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we'll see. Use that format at part of one there, a ski or much. The medical school, which I qualified from Cardiff. Risky stations will also cover in a few slides the mental state examination for those of you that one toe learn a bit about that, also going over some common conditions and basic investigation and treatment principles of those. And then at the end of the session, what I have is an Oscar station. Clearly, we're not able to go for is they were actually doing the station. But what I would suggest if you haven't already grab a piece of paper and pen gesture, you connect down there particular gaps where I'm going to ask questions. You're welcome to put suggested answers in the chat as well. But if you drive it just right along, as I put the gaps to ask questions, you can go along at home. I'm guessing how much of that you are able to get also a little bit of a disc, A know which I tend to do stuff to do all my session. So I am only enough to doctor on by no means an expert in psychiatry. Why I'm hoping the session will provide you with is the knowledge that you need to be able to pass an office space station in psychiatry, on the knowledge you need as a foundation, your doctor. So starting off with the psych history. So to begin with, what I'm going to put on the screen is a very typical off ski station that you might have so are very much put it in the format, that card, if you notice he does so having seven minutes to take a history. Just bear in mind whatever medical school you go to your have different Oscar formats in, You might have to do a psych history in a different amount of time to yes, bear that in mind. But this is a very typical case. So your fourth year medical student on placement in general practice and you've got a patient who presents with low mood and your task is to take a history and former risk assessment. So as we go through the next few slides and cover a psych history, we're going to be focusing on both those things. So, in respect to the presenting complaint, how do you guys think you would start the consultation. So, like I mentioned, you can over right? Or you can put some answers into the traffic if we even break what kinds of questions you think you need to open with the psychiatry it's been taking. So I just give you a few moments yet, So someone's put How can I help you? What brought you in today? Yeah, all really good suggestions so far? Yeah, lovely. So that's really good. So, yeah, lots of people are mentioned about open question, giving examples of open questions or saying to include open ended questions, which is brilliant. So this is not unique to psychiatry in any Oscar station. It is really important to start with open questions on very much dependent on the format at your medical school. So it's really important to introduce yourself on Do get consent. Ideally for speaking to the patient on a lot of medical students, I found get really fast about this on, but feels though, if they don't mention it in the organization and you come in part of any station, that other psychiatric station will have quite a detrimental, not contract. On the mark I found from my experience is in an examiner. That's very rarely the case, but it's get something to bear in mind and usually advise for a while. See stations, including psychiatric stations, to start with two to create some questions. So we've already got a number of good examples on the trapped. This is the introduction I used to use a somatic ulcer to Dent's. So hello, my name's virus is saying I'm one of the year for medical students. I know that some medical schools, like the medical students, to introduce themselves a doctor as doctors. But card if they tend to ask this used to introduce themselves at Steven's. Um, mentioned that you're with the GP practice we with whatever team that the station is set within. 10, uh, confirm your full name. I always tend to ask the patient for their age because I used to struggle to remember to calculate their age from the date of the and then from then I would go to say, the GP or the doctor I'm with is asked if I can ask you a few questions today. Is that okay? And then, as has been put in the tap, guess a couple of questions. Can you tell me what's been going on? What's brought you in today and then usually advise most people to follow on a less bit more to ask them. Can you tell me a bit more about that particular patient in Sure, So it might be in Staten, the psychiatric station, they said they initially start quite slowly and say, I've been feeling a bit low or I haven't been sleeping great. Usually at that moment, it's best to try and prompt him to give you a bit more of an open ended answer rather than going to close questions straight away after open questions. So again, if you got a part of paper on what to write out, what sorts of things you think you want to be asking next. So let's say the scenario is this. As it was, a couple of side to go to the patient, presented with low mood, they said that they're adjusting, feeling quite low over the last few weeks and not being feeling too great, and that's all. You get it after them after the first couple of questions. Yet, so someone's mention the Depression screen good onset. How long have you been feeling like their skirt triggers have been mentioned progression yet really, really good. Did anything percent take this previous episodes? Appetite and see? Yeah, really good. So those are all really good options? Mention stresses. Well, lovely. So I tend to advise most medical students toe actually go with the Socrates framework. The reason for that is because you can apply it to an indication that the psychiatric station on often works just as well for the boss majority of presentations. Clearly, some things don't work as well as other. So if you trying to link site Teo something that psychiatric such a slow moving, it's not going to work as well as things such as onset. So I've just given a couple of examples here so you can ask about on the set by saying, When did this start? What seemed to bring this on? What triggered this on my character? That could also be description of how that mucus, when someone describes the mood that they may be mean in something different to what you're interpreting. It might be that their their feelings are more associated with just sadness, and that's easy explainable because of a recent bereavement. Or it might be that they're just feeling quite flat and not feeling any emotions at all what so ever with associated symptoms. So that's mainly focusing on your somatic symptoms. So a couple of mentions of in the chat about sleep so just asking a general question. How is your sleep been? Typically, you get early morning waking it, but you can have hypersomnia so you can have some cases of patients that couldn't even more than usual saying with the appetite is typically lower type that you can also see the opposite is well and then also just asking in general about any GI levels and how their concentration has been with respect to time. That's often asking about progression. And if anything in particular has made any worse or better, you might find that you get a little bit of repetition using Socrates framework, so you might get, for example, more information about triggers when you're asking about time and elevating in the eights. And factors on with severity is really important to try and clarify sort of how things progress because usually patients with with presentation such a depression or so cases tend to present quite late. So it's really important to establish how things changed over the coming weeks on why things have changed in the context of the osteo. That's usually our advise most patients to start. So as we've gone through already is to start with introducing myself. Open question is then to move onto the Socrates relative to the presentation. At that point, for most typical lost a station. So again, thinking back to the fact that you only have seven minutes or however many minutes you have long for your psychiatric off ski hot tend to advise most people that want to gradually ship them to do in a risk assessment. The reason for that. And it's not reflective of what happens in real life. If you've been on the psychiatric basements, when you often have quite a long time when your assessment a patient for the first time. But the reason is at the stage that Europe towards the end of medical school, they want to see that you can deliver these questions well and that you're able to do that assessment quite succinctly in precisely so it's really important that you have to think about what we read five questions you can ask and absolutely essential feature. If you want to get market for communication and empathy associate to sign post that you're gonna ask about those things. This doesn't just supply for the psychiatric stations. Well, whenever you're asking a patient about quite intimate quite into the topic, for example of sexual history, so is really important to sign Post a patient. I've seen numerous examples when medical students a vast um, quite a shocking question, for example, is only possibility. You could be pregnant with that sign post in it to the patient, and often it causes quite a shock. So it's really good to try, and someone thinks that you're going to do a risk assessment. So again, if you could write down that home or if you want to put in the chart, what sorts of things are you looking for on a risk assessment related to a psychiatric a ski station? We'll just give you guys a few minutes. Rest yourself to others from others. Good suicide, self harm, previous attempts, self harm rest of south for Yeah, yes. So that's all really, really good. Self neglect. Brilliant. So you guys had come up with lots of suggest mints. Risky drive in alcohols mentioned. Other times he brilliant. So you guys are along the right line, so that's absolutely fantastic. Except as a bare minimum, I say the absolute two things that you should ask about and you should ask about them separately. It's self harm on suicide the way I tended to ask about it, and I still knew this today is I'm quite direct to be on this day. I meant to ask the patient, Be honest with me. Have you had any force about once and harm yourself on? Have you had any thoughts about wanting to end your own life? Those of the absolute minimum? Two questions that you should ask him in a psychiatric risk assessment. And usually that should mean dependent on how your station is mark. But usually that will be sufficient enough to gain the marks the way. If you wanted to show off that you can discriminate between suicide or self harm, forts and actions is asking about ideation and behavior. So, for example, if you're asking it in relation to South, are you could say, Have you had any force of wanting to harm yourself. Um, have you ever? And then as a follow up from that, have you ever acted on any of these, um, force? It'll have you ever tempted to harm yourself in the past? You can ask the same question Relation to suicide, a swell harm to others is oh so very important to ask about a Well, that's probably the second most essential thing I would say to try and fit into there and again. You can try and put that into ideation in behavior, the other things. So I've had a question about how do you sign post going into a risk assessment so I can answer that quickly. So the way I tend to praise it is so because we're having the chat about your mental health at the moment and how your mood has been in the last few weeks, there are a few questions that I tend to us all patients that I see with similar presentations to yourself, which can be quite intimate, quite difficult to answer on. But there is really important that we get the information about the your answers to those questions. At this point, if that's okay, that's how I tend to raise it. But as long as you I would say the level of the fourth year medical student or going into your finals as long as you make a reasonable attempt, that sign posting now, I just want to be able to see that you try to do that. So I had that answers, the question, that person. But the other elements that I would try to introduce into the risk assessment that these are less essential. And these are the sorts of things I'd expect of someone who scored an excellent to be honest in a hospice, a shin trying to ask about dependence directly. So what I mean by dependence is usually any Children at home, any partners, any pets, and again, it's trying to explore ideations. They do they have any force about wanting to harm, and you want a home of them. Have they ever acted on any of the sports, you know? So if you really want to the stroke off, try to ask about neglect directly. So the way that I would ask about that is, have you ever found that any of