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This BLOG is FREE!... YES... FREE!... It is Especially for the Smart GP Registrars,... Who Feel Like the 'Little NEMO' Lost within the Deep Blue Ocean...... To Support Each Other and Be Creative... Above All, TO BE SUCCESSFUL in CSA... Woo-Hoo!.... In short.... FOR THE GP REGISTRARS --- BY THE GP REGISTRARS...... I'm HEMA -- In short, I am a Doctor, Jewellery Designer, Blogger --> All by Passion... (Founder of www.royalamore.com - For Fashion With A Mission).. I have grabbed every opportunity to make mistakes in this Blog! I warn you! I am not a Grammar Guru!... ALL THE ARTICLES ARE FREE... YES, FREE...You can Use it... Fax it... Print it... Share it... The Choice is Endless:-)... This Blog is NOT for Gossiping... Whingeing... or Complaining... As They Put Your Precious Creative Attention on the Problem..... Above All...If You Are Struggling Alone and Need Some Extra Support for Your Exam Preparation... Please Email Me... I Will Certainly Try My Best to Help You... I Mean It Truly From My Heart!... To Your Success :-) Hema xoxo.

Sunday 24 June 2012

2WW REFERRAL - CSA EXAM CHEAT SHEET- 1 OF 5.

Hellooo Friend!!!
Hema Here!
As a doctor,
Don't we have a crucial role in the detection of cancer?
Most important tool - 'Two- week Referral' Guidelines.

We can save lives if cancers are identified at the right time.

It is the Most Important Information We Must Know.

This is one of the topics to freshen up just before your Big Day - CSA .***

Star*** marked means - Needs to give more attention...

Get NICE referral guidelines from -
http://www.nice.org.uk/nicemedia/pdf/CG027quickrefguide.pdf

We can have scenarios either  -
To negotiate the plan to be referred for 2ww clinic or
To reassure that there is no need for 2ww referral.



Make sure the Patient understands -
Be unambiguous about the nature of the referral with the patient.
Patients sometimes findout that a clinical suspicion existed only after their hospital appointment.
This is understandably distressing and often leads to anger and shock.

Safety net and follow-up

Always advise patients to contact you if they have not heard from the hospital within two weeks.

It is good practice to see the patient after the diagnosis to offer emotional and psychosocial support.
Practise as many scenarios with your Trainer and Colleagues!

Top Ten Topics are :
  1. Lung
  2. GI - Upper & Lower
  3. Breast
  4. Gynaecological
  5. Urology
  6. Haematological
  7. Skin
  8. Head & Neck
  9. Brain&CNS
  10. Bone.

It is important to remember Paediatric cases as it can come not only in CSA but also in our normal surgery!

We can see the Lung and GI Guidelines in this sheet 1 of 5.
Rest in the Next sheet 2 of 5.

1. Lung

A. Admit Immediately 

     SVC obstruction & Stridor.
     (Very difficult to stimulate in CSA)


B. Urgent 2ww referral
  1. Persistent Hemoptysis (Ex/Smoker)  > 40 yrs ***
  2. CXR suggestive of lung cancer
  3. Normal CXR but high suspicious of lung cancer.
  4. CP or SOB with h/o Asbestos exposure with CXR abnormality.
Theses can be stimulated easily in CSA. This highlights the importance of exploring the occupation including previous ones and be specific in ruling out asbetos exposure, smoking history etc.


C. Urgent CXR if symptoms  > 3 weeks ***.

            (MY TIP : Remember - 3 letters in CXR - So 3  weeks)
  1. Hemoptysis
  2. Changes in symptoms in patients with chronic lung conditions.
  3. Unexplained, Persistent (> 3 weeks)
    1. Cough ***
    2. Dyspnoea
    3. Hoarseness ***
    4. Weight loss
    5. Lymphadenopathy - cervical or supraclavicular
    6. Finger clubbing
    7. Chest signs
    8. Chest Pain or shoulder pain***
    9. Secondary mets in Brain, bone, Liver, skin.
HIGH RISK - Smoking/  COPD/ Asbestosis/ Previous cancers.
Have a low threshold to seek advice and refer in these patients.

