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Yeah, you sorry? Yeah. Yeah. Ok. Hi, everyone. My name is John. I'm an S FP me at, from Sheffield and I'm presenting the topic, clinical stations and A&E scenarios to see how we prepare for the S FP interview with Jane. Jane. Would you like to introduce yourself? Um, hi, my name is Jane. I'm also um, a doctor working in Sheffield, um, doing S FP research at the moment. Nice to meet you all. Ok. I can't see the chart right now, but if you can't see if there's any message, then let me know if that's ok. Yeah, of course, I'll, I'll take a look out for you. Ok. How silly am I presented ourselves without showing the pictures? Not too late. Yeah. So today will be a quite interactive teaching. We'll go through around six scenarios. It'd be great if you guys can put stuff in the chat to see what you would respond as an F one or even better if you like to unmute yourself and go through the first scenario with me if that's OK and then we'll show you an example answer of what we should say during the interview and how I approached the question just like a model answer for you to either put it as your own answer or incorporate it as the style as the way you do it if that's OK. So the first question is, there's a scenario one, a patient with UTI was given a dose of nitrofurantoin and she collapses minutes later and as an F one, what would you do? So I'm not sure if the p as husbands allowed to like unmute themselves and practice with us. So, and I'm not too sure about that. Don't worry. Does anyone likes to put anything in the chat about how they will approach this scenario? I think we'll give everyone two minutes just to, just to make sure that something is put in the chat and then I'll go. So people are saying take an A to e approach. Yep, I've got two answers so far. OK? No problem. I think because of the time pressure and the amount of scenarios we have to go through, I'll just go through it with yourself. I'm pretty sure you guys all know what to do. It's just polishing the way you do it. And also because it's an interview, you're only given around 10 minutes for your clinical station and 10 minutes for the academic or personal station, you have to really sell yourself and you know, make use of every single second of the interview. So as long as the interviewer didn't cut you when you're saying all that you want to do don't like stop yourself or ask the interviewer. Are you supposed to say this? Are you supposed to go through everything? Just go through everything as thorough as you can and as best as you can. So the way I could go through it as a divide into different parts. So even before I go through the at EI would do a bunch of things. Even before um you assess the patient as an at, for example, if you imagine yourself as an iphone on the ward, and you're asked to assess the patient, you wouldn't just rush to the patient without um getting any observations or even assessing the the response. So firstly, what you should do is before approaching the patient, you should shout for help first and check if there's any signs of life in the patient. And if there's no signs of life, then call the resuscitation team and start commencing CPR because it could be a card arrest situation. But if it's a less acute situation in real life, you would ask the nursing to grab the patient's notes and look through them while you go to the patient yourself and looking at the results status is the DNA CPR status. I know it sounds a bit like artificial. Why would you do it in an at E scenario? But that's what we do in real life. Before you start seeing a patient, you have to get um, all the things straight is then is then DNA CPR and the situation would change your response a lot. Why the patient was admitted is admitted for a surgery, any past medical history, any allergy status. Um, what's the baseline at, is the oxygen set usually 92%? Is it 88 to 92 or is it more than 94% that will help you determine if you want to put an oxygen mask on if the patient is on any uh medications at the moment. So you should mention all of these to the interviewer before you do your airway. You don't just go OK, I'll start with the A TBI assess airway because like 99% of the students would do this. So if you do it the same, then you wouldn't stand up from like all of the other S FP applicants. So you need to be a bit extra in your interview. And then you ask for sa handover from a nurse and you ask the nurse from all the observations. If the interviewers say there's no nurse, then um you need to do all of them yourself. But you could ask, is there any clinical support worker, any healthcare assistants, they can all do the observations as well. So use your knowledge of the MDT around you and because you know, UTI and then given dose of uh antibiotics, the first thing and then collapse, the first thing, we'll be thinking about is anaphylaxis. So you could ask for uh anaphylaxis box that will have adrenaline on. And before you even see the patient, if you're a bit out of depth because you on, you only have one on the ward a lot of times. And um because there's an unwell patient, you, you should communicate actions to a registrar. You should say I have really unwell patient should do you want me to go see the patient or would you like me to see other patients first? And you will come and see this patient? So then then you go to a which is airway. So you wash your hand, you put on a PPE cause now COVID is on again and of course, the examiner will want to know if you're really going to