as an F one, you'd probably have help by that time. So we're looking at things like IV Phenytoin and IV Levitra as well. Cool uh Any questions about that. If not, then again, I would advise you just have a look at this before your interviews. Um And so it's fresh in your mind, obviously, it's may be quite difficult to remember all the drugs. But whenever you're stuck in the interview, you can always say things like I'd advice guidelines or I'd ask my colleagues for help, that kind of thing. Um, if no more questions, then I'll pass it on to Kylie. Um, yeah. So the next scenario is a 45 year old male who just undergone surgery. Um, he has a nonhealing ulcer on his right leg. You've been called by the nurses and they're quite concerned, they're telling you the patients in pain. Um, the skin on his right leg is now red hot and swollen and he has a new temperature. Um What would you do at this point? If you're caught by the nurses, it means you're you're not by the patient's bedside. Um Always answer that you want more information. Um How would you assess if it's urgent if you're on the phone is by asking the nurses about more information, you can get their ops on the phone, you can get more information about the patient, whether he's on any antibiotics. Um Any pain medication he's received what operation he had recently and you can check the notes as well. Um Next question you ask yourself is, would you wanna see the patient now? Um in some dry? So my London dry give you two stage two scenarios and then you have to pick the more urgent one. You call both nurses and what I normally say even in clinical practice is I tell the nurse of the less urgent case to either call the rapid response team or 2222 if patient is deteriorating and that kind of protects yourself and it protects the patient as well. Um So once you've seen the patient, um, start your ABCDE, um, if you wanna just go to the next slide. Yeah. So you wanna go through your ABCDE. Um, when you do that, you found that his airway is clear, he's tachy. Um, he's saturating fine. Uh, cap refill is fine. His heart rate, so he's just slightly tachy. He's normal tensive and he has normal heart sounds. You'd probably be slightly worried about the um BP cause he's tachy cic. So it could be compensatory mechanism. His G CS, um What you're concerned about is his new temperature and everything else shows a swollen, right, uh right leg and pain beyond the erythematous region. Once you've done your ABCD E if your patient is stable, check any charts that patient have by your bedside, this includes any news charts, any drug chart, any urine chart, um, check that drain if that's one available. So if you have a, if you have a surgical emergency, um check to see whether they have anything coming out of them and that's any surgical drain, any um catheter they have on them, uh or any ng tubes or anything like that. Um So what would you do upon seeing this patient is? Um basically what your concern at present is S sepsis. Um Do you wanna, oh, that's fine. You can just keep it at this life list. Um So after doing your ABCDE and assessing the patient. Um Do you guys have any differentials? Um No, that's fine. So, differentials wise. Um Necrotizing fasciitis is one of it. It's a fever patient has a non history of a nonhealing ulcer. His leg is now red and swollen and the pain is beyond erythematous region, uh which could be a sign of neck rash. It could be simple cellulitis um or he just had a recent surgery. So DVT should be part of your differentials. Um And if those are your differentials, uh we'll move on to investigation and management. Uh You go to the next slide, please. Yeah. So given all the um ops that you've seen, you've seen the patient um manage the patients sepsis first. So, sepsis, six treat them by giving them high flow oxygen IV antibiotics. Uh and um give them some fluids. Um In this particular case, you would probably want to mention that you give them a broad back antibiotics. Um Given that your source of infection could potentially be from that ulcer that you have, which means it's type one neck fash and it's polymicrobial. Um as part of your investigations, you take blood lactate, get urine output. Um And then could you go to the next slide, please? Um And in addition to all of those with the differentials you have in mind, you would need um blood such as um your clotting as well cause you're worried that this patient might get D IC. Um Do your BG if you think of cellulitis, add a skin swab to it. Um His swab his ulcer as well and if you're thinking of DVT, um get calculate the well score, get ad dimer, get um a Doppler ultrasound for the leg. Um Sorry, the CTPA was from the previous slide management of neck fash in this case, given patient's symptoms um and pain beyond margins and his past medical history. Um depending on what you tell the your interviewer. If you're treating cellulitis, treat the cellulitis. If you're treating neck