Dr Sadek Elrokh - MRCP PACES

[00:00:03]okay yeah hello everyone uh nice to meet you all um first of all we are going to explain how to approach a case of station 5 or the skeleton or schema station 5 first we have to be aware that basis exam is an exam of acting it's not how much knowledge you have it's not about how much information you know it's about how you act as a good doctor and to show yourself and depress the examiner so you have to practice a lot how to pass the exam reading a lot will not help you actually um but practicing a lot would be the cornerstone to boss cases so first of all um so our session today will be interactive simulated session of the exam one of the candidates will come and we are going to present a case together uh same case of the examination five chest pain but first of all we have to um to know how to approach what the skeleton of the station 5 and exam which is a brief consultation session 5 like you see it's two cases every case is 10 minutes uh eight minute would be with the candidate sorry was the patient or the surrogate and two minute would be with the examiner to ask you about the case your clinical finding and investigation and diagnosis so let's start from the beginning okay before every case you will be given five minutes to read the scenarios of every case most cases before going inside and you have to be that that's right like that and you have to be um very careful when you're reading the the case about the formation of the patient the name of the patient the age the comorbidities of the patient and your rule of the uh in the exam uh these five minutes are very important to focus and to uh to know all the information provided to you because every tiny information is provided in the exam means something it will decrease the differential diagnosis if you are given a drug history for example this drug history or any medication division is taking may have maybe a culprit and it may you you might need to stop this medication uh later on when you have the diagnosis so every piece of the information is important indicate in in station five so um again station five is brief consultation you have to be organized you have to have a brain map how to approach the case and this is what we are going to discuss later this is a structure of a brief consultation number one is introduction you have to introduce yourself to the vision you have to confirm the vision identity that's why you have to memorize the name of the vision uh you have to confirm agenda of meeting and take permission to start the discussion uh as ob question for example in the beginning can you tell me more about your condition this is introduction of the station five number one uh of the skeleton notification file of the scheme number two is focus history so station five is composed of or uh uh number one introduction number two is focus history number three is focus examination number five is problem division and at the end of discussion between you and the examiner so uh we finish number one is introduction number two is the focused history focus history should be about number one analysis of the complaint you have to do good analysis of the complaint in terms of offset course duration progression diversity factor and reliefing factor number two to ask about symptoms of your differential diagnosed list if if you bought seven or eight differential diagnosis for the case you have to ask for every uh center every differential diagnosis you you bought in your mind number three systemic review of the case for example if you have a clear case in front of you like um acromegaly for example acromegaly there's no differential technology the case is very clear in front of you so what he needs you to do is just to review the systemic or to ask for the specific symptoms of acromegaly not the differential diagnosis but there are some cases you need to put a differential diagnosis to ask about them like chest pain for example average bleeding shorts of breath but in clear cases just to approach the systemic review of the case not to ask about differential diagnosis we are going to discuss that later but just to have a skeleton or scheme in our mind uh again uh social uh about the focus history so on the focus history we have to ask about uh uh number one is announce of the complaint number two is uh centers of differential diagnosis or systemic review division number three is social history in station five you have to ask about social history and we have four questions on social history what the mission is doing for living how much his symptoms affect his job and usually activities and with who the vision is leaving at home who's supporting the vision at home and if the bishop is financially well financially supported if the bishop is smoking or drinking alcohol these four questions are fixed for all the cases or for the social history of all the cases medical history is very important to ask about any long-standing disease like diabetes high blood pressure or heavy culture disease family history of similar condition or long-descending disease drug hit list of deficient and you have to ask about in the drug history about regular medication over-the-counter medication or recreational drugs this is the focused history for station five don't ask and relevant questions because you don't have time in just 10 minutes so you have your question should be targeted to the point to the analysis of the complaint to the symptoms of differential diagnosis to the symptoms of systemic review of the vision in addition to that social history medical social history family history medical history and drug list after that story still after that will be um the focus examination focus examination you have to examine all these sent the signs relevant to the case don't do full examination just these signs which is negative could be negative or positive relevant to the case uh after that trying division concern this is a scenario let's start directly uh to have stimulus simulate the case of the exam so mrs leonard is 42 years old she presented to any with history of chest pain for the lot for the last five days for your kind care so you are giving this scenario now you have to be in your mind the differential diagnosis before going inside to see the patient and try to be uh or try to think about the more often or more frequent differential diagnosis so i need someone to start and to have you know this simulated exam case with me we are going to give 10 minutes uh who's going to present the case with me asia can would you like to do it that's right you can come here it's all right you have a couple of administrations to prepare yourself and to make a good differential diagnosis and to make a brave map for the case as we discussed introduction focus history focus examination and replying division concern uh i think we have like four candidates online so uh we can open the camera for them can you see us online can you see us that's all right now i'll represent the candidate i'm mrs lunard okay but you can start uh yes uh first of may 19.