    2a. Upper GI

    Refer for Urgent Endoscopy -
  • Recent onset/Unexplained/ Persistent Dyspepsia  > 55 yrs.***
  • Any Age with Dyspepsia and Any of the following symptoms.
  1. Chronic GI Bleeding
  2. Dysphagia***
  3. Suspicious Ba meal result
  4. Progressive unintentional Weight loss
  5. Persistent Vomiting ( > 6 weeks)
  6. Iron deficiency Anemia***
  7. Epigastric mass
  Urgent 2WW referral for
  1. Dysphagia***
  2. Abdominal Mass***
  3. Weight loss with
    1. Abdominal Pain           ]
    2. Iron def Anaemia         ]---> without DYSPEPSIA
    3. Vomiting                        ]
  4. Obstructive Jaundice***
  5. Worsening of Dyspepsia in known Barrett's/ Oeso pathology/ Peptic ulcer Surgery, 20yrs ago.
Beware of subtle symptoms like jaundice, signs like abdominal mass.

These cases confirm the importance of examination.

So be systematic in your consultation and follow an regular order, write them up as a list and practise...

Have that LIST in between you and the stimulator...

Have a glance at it and follow to have a structured consultation...
      2b. Lower GI
    2WW Referral - It has criteria depends on ages***. - Any, 40 or 60 yrs.

    Any age with -

    1. Abdominal/ rectal Mass.

    2. Unexplained Fe def Anaemia and Hb -       
            Males <11 ***
            Females <10 *** (non menstruating)
    (MY TIP - 11 is in MaLLe.  Also 10 in women)

    3. Symptoms with Red flags - Ulcerative Colitis, FH of bowel cancer.


    If >40 yrs - Both symptoms for > 6 weeks.
    PR bleeding with change in bowel habits or increased stool frequency.

    If > 60 yrs - Any one of the above symptom for  > 6 weeks.

                   (My tipColonic Chaos for Cix weeks)


    Thats all in this post - sheet 1 of 5.

    It will be tooooo much to take in ...

    The Secret of Success in CSA is to Practise as many scenarios as possible... to remember the age, weeks etc...

    Have FUN!

    Remember the star *** marked ones!

    So we will see the next Topics in next sheet 2 of 5:-)

    To Your Success,

    Hema xoxo.


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Saturday 23 June 2012

STI RISK - CSA EXAM CHEAT SHEET.

Hellooo Friend!!!

Hema Here!

Why Do we Shy Away from STI Risk Assessment?

STIs - Not the Greatest of Subjects...

That is probably why we don't spend awful lot of time in exploring them.

Until You Try, You Don't Know.


I know, the image is talking about Blood Donation, But...
The inner message is the same.
Yes... Blood / Body fluids Can Rewrite a Person's Fate! 

We Can Save a Life if Diagnosed at the Right Time!

I am sharing the STI Risk Assessment Questions here...

Let us discuss the rationale behind them.

It would Make Sense :-)

Easy to Remember!


Example Structured Approach for You
Feel free to change the words You are comfortable with.
Play if you want - http://www.stdwizard.org/

(1) When did you Last have sex/sexual intercourse?
      As STIs have incubation and window period!

(2) Was it with a Man or a Woman?
      For eg - TV is common in women, LGV in MSM.

(3) Was the person a Casual or Regular partner?

       The risk varies with the exposure rate!

(4) Where was the partner from and what is their Ethnicity?
       Afrocaribbean, Mexican etc have higher  risk.

(5) In which Country did you have sex?
     Countries like Africa, Mexico, Thailand have higher risk...

(6) What kind of sex did you have?
          It guides which tests are needed- swabs etc.

(7) For each type - oral, vaginal, anal—did you use a condom?
     
For heterosexual sex: was any contraception used?
Relate to risk of pregnancy when asking about last menstrual period in gynaecology history.
Assess whether they were the active/insertive partner or passive/receptive partner, as appropriate.

(8) Does/did your partner have any symptoms?

(9) When did you last have sex with someone different? 
       Return to question 2.
Repeat this for all sexual contacts in at least the preceding 12 weeks.
Tip  :-)      Never assume the sex of previous partners.

For men who report recent sexual activity with women -

It might be useful to ask if they have ever had sex with men in the past.

(10) Have you ever had any previous STIs?
         Any previous Drug allergy, Drug resistance etc.

(11) Have you ever had a sexual health check up before? 

(12) Have you, or have any of your sexual partners, ever injected drugs or shared needles?
For women,
Have you ever had sex with a gay or bisexual man?
For men,
Ask about any history of sex with men, as per point (9).

(13) Have you ever had an HIV, hepatitis, syphilis test before?
        (Assess risk and offer tests as appropriate)

(14) Have you been vaccinated against hepatitis B, or have you ever had hepatitis?
      (Assess risk and offer vaccination if appropriate).

The most imortant thing is to show Empathy...
Be Cautious when dealing with the Highly Emotional Packed Scenarios like Rape, Assault, etc...