placements. So you put on your pe so and you have to protect yourself before you can, you can see a patient. So you assess the danger around the bedside, assess response. Uh And then you say you perform primary survey using the airway breathing circulation, disability exposure approach. Following the A LS principle. You need to say all of these sentence all at once because everyone say an A to e but no one really defined what it is. So because it's an interview, it's quite artificial, you just have to be quite thorough in your interview. Firstly, I'll assess patency of airway, believe to speak in full sentences. If you can, then move on. If not, then you have to follow a look, listen and feel approach. So you always, whether it's airway breathing, circulation, always follow a look, listen and feel. So first you look inside your mouth. If there are any secretions, listen, what do you listen for? Hoarse voice, stride or gurgling snoring. And also, um if the airway is not paid down, I'll perform a chin or jaw trust. I'll use airway AJ such as oral nasopharyngeal airway. If it's still not paid in, I'll put out a peri arrest call. It depends on a hospital where I work at Sheffield. We don't have um a Met call. I know some hospital has a Met call. If the hospital where you interview, for example, I think Northern um or Newcastle, they have something called Met call. But if you interviewed for like East Meats or any other place, just look if the hospital had something like that. If not, then just say Perret call, it's a double two, double two call. And then you might need to fuss we and set that registrar for intubation while waiting for it. You put, I'll put the oxygen, I'll put the patient on a laryngo mask, a back valve mask and then you always make sure that a uh the PVI step is OK before you move on, move on. So before you move on to be, you need to make sure that airway is secure, then you ask the help of the nursing staff to check the sets the respiratory rate for the uh for the breathing. And you again, follow a look, listen and feel the reason why you do it is you don't want to forget anything. So you look for um is there any increased work of breathing evidence of respiratory distress? What do you feel for? You feel for if the crack is central, if that's symmetrical chest expansion? Listen, auscultate, equal bilateral entry. I remember like in a real life CPR I didn't prioritize breathing cause the patient. I'm in genu at the moment and I thought it was like an abdominal sort of collection that, that causes the cardiac arrest. But then my sho listened the chest and she's like, I can't hear any uh breath sounds on the right side. And then the reason why the patient and um get cut at rest is because there's a liver abscess that causes the lung to collapse. So like always listen to equal entry on both of the chest. Um And then miss the 15 liters high flow oxygen, even if it's like AC O PD retainer um on oxygen, you don't, you just put them on 15 liters uh at the start anyway, and you wean them down and if the respiratory effort is poor, you will back for my patient and call the Perrier team to fast with anesthetic registrar and say you need uh airway support and yep, and always do an ABG uh portable chest x-ray as well. And going back to make sure that the airway is still patent and your breathing is fine. Only then you move on to your circulation. You will ask the nursing colleagues again, you had, you need to utilize the MDT around you uh just like a real life to attach the pulse to me, to do the BP and retrieve the E CG and in the circulation, you also check for the urine output and uh straight fluid monitoring. I think this is the point. I always forget in circulation. I always thought it's just BP, heart rate and CRT but remember ECG and urine output as well. Um Listen to look, listen and feel, listen to the heart sounds and what do you feel for? You feel for the pulse rate rhythm, volume, character CRT JVP and peripheral temperature, simple screening ABDO exam. But if you wanna leave it to ee it's totally up to you. And in circulation, we always make sure that the patient has two large ball cannula, large ball as in green and above pink is around 20 gauge. So green, gray or orange. So around 16, 18, 16 and 14 gauge would be good and you need two cannulas cause you have to run the fluid stat. And if you haven't taken ABG and a lactate and breathing, consider taking in circulation and you give 500 meals of naught 0.9% saline and always reassess um at this point. Um That's just a question from the more that says, why not do a 12 lead E CG instead of a three. No, actually you can do a 12 E CG as well. I it's just, I think it depends on your hospital but some hospital they cut it arrest trolley has like an E CG on it and it's usually just a truly E CG. Um Yeah, I think it really depends on the equipment that you have most ready to do with you and then you would choose the better option. Yep. Um If you're happy with your management of your A two C, then you only move on to D but you have to make sure that airway is still pay thin, the breathing is still fine. The stats are not dropping, the BP is maintaining, then only move on to DD is capillary blood glucose, tympanic temperature. I review the drop chart, check the pupils and check the G CSI know some of you use the apo, that's totally fine as well. Um If the G CS is less than eight, you need to call anesthetist at this point if you haven't yet. So the interviewer might come in and say after you check the G CS, you get a G CS of