the people that you're responsible force of just your Children or partner. You found you've not been taking this care as much in the last few weeks. It's usually do on. Then the last thing that I would ask about to the fifth thing relates of vulnerability. And that tends to be the patient's own vulnerability. So you could ask the patient, Is there any times when you feel I'm safe? But all is there anyone that you feel and any fat trapped from so most commonly? This is related Teo. This is related Teo to drug use and alcohol, not in particularly to criminal activities in the majority of cases, but it could also be related to that. So those are the five things that I would cover as a minimum and the risk assessment moving on to the rest of the psychiatric history. They tend to be certain things, which usually have to ask quite a direct question to prompt. So these relate to your psychiatric specific symptoms. So I've given you an example here of what you can ask the dry, impromptu, um, hallucinations and the supplies both in real life. And then you're sector. So the way I tend to phrase questions like this is, I try to normalize it to a degree. So something along the lines of usually received quite a lot of people who sometimes hear or see things that other people around them don't seem to be able. T you're here. Do you think that this applies to you? I'm usually at the level of a not secure station. That's usually enough to prompt if you've got actors in your osteo to elicit some sort of response that in real life usually that's a good start a question, I would say, and usually prompts their patients that give a little bit of the clearest whoever they are experiencing hallucinations, you can ask about delusions in the same way. It's a bit more challenging. So a delusion is a fixed firm belief that's quite difficult to Shippen's up out of keeping with someone's past experiences and with their culture. The way that I tend to like to phrase it is sometimes you we see people in psychiatry whose beliefs cause on quite strong arguments with with other people, particularly family members and friends. Do you think that this applies to you for phenomena? Again, this is something that I probably wouldn't expect from most medical students. Is that something that you more get to grips of when you're on a psychiatry job? But these are This is thinking about things such as for broadcasting and for insertion when someone feels and so, therefore it's not entirely their own. And again it's phrasing the question in the Barrett's, um, the sort of well trying to normalize that it within the context of psychiatric. Sometimes we chapter be who feels their thoughts are not quite there own and maybe controlled by something or someone else. Do you think this applies to you? I tend to try and put the use of recreational drugs in the main part of the history of the reason for that is because it's such a problematic factor have been psychiatry. Even they aren't diagnosed with the drug related, say psychosis or often contributes to the illness or often worsens their presentation eso the way that you can ask about that. You can be a bit more directed be on this. Then I put in this example. If you want to do with the way I tend to phrase it is sitting in a similar manner, so trying to normalize it. Sometimes we see patients who find that they have particular triggers to their symptoms, such as using a vacuum in such a smoking cannabis. Would you say that this describes your past experiences and then the final thing that I would try to cover again? This is not something that I expect off. Most medical students is related to mania, so this is often quite difficult to get out to someone in relation to when they have made her in the past weeks is often if they're present in, particularly in the primary care Saturday, they may not realize that they had land. So does Hypo Mania Romania, a way that you can ask about this. So typically most patients you have an absolute of hypo mania all mania. They tend to go quite a reasonable amount of time without sleep. That's the most common thing I would say so trying to ask if they've got if they've had a period in the part where they've gone few days where they felt what, and Jackson and I've done lots of activities with little sleep, has this ever happened to, you know, ask usually if they've got full blown mania. The majority of cases end in one of two ways over and hospital or in prison. And so it's more likely that you're able to you and pick up the case of hyper mania, where they usually able to function reasonably well for that period and up. Teo. It's usually about five days that they experience the symptoms of demand more energetic but are able to function a reasonable level, so that's still able to go to work. So it's really important, if you can, to try and elicit if the patient has any signs of organic pathology, so this is quite difficult to do in the context of an office keeps a shin cause. Usually you're expecting it to be very focused with in psychiatry, but in real life it's really important. More cover this more in the investigations and monitoring section. But to try and also ask general systems reviewed, particularly if you've got symptoms which are sort of more and keeping with an acute medical presentation. So the one that classically it is not commonly associate ID with a straightforward psychiatric conditions haven't quite significant weight loss. If they've got this alongside other physical symptoms. So, for example, if someone's got a change in the bowel habit, they both. So if they're a female, they had to change in that period pattern. That would be making you more think that this is more an endocrine conditions such as hyperthyroidism. So it's those things to keep in mind, as well as also trying to rule out that the person hasn't got any, in fact, symptom. So temperature tends to any fevers tends to be the most common thing to ask about relation to that course, that that's all that got on a presenting complaint. So those are the most essential elements I would say could cover and relative to you asking now having to think about what you would cover in the rest of the psychiatric history. So again, if you guys want to write down that home or you want to fill options and Captain Tract, what sorts of questions do you think you'd want to be covering in the rest of history? So everything for presenting complaint? Um Woods? Yep, so lovely. Someone's put previous psychiatric illnesses. It's great forensic history, yet really good. So that's very specific to psychiatry. Previous hospitalizations. Yet really good. Any chronic health conditions? Lovely premorbid history. Yeah, I love the family history. Childhood history of sexual history. Lovely. Yeah. So really, really good Drug suit. As you guys haven't it. A lot of it is covering the other aspects that you cover it in a straight forwards history. But there are some important additions, particularly in the context of your species that you want to try. It includes, so we're L. A. TiVo Teo Side Psychiatric conditions. It's always really important to ask about past psychiatric history separately to part medical history, the way I typically tend to do. SPK Ear's often your find that patients haven't really realized that they've been treated for a mental health condition in the past is have they seen a psychiatrist before? Have they gone see a GP about that mental health from the past? And then I always try to phrase it separately to us if they've been diagnosed with any mental health conditions in the past. It's quite common in real life for people to be labeled with depression. Dash anxiety is a diagnosis on, so it's really important to see if that has occurred in the past. Well, Thea. Other things that you can ask about and this is a bit beyond the level that I would expect again for a medical student is if they have been. If they have seen psychiatrists before, have they ever been admitted to a hospital because of the mental? Have a mental health issue? Have they ever had to be sectioned as a result of that? So we'll cover section in the bed later, but that's quite important for sort of judge in the level of risk that a patient might be at. I would then asked about past medical history separately, and you can apply these questions Teo any off skew station or any contact, any medical context. So do you usually see your doctor for anything regularly Your GP for anything regularly? Have you ever been diagnosed of any medical physical health conditions in psychiatry, They tend to use the term physical health separate of mental health matins to cover both medical and surgical conditions. I also tend to do as a practice are, sir patient. If they have stayed in the hospital for anything in the parts, usually that elicits that they've had any previous surgeries perfectly. If they Ah, lot of patients forget fractures I found from experience. So that's often quite helpful for a list in the part of the history with drug history. It's very similar to your standards history. So are you on any regular medications always ask about allergies particularly qualified? Obviously, they're very hot on making sure that medical students asked about allergies. I would ask about over the counter medications separately again. Card for quite hot on that with regards to expect in Magical seems to ask about that separately. Two. Prescription medications And if you haven't already asking about recreational drug use, that can be quite important if you get a positive answer to that. So two recreational drug use is really important to quantify in a similar way that you do with smoking or alcohol. How much of the recreational drug they use in within a week? How long has this been going on? For a bit difficult, within the context of a Noski to do a dependence independence scream. But if you want to do and felt you have enough time could ask about whether they feel is they. They have to take their the medication every day if they did up the tolerance to it, So are they using more and more each week with Today. These are a couple of the the's, a rough couple of medications that can cause symptoms of common presentations related to mental help. So in practice, I would say it's more. It's more that if they don't end up being diagnosed with depression caused by B two blockers, it's more that it's a It's a medication that you think once or twice about stopping, or a medication that perhaps worsens depression or anxiety, particular stimulants and related to anxiety that is incredibly common in practice. So I won't talk through all of these in detail. But it's just so you can see through extensive list of medications that can cause quite common until health presentations on the same you've got for mania and psychosis is, well, eso the guess things important to bear a mind, which is why it's always important to try and get an extensive medication history. You can get at the office kilo of Alli think they would just expect you to go through what the drug history is on if there are so, for example, if they're on benzodiazepine, and they've been on that for a very short period of time. We've got new presentation of psychosis that would make you think that the benzene, Diazepam said, perhaps triggered that presentation. But that could be the same with any new medication that has started. So that's why it's quite important to try and listen. Yeah, so the extra things that you would out within a psychiatric history, I'd say a day off skiing level. If you do have time, it's quite difficult to go into detail even in real life, because you can spend quite a long time talking to a patient about Is that personal history? Usually that relates to essentially their child took their education on like story up to the point of which they've met you. In practice, I tend to ask most patients about their childhood, my mostly the start when I'm covering a personal history. The reason for that is because often and it's really quite shocking, how mental health issues can develop going quite you really aged on how typically common dramatic episodes are in childhood, especially so that is something that you can try to fit in. I found and practices know expected for the bottom drawer. It evolve skis across the UK, but it's something that you can try an include. The other thing, which I would say is more commonly expected, is asking about a forensic you only need. Two are usually in the context of of skis. Have they ever been involved with the police in the past and really like that usually triggers in the responses I found in practice, You tend to know that before you go and see the patient just from the medical records. But it's often quite clear where they've been involved in the police in the past or not. It might be that the police have been involved in section and a swell. So one of