Take your Time...

Be Patient centred all the time!

Thats All...Great!

To Your Success,
Hema xoxo.


P.S.
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    Share your Comments ---> Sign Up!  
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Wednesday 20 June 2012

MENOPAUSE MAKES ME CRAZY IN CSA EXAM!

Hellooo Friend!!!

Hema Here!
Give me a Bigggg Hi 5!

Have You Ever Thought that Menopause makes You Crazy?
You are not Alone!


Menopause Makes Everybody Crazy !

Poor Patients!

 




I love to share with you all about 'Menopause'.

Recently, I heard one of my Male colleagues saying, 

'Judi Denches would haunt him asking for HRT in his dreams' (or should I say Nightmares).

Feels scary to cover Menopause in 10 minutes in CSA!
It is difficult to cover all the relevant issues if not prepared WELL in advance.

That is why we should have our Laser Targeted Questions ready!

Ideally A Case might be for the following reasons...

1. Just for the reassurance.(Need to rule out depression etc)

2. For Self Help advice.

3. For HRT.

4. For Non Hormonal managements.

5. For advice on Alternative/Complimentary methods.




What Else?

 

It is important NOT to guess the nub of the case.

We need to Shut up and Listen to the patient till we get their agenda.

(You know me, right? First bit is difficult for me :-)

Then Proceed with the Flow.

Have a Patient Centred/ Led Approach!

It is important  -

To empathise when the patients express their struggle with the symptoms as we do in our normal surgery!

It is very easy -

To get Doctor /Exam centred if we started to work up a step ahead in our Mind.

 

Live that moment!

Feel Light!

Relax!

It is Easier this Way!

Chat as if You Do with Your Friend.

Be Real!


Ten Points to Cover


1. What are the patients' ICE?

2. What is the EFFECT on her?

3. What she KNOWS about the options?

4. Is HRT suitable for her?(our agenda!)

5. If Suitable, Has she still got her uterus or not?

6. If not suitable, what Else can we offer?

7. How can we Explain HRT/ Alternatives?

8. How to incorporate the Life styles changes?

(That is why we need to explore about Smoking, Alcohol, Caffeine, Diet, Exercise etc)

9. How to share our Difficulty in suggesting Herbal remedies?

10. How to Safety net / Follow up  - when prescribed HRT or not?

BNF - Our Best Friend

HRT is one of the pages we should definitely put the colourful tag in our BNF!
( Mine had all the rainbow colours, looked vibrant on the table during the CSA!)

 

Practise How to Share the Risks AND to be Neutral.

Empower Patients to take the Informed Decision!






More Points to Remember :-)

Age, Hysterectomy,

Migraine, Breast cancer,

Stroke, VTE, Smoking,

BP, BMI. (Feel free to add...)

 

If it is your weakest link,

Do as Many Times as Possible and Get Comfortable!

Practise, Practise, Practise!

Till You GetThem RIGHT.

 

Get more golden nuggets from

1. http://www.patient.co.uk/doctor/Menopause-and-its-Management.htm.  (My all time favourite!)


2.http://www.nhs.uk/Conditions/Menopause/Pages/Treatment.aspx 


3. http://www.womenshealth.gov/publications/our-publications/fact-sheet/menopause-treatment.cfm


4. www.menopausematters.co.uk

5. Of course, our BNF etc.



It is Easy - Peasy! Lemon - Squeezy!!

Keep interacting!!!     

You are not Alone....

To Your Success,


Hema xoxo.



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CSA CONSULTATION SKILLS - WHAT RAMESH SAYS ABOUT ROGER?

Hellooo Friend!
Hema Here!

Give me a Biggg Hi5!
For those who are really busy and have no time for Roger!
I have added what Ramesh says about Roger for a 'Quick Start'!
(I luv Quick Starts when struggling with new techno)




Dr Ramesh Mehay has kindly allowed us to use all of his materials from his website! 

The great www.bradfordvts.co.uk.

Thank You, Dr Mehay!



You can access the original article by the following one of the options ( I am still in csa mode)

Option 1 -  Google 'Inner Consultation' and follow the 4 th link.( It is working)

Option 2 - Search from www.bradfordvts.co.uk

Option 3 - www.bradfordvts.co.uk/.../0200consultation/consultationmodels/... (showing error now. I think Ramesh is updating his website!
Let us read what he says about our Roger!

It is five pages! and gives the essence!