[00:10:20]it started suddenly five days ago what were you doing at the time oh i was at first doctor i was watching tv and you said it came on suddenly yeah that's fine has it been continued since then or has it been coming yeah it's intermittent doctor coming on and off have you noticed anything that makes it worse or better uh my father so for example if you when you're walking does that make it to us uh i'm not sure doctor but i think i have it even at rest okay what if you like that does that make it worse no doctor okay um when the paint came on whereabouts in your chest was it where abouts in the chest was it what about where where was it uh and the center of manchester uh and did it anywhere else there was just no did you take a deep breath in because that made the pain worse that's right doctor deep breathing make it worse okay and did you have any palpitations no any shortness of breath yes and is that short surprised just sitting down or earlier when you're working oh i think it's getting worse with movement with exercise okay and how far you end it could up for 100 yards okay and how far can you normally walk before this place entered i didn't feel suppressed with the type of exercise okay and have you ever had any pain like this before no this is my first time have you tried it to take any pain relief from it i've tried first of all but it doesn't help long distance journeys recently no do you have long periods of time sitting at the desk yeah all right so just a few other questions um is only do you have any family history of any heart problems yeah doctor i have my my sister she had history black and are you allergic to anything so routine questions we ask everyone and do you smoke at all and did you drink alcohol no i'm sorry i'm just going to examine you so i just want to have a few of your posts is the size of it for examination that would be the main considerations okay um is there anything in particular that you want to say yes um from what you're describing it doesn't sound like a heart attack um but before we can say for sure there's some tests that we need to do and what i'm more concerned about this being a blood clot and because you're in a contraceptive pill and that can increase your risk of having blood plugs um so what i would want to do is do some more tests so we'll do some blood tests and a chest x-ray and then depending on what that shows we can then do more um investing other scans and conversations okay but i'm going to be admitted so i think um we'll just check your observations just check your oxygen levels and your blood pressure and heart rate and if they're stable then we'll take the blood test just wait for the results of the plugs to come back if the blood tests are fine um we can send you home with uh depending on what the plus show and we can send you home today as long as everything's stable if you need another scan and we can encourage that to be done as outpatient and you're free to come back tomorrow um but if the bloods are concerning or if you're needing water and then we might have to keep your construction once you've started on the treatment then that will get on top of it um you will need to stop the contraceptive field and so i would recommend that you speak to your gp um about different type of contraceptives and then you can and for how long i'll be on uh we'll um the gpg review equipment just to make sure there's nothing because and then if there's nothing else as long as you stop the pill um you can stop that regulation as well do you have any other questions no thank you thank you so much oh still goodness tell your power one minute tomorrow that's right discussion with the examiner uh what's your clinical finding here which describes a um history of periodic um chest pain that started uh suddenly five days ago and symptoms are present at rest and insertion is when limited hair original protein station can only have 100 and she was recently started doing an intersective film and she has a family history of previous books as well and so my top differential image without apd and most observations and then arrange blood tests for blood count and uh just through that infection and also do a d liner if the d diameter is positive i would then need to do a ctpa and i also want to do an account um subject writing gps training can be raised in other conditions other than pe but if the d-dimer is normal then this indication that pe is um could what if the probability of b is law what was this code what's an instead um so you could arrange a ultrasound doppler first but given the symptoms and presentation there it's more likely that doesn't mean there is nothing what if the vision is shocked what the first institution to be done to diagnose so you stabilize the patient first um you can do an echo a bedside deck at a time and see if there's anything obviously any cg is working for you what kind of suggestion echo uh does the points are just um so the right ventricle might be dilated and you don't have any ovc would be easy flux going to the ibc as well thank you doctor thank you okay [Music] so now we will do an open discussion about what could be missed from aisha here if anyone has any comment want to have something which could be missed from asia nothing she did it perfectly i would just say in the history taking if you have a lot of time you missed a little bit of associated symptoms like coffee yeah yeah and then the next one is social history because he's not able to walk yeah social history is very important actually and to sort out your problem in social history i mean we can give you like a sick leave or something you know until you are completely fit to go back to work these