eBook
Available on Compatible NOOK devices, the free NOOK App and in My Digital Library.
Related collections and offers
Overview
This book helps you to revise and prepare for the CSA part of the MRCGP exam. The new edition features an additional 11 clinical scenarios, all presented in the same standardised format to help you to improve your:
* data gathering – a broad range of appropriate questions to ask the patient are provided and red flags are highlighted where appropriate
* interpersonal skills – each clinical problem is described using terms that you can use in your explanations to patients
* clinical management – tells you which examinations to consider, which investigations to order, and how to manage each clinical problem based on the latest guidelines and current best practice
* consultations – to help you practise, every clinical case features a realistic role play scenario, all of which have been extended with additional information in the new edition.
Every clinical scenario in this new edition has been updated and new appendices have been added to cover driving and the latest DVLA guidelines, and when to suspect child maltreatment.
The book is designed to be used as a workbook, with wide margins to allow you to add in your own notes, questions and other aides-memoires. Used in this way, CSA Revision Notes for the MRCGP is the ideal book to help you successfully prepare for the exam.
From reviews of the first edition:
“Following the glowing reviews of this book I bought it for my CSA preparation. It is a very well written book and a good resource for the CSA. I like the lay out with different case scenarios presented in the CSA style of – data gathering, interpersonal skills and clinical management. I like the open questions and focused questions for each scenario and the role play idea at the end of each case scenario. Interestingly this is the recommended read from our VTS programme.”
Product Details
| ISBN-13: | 9781907904721 |
|---|---|
| Publisher: | Scion Publishing Ltd. |
| Publication date: | 03/15/2013 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 236 |
| File size: | 23 MB |
| Note: | This product may take a few minutes to download. |
Read an Excerpt
CSA Revision Notes for the MRCGP
By Jennifer Stannett
Scion Publishing Limited
Copyright © 2013 Scion Publishing Ltd,All rights reserved.
ISBN: 978-1-907904-72-1
CHAPTER 1
General practice consultation
Telephone consultation
• In a climate of increasing targets and demand for access, telephone consultations are playing an increasingly important role in the delivery of healthcare by GPs.
• The scope of telephone consultations is wide ranging, and includes triage, management of acute and chronic problems, follow-up care and delivery of information.
• It is important to be aware of the limitations of telephone consultations. Telephone advice is not always appropriate, and they do not provide the non-verbal cues that make up around 50% of face to face consultations (GPOnline, 2008, Consultation skills - telephone consultations).
• Key skills in telephone consultations include active listening, frequent clarification and picking up cues such as changes in the tone of voice.
Framework for telephone consultations
Preparation
• Look through the patient's notes prior to the telephone call, familiarising yourself with their past medical history, medication history and recent consultations, etc.
• Have a notepad or paper available in case you need to take notes during the consultation.
Introduction
• Introduce yourself and ensure that you are speaking to the correct person to ensure confidentiality.
• Try to build a rapport through the tone of your voice.
Data gathering
• A detailed history is essential in the absence of physical examination and signs.
• Use open and focused/closed questions to include/exclude relevant conditions.
• Remember to exclude red flag symptoms.
Summarising
• Ensure that you have established the patient's ideas, concerns and expectations.
• Allow time for the patient to ask questions.
Clinical management
• Agree on a plan of action and give clear information about when to seek further advice or help (safety net).
• Request that the patient repeats the advice given.
• Allow the patient to end the call first.
Documentation
• Accurate records should be kept for all telephone consultations, with details of the management plan and follow-up agreed with the patient.
Home visit
• Home visits still remain an integral part of primary care, although their use is diminishing.
• In 1995, 9% of all GP consultations in the UK were home visits, whereas in 2006 this had decreased to just 4% (ONS and DoH Survey).
• GPs tend to visit a patient at home when the patient is confined due to illness or disability, or when urgent treatment can be given more quickly by visiting.
• The disadvantage of a home visit is that it is very time consuming for the GP and there is not access to some medical equipment which might otherwise be available in the surgery.