THE INNER CONSULTATION

Roger Neighbour, MA, MB, BChir, DObstRCOG, FRCGP

(C) Roger Neighbour 1989

The Inner Consultation is an approach to the teaching and learning of consultation skills based on cultivating the doctor's ability to pay high quality attention to certain information-rich moments in the consultation.
The method is a development of the 'Inner Game' approach to sports coaching described by Timothy Gallwey in the fields of tennis, golf and skiing. 
In sport, peak performance is often impeded by the intrusion of self-critical thoughts. 
The solution is to direct the player's attention onto external events such as the moment of bounce of the tennis ball, which are relevant to performance but emotionally neutral.
The traditional approach to teaching consulting skills has been to identify a fairly large number of component skills (such as asking open-ended questions, checking for understanding) and tasks (such as achieving rapport, agreeing a management plan). 

While such models are descriptively valid, conscious determination to apply them in real life can come to dominate the doctor's thoughts during the encounter with the patient, to the detriment of both. 

Alternatively the doctor, in the heat of the encounter, forgets all about his intended performance and just responds spontaneously.
In contrast to a skills-based approach, the Inner Consultation is a technique not of instruction, but for releasing communication abilities which by this stage in the doctor's career have already been installed.

 

MINIMAL CUES
Patients signal, in various verbal and non-verbal ways, those moments in the consultation when important things are happening - when they are thinking seriously, or avoiding sensitive issues.

If the doctor's attention is fully on the patient at such times, appropriate responses will be made without forcing. But the doctor has first to recognise these information rich moments. 
They are signalled by distinct clusters of physical signs - minimal cues.

Gambits
- the 'rehearsed'  opening remarks made by the patient, defining his or her starting position for the consultation. 

E.g. "I've had a pain in my stomach for 2 weeks."

Curtain-raisers
- the 'un-rehearsed'  unguarded remarks which often precede the planned gambit, into which may leak information about the patients emotional state, attitudes or hidden agenda. 
E.g. "You'll probably just say it's my nerves; anyway...I've had a pain in my stomach for 2 weeks."
Internal Search
- a cluster of non-verbal signs indicating that serious thought is in process, and that whatever is next said may be of greater significance than average. 

The signs are:
Ÿ Sudden brief bodily stillness, sometimes even 'freezing' in mid gesture.
Ÿ Changes in gaze; the eyes either:
            (a) move around very rapidly, as in REM sleep, as the thinker scans numerous memories, or
            (b) remains steadily fixed in one direction, usually to one side, either upwards or downwards, or
            (c) become defocused, as if gazing into the far distance.
Turbulence
- a noticeable increase in the energy level of speech.  As the speaker approaches 'dangerous territory', the flow of speech becomes more agitated than before, erratic, fragmented, with abrupt changes of pace, pitch and volume.

Speech censoring
- various ways in which the speaker consciously or unconsciously attempts to avoid going into explicit detail about matters that might be sensitive, embarrassing or worrying. 

Forms of speech censoring include:
Hesitations & Prevarications
- long pauses, "Errm..", "Well.."

Imprecisions
- using vague words and phrases such as "things like that", or "you know what I mean".

Non sequiturs
- remarks that don't appear to make sense, because intermediate connecting thoughts have been left out. 
E.g. "My period was late so I ate lots of fruit," (omitting the intermediate "I thought constipation could be the reason.")


APPLICATION
In the Inner Consultation, the doctor practises alerting himself or herself to the constant flow of minimal cues emitted by the patient, using them as signals (should attention have wandered) to redirect full attention onto the patient.
lt is NOT necessary to try to interpret the significance of every minimal cue; if there is significant meaning, it will be recognised without conscious effort, just as we all do in everyday social conversation. 
The benefit arises from the fact that the doctor, in endeavouring to spot minimal cues, changes the quality of the attention paid to the patient. 
From this improved attention come more astute perception, better communication and more effective consulting

REFERENCES
Neighbour, R.H. (1987) The Inner Consultation - how to develop an effective and intuitive consulting style.  Lancaster, Kluwer Academic Press
Neighbour, R.H. (1992) The Inner Apprentice - an awareness-centred approach to vocational training for general practice.  Lancaster, Kluwer Academic Press 


A '5 - CHECKPOINT' MODEL OF CONSULTING

Think of every consultation as a journey with 5 stops en route.  Or a better image would be of an orienteering course, with 5 checkpoints, at each of which you have to report before proceeding to the next. 
How you get from one to the next is up to you - a matter of your own skill and judgement - but a map and some basic fitness training help.
As you move through the consultation from start to finish, direct a part of your free attention towards attaining each of the following 'Checkpoints' in turn.