the sections which were talking a little bit of that later, is, um, a Section 136, where they can take a person from a public place and put them to a place of safety, which is often the emergency department or a psychiatric hospital serves important things can sit up with family history. I would try, and in the set separate questions in relation to history of mental health conditions. Often, I found in the vast majority authorization they don't tend to put extensive amounts of information in this scenario is in relation to family history that are still nonetheless really important to ask about again, as I mentioned in the party medical past psychiatric history to ask about those things separately as well. One important thing to note about all Oscar stations in general. It's one of my frustrations as an examiner when I see it happening is for students to try and use all of the time that they given when they're given, say, seven minutes to do a history or five minutes to do a history or 11 minutes? Yes, sometimes quite frustrating when you have a student who finishes five minutes when they've got seven minutes to performer history on, there's complete silence for the rest of the time. Usually, most examiners were the new students on to the next step when that time allocation has finished. So if you do, you get to the end of cover and all the bits that we've covered so far in history make sure you go back and cover your social history. Cover your ice cover your systems reviewed. So with the social history. This is quite similar. Teo, covering it in the straight forward history, reported things that their minds in relation to psychiatry is that alcohol and drug use is quite common. So you might need to get more extensive information about want if I in it. It's quite frustrating to see is a junior doctor and Clarkin's where you have someone in the clock and written up. It's a social drink. It doesn't really tell you a whole lot of information. So try to quantify how much alcohol they're using in the similar manager smoking. Say how much alcohol they drink in a week. How many days a week and what type of alcohol are you drinking? We're about to occupation and functionality, So ask if they're currently working on. But they used to do for working. If they're not working, why is that case functionality? So that doesn't apply so much specifically to the psychiatric hospitalization. But talk speciation is, in general as get more asking. What are they able to do? The activities of daily living? And if you're stuck for what questions to also tend to ask patients, are they walk up in downstairs? Are they able to get outside the house are they're able to dress and wash themselves on an important question, which is very important to ask, is a junior doctor when you're working on as part of the medical team, is who the patient lives at home with you If they got us that school, if you manage to get to the end of that point, so you have a couple of minutes left eye buys most on. This isn't specific against a psychiatric stations to go, then to cover your ice. So most people might notice that about an extra E. So ideas concerns expectations and then to ask about their effects on life. So credited to a presentation of low mood, you might want to ask that point If you're not missing already, how is this affecting your life date today? Is there anything that in particular you're finding quite difficult? Is there anything that you would want to change in respect to how your life is going up the moment you managed to cover all of that and you still got time there advise and again, this is not specific to the psychiatric station to do for systems review So what I mean by that is to *** to toe usually and just ask a couple questions relating to general symptoms. So, for example, if you could, uh, do you currently have any headaches going on at the moment? Any problems with your vision and hearing with the chest? You can ask, Have you gotten your chest pain and chest tightness and difficulties breathing? You can't know. Some split it by specialty. I've got some colleagues who tend to do. That's a tent off. One cardiology related question, one respiratory related question and so on and so forth. Say, I advise you for any Oscar station. If you could take one thing away from the history part, make sure you use a little time and just try and ask more questions at the end. If you do have a bit of time after you're finding that with your practice stations, a couple of do's and don'ts for psychiatric station. So I'll given example of the summary later but important things to try and bear amount. And again, you can apply this. The most obscure stations try to sign post a different section, so it'll already talked about the importance of side post into risk assessment that tried to do that for at the various points of your history. So you could sign post, for example, now getting lasting a few questions just related. Teo, your background of that's okay, So asking whether you've been in hospital are still not, I tend to advise most students, particularly for the lady, is not to summarize back Teo the patient when they're going through the history. The reason being this often in most Oscar stations on guard if does this is well, is that you're often asked to present back your findings to the Examiner on The Examiner is marking your history so essentially they'll hear your presentation back twice if you present back to the patient as well. And often, I found that most students that end up summarizing back to the patient could spend time asking other questions that they have is not covered yet, so I only tend to advise it if you're in nearly stages of the medical school career. So usually for the year 2 to 3 off skegs am in a shins robbed in the later years, I tried to get a few empathizing statements in your history. So when someone tells you that they've been having real difficulty, say, sleeping at the moment, they're lacking the motivation to go out and do a anything. It's really watered to dry and acknowledge that. And that could be a quick, easy statement saying, Oh, that must be really hard. I'm sorry to hear about that, and that's quite good for showing that you can amplify. So the patient and you you've got good human communication skills. I It's hard to go on that, so I tend to rise. Most people when you are presenting back, try not Teo. Try not to make stuff up. It sometimes does happen, particularly when you see students almost panicking about trying to remember the patient demographics and protected at the age. If you're not sure there's nothing wrong, I would say if you can to say I'm not aware of the patient's age, But today I took a history from a female in her twenties, just trying to get ruffled part bigger, and there's nothing worse when a medical student is seemed to make things up a lot. Claims that they asked her where it didn't they didn't actually ask it in the history. I would always advise to try and pro for details. So if someone says that they do take time the best. Try to get a bit more information if you can't. So how often are you thinking about this? How many times a week How What are they using for smoking? Uh, the smoking. Just simple joints or they're smoking anything else. So it's really important to try. And unless it those those findings as well, and don't forget about physical symptoms as well. In the psychiatric station, it's really important to try and ask about those things. If you do have time on, that's where the systems reviewed can come in at the end if you do manage to have a couple of minutes. So I've just put a summary side of essentially what you should cover in a psychiatric history. This is very focused, I would say towards thie, a Noski framework. So if you really had seven minutes or five minutes, that very history, what's the sorts of things you'd want to cover? So that's the end of the section covering in history. I'm now going to move on to the mental state examination I'm so I noticed that there some questions in the chat magnets. All right, if I go through, those were better time at the end. I'll go through the rest of the presentation so I might cover some of the other questions assay come through yet, of course, whatever you want to do, whether you prefer. So what we're going to cover now is the mental state examination. So I found from experience that this is tends to be less commonly assessed that the medical school level it tends to be more common up as a psychiatric training that you're asking for a mental state examination directly. So what I'm going to cover is that basic framework and how you can perhaps apply that to your psychiatric history. But I'm not going to cover it in such extensive detail that I give you an Oscar format term and water mental state examination station like that quick so anyone wants so so even write down at home. Or if you feel and breaking chapped, what do you think you are? The stage is essential stages of the mental state examination. Yes, so someone's but moved appearance yet really good. Someone's put acronym Aseptic, which is yet That's one of the ones I've heard of. Memory behavior Good for process in sight goods. Yes, it is. It will. Really good suggestions. Deception in cognition. Yeah, cognition that they speech. Speech? Yeah. Lovely. Great. So So these are the essential components that I would say you'd want to cover in a mental state examination. If you're asked to do that, are present that back. So you want to be covering appearance behavior? Speech moved in effect for this perception, cognition, insight and judgment the way that I remember in med school. And it's not the only way to remember. I saw a couple of people put the acronym a septic in the chapter, which I know is just It's good is the one I'm about to put, but I used to use a B C. Smith. It's a slight cheap because there isn't a P and F a perception. So I used to remember hallucinations, and if I remember that, I used to remember receptions. So now go for just a couple of questions or a couple of things you can do to try prompted to the things were in relation to that So with appearance, even at the level of foundation your doctor, you're not expected to go beyond simply describing what you see. So looking at this, you want to be describing how their clothes are. So they were in quite dolly colored clothes or practical close. Do they let her I gene addressed? Are they dressed appropriately? That tends to be the main majority of documentation you see in relation to appearance in mental state examination. If you want to do, you can comment on the body, shape and weight of the patient, or any stigmata of any physical illnesses as well. So it might be, for example, that they've got needle track marks on their arms that easily visible. But it might be that you end up So, for example, the weather for psychiatric patients. I was looking after he had quite significant psoriasis say that was quite often documented in whenever we performed a mental state examination on him. But my biggest advice would be to keep it simple. Overcomplicate er with behavior. The main thing that you want to be looking at is the therapeutic relationship that they have review as you're as their condition. So you want to make a comment about what their reports been right, whether it's been appropriate. Web in Aggressive Web in quiet in relation to that, you can discuss their body language, so it might be that they have quite restricted quite closed up body language between creates that you've got someone who's quite anxious or depressed. It might be that they struggled to make eye contact or they're very good at making eye contact in. Our contact is quite aggressive, so there's a one things that you can comment on again. It's not really expected, I would say, the level of at medical school. But if you if you felt confident enough, you can comment on psych A motor on changes so often you find that patients are quite slow, who are depressed in their movements, are quite retired it so they're quite slow in their arm movements in that leg movements. It might be that they have on abnormal movements as a result of and psychotic use, so they might have to keep dystonia, for example, or tired of this kind of seizure again in the office Keith format. It's very unlikely that long time to septations, but you sort of get spare Those signs in mind companies cognition relates to a lot of things that you would cover and the mental capacity act. So does the patient have a reason on memory? Are they able to record the conversation? Are they orientated to time and place to Do you know where they are? They able TEO comment. Other in the hospital. Whatever Saturn they are in, are they able to maintain concentration where they're talking through on you're taking a history from them? Or you're often and questions are they to