seven. then you definitely have to call the anesthetist because they are a point of respiratory uh failure. At that point, they come in take their own airway. If their, if their G CS is less than eight and you're thinking about something like meningitis or things like that, you have to check meningo irritation, but just check for gross motor impairment and uh any response at this point. And after you're done with A and DA to D, you move on to e, you have to keep mentioning that you checked the airway breathing circulation p before you moved to e you can do a top to toe examination to look for any injuries and rashes and check the cough for any signs of DVT. OK. And after exposure, you assess everything else. So you look at the patient's notes. Um If you've been to a card arrest, then you know, there'll be a lot of people, definitely, one of them will be looking at the patient's past medical history and notes trying to go through the 4h and four Ts to rule out the um causes for cardiac arrest. Um You repeat the ops every 15 minutes, ask for a strict fluid chart and document the patient's notes. If you're facing a scenario like uh major hemorrhage such as an upper gi bleed, then you have to activate the major hemorrhage protocol by calling double two, double two. Again. Um if the blood loss is more than one liter, then say coat red and you hand it over to your senior using an SBAR approach, which will go over a bit later and prescribe antibiotics. They always start on something like tazocin, uh Prazin and tazobactam um for the patient, take into account of any previous allergies to penicillin. I if the patients await, you take a brief history and follow local guidelines for management and always correct electrolyte imbalances, you talk to the medical team for a debrief and you document all the assessments and management completely and you fill up incident report form if necessary. So this is how I would go through the scenario. And of course, in the interview, you need to say all of these all at once. If um the interview doesn't really interrupt you, then it will really give you the opportunity to shine. So just go through all of these all at once. Um Yeah, and you'll, you'll be pretty safe. So if it's a case of anaphylaxis in this scenario, I divide it into acute management and subacute management. So remember the pooled emergency buzzer, remove the source. Uh In this case, if it's an IV antibiotics, remove it immediately lie. The patient flat. Give im adrenaline reassess the airway. Yup. And after five minutes, you can give a second dose of adrenaline and start acute management of anaphylaxis. Refer the patient to an allergic specialist. Take bloods for mas mast cell tryptase, you would take it. Um You can check the protocol, but I think it's during the anaphylaxis episode two hours later and six hours later, just to check for any biphasic episode. Consider 200 mg of hydrocortisone and 10 mg of antihistamine. You used to give them during the um anaphylaxis, but now it's just consider them after it. According to latest research guidelines observed it for six hours. Uh but at least before you can discharge the patient, consider careful safety netting, you give them EpiPen and discharge, refer to an allergic uh allergy clinic, maso tripp dose. Sit there already. Yep. So how many minutes have I got? So I have about 12 minutes before I hand it over to James. So we'll go through another scenario. So this imagine again, you're the F one on the ward. What you, what would you do in this case if there's any question in the chat as well? No questions so far. Just waiting for some answers for this scenario. OK? If anyone is able to turn on the microphone, you can do. So if not just pop your hands in the chat, what you got? Um Sarah, I just said um A to e again. Yup. Yup. Anyone have any idea what, what might be happening? Any differentials? Yeah. So it's just said an upper gi bleed, acute pancreatitis, any differentials to upper gi bleed. Like what's the four most common differential? No, we have esophageal varices definitely take ounces ounces. I think people are getting to a point prefer to Os Yeah. Yeah, definitely. I'll just go through it with you guys. So I will reveal this I just take a screenshot on the book because like, I'm really busy this week so I didn't really have much time to prepare for it. But I'll um I highly recommend you to get your hands on this book if you're preparing for the S FP interview cause it has all these scenarios that can possibly be tested in the interview other than the ones at the back of Oxford H of Clinical Medicine that's really helpful. But I feel like this book is better as in, it really lays down from Dr Abcd, E like what you should do and it follows the look, feel, listen approach just so you won't miss each of the points. So I would really recommend this book. It's called Medical and Surgical Emergencies and ABCD E approach. I feel like most of you must, must have heard of this book, but if you haven't yet, um I'll show a link to the book later and try to buy it on Amazon or anything if that's ok. So the um assess if it's safe to approach the patient, I'll dawn my PPE. Um I'll check patient's response, patient will appear. And then at this point for you, I might say patient get confused. Um I'll make sure the airway is patent cause in upper join blade, it it is usually patent so you can just move on breathing again. Look, feel and listen, approach. Like I said before, look, the patient's breathing rapidly feel for the trachea, chest expansion and percussion. Listen, it