1. CONNECTING
- achieving a working rapport with the patient; getting on the same wavelength.
Sometimes this is easy, but may have to be consciously worked at. 
The usual problem is suppressing our own internal dialogue, prejudices and assumptions. 

This is best done by non-­judgementally noticing the patient's physical, verbal, para-verbal, non-verbal, postural and behavioural characteristics. 

It may then be helpful intentionally to 'match' some of these by adjusting your own behaviour accordingly.

2. SUMMARIZING
- obtaining a sufficiently comprehensive idea of the patient's real reason for consulting you.
The best way of checking that you have a clear understanding, and thereby reducing the chances of missing the underlying concerns, is to offer the patient an explicit summary of your perception of his or her needs or expectations. 
If you take the sort of history and facilitate the sort of communication that puts you in a position where you can summarize with confidence, you will find yourself becoming more insightful and more economical.

3. HANDING-OVER
- making sure the patient is happy with the outcome of the consultation.
Every general practice consultation results in some form of management plan.  This may be implied or expressed, precise or vague, clinical or managerial, immediate or long-term, doctor- or patient-centred. 
Reaching and 'handing over' an acceptable management plan may involve strategies, and 'gift-wrapping' - expressing your plan in terms to the patient. 
Otherwise compliance may suffer.
4. SAFETY-NETTING
- planning for the unexpected.
Both you and the patient will feel better if you acknowledge that general practice is the art of managing uncertainty, and things don't always go according to plan. 
Your confidence will benefit if you qualify your management plan by asking yourself three questions:-
                Ÿ If I'm right, what do I expect to happen?
                Ÿ How will I know if I'm wrong?
                Ÿ What would I do then?

5. HOUSEKEEPING
- taking care of yourself.
Doctors have needs too; we get tired, bored, irritated, tense and so on. 
We have a professional responsibility to do whatever it takes to keep ourselves in the best possible state for each successive patient. 
A consultation is not finished until you are ready for the next one.                             

MINIMAL CUES

Internal  Search
         
Brief bodily stillness, eyes uplifted to left or right, or downcast, then
returning to normal gaze.
Turbulence:   
                 
Noticeable increased agitation or fragmentation in the flow of
speech.
Speech censoring:        

A noticeable imprecision, vagueness, circumlocution, evasiveness,
hesitancy, suggesting the speaker is guarding his/her words.
Attention shift:               

An abrupt shift in the focus of the speaker's attention, e.g. external to
internal, present time to past or future.


SUMMARIZING (ELICITING)

Checking:                   

A mini-summary, e.g. "If I understand you ... Let me see if I've got this right".
Echoing
                                       
Repeating either verbatim or paraphrased the speaker's last words or
idea, in order to prompt further development.
Explain why you're asking:               
E.g. "So that I can tell why you might be particularly worried, tell
me whether any of your relatives ever had cancer".
Statements make good questions:   

E.g.  "Blood in the motions can be an important symptom",
"Every magazine  seems  to  have  something about  allergies".
My  friend  John:                                     

Inviting comparison with a 'proxy' figure,
e.g. "Some patients are embarrassed to mention impotence", 
"A  lot  of  people  think  antibiotics cure colds".


HANDING OVER

Questions make good statements: 

E.g. "Did you perhaps think antibiotics were a cure for colds?"

Presupposition:                       

Assuming the desired response has already been made, e.g. "Would
you prefer to come to me or to the clinic for your smear test?"

Pre-empting:                   

Anticipating and dealing with possible resistance,
e.g. "You'll probably curse me for wanting another blood test, but. "
Shingles:              

Overlapping a series of explanations or instructions so that each leads inexorably to the next. 
"A causes B. Because of B, then C. Therefore D".

My friend John (again): 
                     
E.g. "I had another patient like you who..",
"Someone less sensible than yourself might have ... "


INNER CONSULTATION CUES CHECKLIST

CURTAIN RAISERS



GAMBITS



INTERNAL SEARCH



TURBULENCE



IMPRECISION



SPEECH CENSORING



NON SEQUITURS



ATTENTION SHIFTS




Once again, Thank you, Dr Ramesh Mehay!

You can buy 'The Inner Consultation' from the Biggg Amazon website.

But, Please Buy from one of our websites :-)

http://www.rcgp.org.uk/bookshop/info_1857756797.html

OR

www.bradfordvts.co.uk via

http://astore.amazon.co.uk/go2emedia0c1-21


I think from penninevts website as well. Not sure!




To Your Success,
Hema xoxo.


P.S.
    I 'd love to hear from You...
    Share your Comments ---> Sign Up!  
    Go Ahead, Its FREE - Share it!