maintain those things again? Same disappearance. Try and keep it simple. You don't have to get into huge level that with speech. This is purely descriptive, I would say a day level of the foundation, your doctor or at medical school. You want to be commenting on how quickly there talkin. So, for example, someone who's experience the main your episode and hoping mania it may be that there are that they're speaking quite quickly s so you might want to comment a bum that again you might experience. You sit with depression. You could no so talk about how much they're talking this well, relations this mission. It's again. It's just common sense. If they're speaking loads, you can say that they had a high amount of speech or lower and stretch. It might be that their tone is quite quite monotonous, quite quite slow in that they're not speaking in the same tone, and they're keeping it quite a level picture on what the that. Raising that and again you could describe for you 100 thumb In the same way someone has asked to explain the difference between tangible Gillet e and derailment. So tangent it is when someone fears topic. When they're speaking, that's have been so quite commonly happens. Main your psychosis. But then eventually they managed to bring what they're talking about back to the original subject. So, for example, if you are someone about the weather, they might go off on a tangent on despicable about what they're doing currently for their hobbies. But then, which is nothing to do with the weather, but then bring it back to the weather. Derailment is when they start speaking about something and go completely off topic and don't return back to what they're speaking that originally, those the essential main two differences mood and affect again. This is something that I wouldn't expect most medical students to be aware of. But if you wanted to comment on the patient's mood and affect the affect is best described as your objective assessment of their emotional, which is a bit controversial because whether you can objectively assassination is a controversial statement. It's up. That's essentially what your faults are regarding how that person is presented. So it might be that they're coming across. Is being quite sad in your eyes or they're coming across is being quite lethargic. The mood is essentially how the patient describes themselves, so how they feel in themselves, and it's often describes a subjective, eternal states. A good, um, a good way that was often described to me is that the effect is like the weather on the climate is often described is their mood of the patients. So I've got examples of some phrases that you might want to want to use if you'll describe in. If you ask to describe someone's affect on me, so you might want to describe that they're coming across, it's happy that come across. It is as aggressive, quite all style on on then then move they might describe. They might describe themselves as feeling quite anxious they might describe themselves. This being quite low to those two different phrase is that you can use to separate the two when you move on. Teo Insight. So inside relates to whether the patient is aware that they have got a condition going on. So they're aware that they got a mental health issue at the movement. And they're aware that what they're experiencing is largely abnormal in the sense that it's causing them to be in hospital or their presentation doesn't quite fit in with how they work for so often. Your find. Patients with psychosis don't tend to have insight into that today on this, initially until they're treated with respect to judgment. So that's relates to whether the patient is a sensible decisions. So in a similar way, Teo Cognition and capacity. It's basically whether they're able to make a weight up decisions, and they're able to act appropriate. So example can be is the person able Teo, if you ask them what we do. If we were to, um, to suddenly have a fire broke out in the next room on they say that they would walk outside with the rest of the stuff and get to the base of 70 so that would be demonstrating good judgment. Whereas if they said that they were just staying in the room and wouldn't do and and that gives you a sense that they have not got good judgment of the movement. When you come to speak about force again, you want to be commenting on the fort form. So it might be that again. You're overlapping with how the patient is speaking and what they spoke. Um, previously about their and their cognition on might be that the day you discuss your oh, so they're content. So particularly relation to the things that we discussed about risk assessment. If they've got any sports of once and harm themselves and the force about wanting to end their life, you know? So talk about for possession here. So for broadcasting, withdrawn and surgeon of the most common ones to be aware of their exactly the sound. So someone's what football costs, and they feels though their ports of being broadcast out that can be heard by something or someone else for withdrawal. It's a so they feel that force of being taken away from them on before insurgents. That someone is sitting in force into the head or something is doing that. It's guess is simple as it sounds. So you don't need to cover this and extensive detail when you are going for a mental state examination. When you come onto perception so often a day level of the ski, it's usually about asking about loosen a shins. You can ask about depersonalization and the realization so depersonalization it is when the person doesn't feel as though they are really. So that's quite a reason common feature in psychosis. It's often as they describe themselves, being in a dream. The realization is the opposite. It's when they feel bad, really, but the surrounds around them and not feel a swell with hallucinations. In practice, it tends to be the water treat him use nations that more common or often described is being more common in psychiatric presentations. Weather's inorganic before the GI. So, for example, in delirium, which is driven by infection, it's often visual hallucinations, which are more common. There are some over that. I've seen plenty of patients. Diagnosis gets for only describe visual hallucinations. That's just something to be aware of is well, so I'm now going to go on two common conditions and management principals. So what? I'm going to speak for you. So I'm going to bring a lot of tables going through essential things to have a look at, essentially for each of the different conditions. And then we'll go into the example station Meghan unconscious that you mentioned that there was a break coming up. This might be a natural break to use if we wanted to put women. Yeah, I think this would be a really good time for a break. Give you five minute breather and we'll come back at five past, if that's okay with you. Yeah. Yeah, that's absolutely fine with me. I will. Just making note. I'll try and answer all the questions. I can see that I'm getting some questions for you in the tractor at the end if I don't cover them in the presentation. Um, but yeah, I'll just making it to those in the break, but yeah, we'll start back in five. That's five. Thank you. And just for everyone is here. I'm just popping in the chat the surveilling for our ski. See end of your survey if you could fill that in on, but also put the feedback thing for this session. If you feel it in, you'll get access to the slides and recordings, which are very, very useful, as you guys already have seen. So please fill that in a swells up or skis. The survey. Thank you so much. Lovely. So I'd just like to repeat few questions in the chapter. It's made me realize that I'm muddled at my definitions when I was going through. So if I go through, someone asked me What about the differences between circumstantial itty and time kitty speech? So I go back. So I think someone also asked me about derailment. A swells. The derailment is when there's quite a sudden shift doing what the patient is talking about. Sometimes you may hurt here, referred to as nights move, thinking a swell or talking to. They have quite a sudden change in talk it. Circumstantial bility is how I described and 10 ton till speaking earlier. So it's when they be a rough topic. But then they gradually come back to what they were speaking about originally s. So I was confused in the two tens next up, which demonstrates how infrequently I used them, where the tangible speech. It's not the same a some circumstantial bility and that you veer off topic. Quite gradually, we don't use the end up. Return to your main point. Say you still go off in a tangent, but you don't end up returning. Weather's with Sir Constabulary. Do you do end up returning so someone has asked, as a father would derailment require nudge to get back on topic? So usually it's quite difficult, I found when someone goes into true derailment to try and get them back to you and speaking about what they originally trying to talk about. So usually it does require that condition to take a bit poor, only ship over a leadership of the conversation. Someone has asked as well, What would you do if someone said that I wanted to die and if you felt was a empathizing? That's the saying. I'm sorry to hear that could be quite harm for inappropriate for the in general, I would say so in real life practice, if someone generally says that they want to die. Usually, I try to ask him a few more probing questions afterwards by exactly what they mean by that, and that's mainly relation to their risk assessment. So it's two different things if they said that I'm I want to die, but I haven't made any sort of concrete plans. Are efforts to try and make that happen compacted, just having the force that they want to end their own life. So trying to elicit those in the case of the osteo it in if you are. If you do have a patient who says that they do, they do want to end their own life or they say it quite, um, a dramatic way saying that they do you want to die? I I would take knowledge that you don't necessarily have to say, I'm sorry that you feel that way, but something along the lines of that that that is difficult to hear. Can I ask you why you're feeling that way, or what seems to be triggering that on? Usually by asking a couple of prompting questions? You can get bit more information in the context of the hospital quite quickly. In real life, you might have to do a bit more gradually, bit more slowly, to be honest. But that's in general. What I would say. There was one more question, which I'm just going to try, and someone has asked about whether you would ask about judgment during the history. So to be absolutely honest, I probably would put it into the straightforward on psychiatric history. If you ask to do specific mental state exam, I would ask about it specifically, But I wouldn't do it in the context of over straight forward history, because it's quite an out there question. I would say You're you're more likely to get a sense of, say, if you got a presentation of psychosis and they've got quite significant in Houston, a shins inclusions. You're more likely to get a sense of bed judgment and their insight from asking the program questions in relation to those so asking them say, for example, that they that they say that experience in collusive nations asking them how long the solution a shins, How long of these voices but old visions been going on for? What did they say into you? Do you believe what they're saying on do you usually the strength of whether they're they're listening to those forces. For example, if it's Belushi INS have strongly committed, they are to those divisions that will give you a better sense of what they're inside in judgment. So So I hope that answers the questions for the people that ask. Ask them if they want to put more questions in the try. I can try and answer those later lovely. So I'm now gonna hope it's a bit more specifically on a ski presentation. So if you can just have a think about yourself and again if you want to put into the chapter more than welcome to just have to think about what are the common presentations that you would expect to see at the level of the medical student or medical school, particularly those guys that you've got finals coming up? What sorts of mental health presentations would you be accepted to be able to manage? Overdose your arms? I t. The pressure and, yeah, so schizophrenia has been mentioned. Bipolar. It's frightening dependency, this order, but they there's a lot good suggestions. OCD delusions. Yeah, really, really good PTSD. Okay, cool. So most commonly so the ones that I've cited in the next few tires tend to be the most common. I'm saying Presentations are more clustered it by by symptoms by symptom presentation, robin and specific diagnoses, which will make