measured respiratory rate and SATS. But in upper gi bleed, the problem is usually not the breathing. So you can uh move on and deal with the circulation, which is your most important thing in the upper gi bleed. Again, you have a look if the patient had any signs of paler, any active hematosis, any signs of dehydration. Feel if the patient is cool and clammy, feel the pulse, listen and measure heart rate BP severity. Uh, consider an E CG and urine output. Uh, insert two large for cannula again and run n 0.9% not 0.9%. Saline stat and insert urinary catheter and ask the nurse for a strict fluid balance chart. So at point C, you might consider some investigations like I said E CG, um ABG if you haven't done it yet in uh, breathing, breathing, you only do ABG if the oxygen is less than uh 92%. So you might consider it, but you, you might do an ABG in upper gi bleed even though the e the sets are above 94% because you're looking for a raised lactate, which might suggest that the bowels are actively dying. So that's why we always do an ABG in an acutely unwell patient and a raised lactate can al also suggest severe dehydration and usually repeat the ABG after the episode to see if the lactate has calmed down. So anything above um one or 1.5 is considered a raised lactate and you can look at the hemoglobin as well cause uh apo gly, you need to consider blood transfusion and also activate the major hemorrhage protocol. A double two, double two, you send off a set of bloods. There are five bloods, I would say that usually order in every patient regardless. So you can just say them out F PCU ne L FTC RP and glucose just say them you would need. You ordered these five blood tests in any scenarios. And if you've been in your j search placement, then you know that we do uh clotting and Emla for all of the patients that come in regardless of anything. We did it for appendicitis. Basically, if you had abdominal pain, we will order clotting and amylase automatically for you cause we just wanna exclude any pancreatitis and also make sure that your clotting is fine. So those are the blood tests that you absolutely must do for all of the patients regardless of presentation. And because you're considering upper dry bleed, remember to take a group and safe and cross match 4 to 6 units of blood. You move on to disability, uh G CS blood glucose people and lastly exposure look for definitely do apr exam. Look for any signs of uh active bleeding and any signs of chronic liver disease that can suggest esophageal varys like you guys said, uh also acute pancreatitis as well. Consider performing erect chest x rays to look for any bowel perforation and calculate the patient's glass go black foot score and also Rockel score. Um If you revise upper gi bleed, then you must be quite familiar with two of the scoring system. So you hand it over to you, always hand it over in sbar situation and and as a pain of you, you can, you definitely will be asked to hand it over to do a handover. So you always follow a situation, introduce yourself, where you're from, what are you calling about and what your name, what's the patient's name? Background and in your assessment, put in all of your A to E so on a patient had a patent airway breathing his oxygen as well, his sex as well and his circulation, all the um investigation findings that you have done. And what's your initial management? Like what have you done? You've run fluids, you put a patient on oxygen, put all of that in your assessments and uh basically in your assessment, you put your A to E plus your initial investigation, plus your initial management. What have you done? And then in your recommendation are you would say your plan? So you would say, I think this patient needs to go to the theater. I need, I think this patient needs an urgent scene review and uh my differentials are whatever and put them in your recommendation. Yep. So I like this book because even after the scenario they gave like, what is the common Viber questions that you might get asked if this is the question you get in your interview. So what's the common cause of upper gi bleed peptic ulcer, viruses, Mallery, white gastritis stuff. And if you haven't uh go and revise the blatch blatch foot score and Rockel score cause um you ha when you refer patient to uh upper gi surgeons, you always have to tell them what the blatch foot score and rock score are. So Blas foot score is a score that you do to try each patient. Any patient more any uh score of more than one, more than zero, sorry, any score of one and above the patient needs an urgent O GD. And after the O GD, you do a full recall score um to assess if the patient um can be discharged or not. Basically. So before the O GD, you do a blood foot score. After the O GD, you do a rockal score and how do you manage an acute uh va recently, I'm gonna leave it to you guys to read just cause I'm running out of time. But basically tolereen prophylactic antibiotics, high dose BPI something fancy like a since they and like more tube or a tips procedure. So II slipped some slides from uh bite medicine. I'm gonna like attach the slides on metal later. So you guys can have a look, but I totally recommend the book and bite medicine. If you have not, if you don't know what bite medicine is, go and Google. It, it's really helpful in my finals and all my Ay and Mosler, it is, it is a bit pricey. The subscription, but I would say it's totally worth it. I'm not sponsored in any way. So they would do like these type of things. What you would do if the Gla Glasgow