Communication skills for Paces

Communication skills is part of the Paces exam. It is also part of every day practice.
I started a new blog which should cover different communication skills and tools needed to master your consultation needs.

http://patientdoctorpartnership.blogspot.co.uk/

please check , feedback and questions are welcome

MRCP part I exam format

http://www.mrcpuk.org/Part1/Pages/Part1Format.aspx

Number of questions per speciality

Cardiology 15
Clinical pharmacology, therapeutics and toxicology 20
Clinical sciences** 25
Dermatology 8
Endocrinology 15
Gastroenterology 15
Haemotology and oncology 15
Neurology 15
Ophthalmology 4
Psychiatry 8
Renal medicine 15
Respiratory medicine 15
Rheumatology 15
Tropical medicine, infectious and sexually transmitted diseases 15
200

How to Pass MRCP exam part I and II ' MRCP guidelines'

How to Pass MRCP exam part I and II


MRCP covers big knowledge and the idea of you passing without putting effort or passing after studying from books is not right.


MRCP knowledge tends to be specific to the practice in UK and guidelines published by NICE or SIGN.


The advice I am providing here is based on my own experience and couple of my friends who followed the same plan.


I will try to be concise and to the point


Time needed at least 3-4 months if you are sitting it for the first time and less than 3 months if it is your next attempt.


So, you have got nearly 13-14 branches for MRCP part 1 and less for MRCP part 2, multiply by 3-5 days average per branch depending on your ability, that’s maximum of 70 days of continuous study.


Build the number of hours slowly, starting with 4 and accelerate up quickly to 6-8 within 2 weeks.


Your aim should be answering questions and understanding the answers, understanding the small bite of knowledge in it, so if it recurs in the exam from a different angle, you would be able to answer it. Read around the topic of the question only if needed.


Don’t worry about the amount of knowledge required to pass the exam, you will have it if you put enough effort in questions. ‘You will finish the elephant doing those small bites’.


Basic knowledge questions annoying, you need to memorise some, I would advise to leave it to last and redo the wrong ones just before the MRCP part 1 exam.


Percentage of speciality questions tend to vary from one exam to another, so you would find some who would say we had lots of cardiology questions, others would say we had lots of rheumatology questions, the idea you should be prepared.


What I tend to do is to do branches separately, that helps me to build a basic knowledge about each speciality questions and because some topics recur in different questions, I found that I start to build knowledge around each topic without realising.


Plan your study around the precious statement and give yourself good time to for the specialities you score badly in. note I am not saying the branches that you are not good in, you may be a cardiologist that would score badly in cardiology questions because you are practicing in another country.


Leave space for breaks, work, family, etc. apart from the fact that you will need it, that is life and you will have to comply with your commitments, either you agree or not.


Example of plan built on 5 days per branch, is 5 branches per month that is 2 months and half and one week for repeating wrong questions. Don’t worry the number of questions you would be able to answer at that time would be significantly higher than your starting rate.


So what to do after I finish? You will need to repeat all questions that you answered wrong. That will vary on your first set score.


What books do I need to use? I used none, if it worked for me why it should not work for you. The advice I give is just do questions, questions and only questions.


Where to get questions from, pastest or on examination, don’t use old course contents as that would have changed, both websites are professional and keep updating their data bases with new questions and answers. Save the money of the books and the money of sitting the exam again and pay them, I believe it is worth it.


So to plan you need an aim, aim is to finish questions from one those websites and repeat wrong ones, if you managed to finish that before the exam, next aim is to simulate exams by sitting random 200 questions at 3 hours.


Sleep is essential for good memory; make sure you get 8 hours daily the last week before the exam.


Go to the exam in a good set of mind as you would come across questions that you know the answers for and questions that you don’t have clue about and trust me you can figure the answers of both if you are relaxed. on the other hand you can answer both wrongly if you are stressed and tired.


Don’t think about passing rate as that is variable from one exam to another, Royal college has passing standard if you achieve it you will pass.

Finally, enjoy the process as the target is to make you a better doctor and you will be, that doesn't come over days or weeks, it takes years but again small bites will get you there.