things are very very important actually in business all right just x-ray okay we can explore together uh what asia missed and she did it very well actually but just you know we can focus on um things that she missed just to to be perfect you know so first of all you have to to about a very good differential diagnosis in your mind for uh just being in the exam we have a long list of differential diagnoses but we have to focus on the most common uh differential diagnosis first of all is cardiac reason cardiac causes uh first of them is acs a great cardiac is myocarditis injury cardiac and awareness dissection second one is the melody causes including peliers pneumonia hemothorax and pulmonary edema third one vascular causes like pelvic embolism gert as git causes scared musculus cliton and herpes zoster these are the most common uh you know a differential diagnosis of um coming in the exam and the exam actually uh the most common case are coming are pe acs and aortic dissection that's never the idea the brain geared as uh the first differential of just finding the exam never the they bring it as little uh cause in the uh the top of the differential diagnosis focus history as we mentioned before focus history you have to uh make a very good analysis of the complaint so chest pain onset course duration progression uh prosthetic factor improving effector associated symptoms and for any pain at all you have to ask about the sight of the vein character of the vein radiation of the vein intensity of the being and um yeah so onset with this chest pain started exactly suddenly or gradually is it increasing decreasingly the same coming on and off all the time with you did you notice anything that works in the vein like you have to mention the triggering factor like exertion or moving around or did you lose anything improving the vein like breasts or any painkillers okay where is the side of the vein exactly in your chest and what if the character of the pain is a stabbing pain a char pain the leaking pain um this is the character of the vein radiation doesn't target anywhere else like your jaw your neck your back this will narrow your differential diagnostic range um intensity of the pain how much do you give this pain from zero to ten okay like that associated symptoms like shorts of breath cough coughing up blood phlegm fever yeah like that i finish analysis of the complaint number two is systemic review of the differential diagnosis list number one is cardiac symptoms for any any cardiac you know cause like acs greek heart dietitis or aortic dissection so you have to ask about any uh history of racing of heartbeats short suppress we asked about it before in associated symptoms uh any history of the short suppress uh and if they're suppressed is it um a length or a trust or with exertion and if with exertion how many yards the vision can walk to develop shorts of breath any history of high limit profile or any family history of heart problem uh to to ask about territory causes or herditary uh hypercrystalline hypertrophy for example the symptoms any history of fever cough coughing up blood phlegm noisy chest and we asked about them already on the associated symptoms it's very important actually to ask about risky factor of p of p e i think ash asked about most of them already if there is any history of long journey in the last couple of weeks if there is history of immobility for the last couple of weeks if the vision is on any medication which cannot use a pe like intercepted bills if there is any history of here antiphospholipid syndrome instead of miscarriage for example the position was and this patient has miscarriage by the way two times which can raise the suspicion of antiphosphate syndrome as a cause of pe for this patient a history of miscarriage uh and if the vision is receiving or uh oral contraceptive pills sle symptoms why to ask about escalation especially in young female patients b because slee could be associated with secondary anti-fossil syndrome so we can ask about uh a history of following over here skin rash on the face or joint pain or mouse ulcers from buffalo so we can ask about family history of uh black blood before or similar condition because uh some cases could be hereditary thrombophilia could be associated with autosomal dominant predeposition of blood plus um geared any acid brush sensation do you think that the veins increase after eating which can force in the vein for hair disorder any skin right so like that we finished already asked about all the differential lists of the case now social history can i ask what you do for living how much how much your symptoms affect your job and usually activities and if it's affecting i'm sorry for that i can refer you to a social worker sort out this problem for you or maybe to give you a sick leave um during these days or um i'll tell you you get better and who do you live with at home who's supporting you at home are you financially supported do you smoke you drink alcohol the far fixed question for social history for every case medical history do you have any long-standing disease like diabetes hypertension high blood pressure drug history irregular medication or over-the-counter medication or recreational drugs like that we finish the history after fetching the history don't ask about the concern you have to continue your station to do focus examination of the vision the concern is the last tip in the in the case because the concern you are going to give the possible diagnosis and what you are going to do you cannot do that without examination right so examination what uh hms is very important the first of all in any acutely ill patient in station five you'll have to tell