rash, immediately, call the surgeons. Um Early surgical debridement is your answer. You would probably want to involve the primary team of that patient. So, if the patient recently have some urological procedure, you still want to inform that team that you're under um IV antibiotics and basically treat any um complications of that. In my interview for Oxford, they asked very uh pathophysiological questions such as um how does a patient decompensate in pe? So uh station like this? What they can ask you is the pathophysiology of a non healing ulcer. So there's 33 main things that cause a he an ulcer to not heal. One is a pressure ulcer. So things like constant pressure, um then you increase risk of she constant injury and then it doesn't heal. And this is what you typically see with diabetic ulcers. Um they tend to have ulcer and areas of uh where they're putting pressure and because they don't feel anything, the area doesn't heal. Um people with peripheral vascular disease, they have opathy which leads to vascular dysfunction, um occlusion of blood vessel due to poor tissue perfusion, dry skin, poor healing. And then the cycle just repeats itself and venous insufficiency, which is your venous ulcer would be stasis of blood, increased pressure and then poor blood flow plus pressure causes the um tissue around that area to break down. Um Yeah, so um if any of you have an Oxford interview, just make sure you understand a bit of the path of physiology of disease cause. Um those are questions that they can ask you. So, moving on um to the Mental Health Act um assessment or the Mental Capacity Act, um we're gonna cover the MHA first. So the MHA is specific to mental health condition. Anything you do under the Mental Health Act has to be for the patients um uh mental illness. So you can't treat someone's physical illness um as part of their mental health unless it's part of the plan such as in anorexia. So we're gonna cover the common sections that they might ask you about. Um Section two is for you to detain someone for um up, up to 28 days, you need two doctors. Um One has to be an independent and you need an m or an approved mental health profession. Um So that's 28 days and that's for assessment. Um, you can extend your section two by um changing it to a section three and section three is up up to um, six months and that's similar to a section two. You need two doctors for this and, and MS 52 is more commonly used by juniors. So if you have someone that's having suicidal thoughts in the ward wanting to discharge from the ward, um, as a junior doctor, you could section the patient on 5252 is for 72 hours. It only requires one fully qualified doctor. So not an F one. and patient have to remain in that area for 72 hours and they can't leave against uh their will, they kept there against their will basically um and they're there until someone that's qualified to assess them can assess them. 54 is something for nurses. So if you are called about someone that nurses are worried about um about suicidal thoughts and then they want to self discharge, you can advise the nurse to section a patient and the fight four, whether they do it or not is a different story. Um Section 135 is uh basically a warrant for police to enter a private property. Um and this is for uh for a mental health uh assessment. Section 136 is for the police to bring someone from a public area to a safe place for um an assessment. Um So mental health wise, a nearest relative can ask for it. Nearest relative is someone closest to the, the person. So if they are married, it will be their spouse. If they're living with someone, it will be their legal, um, their legal marriage person. And if they're not married, it will be the oldest parent. So if your mom's older, your mom's the nearest relative and if your dad's older, your dad's your nearest relative. Um, So you can give rapid strength to a person under an MH A. So that's your I uh I am Lorazepams. So next, we're gonna talk about mental capacity. So capacity is specific to decision and time. You can have capacity on um treatment for one condition, but no capacity on something else. You can have capacity for receiving insulin. Um but don't have capacity to, to decide uh for your uh a scope or a an operation or even a financial decision. Um capacity changes with time. So you need to constantly do capacity assessment if you think a person doesn't have capacity. So four assumptions you make when you're assessing capacity is that everyone has capacity, um individuals should be supported to make their decisions. Um Unwise decision doesn't mean that they lack capacity and a person has a right to make um ridiculous decisions. And if they lack capacity, you have to act in their best interest and in the least restrictive option. So to have capacity, one must be able to understand what's being said. They must be able to retain, weigh the pros and cons and communicate that decision. Um