score is zero is more than zero means one and above, then you will admit the patient. Um It also summarizes the nice guidelines really well, what you do and it gives you like this really good diagram. But pathophysiology causes clinical features and investigations and management and complications and stuff. So just a quick question before I pass on to Jane. So my last scenario is a patient with AKI I and hyperkalemia and this patient had potassium level of 6.9. Looking at this E CG, what would you do? This is my last scenario. Just anyone can put anything in the chart. OK. So we've got people saying calcium gluconate insulin, EIP patient insulin and dextrose. Yep, they're all correct. But um yeah, he and then looking at this E CG, there are actually no active signs of like hyperkalemia. So it shows that it's still not affecting the heart. So if you follow the renal UK Renal Association guidelines, even if it's a severe uh hyperkalemia with K plus more than 6.5 and you follow the arrow, it says if they assess if there's any acute E CG changes present. So PT waves absent P waves, broad QR s, there's none of that on that E CG. So you follow the no. And then if you go down, it says you don't have to give calcium gluconate or calcium chloride. If the E CG is normal because they don't bring down the potassium or anything, they just protect the heart. So what you should give in these scenarios is actually insulin and glucose. So the way you give it is on my right side. So glucose, 50 meals, 50% this might come in your P SA or things like that on your SBA. They might say um how do you prescribe glucose and salbutamol or glucose and insulin for hyperkalemia? So that's 10 units of glucose. Uh Sorry, 50 mils of 50% glucose. Basically with 10 units of insulin, you can give salbutamol 10 mg and refractory will consider dialysis. Yep. So before I hand O I went over with Jane, I would just like to recommend ox hand book. Um and then the book, like I said, this book, Medical and surgical emergencies, ABCD E Approach Bite Medicine and practice with your friends. Just run through scenarios. Make sure that you don't forget the look, feel and listen of every A ce. And if you go on placements and stuff, if you're in a and placement. It definitely help with your interview as well. I'll pass it to Jane. Would you like to share instead? Yeah. Uh stop then. Ok. Which option do you choose just now to share window? Uh share all of my screen? Ok. And Tre T so sharing now and I All right. Can you guys see that? No, no. Would you like me to share instead? Um ok, let me just give it one more go. Yeah. Hello. OK. It's probably not doing it. Um If you could share instead, please, I've included a lot of transitions. So you might just be clicking and clicking away. Um OK, so sorry about a delay guys. Uh So I've got three scenarios to run through and in the interest of time, I would, I'll just ask a few questions here and there, but I'll be doing most of the talking, feel free to interject with any questions if you have any at any point. OK. So the first scenario is um so you are an F one and A&E and then you've been asked by a nurse to see a 26 year old man who had a week long flu. He has been using multiple nonprescription products to manage his fever and body aches. Now he is experiencing vomiting, abdominal pain and confusion and the family has also mentioned that he has seemingly consumed several bottles of acetaminophen containing products next like please. And so the nurse on the phone, gives you these vital signs and says doctor has done his arts and these are the results. Um So please assess and manage this patients. So how would you approach it if the examiner says, please assess and manage this patient and you've just received these vital signs from your nurse. I think I can just jump straight in and say it's an a two year approach, right? So, um yeah, so it's gonna be an a two year approach, the observation so far. That doesn't seem to be anything that you can correct over the phone. So you're gonna say yes, I'm just gonna assess at e next slide, please. So I'm not gonna run through everything. I think everybody has done a to a to death. So, but basically, in terms of an interview, how, what's most important is how you structure your answers. And so in terms of airway, you will want to say something like what June has also kind of um given an example, um I will assess um the airway first. I will see if this patient is able to speak to me in full sentences and that shows that the airways patient. I would also um see if there's any uh extra noises such as gurgling and snoring that might indicate a partial obstruction. If there is a partial obstruction, then I would da da da da. So you basically want to put in as much information as you can just to let the examiner know that you are thinking about these things and just to quickly run through, if there is a part re we can try some, um, some airway maneuvers. And if that doesn't work, then you might use an airway adjunct like an oropharyngeal airway or a nasopharyngeal airway. Right. Then after that, you've moved on to be where you go through once again. Um, I'm going to assess for any usage of accessory muscles. Um I'm going to ask the nurse to give me another up to date ops on your respiratory rate or your oxygen saturations, check for any tral deviation, check chest expansion, percussion, auscultate. So it's all these things that you repeat day in, day out. All right, same goes for um CD and E I would just sort of highlight the uh abnormalities in this A to E