Framework for home visit consultations
Preparation
• Ensure you read through the patient's notes prior to visiting, familiarizing yourself with the patient's past medical history, medication history, allergies and recent consultations. It is useful to take a print out of this information on a home visit.
• Ensure that you pack a doctors' bag with all the relevant equipment.
• Ring the patient beforehand to determine the reason for the home visit request and confirm with them that you will be visiting.
• To ensure your safety, let a member of staff know that you are going on a home visit and give the details of which patient you are visiting.
Data gathering
• Ask open questions, followed by focused questions including those to check for red flags.
• Establish social history: Is the patient coping at home? Is additional help required?
• Examination.
Clinical management
• Decide if the patient is safe to remain at home or if they need to be referred to hospital.
• Are any further investigations required?
• Is any medication required?
• Safety net - involve relative or partner in this conversation if appropriate.
• Clearly document the consultation when back at the surgery.
Angry patient
• Managing an angry patient can be upsetting and potentially dangerous.
• The reason for a patient being angry can include anything from social or financial problems to difficulties getting GP appointments, poor communication, or a doctor ignoring their ideas, concerns and expectations.
• An angry patient can escalate to a violent patient. Signs of escalation include shouting, swearing, raising a clenched fist, pacing or adopting an aggressive posture.
Tips for managing an angry patient
• Remain professional and calm.
• Start with an open question - "Can you tell me about what's upsetting you?" or "Do you mind telling me what happened?".
• Give the patient space and time to vent their anger.
• Apologise, for example by saying "I'm sorry you've had to go through this"
• Do not blame others, for example, colleagues.
• Be empathic and express concern where appropriate.
• Listen to the patient and explore their concerns.
• Agree an appropriate management plan, for example, raising the issue at the next practice meeting.
• Summarise the plan and ensure there are no other issues that have not been dealt with.
• Offer details of how the patient can make a formal complaint. A complaint to the practice manager will usually be acknowledged within two working days and responded to within ten working days, although this varies between practices.
• Housekeeping - it is also important to look after your own well-being.
Breaking bad news
• Breaking bad news is a duty which understandably many GPs dread, but is nevertheless a necessary skill to learn well.
Tips for breaking bad news
Preparation
• Arrange a face to face meeting and not a telephone consultation ideally.
• Ensure a private setting with no interruptions.
• Invite a relative or friend if appropriate.
• Prepare beforehand by familiarising yourself with the patient's clinical details.
Data gathering
• Discover what information the patient already knows or what they have been told so far - "Before we start, do you mind me just asking what you understand about the tests and why they were done?".
• Discover what has happened since the patient was last seen - "How have things been since you were last seen?".
• Give the patient a warning shot that difficult information is to follow, for example: "I'm afraid that it looks more serious than we had hoped" or "I'm afraid that it is rather bad news".
• Share the information in small 'chunks,' clearly and honestly, repeating the salient points. Allow pauses where appropriate.
• Avoid jargon.
• Continue to check the patient's understanding.
• Be aware of the patient's non-verbal cues as this can help to gauge the patient's need for further information.
• Show empathy, for example, "I know that this must be very difficult for you".
• Address the patient's ideas, concerns and expectations.
• Enquire about the patient's social history - support network, occupation.
Clinical management
• Decide on a management plan which should include some sort of follow-up appointment and safety net.
• Offer some hope but this should also be tempered with realism.
• Offer a patient information leaflet if appropriate.
• Offer to make another appointment with spouse/relative or to speak to them on the phone.
Patient with learning disabilities
• Learning disability is defined as a 'significantly reduced ability to understand new and complex information, to learn new skills (impaired intelligence), and with a reduced ability to cope independently (impaired social functioning); It starts before adulthood with a lasting effect on development. Often there are associated co-morbidities, for example, epilepsy, mental illness and behavioural disorders (DoH White Paper, 2001, Valuing people: a new strategy for learning disabilities for the 21st century).
• A consultation with a patient who has learning disabilities can be challenging for both the patient and the doctor.
• The patient may feel that their health needs have been neglected, whilst the doctor may feel frustrated by the potential difficulty in gathering the relevant clinical information to formulate a management plan.