Leave a comment or question if you have any

for communication skills for PACES and other OSCE exams please check

http://patientdoctorpartnership.blogspot.co.uk/ 
 
Allah al Mowafek

MRCP knowledge

The medical knowledge coming up in MRCP exams is quite vast and while I can write on more than few topics I would really appreciate if you leave me in the comments section things that you find more difficult to tackle, either to understand or to memorise.

MRCP exams are easy if you put the right effort into it and MRCP knowledge is useful in everyday practice, so lets do this together.
I would like you guys to be specific about the topics, so rather than writing a name of a branch like neurology, writing a topics of the branch would make it easier for me to come back with guidance about it.

so leave me a comment if you want to help

Migraine ( next post covering all headache types)

Migraine

Prevalence in Men 6 % in women 18%

Typical Characteristics

Can be preceded by aura, visual or auditory or nausea and vomiting

Aggravated or starting with physical activity

Unilateral, throbbing (pulsating), moderate to severe, lasts 4hrs to 24hrs

Better with staying in dark room

Common triggers

Light, chocolate, wine, alcohol, cheese, citreous juices, tiredness, stress, menstruation and COP

Treatment

Acute attack

Paracetamol + NSAIDs + antiemetic

Sumatriptans (5HT 1 agonist) Start as soon as the attack starts

S/E chest tightness/heaviness

Contraindications IHD/ MI/cerebrovascular disease

Prophylaxis

B-Blocker /gabapentin/ sodium valoprate/ venlafaxine/  5HT2 antagonist

Fatty liver, non - Alcholic steatohepatitis (NASH)

Fatty Liver

NASH stands for non-alcoholic steatohepatitis
It is a new identity introduced to medical literature on 1980 by ledwig et al.,
It covers spectrum of liver disease, ranging from benign fatty liver, to Nash which is inflammatory process that may lead eventually to fibrosis in the absence of alcohol history.
Now it is believed that it is the most common cause of abnormal function tests in the US.
Causes of NASH are either primary or secondary, where primary NASH happens in association with metabolic syndrome, in other words it happens more in fatty people.
Secondary causes include drugs, like methotrexate, steroids, isoniazid, NSAID and others, other causes of NASH include toxins and metabolic disturbances mainly genetic, It was also reported in people with sudden weight loss and jujenoileal by pass operations.
Histology findings are similar to that found in Alcohol, with accumulation of Fat inside the liver cells and inflammatory infiltrates and fibrosis.
Pathophysiology process has not been confirmed but all happens mainly due to insulin resistance. Insulin resistance cause more lipolysis, more FFA entry to liver cells and increased FFA inside liver cells. Impaired beta oxidation inside liver cells causes the release of oxygen free radicals causing the inflammation.
Symptoms and Signs
Most of patients are asymptomatic, or complain of mild symptoms such as fatigue and right hypochondrial pain; however Hepatomegaly is the most common clinical findings.
30% of patients with fatty liver will progress to has liver fibrosis and cirrhosis and those may present with more advanced liver failure signs.
Investigations
ALT normal or raised up to four folds
AST normal or raised up to four folds
AST/ALT ratio is less than one where it is more than one in alcoholic liver disease
Low Albumin, impaired coagulation profile and low platelet are all features of chronic liver disease that may present in patients with NASH
Don’t forget that Nash is a diagnosis of exclusion and s copper, -ve autoimmune studies and no alcohol history is mandatory to diagnose NASH.
S ferritin is sometimes raised and it may be a challenge to differentiate it from haemochormatosis.
U/S is easy and cheap but not accurate, as it doesn’t detect less fat when it is less than 30%, It is also challenging to perform it with good result in the obese population.
Liver biopsy is the gold standard and it helps not only to diagnose NASH but also to stage the degree of fibrosis.
Treatment is to treat obesity; weight loss was proven to be beneficial and to decrease the degree of inflammation inside the liver.
Drugs to increase insulin sensitivity like metformin and glitazones are also helpful.
Other modules of management are lipid lowering drugs like statins.