scenario which would be and in E the patient has right, upper quadrant tendinous mount icterus at the sclera. Otherwise everything in the A two E is completely normal and also your refill time is slightly prolonged at um three seconds but not marginally huge. OK. Anybody have any issues with this A to e any questions so far? Ok. If there's any questions, just feel free to pop in the chat and we'll address them. Can I have the next life, please? So at this point, I examined them, I asked you what are your differential diagnoses? And we would really appreciate if anyone can put in what their thoughts are at this point. OK. So we have acute cholangitis, acetaminophen toxicity, paracetamol overdose, unintentional overdose. So, yes, correct. So in this scenario, give you a quick next June. So I would structure my answers in a differential diagnosis as into my most likely differential in this case is a paracetamol overdose. My other differentials would include acute viral hepatitis and salicylic poisoning. So not just getting your, the right answer is important but also structuring it in a more systematic fashion might set you apart from another student who's just going to spill out a a long list of things. So that is something that you guys can adopt. Ok. So his paracetamol overdose because um in the stem, we sort of said that the patient had a week long history of flu. And so he's been taking a sort of paracetamol just to kind of tide over the fever and whatnot. And the family saw several bottles. The right upper quadrant tendon is, is more alluding to hepatic injury because of the paracetamol overdose. But anything, any differential like acute cholangitis and whatnot can also be accepted as long as you can justify it. All right. And so next, please. So what investigations are you going to order in this scenario? Ok. I'll just run through them quickly then. Yep. So basic blood count all. Yep. So once again, in structuring answers, I personally divide my answers into my investigations into bedside tests, splits and also imaging. Ok. So for my bedside test, I would like to order an ECG because according to the vitals, the patient was tachycardic. Uh in terms of bloods, I would like to order a full blood count using these all and coagulation profile with I nr because I am suspecting a paracetamol overdose. And hence, I want to look for any liver injury and any coagulopathy is uh important in this scenario. I would also like to do a paracetamol level and salicylate level. I would also want to do a V VG to check for any acidosis as well. And in terms of imaging, I would consider a liver ultrasound in this case. Thanks. So then I examine them and ask, what is your initial management plan? What do you guys think? Ok, we have charcoal, we have N acetylcysteine. Yup, Mark. OK. So I think everybody has good knowledge on what to do in a person tomorrow. It does. And next, please do. So the IV, the answer is IV and acetylcysteine. And rather than just saying NAC alone to be an excellent candidate, you would give a little bit more information to flex your knowledge. So you're going to say I'm gonna give IV and acetylcysteine based on presentation and time of ingestion because obviously the stem doesn't give you too much information, doesn't it? So in order to show the examiner that you are thinking about the different sort of branches of paracetamol overdose management, you're going to structure your answers as such. OK. So if you want to be an even more excellent candidate, you can then detail and say um if the patient ingested the paracetamol less than four hours ago, I would wait until four hours post ingestion to do a paracetamol blood level and then treat based on the uh nomogram treatment line. Or if the patient has taken a staggered overdose that I will start IV NAC immediately. So just give extra information as it is always good for the examiner to just be impressed with you. All right. And with any at e scenario, you would always reassess the patient once again with A to E because they can change at any time. And because this is something that is not really expected of your level to um manage independently, you would always escalate to a senior or a medical registrar. And most importantly, they want to see you be a safe F one. So always, always escalate to a senior and they'll be very happy with that. OK. Uh Next, please. So this slide is just um some extra information about um the bun neck. If you do know it, you can impress the examiner further by saying I will prescribe nap uh based on the snap protocol. So currently snap is more favor than the standard 21 hour regime that was used in the past the difference between the two regimes is um really just the rate of um rate of infusion that they give the neck in and also sort of the um the the number of doses. But both regimes will ensure that the patient receives the same total dose of NAC if that makes sense. So, um aside from that, there are a few scenarios where you do give neck immediately when they have ingested more than 100 and 50 mg per kilo of paracetamol. If they are showing any signs of jaundice or hepatic tenderness, which is what this um patient in this scenario is presenting with. You would give it straight away if you're not sure when they have overdosed and when, and they have a stack overdose, you would give it straight away. All right, next place. So at this point, your BBg results comes back and it comes back as the patient having a patient of 7.1. What would you do? Anybody have any dogs? So OK. Yep. So patient might potentially