In the interview, if they're gonna give you something more ethical, they might say that person doesn't speak English or the person might um be deaf and it is your duty to provide them with an interpreter. Um or someone that can uh speak sign language for them to be able to communicate their decision. Adults is part of the Mental Capacity Act. So adults is the deprivation of liberty, safeguarding and is basically paperwork you feel in order to um to treat a patient under the Mental Capacity Act with mental capacity, you can't give a patient rapid tran. So you see lots of things like in delirium, they might give im haloperidol, I am LORazepam and when you're giving a patient, I am LORazepam or Im Haloperidol, you're giving it to them under common law and that is to protect um the staff and people around the patient. So rapid trank in someone that is not sectioned under mental health is always under common law and that is to protect people around the patient. Um moving on to advanced directive or decision so advanced statements um uh to for particular um treatment is not legally binding. So um you can state your preference but a doctor may not, does not need to legally follow that. Um such as you can tell them that you would like to be in intubated and ventilated. But if they think it's not suitable, they um may not do it. You can't do things that are illegal with that one statement. So you can't say I want to be euthanized. Um Those are not legally binding and uh won't. Um no one's gonna follow that you can however uh make advanced decision to refuse treatment. So you can tell um people in advance that you don't want to um be intubated. Um when you are unwell and those uh in general people will follow that it's legally binding. Um Yep. Um That's basically advance directive um in a nutshell, moving on to lasting power of attorney. Lasting power of attorney is a legal document. Um There's two lasting power of attorney that's typically used, which is for your financial decision and for health and care decision. So financial decision is how you spend your money and health and care decision is how you are treated. Uh lasting power of attorney is um more or less legally binding. However, if you as a health professional feels that there is safeguarding concerns or that um whoever who is lasting power is not acting in the patient's best interest, you can um raise it up with um tribunal courts and act in patient's best interest. Um And that is only if you can prove that there are safeguarding concerns. Um Again, lasting power doesn't give um a relative or anyone that's in charge to um to demand specific treatment or to do anything that's uh, unlawful and that's it basically for your ethics. Um, if you ever make a mistake in your stations, such as if they said that you've given patients something that they are allergic to, um, with ethics as well. Just make sure you cover duty of candor of a doctor and that's most of your ethical situation that will come up. Thanks. Er, thanks. Um, if there's any questions, we're happy to take them. Now, um This will probably be the last opportunity for you to ask questions before your interviews happen. So you're welcome questions about anything from uh academic stations, personal stations and um your A to E scenarios. Um So, you know, the, the most we can say is, you know, make sure you're confident with things, practice your er, you know, you, you, you, your explanations for things, make sure you look at the guidelines and everything. Um And also the most important thing to say here with the at E scenarios is that I know we've presented in a way where you have a set, a two E assessment and you have a set er, management plan, but usually this will be a conversation between you and the examiner. So they'll usually say, oh yeah, so this patient tell us what you're gonna do and as you go through the airways, you're, you're saying, ok, I'm gonna listen for any sounds, any difficulty breathing, then they'll say Oh, yeah. So this is happening. What do you do now? And it'll be more of a conversation. So it'd be, it's a really good idea to, you know, practice with your friends. Uh, come up with scenarios, have a discussion about the scenarios and make sure you look for your, listen as you go through the A two E, make sure you treat as you have the symptoms. So you treat the airway first, you treat the breathing first, you treat the circulation next. And uh of course, that's not for anaphylaxis. For anaphylaxis. Stop defending medication and give them the adrenaline. That's the first thing you do or for seizures. If their glucose is low, you give them some glucose. Um If there are any specific questions about scenarios, we'll happily take them. There's also a feedback form in the chat if you guys don't mind filling that out. So these are some of the common scenarios that might come up non exhaustive list, but they don't tend to be really complicated, you know, uh ITP