sense when I pull up the next few sides. And I've gone through what I find this commonly comes up in medical school examinations. So to start with the depressive depressive episodes that when someone has an example that excited that start presents with low mood back is a very common presentation that might be related. Teo. Someone mentioned about an overdose attempt in the chat so it could be in relation. Teo. Someone's presented with self harm or a suicide attempts. It's important to bed that online with the contacts. When you're asked if it depends very much from Los People map that you might be asked what's but the particular trigger, what cause behind in the bassinet. See, there's no one direct cause, so I'll talk a bit more about the biopsychosocial model. When we look at treatment, that's essentially important to say that's a multi factorial driven process in relations. The genetic risk factors, personality and upbringing. I know so having particular environmental triggers. So, for example, it might be that someone has quite a number of environmental triggers. Such a second, if temporary, vehement, the loss of the job, a break up from a relationship and that in combination with other things going on such a I'm being genetically predispose. So so the about depressive accident may call someone Teo go into a full blown depressive. It's important we already gone through a lot of the symptoms by discussing the elements of the history, but essentially want to be able to identify the core symptoms of depression. So that relates to an had, oh, near so lots of pleasure an energizer. So a loss of energy on low mood, those who are free, essential symptoms of the passion. If you able to identify those in your history and you're along the right line, you think, then split the other symptoms into your somatic ones. So most tend to be the more physical symptoms that you associate of depression. So those mood might be having a decreased sex drive have been being more emotional, reacted. Having reduced concentration, you may also want to ask about sleep appetite and weight loss. Not too significant weight loss but weight loss enough that I have that you realize that it's been proven by having a reduced appetite in a majority of cases. And then, of course, asking about suicidal ideation and behavior with diagnosis again, it might be that you are specifically how you had died. Know someone on with the depressive absolute. So in UK, they tend to use the I CD 10. Sorry, most saris, some now shifting to become the I CD 11 within the next year. Diagnostic criteria. So it basically relates the number of symptoms, I would say the stage of medical school. You don't need to know how many symptoms they fit, each criteria to be able for the purpose of a nice peak. But just to recognize that essentially, the more symptoms that you do have at the more likely you are to be diagnosed with moderates of the X is you can have depression. Diagnoses of psychosis backs quite difficult to differentiate from schizophrenia, another psychotic illness. Most importantly, they need to have symptoms of two weeks. Um, someone has asked about what were the core symptoms, and so the frequency symptoms to be aware of eso you have to have these, usually to get a diagnosis of a process that so so low mood and adonia, which means it reduced pressure on low energy with regards to treatment. So I'll talk about management than investigations in general bit later, but specifically for a depressive episode, you want to be aware of the Biopsychosocial model that includes using biological treatments such as antidepressants, mainly any CT in extreme cases, so electric controls the therapy. CPT for your psychological treatment say I sculpted behavior therapy. There are others, but I wouldn't be aware of them at the level of medical school being aware so beneath for a risk assessment and then for your social interventions that would be revolving around social support groups and essentially with the mantra. And the passion is a step care model. Say, if the symptoms are significantly was, you essentially have more intervention on each of those three levels of bio psycho social. With psychosis again, you can have a number of different diagnosis, psychiatric or or physical health problems that you're driving. This main Teo I would say to be aware of as a medical student for psychiatric conditions include schizophrenia and bipolar, effective disorder. You want to make sure that you're able to rule out your organic causes a swell so it might be. We already discussed that you can have a number of medications which may be driving the psychosis, such as an effective means or Cannibis. It might be due to the electrolyte abnormalities of highlighted some of the common ones there, and it could also be due to delirium is well, so it could be on top of that infection in relation to clinical features. You just want to consider your main symptom psychiatric symptoms, particularly schizophrenia. So usually, in the vast majority of cases you've got patients, you've got hallucinations and delusions, which we've already discussed. They may have a formal fort disorder, so it may be that they feel as though the force of not quite there own or they're forced to possess. So for sexual disorder as well. And it's so so as I've already mentioned the bath majority of patients. You have a first, some caustic absolute, which is untreated. Dead tend to have it in sight and condition again. You use I CD 10 rise to the 11 diagnostic criteria on that's important as well. We'll discuss a little bit about investigation for homework late, drawn to make sure that you investigate forgot nickel physical health problems with implying the biopsychosocial model for psychosis. It's important, Teo, make sure that you're aware that antipsychotics form the main same management so acutely. You tend to start patients on access psychotic pretty soon after they have presented, and then they need to be established on treatment for quite a long time. Before you consider adjusting the usually about 4 to 6 weeks, it's important to recognize the note. I suppose as well in the cases gets a friend here. That closet team, which is the most effective and psychotic, nearly be started after you've tried to previous other and psychotic. Say, for example, the two examples that but they're haloperidol on a Lancet E and similar for the cycle in social rolling around CBT, which is specific to schizophrenia on dose of making sure that you provide the patient with social support and a nap, acquit, risk assessment or mania again, it's important to consider both psychiatric causes an organic causes, so it's often that sometimes mania presentations overlaps of psychosis. It can be sometimes quite difficult to tell the difference between the two, but usually from experience presentations of mania. It tends to be that they're fastly more energetic. And the patients who have got full blown psychosis, who often look quite vulnerable in the vast majority of cases and don't tend to be, for example, with someone hyper mania. Romania. They tend to be acting quite anxious. They're able to They feel they're they're able to be lots of active activities, and they feel quite you for it. Why this? With full blown psychosis, it tends to be the upset, and it's really important to make sure that you're able Teo recognize that these patients are diagnosed according to symptoms. So the difference between Manier hyper mania so bipolar, effective disorder Type one has at least one episode a mania alongside an accident pressure, but in practice it tends to be diagnosed. When you have the main year, so same would talk to bipolar. Effective disorder tends to be diagnosed when you have the hypo mania, so that's less commonly diagnosed because often patients with hypomimia are able to function a bit better and and less like these. I mentioned to you end up in hospital in prison with the treatment. So it tends to be acutely that you manage these patients with antipsychotics if they've got a manic episode, and then we start them on the made mood stabilizing medication most common or intense to be left knee Um, which is also the Ms Effective, comes with those side effects, which is why you tend Teo, initially manage the patient on so cause it's getting stable first before starting the patient on that because it quiet, quite intensive monitoring and again specific cognitive behavioral therapy for these patients. They also have into personal therapy in family therapy, which has been shown to be quite effective But the stage of medical school. I would just be aware that that of multitude of different Pappy's we were all over then. Remember in a specific types with anxiety. So there are a lot of different anxiety related diagnoses, and I wouldn't necessarily be aware off a lot of these. Perhaps the main two, I would say, to differentiate between each is generalized anxiety disorder. Panic disorder on the difference, really simply is that generalized anxiety disorder is exactly that sounds intensity, that patients are worried about pretty much everything or a lot of things, but no one specific in your particular where was panic disorder? They tend to have particular triggers that causes them to, you know, have a panic attack essentially, rather than happened symptoms of a panic attack. Time on someone has just put a question and capital patients hyper manic. Do you just upped the living will? Do you get in that cycle, too? That's a really good question. So in practice patients with hyper mania it depends how well they are when they first present. If they've got a hyper manic episodes and I seen by, say, the GP, for example. But they're not actually too bad. They're just sleeping a little less, but they're still able to go to work. They haven't got any delusions of grandeur. They don't have any hallucination. It might be that are not started on anything to keep these, such as an antipsychotic, provided that no risk of harming themselves or others. Um, however, in practice, I have found that patients do end up presented to have a professional robber. It's a diagnosis of, however, it's a diagnosis of bipolar, effective, still type one that's like two or may not have made it. They tend Teo be admitted or be seen, and then our prescribing those psychotic. The reason being If patients often patients that are having hyper manic absolute, that's often that they're spending quite a lot, and they are cause in some form of harm to themselves. So it often is treated first instance in a way that I've described the initiation and some cottage to stabilize them and then followed by everyone stabilizing medications and certain such a lefty. Um, so the incorporate or compromise city lovely. So going on to an aside itty So we were discussing. How about the gabapentin to the store during the mean to try to differentiate from with the symptoms, So the symptoms are often everything in hyper mode, so we're relation to card, except the patient's often get palpitations. Chest pain. With relations, it's more spiritually symptoms. They have them come short of breath, sometimes in extreme cases when patients have a panic attack, age and experience episodes of the realization or depersonalization as well. With the diagnosis again, this is according to I see, 10 Ice didn't 11 criteria, so it's just something to be aware of a swell. The management is broadly quite similar to the pressure in S O U manage, the patient's with antidepressants usually accessorized in the first instance. Benzodiazepine is we very rarely give, and it's something that is not really recommended in the literature. But we tend to give him very extreme cases, particularly when patients I haven't quite disabling um, panic episodes or quite extremely actress. The cognitive behavioral therapy is best quite specific models in relation to anxiety. But again, I will not be aware of one thing I found for progress as questions. So EMDR So I movement. I moved. The sensitization therapy is used quite often approached dramatic stress disorder management, so it's something to be aware of. So I'm now going to go on to investigation. So this is more framework that you can apply for skis in general, on book specifically of the psychiatric station for so if you guys want to put in a chapter what you think, eh? So say you have the patient presented with low moods or or anxious mood, and you're in the gp setting. What investigations would you ideally do for this patient? Lovely. So I can see some bloods coming in F B C T F T s knees. Uh huh. But the calcium has been mentioned there. Someone has put a PHQ nine, which is good. Listen, d lovely. So it's all really good Suggestions. Basic observational. Fireman. Lovely. So in general, I advise most people to use the framework be boxes for remember investigations in the context of of