need a transplant. Yup. Good thought. Hang on to that thought. And so what we want to um do at this point, y the King's College scoring criteria. Yep, you're two steps ahead of me. And so what we want to do at this point do if you would click, please is to escalate to seniors. So the main point that I'm trying to um get across is that the patient is acidotic and that means the patient is really, really sick and you're very unwell. And so you must recognize that this is out of your hands and you need to get seen as a e in this scenario. So sometimes the interviewers might throw in these kind of questions just to see how you might handle, just always make sure you're being a safe F one. So escalating to senior is never the answer. OK. Can we move on please? So, uh yeah, what criteria would be relevant in this scenario? As so as rightly said, uh Mister King's college scoring criteria and you guys can look at the little graph in your own uh the little table in your own time, which is basically the criteria that you need to satisfy for a liver transplant. Next and what complications are you worried about? We can bring that up. Uh Yeah, would be liver failure, any bleeding from any fatigue from the liver injury and also renal failure. Perfect. OK. Next please. So next scenario would be once again, you're on call F one and you've been called by a nurse to see a 69 year old man presenting with severe vomiting and fever. Next fine nurse on the phone has given you these vital signs from just initial thoughts. Um It's really hard to pinpoint what might be going on. So as you go through your A to e in your next slide, next speech, these are your findings. So um just to recap on the vitals. Uh Your patient is hypotensive tachycardic um has ABM of 25 and generalized tenderness over the abdomen. Otherwise, respiratory wise, we're not wor worried about anything. What are we worried? This patient might have any takers, any answers? Mhm. Next slide please. Yup. So we'll consider sepsis, six escalate anti. So for DK A very good E ge acute gastroenteritis. Yup. Ok. Yeah. All very, very differentials. So once again, you will structure your um answers as most likely. I think it's diabetic ketoacidosis. Um Other differentials that I would also consider would be hyperosmolar hyperglycemic syndrome and acute pancreatitis. And all your answers over there are completely valid as long as you can justify. It's honestly fine. So what investigations are you going to order? Yeah, we're going to structure them based on what we have said previously with um, give you a quick next, please do. Um Yeah, so we're gonna categorize them once again, bedside bloods in this case, imaging is not really indicated. Uh I've just highlighted sort of like the important investigations that you do need to uh make sure you have do which is capillary, ketones and E PG of ABG. Uh based on whether or not you are worried about this patient's oxygenation and these are important because they follow your criteria on diagnosing DK A correct. Next, please. So, what is your immediate management plan from here? Um So what we're gonna do, we can click next is a fluid resuscitation. So it might not be really apparent. But uh when the vitals were given, this patient is hypotensive at 86/65. So befo you need to give them a bolus to bring up their BP first. And once you've done that, you can then start with your uh DK A protocol which will be one liter of normal saline over one hour, right? And whenever you're giving fluids, if you want to impress your examiner further, you can also say I would also do a fluid assessment just to uh make sure that you're not fluid overloaded before I give them the fluids also have a quick check of their past medical history. Um If they have any uh chronic kidney disease or any heart failure just to show that you are thinking about these things. Uh and it's especially important uh in an elderly patient. Ok. And so we're gonna start a fixed rate IV insulin, uh 0.1 units per two per hour, start your 10% dextrose when your blood sugars drop below 14. Uh I would also monitor potassium levels and replace as needed. And also of course, repeat the last two lines for any steroid that you get, which is going to reassess and escalate and over there to put this in the text box, it's just um some extra information on uh how you've replaced the potassium next, please. And what complications are you worried about in this case with the cerebral edema if let's say you um correct uh too quickly, I think. But yeah, next week, let's just move on in the interest of time, right? So there are some excellent points that you can give if you do remember that, remember to say uh next. So I only knew about this when I started F one. So honestly don't stress it if you don't get it out on the day. Um So a DSN review stands for a diabetic specialist nurse review. Any patient with um high BMS who goes into DK or HSS would get a DSN review regardless. And in that component would also be um in your overall management to make sure that the patient is well educated about the insulin. And also I will continue the patient's normal longacting insulin alongside with the DK A management. OK. Next thing another please. So the last one is uh you're the uncle F one in A&E nurse has asked to review an 18 year old college student who's presenting with fever and headache mix. So your vital signs are as below as what the nurse tells you. He is hypotensive, he is pyrexial, he's oxygenating fine so far and he's also tachycardic. Next. And of course, when you do your at