• Evidence has shown that people with learning disabilities have much greater health needs than the general population, yet they don't access primary care as often as they need to (NHS Primary Service Framework, 2007, Management of health for people with learning disabilities in primary care).
• Management of patients with learning disabilities involves a multidisciplinary team approach.
Tips for data gathering and clinical management
• The people caring for the patient, whether the patient lives with their parents, or has a carer, or lives in a residential home, are all very useful sources of information.
• Listen to the patient and give them time to express their concerns.
• When history taking, ensure that the patient understands the questions asked and avoid using any jargon.
• It is important to try building a rapport with the patient, and ideally they should see the same GP each visit.
• When giving information, writing things down can be useful if the patient is literate. Drawing diagrams or giving patient information leaflets can also be helpful.
• All patients with learning disabilities should have at least an annual health check, and should have an individualised 'health action plan' (DoH White Paper, 2001, Valuing people: a new strategy for learning disabilities for the 21st century).
• A health check should include a minimum of:
* provision of relevant health promotion advice
* chronic illness and system enquiry
* physical examination
* consideration of whether the patient suffers from epilepsy, any mental health or behavioural problems
* specific syndrome check
* medication review
* review of co-ordination arrangements with other healthcare providers.
Patient with hearing impairment
• Hearing impairment in general practice is a relatively common problem; however, research suggests that the needs of this patient group are poorly met in many GP surgeries (Patient UK, 2009, Survey of people with mild to profound hearing loss).
• The problems that patients with hearing impairment face include problems trying to book appointments, not hearing their name being called by the doctor, not being offered an interpreter, and not being able to understand the doctor.
• In the CSA exam there may be a hearing impaired patient, and they would most likely communicate by lip reading.
• When communicating with a hearing impaired patient, it is vital to ensure that you communicate clearly, with good face to face contact, and regularly check patient understanding.
Tips for dealing with hearing-impaired patients
• Always ask the patient at the beginning of the consultation how they wish to communicate.
• Always look at the patient when listening and speaking.
• Avoid looking at the patient's notes when talking to the patient - look at these before the patient enters.
• Ensure you are sitting in good light and keep your hands away from your face if the patient is lip reading.
• Speak clearly but not too slowly.
• Don't exaggerate lip movements if the patient is lip reading.
• Keep a pen and paper handy in case you need to write anything down.
• Ask the patient to summarise what has been said to ensure understanding.
• Offer additional written material at the end of the consultation.
• Drawing diagrams to explain things may be especially useful in this case.
Healthy people: promoting health and preventing disease
• Hypercholesterolaemia
• Refers to a high level of lipids in the blood stream.
• It is more specifically defined as an elevation in total cholesterol, low density lipoproteins or triglycerides in the bloodstream.
• Fatty lumps called atheromas can develop in the lining of the blood vessels if the cholesterol remains high.
• A build up of atheroma can result in ischaemic heart disease, stroke, TIA or other arterial disease developing.
• Other risk factors for atheroma formation include high blood pressure, obesity, diabetes, unhealthy diet and strong family history.
• The figure below shows how you can illustrate the effect of atheromas on blood vessels.
Data gathering
Open questions
• "I gather you recently had a cholesterol test done. Do you mind telling me what you understand about this test?"
• "What do you know about having high cholesterol?"
• "Tell me about your diet?"
Focused/closed questions
HPC: "Do you have any chest pain or shortness of breath?" (red flags)
PMH: "Do you have any history of high blood pressure, high cholesterol, heart disease or diabetes?"
DH: Certain medications can raise cholesterol, e.g. antipsychotics, isotretinoin (roaccutane).
SH: Smoking/alcohol/illicit drug history? Exercise?
FH: "Do any of your family have high cholesterol or heart disease?"
ICE: "Do you have any thoughts as to why your cholesterol is high?"
Examination:
• blood pressure
• BMI
• cardiovascular system, including inspection for xanthelasma and tendon xanthomas.
Clinical management
Investigations
• Fasting cholesterol screen - total serum cholesterol, HDL, LDL, triglycerides.
• Fasting glucose.
• LFTs - if starting statins.
• U&Es - to check kidney function.
