The Hands-on Guide to the Foundation Programme

Introduction xiii How to use this book xiv Acknowledgements xv Abbreviations xvi 1 Starting up 1 Panic? 1 People to help you 1 Three basic tips 2 Other useful start-up information 2 Dress 2 Equipment 3 Geography 4 Ward rounds 4 Social rounds 5 Night rounds 5 Discharging patients 6 Work environment 6 Bibliography 6 2 Getting Organized or 'The Folder' 8 Personal folder and the lists 8 How to make a personal folder 8 Keeping track of patients (List 1) 10 List of things to do (List 2) 10 Results sheet (List 3) 10 Data protection and confidentiality 11 3 Paperwork and electronic medical records 12 Patient notes 12 Incident forms 13 Blood forms and requesting bloods tests 14 Discharge summaries (TTO/TTA) 15 Handovers 16 Referral letters 17 Self-discharge 17 Sick notes 17 4 Accident and emergency 19 General advice 19 Admitting and allocating patients 20 Keeping track of patients 21 Medicine 21 Medical and surgical assessment units 22 Fast-track patients 22 5 Becoming a better doctor 23 Foundation Programmes (United Kingdom) 23 Academic Foundation Programmes 24 Assessments 24 Situational judgement tests 25 Moving on from the Foundation Programme 26 Information technology 26 The internet 27 Online medical databases 27 Keeping up with the literature 28 Evidence-based medicine 28 Clinical audit 29 Quality improvement projects 30 Case reports 30 Courses 30 Professionalism 31 Communication 31 Consultants and senior registrars 32 GPs 32 Nurses 33 Patients 34 Patients' families 35 Confidentiality 36 Exceptions to keeping confidentiality 36 References 36 6 Emergencies 37 Acute coronary syndrome 37 Stroke 37 DVT and PE 40 Haematemesis 40 Acute asthma 41 Life-threatening asthma 42 Acute severe asthma 42 Brittle asthma 42 Acute pneumothorax 42 Anaphylaxis 43 Meningitis 43 Collapse or reduced mobility 45 Overdose 45 In general 46 Treating the patient 46 Surgery 48 7 Cardiac arrests and crash calls 49 Cardiac arrest calls 49 'Do not resuscitate' orders 52 8 Common calls 54 How to use this section 56 Considerations for all ward calls 56 Abdominal pain 57 Differential diagnoses 57 Anaemia 58 Arrhythmia 60 Calcium 62 Hypercalcaemia 64 Hypocalcaemia 64 Chest pain 65 Confusion 66 Differential diagnoses 66 Constipation 68 Differential diagnoses 68 Diarrhoea 69 Differential diagnoses 69 Electrocardiograms 70 Important ECG abnormalities to recognize 74 Eye complaints 74 The acute red eye 74 Sudden loss of vision in one or both eyes 75 Floaters 75 Falls 75 Differential diagnoses 75 Fever 76 Differential diagnosis 77 The immunocompromised patient with fever 78 Fits 78 Differential diagnoses 78 Intravenous fluids 79 Upper gastrointestinal bleeds 81 Lower gastrointestinal bleeds 82 Glucose 82 Haematuria 83 Headaches 84 Differential diagnoses and key symptoms 84 Hypertension 85 Peri operative hypertension 86 Hypotension 86 Differential diagnoses 86 Insomnia 88 Differential diagnoses and suggested management 88 Management with benzodiazepines 88 Itching 88 Differential diagnoses (if no visible skin lesions or rash) 88 Major trauma 89 Minor trauma 90 The moribund patient 91 Nausea and vomiting 92 Differential diagnoses 92 Oxygen therapy 93 Methods of oxygen delivery 93 Pulse oximetry 94 Phlebitis 94 Management 94 Potassium 94 Hyperkalaemia 94 Hypokalaemia 95 Rashes and skin lesions 96 Disease categories 1-10 96 Shortness of breath 97 Differential diagnoses 97 The sick patient 98 Sodium 98 Hyponatraemia 98 Differential diagnoses 99 Transfusions 99 Blood transfusions 99 Platelet transfusions 100 Urine: Low output (oliguria/anuria) 101 Basic emergency routine 102 Obstetrics and gynaecology calls 103 Talking to the patient 103 Gynaecological examination 103 Obstetric examination 104 Being a male 104 Common gynaecological calls 105 Termination of pregnancy 106 9 Death and dying 107 Terminal care 107 Communication 107 Breaking bad news 107 Ongoing communication with dying patients 108 Pain control 110 Symptom control 110 Prescribing for the dying 110 Support for the dying and for you 111 Death 111 What to do when a patient dies 111 Telling relatives about the patient's death 112 Religious practices on death 112 PMs 112 Death certificates 113 Writing the death certificate 113 Referring to the coroner (Scotland: Procurator fiscal) 114 Cremation forms and fees 114 To check for pacemakers 114 Further reading 114 10 Drugs 116 General 116 Prescribing drugs 116 Drug charts 116 Writing prescriptions 117 Controlled drugs 117 Verbals 118 Giving drugs 118 Drug infusions 119 Prescribing drug infusions 119 Intravenous drugs 120 Specific drug topics 122 Antibiotics 122 Anticoagulation 122 Digoxin 125 Therapeutic drug levels 126 Miscellaneous tips 126 11 Handle with care 134 Alcoholism 134 Alcohol withdrawal 135 Capacity 136 Children 137 Depression 137 Elderly patients 138 Haemophilia patients 139 Taking blood 139 For theatre 139 HIV/AIDS 140 Taking blood 140 HIV testing 140 Jehovah's Witnesses/Christian Scientists 141 Pregnant women 141 Sickle cell anaemia 142 The patient