E you see this rash, right? Thanks, please. So your notable findings uh would be hypertension, tachycardia and this non blanching particular rash on the trunk and he's also pyrexial at 39 degrees. Anyone might want to just throw out what might be happening. That's fine. Perfect. Brilliant. OK? We all get the point. So when you do going through your A to E and then you're starting to get an impression like, oh no blood, a particular rash, OK. That I think this is gonna be a case of meningitis, meningococcal septicemia. You can throw in extra knowledge to impress your examiner and say next, I'm going to do additionally a current and Bruces Ski examination. OK. This all makes you just look really good that you're just not regurgitating A to e and that you're actually thinking and this little picture over here just just to help you remember, which is which I've always struggled to differentiate the two right next side, please. So while your differential diagnosis, once again, we do structure it less, most likely, less likely. These are your different shows. Ok. Uh For anybody presenting with a headache and fever, this would be sort of the things you need to rule out. And next, what investigations are you going to order. So we are going to start real estate manner next place beside that imaging and other things in this scenario, um You have clotting profiles being important because you're worried about D IC, you're gonna do your blood pouches. Um You're also doing ABG VBG so that you can get a quick lactate if you're worried about the person being very, very septic And so in the case of meningitis, the way to diagnose is an LP. But also do, let you examine and know that you will only do a lumbar puncture if there are no contraindications such as erased ICP. And I will look for signs of raised ICP including papilledema and conf um yeah, confusion and whatnot and then you'll do a septic screen as well. OK. Next place. So what is your immediate management plan? X, once again, we will do fluid resuscitation because he's hypotensive, right? And we'll start pro IV antibiotics and repeat our two golden lines, reassess and escalate like please and to be an excellent candidate, you will then continue to say in my uh general management plan, I will also contact Public Health England for contact tracing and also make sure that prophylactic antibiotics are given to close contact of the patient right neck, please. So just to quickly summarize um uh what I was trying to get in terms of takeaways would be I know we didn't run through like a proper at e with someone having to go or having a practice because of time. But um do start initial treatment as early as on the phone with the n. So if they give you a scenario where the like I'm gonna act as a nurse and I'm going to call the doctor and I'm gonna give you these vital signs if they're hypotensive. If they're saturating low, just tell the nurse that. Could you please start the patient on 15 liters of oxygen by a man brief mask? And could you also start the patient on a five mil saline bonus? And I'll get there as soon as I can. Um these do count for points. Um uh as I was told by someone who has done the interview before and um one of the marks that it got deducted was not starting intervention early. So if you recognize that there's something you can fix and um the nurse is able to do it, then do fix it. OK? And secondly, we need to uh mention in detail the components you will look for in each individual section ae as um sort of what I briefly tried to go through in the airway example. So just to even though the patient might unlikely have a uh airway compromise just to get it out there, it's like a script that you got to regurgitate just so that they know that you have thought about all bases and you have knowledge that point would be, you know, differential diagnosis just to structure it by putting your most likely one first, if you have a broad list of differentials, for example, a patient with breathlessness um or chest pain and you have cardiovascular causes and respiratory causes, you can group them by system to make you seem smarter, right? And fourthly practice your sbar, it is quite likely to come out in the interview and it is something that we all struggle with. So practice with your friends, get comfortable with seeing it and finally, uh, the scenarios you don't have it but do know your doses for some common medications such as a CS and asthma. Uh, they do come for points. Um, though, if, if you do not manage to get it out on the day, don't have to worry not to stress out because it is um minor amount. It's like maybe half a point or so. But if you do remember, do say it. All right. Um So thank you for listening. And does anybody have any questions at all in regards to the scenarios that we presented? We're happy to take any, I do apologize. It was a bullet train of scenarios and we just had to rush through them. Uh I saw you answer the question really well, which is would you change your approach? So that's suitable for an online interview? Um The script that I prepared is for my online interview anyway. So yeah, Jane answered really well. So thank you um for those of attended. Thank you very much. If it would not be too much trouble, could you kindly fill in some feedback for us? Um Just so that we know what we're doing well, what else can be improved and it would just really help us in terms of portfolios and whatnot that you guys will need to do shortly as well. I think we'll call it a day. Yeah. So thank you very much for everyone here.