skis. So the first the stands for bedside Say what you would do with the patient right there and then So that includes if you haven't already second for history, maybe a rather than examination dependent on the statin and doing essentially in score. So all the observations that, um, that you would do routinely in hospital whether able to do the 90 practice or not full bloods said I have less. It'll the blood which irrelevant in psychiatric, sat in in most cases. So that includes a full blood count using the CRP LFTs. Those are generally done, I would say for screening test to rule out that the patient hasn't got anything like infection. It'll hasn't got anything out of normal. They're sometimes they're so used for monitoring purposes, particularly LFTs because of the complications associated with fatty liver disease as a result of the antipsychotics, and lots of people mentioned firewood function tests as well. That is really important to keep a measure of because they you can have presentations of hyperthyroidism that presented with a depressed patient someone in the shatters mentioned lithium level. Yes, that's really important. If someone is on the, um, say That's why I mentioned I've mentioned it mainly relation Teo, taking the patient's power cetera level they presented with a drug overdose or alcohol level if they've got on alcohol dependence. But again, lithium was very important to take a swell with antipsychotics. You can also have a therapeutic level measured a swell, particularly with cause it means of that symptom to bear in mind as well. Oh, it's the or muscle tests, say, as a baseline. I would say you'd want to get a year and dip off most patients in the psychiatric Ceftin, possibly a sputum sample if they have any chest symptoms making bears and not in accidents ST. To do that axis the X ray and then yet years for the C. G. So in general, you're find when you're working as a junior doctor. Get him straight forward. Pain film on X rays is quite simple, including a trust X ray. AP Do X ray on You want to get a baseline EKG? You do want to get a baseline EKG Teo Establish. It may be that the patient hasn't got long QT, so that's just important to Barrow. Mind as well, someone has asked, What's the significance of checking the corrupt? And I've also well spotted it who have managed to see that so her lap it intense be measured mainly in the context of antipsychotic on the dream. So it's quite common for patients out of raised prolactin as a result of that psychotic use. Because of the mechanism of action because they work on dopamine receptors so often you do. It's not uncommon for patients have a raise prolactin, and in extreme circumstances, patients may get symptoms as a result. So, for example, galactorrhea and it doesn't be. They tend to be something in practice that we do an awful lot amount because usually the patients often on quite stable when they're on and psychotics the S relates to your special test. So I have specifically mentioned the ones that you would want to consider in relation to psychiatry. So for a psychiatric review so dependent very much on the context of maybe the patient was referred from the GP for psychiatric assessment, it may be that they have a mental health actress estimates. A swell from here. A swell. You also want to consider whether they need any special particular image in. So that might include the CT or an MRI, just a definitive rule out on all organic cause of the pathology. I remember we once had a patient. You had quite full blown psychosis, which was unexplained for a while, and they weren't responding. Time to psychotic medication ended up doing the CT of the head, and they have a brain tumor. So it's ruined up for those rare organic courses that comes sometimes calls for bone presentations of psychosis. You may also want to consider referrals. Teo Stash it of a specialist. Seems particularly from urology that tends to be the most common one. I found them practice. You tend to refer psychiatric patients, but it could be for any medical team. Someone has asked. What's the indications for an abdomen X ray So, to be honest, when I put that in the phrase, that's more just to say that something that you can all do quite quickly in straightforward in psychiatric patients in general, the most common reason I find that you request a nap do X ray is because certain antipsychotic, so particularly clozapine, it's notorious for causing quite significant constipation and in extreme cases can call small bowel obstruction. So if you had say, for example, someone who's on antipsychotics, he had a bit of tummy pain on day had problems going to the toilet. It would definitely be someone you want to be considering doing. Outdoor X ray for two A lot on obstruction quite quickly, this is Justin. Note more for communicating investigations and management plans and Oscars in general. Just remember the context. That's to where you are. So remember in your ST Station Webber Urine GP or hospital. Remember the patient that you've taken history from? I've seen quite a few examples as an examiner where students of I felt that the patient is more or less and well than they actually are, and then when they've gone and particular form of carb Cardiff, when you're asked to take your history for a patient and then say what investigations you do for that same patient. It can, um you can have cases where students don't contextualized their investigations to the patients just in. So just bear that in mind to make sure you try and leave the two things ever. So we've already discussed a lot about management already. But does anyone want to mention in the chat what they think that well, We've already mentioned some of the treatments, but there's anyone want to suggest what kinds of treatments you'd want to also be considered for psychiatric patients. So you already discussed about one specific conditions. Is that anything yet? Someone's mentioned sections which is really in who we have covered it a lot already. CBT cognitive behavior therapy, Conservative management PCT electric compulsive therapy that they they were already covered. Quite a lot of these already in general that two things that are over remember when structuring your psychiatric management. So when you ask, how do you manage this patient? So using the biopsychosocial what model but also remember in to mention something about escalation a swell. So does this patient need to get until hospital. Is this patient safe to be managed in the community? Answer that question. What's the most important say particular context of the Oscar psychiatric station? Is that their medical problems? So if they presented with, say, an overdose of Aricept herbal, that has to take priority. So when you are asked, how do you manage this patient? It's important to mention what you do in that instance it first. I'm not going to talk through how you do that in the context of a medical office space station. But broadly speaking, you structural management. What would you do? Treat the so in a to the assessment contextualized against the patient and inspection things into conservative medical and surgical in the context of a power satellite overdose? Because I know that's quite common scenario across most medical schools. You'd want to be measuring and parasites Immel serum levels, plotting it against a normal gram relative to how long ago they took the Aricept more tablets and judging whether they need Teo. They need Teo have an ass. It'll Sistine given IV on. Once their medical issue is sorted, you condemn move on to describe in the psychiatric management for that patient with a psychiatric risk assessment. The things you want to be considering our, whether the patient needs to be section. So there's a very helpful table that I've included at the end of this presentation, which goes through the essential information that you might want to know about each of the different types of sections. In practice, it tends to be a foundation, your doctor, the ones that you need to be aware of the sections to and free on day 5 to 54. If you're working in E. D, you might need to be aware of 135 from 136 on. I'll go through those right at the end because there's a helpful table which explains all. The main difference is the ones for those. But in most important, thing is the purpose of the section is to make the patient's safe. On those who may be vulnerable is the result of the patients. Will in the safe is well, so that has to be the primary concern when you're considering whether or not a patient requires a section with regards to management. So I've discussed some of the main things here with respect to, um, your bio part of the management. So you buy our bio psychosocial. So with antidepressants, you want to have a significant trial period, usually 66 to 8 weeks. Most patients tend to start on SSRI, so surgery intensity into those common that's prescribed in primary care. You can have alternatives. Teo Guess it might be a little prescribed on another SSRI. Such a citalopram Matassa pain is quite commonly use because it's quite a good appetite stimulant as well May of sissy augmentation so that patients have prescribed two antidepressants at the same time. That tends to be in your more severe projected cases of depression. With antipsychotics, it tends to be in the acute instance. So when someone's acutely psychotic I behind the Parador lorazepam dependent on their relative contraindication, I tend to find that in psychiatric patients, they tend to go for how the parador first line on bastard or itchy of cases weapons For some medical patients, they prefer the Rowasa palm. You then want to consider initial on long term after your initial and psychotic man from long term management. This involves starting the patient as I mentioned before, usually a second generation antipsychotic such a lancet mean you have to have tried thio and psychotics in total, would fall being considered for clozapine, which is used for treatment resistant, anti treatment resistant psychosis. So closet in tends to be most effective and psychotic that has quite extensive monitoring requirements on Do have a long list of side effects as well. A Lancet intends to be your sack invented effective on and the rest of the antipsychotics, such as your spirits down, Um, on how the parador, for example, they tend to be along the same line you can consider using the depot is well, which is an injection patient has. Most them usually come about once a month on, and that's quite good if you patient adherence the tablets is an issue with bipolar effective disorder. We already discussed a lot of the Mandarin, how you initially start with and and psychotic for the main your hyper mania and then long term, um, you know, treatment after that for depressive episodes, you may treat that with with antidepressants but despair in mind and ss SSRI SSM um, other antidepressants can trigger mania to occur, so you want to balance that against the benefits and the rest of starting the patient on on antidepressant with the CT said the main indications for a T T. R. Catatonic schizophrenia. So to the point where they're not moving, that know eating and drinking or severe depression, and that's usually use is the last resort. It tends to be quite effective, so I know a number of patients who have responded quite well to E. C. T. But the reason why it is usually reserve this is a last resort for treatment is because there's a risk from the general and the sciatica is there is we've used in general anesthesia with any surgical procedure, but there's also you tend to get quite commonly short term memory loss as a result of that, So that's just something to bury mind. It's often senior lead decision, so it's awesome consulting like decision, um on when it is used, it tends to be the last option with sites, so I'm not going to spend too long going over Yes, yes, for time. The CBT is the main psychological therapy that I would be aware of your essentially looking at the patient's forks, emotions and behaviors in the context of their environment, and it tends to be used for most psychiatric disorders. The other therapies I wouldn't worry too much about remember in the details about them their particular ones, which are focused towards a particular psychiatric presentation of center example. Exposure risk social therapy for for anxiety related illnesses MDR for PTSD. But again, that's not something that I would directly be aware of because it's often contractual I specifically to each patient for community. Imagine meant win relation to psychology there, often reviewed by a psychologist who is not the same as the psychiatrist on draft. In giving self help guys particularly, they're quite stable community patients. I'm someone has asked how much of the mantra know expected to do is a junior in an Oscar bashing with