on steroids 142 Side effects of steroids 142 Managing ill patients on steroids 143 Treating common side effects 143 Withdrawing steroid therapy 143 Haematological and oncological emergencies 144 Spinal cord compression 144 Superior vena cava obstruction and airway compromise 144 Raised intracranial pressure 145 Tumour lysis syndrome 145 Hyperviscosity 145 12 Approach to the medical patient 147 History and examination 147 Getting to know the disease 148 History and examination 151 Clinical stalemate 151 Preparing patients for medical procedures 151 Cardiac catheterization 152 Elective DC cardioversion 152 Upper gastrointestinal endoscopy 153 Colonoscopy 154 Flexible sigmoidoscopy 154 Liver biopsy 155 Pacemaker insertion 155 Renal biopsy 156 Specialist referrals and investigating the medical case 156 Cardiology 157 Gastroenterology 158 Haematology 159 Neurology 160 Renal medicine 161 Respiratory medicine 161 Rheumatology 162 13 Practical procedures 163 General hints 163 Interpreting ABGs 165 Bladder catheterization 167 Men 168 Women 169 Blood cultures 169 Venepuncture 169 Cannulation (Venflon/line insertion) 170 Problems with temporary and tunnelled central lines 173 Using central lines 173 Chest drains 173 Managing a chest drain 174 How to remove a drain 175 DC cardioversion 175 Electrocardiogram 176 Exercise stress test 176 Relative contraindications (discuss with senior) 176 The procedure 176 Injections 177 Subcutaneous 177 Intramuscular 178 Joint aspiration/injection 179 Aspiration 179 Injecting joints 180 Local anaesthesia (for any procedure) 180 Lumbar puncture 181 Contraindications (get help) 181 Mantoux test 184 Nasogastric tubes 184 Peritoneal tap (paracentesis) 185 Pleural aspiration 185 Indications 185 Pulsus paradoxus 188 Respiratory function tests 188 Spirometry 188 Peak expiratory flow rate 189 Sutures 190 14 Radiology 191 Requesting investigations 191 Minimizing radiation 192 Common concerns about X-rays 192 Pregnancy 193 Plain films 193 Chest X-rays 193 Abdominal films 194 Ultrasound 194 Computed tomography 195 General 195 CT head - Some emergency indications 195 Radioisotope scanning 196 15 Approach to the surgical patient 198 Introduction 198 Preoperative care 198 Clerking 198 Preoperative tests 199 Requesting blood preoperatively 200 Preoperative fasting 200 Consent 201 Marking 203 Booking theatre lists 203 WHO checklist 205 Perioperative prescribing 205 Anti-emetics 205 Analgesia 205 Laxatives 205 Bowel preparation 205 Thromboprophylaxis 207 Insulin infusion 207 Post-operative care 207 Wound checks 208 Stoma care 209 Enhanced recovery after surgery 209 Theatre 210 Further reading 210 16 General practice 212 What you can and cannot do 212 You can 212 You cannot 212 Referral letters and note keeping 212 General points 212 Public health and health promotion 213 Risks 213 Benefits 213 Condoms 214 Intrauterine system 214 Intrauterine device 214 Contraceptive injection 214 Contraceptive implants 214 Smoking 215 Lifestyle advice 215 Notifiable diseases 215 Vaccinations 215 Breast screening 215 Cervical screening 215 Sexual health 216 The hidden agenda and health beliefs 216 Follow-up 216 Home visits 217 17 Self-care 218 Accommodation 218 Alternative careers 218 Bleep 219 British Medical Association 219 Car insurance 219 Clothes (laundry/stains) 220 Contacting medical colleagues 220 Contract and conditions of service 220 What you need to know about your contract 220 Doctors' mess 225 Making money for the mess 225 Insurance (room contents) 225 Jobs 225 Curriculum vitae 225 The interview 226 Consultant career prospects 226 Locums 226 Meals 227 Medical defence 227 Money 228 Income protection if long-term sick or disabled 228 Student debt 228 Mortgages 228 Payslip deductions 228 Pensions 229 Tax 229 Telephone and online banking 230 Needlestick injuries 230 If the patient is known to be HIV positive 231 If the patient is known to be hepatitis positive 231 Not coping 231 Part-time work (flexible training) 232 Representation of junior doctors 232 Sleep and on-call rooms 232 When things go wrong 233 Bullying and psychological stress 233 Whistle-blowing 233 Appendix I: Scoring systems 235 Cardiovascular 235 CHA2DS2 VASc 235 HASBLED score 235 GRACE score 235 TIMI Risk Index 236 NYHA scoring system (New York Heart Failure Association Scoring System) 236 Neurology 236 TIA-ABCD2 scoring 236 AMTS (abbreviated mental test score) 237 AVPU score 237 (GCS) Glasgow Coma score 237 Anaesthetics 237 Mallampatti classification for intubation 237 BMI 238 Calculating anion gap 238 Calculating serum osmolality 238 Respiratory 238 Gastroenterology 239 Child Pugh classification 240 Renal 241 Trauma 241 Barthel score 242 Bathing 242 Bladder 242 Bowels 242 Dressing 242 Feeding 242 Grooming 242 Mobility 242 Stairs 242 Toilet 242 Transfer 242 Appendix 11: Useful tests, numbers and other information 243 Addresses 243 Mental Health Act 243 Notifiable diseases 244 Results 244 Haematology 244 Biochemistry 245 Useful biochemical formulae 245 Fitness to drive 246 Further resources 248 Index 249