or something. TTP. None of that. It, it, it's gonna be common scenarios, but they will test you on how well you're able to manage them. And typically Cambridge and Oxford interviews, as Kylie mentioned, can be a little bit more uh you know, uh asking about the pathophysiology and a little bit more of the scientific aspect, but generally they will focus on the clinical management and why we covered ethics is because they might incorporate things like, ok, this patient doesn't have capacity. Would you still go ahead with this procedure or uh this patient is say unwell and, er, they have no next of kin. What do you do? Now, those sort of things will be incorporated into your, in your interview, depending on which Deanery you're um applying for any questions, just drop them in the chat or uh feel free to uh uh, say it to us as well. And, um, I think here we've got some resources as well. Um, the Oxford handbook is great. Um, there's also another webinar series, er, for by Doctor Burton. Um, and there's the R rapid e-book, I haven't used that one but it tends to be a popular one. yeah, I mean, there's also mind the bleep, which has really good common fy one scenarios and how to manage it really clearly laid out. It's sort of coming to grasp, grasp with, er, how to manage things as an F one with the competency competencies of an F one. and not so not sort of being scared to take steps but also not being scared to, uh, call for help when you need them, I think, depending on which gene area you have, your clinical station may be different as well. Um, the London one gave, I think two or three scenarios altogether and they're asking you which one you'll go to first and then basically you manage one by one and they wanna know why you choose um the most unwell patient first. Um You basically need to explain your reason behind in both my interviews. They did ask um, one or two ethics question, I believe my London one was um duty of tender and to tell the patient that um the team did something wrong when they did something wrong. And um I can't remember what the Oxford one was. I think you, the patient was really unwell. And what would you do in this scenario if they told you in advance? They don't want it. Um Again, if a patient tells you in advance, they don't want something. Um, you, if they are really unwell and collapse and you have no evidence of that. So like Jehovah Witness, they would need a signed paper if you know that they are Jehovah witness, but nothing is signed, nothing is documented. You would still give them blood if they have a massive hemorrhage. Um So that's what you would do and you, you justify that there's no evidence that they, um they, um they stated in advance that they don't want this treatment. Um, they didn't sign any paper. Mhm. I think, um, if you do refuse life saving treatment as part of the advanced uh directive to refuse treatment, it needs to be witnessed and it needs to be signed. So it can't just be a random piece of paper. Someone has to witness it and your signature needs to be on that piece of paper for life, refusing treatment. Um, and that's sort of what makes it a legal document. Um, and anything for, for, for just advanced statements, it can be anything, it can be you telling your partner or your family member, er, that say you wanna be in, er, in your home when you die, you don't want to be in hospital, er, you don't want this, you don't want that. But of course, that's not legally binding. And when it comes to decision, of course, family members, you do ask the family members to get their input on things on what the patient would have wanted. But at the end of the day it is the best decision that uh best interest decision from the doctor's sign on a call if you want to add anything to that. No, not really. I'm mainly in psychiatry now. So most of my patients don't have a say anyway. Sorry. I'm mainly in psychiatry four days. So, oh, my patients don't really have a say in what treatment they get. Oh, that's why, that's why you're an expert on the mental health act. Yeah. No, it's interesting seeing things in person rather than just reading about them because when you're well, like I've, I've had to do a few mental capacity assessments and uh you know, um, tell people to do some dulls. It's always like, should I should not, should we not like is this ok to do? But at the end of the day you have to think about whether the patient does have capacity and whether they can make the decisions, um, and what's best for them. But of course, when you're actually going through the process, you're always, you know, second guessing yourself, whether it's ethically right or ethically not. Right. No, it's a tricky one. We'll be hanging around, uh, for a few more minutes guys. Um, if you have any questions, just drop them in the, er, chat box. I think everyone has left already. So we should we end this session then? Yeah. All right. Thanks. Thanks guys. Bye bye bye.