Oscar. So in relation to psychiatric patients in practice, if someone has a psyche, a psychiatric presentation say you're on the medical wards, it tends to be referred to the Azor team, the liaison psychiatric teams. They've got psychiatric issues so relation to the pressure or anxiety it might be in the office setting that you expected just so happen awareness of that of when a patient would be referred on, I would say, if you feel a Xopenex has got a psychiatric presentation, and Offseason General is appropriate in the steps River in patients, a psych, um, or ever setting with regards to social at when you're mentioned, it's in your osteo, and so you don't need to describe this in huge amounts of detail. What I would say is this. The patient usually will have a community for the rest of the community psychiatric nurse, and they're usually referred T relative charity organizations that pension on the hour. So Samaritans of mine tend to be active in those spaces in the UK you might owe. So sign post, um, to family and friends. Sipple again, This is very specific to the patient, you know, to talk about proper problematic problem solving, which is usually gets in patients time off work. In the majority of cases, you don't have to get into huge around to detail about this, and you really, really find out about it as a a security doctor. Robert. Then it's a magical so you, so you don't need to describe this and this of a My key pieces of ice for management are just keep it simple. You're not expected in the majority of cases to no, quite a lot of details about which particular antidepressant you would give this patient, which particularly on psychotic. So when you are explained in Mandarin, just keep it quiet Board revolve around the basic principles and use the biopsychosocial nodules. When you are context your lives in it to the patient. What I mean by that is just make sure that you're that the monitoring the you are talking through So say if you've got a patient who is presented with on absolutely psychosis that you are talking about and psychotics in relation to that patient not on psychotics, in relation to patient this resented. Okay, I clear depressive absent on that So lesson, I would say to apply to osteo Let's make sure you contact you guys your answers to the patient. Cool. So this is now the case example. So if you haven't already had to guess getting a pen and paper because I'll give you an example station and just ask you some questions on the back of it. If anyone wants supposed to answer is in the truck that more than welcome to that, you might. You might feel less inclined to do so because I'll go for it reasonably quickly. And if you walk from the some record, of course you can do this in your own time. Say, um, the station is very similar to the one that I've got to start. So your fourth year medical student on case in general practice on deep a shit has presented with low moods. So the task for this particular prosecute station is that you're asked to take a history from the patient and perform a risk assessment. On that seven minutes, the Examiner will stop you and ask you some questions. So I, as I mentioned, this is based on how Cardiff do their ski stations. They called in ST stations. Um se So this is how the patient starts. So I've just been feeling rotten, and I can't stand this anymore. He tells you that he's 27 years old, so I got the first seven minutes starting now. So what questions would you start to ask for your presenting today? So don't feel as though you need to put these in the trap. Just have a thing to yourselves. on Diffuse are watching this on record or you're watching it home now and from right fast. Just right. Well, things now about what things You'd be looking to ask this patient so that scares people a few moments to have to think about yet. So some people going in the chaplain presence of options as well, which is really good. Lovely. So as I mentioned when I was going through the presenting from think part you want to start with to treat, um questions. So something along the lines that can you tell me what more about that. How did this all start on then? We've stopped pretty suggestive buys. Tried to go for his men. Is that is that you feel a subject article? So with this, it might be looking at onset so hard on this all start anything making this any strenuous, any other symptoms at all? How's your mood change on then, in comparison to what you go in in comparison to what you tend to do in really life assignment. And I would try and do the red flags risk assessment questions here lier. So I would, after you've gone through Socrates then launch into your arrest assessment question. So five things that we covered that at least the first two self harm and suicide. But then also, after you've gone through that, try and talk about harm to others, any dependents and even any risk of vulnerability. And then you can also see a very specific questions related to your psychiatric presentations of Loosen a Shins, Delusions and so on. Say, hopefully you got some of those. So these are some of the answers that you got, say, with the open questions you realize that the patient tells you have been feeling alone for about six months. They feel is they get worse. They've got on her Don't near. So they've lost interest in their hobbies. Broke up with their partner about 12 months ago, and they felt that trigger. They describe their feelings as sort of feeling empty and lost, feels as though bad symptoms or a bit worse in the morning. They've got early morning wakening got a little bit of weight loss. That's not something you would be concerned about from a physical have point. To be one killer of three months is not a huge amount, but is I suppose explainable in relation to the context of their reduce appetite. Then, when you go to ask about the risk assessment questions, when you ask about self harm, he the patient tells you that they've been using enough to get their forearms, that they've done this quite a few times last time a few weeks ago on because it was helping with the pain. I haven't made any concrete plans about wanting to end their life, but have fought about it. That's why it's important, if you can, to try and separate ideation behavior, don't have any Children or current partner know force of harming anyone else, and I don't feel particularly vulnerable to anyone else. So I've really given you the information for the presenting complaint on the history on the first part of the history, but you probably have enough information at this point that you can come up with some differential. So again, if you're at home or watching the sun record, try to think of about 3 to 4 differentials that you think this presentation is in fitting with. Then you want to have any suggestions in the charts, and then we'll walk into a swell good. So someone's put a major depressive disorder. Yeah, it'll discuss that little detail the next page depression, yet bipolar that they. So I'll just give a few more amendments for anyone else that everything's working for you. That's cool. So with differential, so this applies to a lot ostentation don't say. In general, I would always try to take for free to four, and then when you're actually presented, in fact, I would try. And just if I least your first differential. In this case, the depressive episode is the way that I would describe it. It's a bit difficult, I would say particularly. And given the fact that you've got seven minutes or so to gray the level of severity even as a psychiatrist, they usually have an hour or so with the patient the first time that you meet them and usually able Teo Diagnosis Pacific episode of depression that they have. So whether that's a major, more direct or mild depressive episode, drugs that are current, impressive, absolute. At the stage of medical school, I would just say classifying it is a process actives enough if you felt cold for them enough that you could grade a smoldering severe you can do after a swell, so I'd say that's your most like your differential could say That's a substance induced depressive episode. You haven't asked directly about recreational drugs that you may have asked about it in the risk of setting questions. But maybe something that's treated it may be a pipe. Oh, the depressive episode. So again, it might be that you have not asked directly that the patient, whether they've had any mania or hyper mania episodes in the parts, Um, it may be that they've got an adjustment disorder or group for action, given the fact that they've broken up with the partner since a bit of time ago. That's less likely because usually with agree, fractional or just in disorder, they usually able to function reasonably well. And it may be an organic cause, so you haven't gotten the blood results have gotten. It has to rule that out definitively say that's in general the way they are structured differential diagnoses in relation to a psychiatric station. I try and keep them quite broad if you can, and you can use different categories so you can see how I've said That's just go straight for depressive episode or it may be related to substance misuse or like, oh, that So again, going on to the rest of the history. So what other questions do you think food are, Say, going back up to the start of the talk. If you just have a big cup, what other things we covered after presenting complaint and again, I will write them down the home where you can put your answers and attractive you want to be? Yep. Say ask him about previous psychiatric history of drug history. Risk the self protective factors. Yeah, really good. Let me Social History Act. I'm not getting independence, Yes, but so good. So as we're going in the framework here, the Esso often separate questions about past psychiatric history, part medical history. In this case, it's negative. It's important to ask about those things. Drug history, asking about over the counter medications separately and regular medications as well it might be. I have a patient today who take Saint John's wart on didn't classify that as a specific medications, so that's something to be aware of this. Well, I'm asking about recreational medications as well, separately as well going on is well also to consider things such as family history, which there may not be anything significant. In this case. That's the case of substance issues. No involvement with the police in the past again, you really need to ask one question about it when you come on to the smoke Social history, it's important to ask about smoking, and alcohol is wells occupation, Function said. Important thing here is that you listed that there's a history of cannabis files from them about smoking as well as a history of cigarette use, and you get It's really important if someone tells you that they've had they mentioned that they use drugs to try and quantify the amount of the using that someone in the transmission, previous trauma. So that's really good in relation to personal history. It might be so That's the one thing you've noticed. I'm not included in the couple of side so far, so it's not really expected at most medical schools, and I wouldn't expect it from most medical students to ask about it directly in relation to personal history. It's one thing that I tried include, but if you're struggling for times, the one thing, I would probably make sure that not drinking. So is the family history of substance misuse significant? So it could be significant in that it's probably a low risk factor for developing in a mental health problems future politically substance misuse problem? Eso it could be rather than depends very much on the contacts in which that is described. If it was, it was mentioned. Say, for example, that there's a history of in this case it's cocaine use but say there was a quite strong history of alcohol use and the patient didn't have any history of alcohol use themselves. You could argue that I'm not particularly significant in that case. So I'm going on this. We've already discussed before. Make sure to use your time. So say, if you come to about six minutes after you've got one minute left at your history, what sorts of things that you're going to be covering so again, if you're home and want to write things down more than welcome Teo, otherwise you can put your answers in the tract. Yet ice really good ice yet Perfect. Yeah, So what we were discussing before, So making sure that you ask about ice? Yep. Social history of Ms that's really important. Swell and systems reviewed. So if you're ever stuff about walk questions to us in this advice for any off cessation, go back to I go back to your system is review. So at seven minutes, you have then asked to summarize your findings, including what you consider to be the most significant point. So if you're home, have a go it just thinking