the examiner i'd like to do three things i would like to follow abc protocol for this station i'd like to see the observation chart of the vision i like to put the vision under close monitoring why because such patient may be critically ill may be chugged may be hypotensive right so to to tell the examiner that you are a safe doctor you have to tell the examiner before touching the patient any critical english or acutely ill patient need three things to follow with protocol to see the observation chart and to move the mission under closed monitoring like that you'd imprison the examiner so much and he will consider you a safe doctor if you don't do that he will consider you unsafe doctor because you are proceeding to examine the division without examining the blood pressure examining the observation chart without ensuring that the the patient is hemodically stable right this is pe and b in some cases it can be associated with hemodynamic and instability isn't it it's the same for aboriginal bleeding for example you have to follow the same protocol before examining the patient tell the examiner that i'd like to do three things i would like to follow the abcd protocol i'd like to see the observation chart of division i'd like to put the mission under closed monitoring then you can examine like asia did from the beginning i examined the pulse for any complication or evolved problem as a complication resequence of pe so sinus tachycardia or atrial fibrillation for example then you will examine the face of the vision this mission is young human patients so there is possibility that she might have sle so you can examine the here for any following of year the phase for any malaresh formation of sle at the mouse for animals also easily right then to go down to the chest to examine the chest for uh don't do fully examination of the chest just sculptation of the mid level line but laterally to check for any crackles anywheses or any added sounds at all then you will go down to examine the lower limb before lower limb edema or swelling or any significant difference of the size and you can even tell the examiner i would like to check the mid conference of the mid leg uh bilaterally just to tell the examiner you would like to check if there is any difference in the conference and you are checking or for dvt for example this is a focused examination the most important here in acutely ill patient don't touch the vision before ensuring that he's hemodycally stable and before telling the examiner the three things we mentioned about hemodynamic stability or division abc protocol uh observation chart of the vision and both division under close military this is in the case of acute elevation averaging bleeding chest pain uh shorts of breath uh what else we have as acute cell patients can can come in the exam bronchial asthma dissertation whatever the case concerns reply the concern should be focused concise informative and to the to the point don't talk a lot um check the vision what you know don't form a deficient uh information you're not sure about so replying the consent should be to the point targeted and concise and informative at the same time what what it could be doctor could it be hard to attack doctor yeah i view his issue for for his reply that heart attack is less likely in your condition but you cannot say this is not hard to attack okay so you have to be to lick your words heart attack is less likely your condition most probably you have a blood clot in your lung okay so what we have to do now you explain the diagnosis you have to explain what the next step so now what we have to do is to put you under closed monitoring and to run some block tests at the scan of your mind to confirm our diagnosis and if confirmed the management's applied you have to tell the vision what what could be the diagnosis what you are going to do and what the management's a plan and applying the concern so if the diagnosis is confirmed we are going to put you on a blood thinner for some time maybe for uh uh for weeks sorry not for weeks for months or maybe forever according to the underlying cause of course if it is uh um revoked or unprovoked but you you don't have to go into these you know suffocated information with the patients okay as a serious condition doctor yeah like asia replied it could be serious of untreated but luckily uh we if we diagnose you you'll be diagnosed in the proper time and will start treatment and the risk will be low in your condition um for how long are you on blood thinner doctor i don't prefer for yourself because you are in the it's easy oh so you cannot decide for how long to do it there's this decision of a senior doctor right so you can you can reply to probably like uh the duration of blood thinner would be decided by a senior doctor according to the underlying cause of your blood plot it could be for a few months it could could be forever according to the underlying cause of your black blood a giveaway was asian that it seems to be provoked dvt or be sorry because of um or contraceptive bills and at that time it could be from three to six months but to be professional and to show to the examiner that you are a safe doctor this decision would be taken by senior doctor according to the underlying cause of your blood clots uh interpretation of clinical finding what's your clinical finding here actual interpretation of clinical funding is very important and it is one of the skills of the exam identifying physical science and aisha when is asking you what's your clinical finding here he mean that clinical finding on examination the signs not the symptoms okay identify clinical signs so the first of all um you you have to say that