I would say the vast majority, if not all, have heard of the word. Neurological examination – if there is anything in the history that creates suspicion, Failure of medical treatment after a couple of reviews, Persistent non-visible haematuria or any visible haematuria. A lot of people in this session noted they would see a clear drop in energy levels as a trainee reaches the second half of the consultation. You should have at least two measurements of BP if the initial one is >140/90. I also found there was no part of the book that I felt the urge to skim read. Locally in Peterborough the psychological wellbeing service has capacity to provide support to individuals who are suffering from chronic disease such as COPD and heart failure. This topic seems to crop up fairly regularly as a tutorial request. Yes that is much easier said than done. That is rule one – believe in yourself. All of these symptoms have multiple potential diagnoses, and it is through further questioning and consideration that you are going to consider whether heart failure is on your list of differentials. E.g. To learn from it required a description of the event and questioning ourselves to analyse why it occurred in that way, and considering ways to change the outcome of the event. Have they had any time off recently? You must address this, otherwise chances are you will fail! Have they ever had thoughts like this in the past and have they ever attempted suicide in the past? We need to be looking for a secondary cause in these individuals and offering detailed assessment. Acknowledge that you understand this may be worrying, stressful, etc. So, I added it to my growing pile of books to read. We have 111 option 2. So ask them about expectations – it might save an unwanted prescription! In addition, the commonest CSA feedback statements are related to clinical management, and this is where trainees are most likely to lose marks. Another reason for writing a concise, clear referral is because it helps you. Don’t forget your clinical knowledge – make sure you know your red flags, your guidelines, your management plans. If I had been able to keep calm, and think ‘I can look this up’ earlier on, it would have facilitated a better consultation. What if I’ve got cancer? Make sure the patient knows what the plan is, agrees with it, knows how it is to be executed, and there is follow up to ensure patient safety. Do they get time for themselves? You really don’t! However, I often make it clear that medication may help the symptoms, but if there is a clear trigger then it is most helpful to address this. Evaluation – Actually, I don’t know if he noticed just how stressed I was, as I managed to keep calm on the outside which was good. You should probably get on and get some bloods taken on the day to facilitate appropriate monitoring of the medications you have started (e.g. It is also very helpful to ask the man to complete the international prostate symptom score (IPSS) questionnaire. I like to try and gather information regarding their other symptoms by turning the consultation into more of a ‘chat’ than an ‘interview’. the lady that’s had a funny turn (possible seizure) who drives for a living, the contraceptive advice for the 15 year old who’s boyfriend is 19. We then send them via a clinic that is specifically to exclude this, where there’s a reasonable chance someone else is going to use this word. The other important point is that your patient should be relaxed and quiet whilst the measurement is being taken. It’s useful to be open when writing a reflection, and feeling comfortable that whoever reads your entries will treat this information as confidential, and be supportive and developmental in their feedback. The hospital is a busy place, and often understaffed at weekends. NICE uses the DSM-IV criteria for diagnosis of depression. Again it makes facing the CSA that little easier. Consider referral if < 40 years old with stage 1 hypertension and nil other risk factors, since CVD risk may be underestimated in this population. Remember this – how many times per session do you sit and listen to a history and make a definitive diagnosis at the first appointment? When observing, I can tell when someone is starting to question their plan because they can’t quite remember what the guidelines suggest, or they don’t recall the cut off values for this and that. as with the above scenario. Thousands of GP Trainees have used FourteenFish to help them pass. I must admit, I have been guilty of both of these in the past. He looks at how modern medicine impacts upon mortality, and the choices available to people of all ages when they are given an end of life diagnosis. If they are not keen initially I will ask them to think about it and discuss it more next time. Are the recommendations in this guideline valid? Where a trainee’s personal protection is currently provided by a medical defence organisation through a bulk indemnity agreement, this will continue. Are the results of this economic analysis valid? In reality, you are referring them to a specialist since you’ve exhausted the options, and you need to see if there’s anything available in secondary care that they can try whilst they don’t meet the threshold for replacement. Options, options, options! You can spend your days treating disease and illness, but you can’t lose sight of your patient as a whole. That is down to your preference. Whats their home set up like – Who do they live with? However painful you might think it will be to address the 14 year old with the 20 year old boyfriend, the drug addict, the patient with back pain who probably has bone metastases, etc. We talk about the need to exclude serious, sinister or worrying causes. So know your stuff. When you are doing your placement in both a GP practice and a hospital, additional professional cover is provided by HEE. Be clear on it. Are they eating? In my head I am trying to be as nosy as possible, and painting a picture of this person’s life. I didn’t get to do that. One of the most common theorists to come up in discussion of reflection is Kolb. If you have any questions then just as and I will answer as best I can. The use of stock phrases just doesn’t work. It’s Ok if you don’t give the drug addict more fentanyl patches. When in GP practice placements, clinical negligence indemnity cover is automatically provided through the state-backed GP indemnity scheme, the CNSGP (clinical negligence scheme for general practice). As with all chronic diseases it is important to consider the psychological impact upon the patient. Apparently my phrase was ‘I think’. Read the last consultation in the next patient’s notes you open and see if you feel that you know exactly what the writer was thinking, and whether it was an easy read! Don’t let your theoretical knowledge slip away. Here’s my thinking – I’m going to tell you if it was fine and you might manage a pass. Stock phrases such as ‘what were you hoping I could do for you today?’ need to be used carefully, and in the appropriate context.
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