about how you'd summarize back. Okay, such as this. I appreciate it's different to do in the old line second, particularly in talking from online group, you know, So I'm not expecting anything to type in. Answer to the chapel. Just have to think about how you try and summarize this. So it's really common feature at most medical school off skis to be asked to summarize back your finance to the Examiner. There is no perfect way to do this, so you'll have some courses tell you that you should try and summarize in this way or that way. In general, I've seen lots of students do it in different way. Some have been good, have been bad, but lot of it is more about the content, and they provide, rather than the structure in general tend to advise most people too short on their summary. So try and be a bit more concise and and precise in what they're saying is what I mean by that is they say, the salient fax rather then trying to present back on the history that they've just taken. In general, I've I've missed people to try and stick to a structure that they're comfortable with. So the one that I've put here is to start off by introducing the patient with demographic on patient demographics. That's usually saying the patient's name. Um, what they come in with as the representative complaint, a certain that you are in the age of the patient and then go through important prostitism important negatives lasted getting through the strip general structure of the history. So I've just given more of a structure in relation to psychiatry. So the extra things I would add in relation to the important positives and negatives I would also go through a risk assessment so quantify in exactly what you feel their level risk is, if you've been asked you what also saying that the end the differential diagnoses that you think most of the patient. So this is just an example summary that you can use for for case such a test. So the way I would do it. So I took your street from Mr X. The 27 year old man presented a GP practice of six months of the mood alongside low mood. His symptoms include things such as early morning, waking in low appetite and social withdrawal. The symptoms were triggered by relationship ended in worsened over the six months to the point of the patients Self harm with life multiple times on the patient describes previous suicidal ideation that has a history of suicide attempts and then going through the rest of the history quite quickly. So there's a family history of substance issues but no previous psychiatric medical forensic history for this patient. You're obese mixed on this on tobacco cigarettes, and then after that, I won't read through all of this just for times a day. But then I would go through the risk assessment. So in this case, I've quantified that I feel the patient is a low risk and justified as to why I feel that is because even though he's hard, multiple self harm exercise in the past, you had no previous suicide attempts in new breathing psychiatric diagnoses on but that point. Then we go on to talk through your other good differential diagnoses again. As I mentioned, trying to justify the first one a couple of lines and then going on to the rest of the differential. Cool. So the next part of the station so they're not going very much off walk? How card of tend to do their Oscar station. So how would you investigate this patient s so again, Just have a thing to yourselves. And if you want to write down our home, what sorts of things you be doing to investigate this patient? Um, again, if you want to put anything in the chapter on walking, too Yep. Someone spit year and drug screen. That's perfectly reasonable. Uh, Bloods TFT is yet cool, so I just give the couple people couple of minutes just to have a thing through things. Mental state examination, history, examination, obs lovely. Say again, using your football be boxes framework the way the outrageous in an Oscar station is that in the immediate short term. I don't want to take a fork sense of history from the patient If I hadn't already, I'm going to cover mental state examination and get a current section observations and maybe considering a relevant examination, depending on the findings for me. So that might be just a general systems examination or abdurixit. I would want to take a set of baseline lugs for this patient s so similar to the blood that we discussed here. The essay clothes will include for birth count news and the CRP and fifties. I've been profile productive and fired function test. I know. So what's considered whether to dio some drug levels depending on my findings from the rest of the street on, you may have to consider doing a year and get well regards to image in an extra. So probably oh, so just do the the easy part of the chest. X ray is a baseline depends very much from a sector in most TV practices are not able to offer a chest X ray. So very much depends whether you think something is indicated for your special test. So it's likely that psychiatric referral is not indicated at this case. The reason for that is that you've got first present presentation of depression. The patient is not deemed to be a high risk. It's not likely indicated, But you can't say that you would want to continue the assess this patient and want to see them back later. No indications that you can see for special in genital because there haven't been any clear presentations of any organic or pathology or physical health symptoms. Cool. So how would you manage this patient's? I'm thinking back to what we discussed about man from principles. Really? What sorts of things would you consider to manage this patient? Yeah. Run one that you're in the gp setting, Um, and you've got the history that we discussed previously. So the patient is a low risk previous history of self harm and presented with what looked like to be a depressive at ST just haven't think to yourselves and maybe writes down what you think you do to manage this patient. Uh huh. Yeah. So refer for cpt. Yep. Say that brilliant psychoeducation CBT self out by a circulation. Want to get so you want to be applying the bio such a social models, this patient and just consider an escalation. So if you're very much in the setting, is a medical student, You want to say that you discussed this patient with the doctor who's supervising you on come up with the mantra part of them in practice. So nice guidelines actually do recommend that in my mild and moderate depression that you might want to consider CBT alone Mr Starting Treatment. In practice, that doesn't tend to happen. To be honest, it tends to be that most patients that started on that the president so, as I mentioned earlier, the sexual intense to be the most common one. So that's why it's important to get any see GI, based on your CD on patients to assess for long Q T, which can be made worse by certain, do the president's. That's just the type of problem a Z I mentioned psychological treatments you just want thickens it. You just want to say, initially, cognitive behavior therapy. There are specific ones with the pressure in, but I wouldn't say that you need to be aware of them, but for an average union doctor or is a medical student only if you've got a particular interest in psychiatry. And then when you're talking about your social management, you can talk about referrals to particular support lines, have a charity support, Septus. True Samaritans. I'm talking about problem solving. Social prescribing is becoming a bit more popular, so you can mention that as well. I would also mentioned was the back of that that you want to see this patient for regular follow up and continue to assess the risk on a regular basis. Cool. So the scenario develop slightly. Say this is just the last part. So Mr X becomes more and well in the subsequent weeks, eso his mental health deteriorates to the point where he loses insight and he feels a so he's become quite he feels is a that is a significant risk of harmony himself. Considering what sections under the mental health that you're aware of, what section do you think would be appropriate to use to admit this patient hospital if it was need, it said. This is just a quick test to see how much you guys are aware of sections. They just have to think about what section you might want to use. Two. You admit this patient hospital. Yeah, really good. So someone is put in the trap section, too, which is the one? The arm, you'd probably say is the most appropriate. So in practice, it would probably be a section to provided the patient wasn't in a life threatening situation. You can use a section for if you feel it's there needs to be active on incredibly kick places within 72 hours. On this table is quite helpful for so the most significant things to be aware of. For exception. I'll go for it briefly, but you'll be able to see this back on the recorder to go back over in detail. As a junior doctor, the main ones to be aware of, I would say the 5 to 54. So when the patient is in a hospital, you can use a five to to detain them league when they're in hospital, usually on a voluntary basis, and you can detain them legally for 72 hours, usually in practice. When that happens, you then have a psychiatrist. You then comes and put some on over a section, too. If they're new to mental health or if they're known to mental health. It's usually back on the section free. You can also have a nurse do something similar, but only for six hours. Importantly, 52 and 544 current in patients. Emergency department does not count as an inpatient. So for patient section in an emergency department, it's usually they're not given a five to a Pfeifle because they don't technically count is in patient in the community. It tends to be that Section two is use most commonly when someone doesn't have a formal diagnosis of the mental health disorder. It's actually usually because they have not been in psychiatric long or haven't been seen by a psychiatrist using first instance. When people are sectioned, it's usually under section to on then that section to can be converted after about a month to a section free, and that's when they continue to have treatment. So Section two is often referred to as the assessment section. Section Free is often referred to as the treatment section, so the section for us I mentioned is usually the emergency power section that tends to be used if you have two section someone quite quickly and is usually change to a Section two after someone is taken to hospital. 17 up A I would not be too worried about was a medical student. It's essentially when you hear that patients are on Section 17 leave. That just means that they our under section, but they're being treated in the community as a result of that so they can be brought back and interstitial under a section for if they don't comply, the sections at the bottom of the tables of one free five and 136 of one side be aware of in the context of them police. So Section 135 is when the police come break into someone's property. Usually their own home and removing person bring into a place of safety. Section one. Free sex is basic insane, but from a public place in practice, that place is usually our hospitals. I mentioned earlier. I've been emergency department or a psychiatric hospital on a way that I used to remember is 135 in your driver dive for that rhymes, and then one free six out on the sticks out on the street. So they're both houses. That's the way I used to remember the differences between the two. If you are asked about section in relation to ask e. So Section two in this context is the one that I would apply in practice. So you only tend to have section and responsibilities as a foundation year, too Doctor and even a classic a shin for my entire psychiatric post. I didn't have to sexual one patient, even though we did have patients who were section because usually it's something that, um is given quite a considerable amount of fall before is carried out of practice. So I hope that was helpful. We've gone through quite a lot this evening. I realize I've talked that age years through a lot to do Psychiatry, say apologies if if I have overwhelmed you of information, I I put my email right at the start of there, right at the start of the session, about put it in the trap. Now, if anyone has any questions, they want to ask even now or by email them more than welcome to do you say key things, I would say to remember is, when you are going through a history, just try to keep to a structure. Use your Socrates and make sure you use your risk assessment. If you are asked to do a mental state examination, just go through a be sitting Smith in your head and don't revert. Go back to your history structure. If you do, you need it on for management. Just remember about bio psychosocial investigations. Um, cool. So So I've got a couple of questions which