this patient is hemorrhagically stable yeah you ensure that he's humorous because uh if you're asking the the the examiner what's the observation chart of the vision will tell you blood pressure is with maintaining saturation as well they will tell you about that division is hemorrhagically stable so the interpretation this patient is hemodirectly stable or this lady is hemodycally stable both examination of the pulse is regular equal 70 per minute and no special character um and on the sculptation there is no equal entry there is no wheezes no crackers even you have to mention the negative points the important negative data or size of the visions but when the examination you know there's clear line fields bilaterally equal and there is no crackers or wheezes lower lamb there is no evidence of lower lymph edema or size difference or difference in size like that you interpreted all the important positive and negative data of division okay discussion with the examiner what's your diagnosis my first differential diagnosis here is pe okay in terms of you can mention the muslim chairman of the return chest pain and the history of oral contraceptive pills and family history of blood clot before and we can think about her dietary condition related homophilia or antiphosphoryl syndrome as underlying cause second differential here is this patient has this patient has history family history her dad died because of um heart attack because of at the age of 55 years old so we came but as a second differential diagnosis third differential then this could be billions so it's not just definitive diagnosis you cannot say only one differential because this will decrease your markers of differential diagnosis clinical skill this is a case of differential diagnosis not a case of definitive diagnosis you cannot confirm this is oh this is be you have to both differential diagnose list but you have to give just two or three differential diagnos which are relevant to the case don't put only one differential don't put a lot of differential diagnosis this will decrease your marks but just two or three differential diagnosis relevant to the case and you can mention what again is the second or the third differential diagnosis what investigation you are going to do you be organized in your investigation as well so the first difference what if situation the first one to ask for a party from basic investigation like fbc um uis and crp assist extra specific specific investigation in the form of like you mentioned uh ec3 uh chest x-ray um trigonometry level and of course d driver driver is just asking in a case of low probability of p e and high probability of p you have to proceed directly to ctpa so what is the importance of d armor in the case of e d drama has no rule in high probability of pe just to have is a good negative predictor in the case of low probability of p so we are using it only in the case of low probability of p e uh if it is low uh it exclude v if it is hyperspeed for c to yeah thank you this is uh um yeah this is a case which is very common exam station chest pain sometimes they can bring chest pain like in such case sometimes they can't bring it as acs sometimes they can't bring it as aortic dissection and in most of these cases all of them you just bring you a surrogate not a patient one of the nurses may be one of the hsca and you'll not find any clinical finding with division if it's a case of um uh so as i told you an exam is not a matter of knowledge it's a matter of performance how you are press the examiner how you are giving the examiner what you want um everyone can from the history can suspect or from even uh um the scenario you can suspect this is a pe because of the age of the patient young age female vision so he can suspect this be before going inside but how to act how to do this short film in a good way to impress the examiner this is the issue and this is um the check of the exam so this is one of the example of station 5 next time in on friday we are going to present a case of communication skills breaking bad news which is very common in the exam if you have any question about this case or about station 5 or basis generally you are welcome to ask any question at all okay yeah of course yeah you are provided with uh uh planned paper and with two cases and five minutes to grow to write what you want but of course uh you are not allowed in the exam to read from the paper you know you cannot read from the bible and ask it be patient because you don't have time actually just 10 minutes you know when you're presenting when you're presenting you don't have time to write down you know what what's your finding you don't have time you know you have to be it in your mind you have to memorize it in your mind that's why brexit is a coronary stone to pass basis when because when you are practicing a lot um you you would be used to it and you'll be more more fluent and know how to present the key because you presented many times before you know uh so um i i think you have exam on john so like we have how many like six weeks maybe six weeks so we can we can um arrange for two times weekly okay every time we can have different case one case station five one case of history taking and one case of uh um communication skills of course it's difficult to have clinical cases we need a case but if you have any clinical case in in our world um i'm more than happy to to do it together like simulated simulated exam cases right yeah also but thank you for attending and currently don't forget about feedback i'll be grateful yeah thanks a lot uh jiren you didn't try the feedback here sorry okay don't forget about it please thank you all and see you later you