• TFTs - check TSH if dyslipidaemia is present.
Explanation to patient
• Cholesterol is a fat made in the liver from the foods that we eat.
• A small amount of cholesterol is beneficial in keeping us healthy.
• If the cholesterol level is too high (approx. >5 mmol/l), there is an increased risk of developing heart problems or having a stroke.
• Cholesterol is carried in the bloodstream by particles called lipoproteins. There are two types of lipoproteins: low density lipoproteins (LDL) and high density lipoproteins (HDL). The LDL are often referred to as the 'bad' cholesterol as they are thought to be responsible for atheroma formation, whereas HDL are referred to as the 'good' cholesterol as they are thought to prevent atheroma formation.
• It is therefore important to keep the cholesterol level down to an acceptable level (≤5 mmol/l), or for secondary prevention aim for total cholesterol <4 mmol/l.
Management (based on NICE 2010 guideline CG67: Lipid modification)
• Use a CVD risk calculator to help explain the risk to patients (e.g. Framingham 1991 10-year risk equation).
• Cardio-protective diet - fewer saturated fats, less alcohol, at least five portions of fruit and vegetables each day, and two portions of fish per week.
• Weight management and exercise - 30 minutes of at least moderate intensity exercise at least 5 days a week.
• Smoking cessation.
• Medication: initiate statins for primary prevention of CVD if 10-year risk >20%, or for secondary prevention of CVD. Preferred choice is simvastatin 40 mg OD. If statins not tolerated other options include ezetimibe or fibrates. Consider aspirin for secondary prevention of cardiovascular disease.
• Safety net - if on statins monitor LFTs within 3 months and then 12 monthly.
Hypertension
• Blood pressure means the pressure of the blood in your arteries (blood vessels).
• Approximately half of all people over 65 years have high blood pressure (hypertension).
• Hypertension is defined in adults as a diastolic blood pressure persistently above 90 mmHg, and/or a systolic blood pressure persistently above 140 mmHg.
• It is recommended that GPs diagnose hypertension only after obtaining two or more elevated blood pressure readings on separate occasions.
• Risk factors for hypertension include obesity, inactivity, alcohol and smoking.
• Hypertension can result in an increased risk of ischaemic heart disease and stroke.
Data gathering
Open question
• "Your recent blood pressure check has shown that your blood pressure is higher than normal. What do you understand about high blood pressure?"
Focused/closed questions
HPC: "Do you have any headaches or problems with your vision? Any chest pain?"
Examination:
PMH: "Do you have any history of high blood pressure, high cholesterol, heart disease or stroke?"
SH: Smoking/alcohol/illicit drug history? Diet? Exercise? Occupation? Stress?
FH: "Does anyone else in the family have high blood pressure?"
ICE: "Do you have any thoughts as to why your blood pressure might be high?"
Red flags: • systolic BP >220 mmHg or diastolic BP >120 mmHg
• pregnant
• malignant hypertension - BP >180/110 mmHg with signs of papilloedema and/or retinal haemorrhage (refer same day to specialised care)
• re-check BP
• fundoscopy
• BMI
• cardiovascular system
Clinical management
Investigations
• Bloods - U&Es, fasting cholesterol and glucose.
• ECG.
• Urine dipstick - check for protein and blood (red flag if microscopic haematuria).
• Consider checking urinary catecholamines if young to rule out phaeochromocytoma.
Explanation to patient
• Blood pressure measurements consist of two readings - the top reading records the highest pressure in the arteries when the heart contracts. The bottom reading records the lowest pressure in the arteries as the heart relaxes between beats.
• If either of these readings are high then you have high blood pressure (above 140/90 mmHg).
• High blood pressure can be due to genetic factors, high salt or alcohol intake, lack of exercise or stress.
• If your blood pressure remains high you are at increased risk of having a heart attack or a stroke.
• It is therefore important that your blood pressure is kept within an acceptable range and it should be monitored regularly.
(Continues...)
Excerpted from CSA Revision Notes for the MRCGP by Jennifer Stannett. Copyright © 2013 Scion Publishing Ltd,. Excerpted by permission of Scion Publishing Limited.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.