MRCP/MRCGP Hyperlipidemia , Statins and Liver function tests

Who should receive statins
All patients with previous cardiovascular events
All patients older than 40 years with 10 years cardiovascular risk > 20%

Aim for treatment
currently some guidance say aim for cholesterol <4 others are saying for cholesterol < 5
NICE has no recommendation for that

current guidance for statins is stop them only if Liver function tests rise above 3 reference range That is ALT more than 135

simple rules to manage hypertension

Medications to control hypertension are easy to use
different categories are available, what works for one patient doesn't work for another

Age groups
<55 years and not from black origin
start ACEi , familarise yourself with one or 2 of them
Lisinopril is once daily , comes in 2.5, 5, 10 and 20 mg , review 2 weekly
ramipril is easy once daily dose, review in 2 weeks , increase dose from 1.25 to 2.5 to 5 to 10 mgs as needed
consider angiotensin II antagonists if intolerant
losartan (cozaar ) comes in 25, 50 and 100mg doses, remember it is more expensive

remember the need for monitoring renal functions 2 weeks after starting ACEi or Angiotensin II antagnoists
add thiazide if needed 12.5 mg or 25 mg
combination is available with lisinopril in the name of carace 10 plus or carace 20 plus

add calcium channel blockers if poor control
amlodipine , once daily, safe and commonly used in UK , comes in 5 mg and 10 mg doses

consider adding b-blocker, or alpha blocker if poor control

IF patient is older than 55 years old or from black african origin
start with Caclium channel blocker or diuretics and try ACEi later on and then B-blockers and alpha blockers

remember achieving normal blood pressure control might not be achievable in all cases
remember 2ry hypertension causes in younger patients, patients with rapidly rising hypertension and resistent cases
familirise yourself with common side effects of the medications you are using and inform your patient to build a trust in your relationship with them and work alongside each other
once good control is achieved review once yearly with bloods for U&E , urine dip stick for protein, fundoscopy for retinopathy and of course blood pressure reading
continue advice about life style changes


add

MRCP/MRCGP Asthma control in adults

Stepwsie approach
short acting B-agonist as required
add steroid inhalor twice daily
long acting B-agonist
increase the dose of steroids up to 800mcg/day
increase dose of steroids up to 2000mcg/day
consider salbutamol tablets, theophyllines

use systemic steroids to control acute flare ups

Primary Hypertension control guidelines

Primary Hypertension control guidelines ( not secondary hypertension)

It is lifelong condition like most of chronic diseases. Treatment need to be tailored to patient preferences and needs and patient need to make informed decision.

For non-UK trainees that is ultimately important as it is not part of our training, you need to think patient is your partner that you need to work alongside him and you need to make sure he is on board otherwise your treatment plan would not be successful. Just think of your role as a doctor is actually a facilitator, to guide the patient to achieve what is best for his health.

First question Why?

Patients with persistent high pressure have higher risks of cardiovascular events (heart failure, Ischemic heart disease), cerebrovascular events (stroke), end organ damage and higher incidence of comorbidities.

Targets

Two Blood pressure readings above 140/90 are essential to confirm the diagnosis. The current recommendation is not to start antihypertensives till readings of 160/100 but once started you should aim for 140/90.

Work up needed for all patients

 Urine test for protein (using test strip)

 Plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL cholesterol

12-lead electrocardiography

That will help you to assess the cardiovascular risk and guide the decision of starting pharmacological agents

Life style changes

It is ultimately important to get the patient to join in, Life style changes alone can be enough measure to bring BP below 160/100 back to normal levels.

Again remember that normal blood pressure decrease the risk of cardiovascular events and death.

Changes to consider

Exercise, Exercise, Exercise………….  Regular moderate intensity exercise, walking 20-30 mins 5 days a week

Maintain low salt, low fat diet

Decrease caffeine intake, that include soda drinks and tea

When to Treat

Patients with BP reading above 160/100

Patient with BP reading above 140/90 with other cardiovascular risk factors ( existing cardiovascular disease, end organ damage, 10 years CVD risk of 20%or more )

Pharmacological interventions

That is the easy bit

Different categories

Patients older than 55 years or from black origin

Thiazides

Calcium channel blockers

Patient younger than 55 years and not from black origin

Angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II receptor antagonist if

an ACE inhibitor is not tolerated).

The Combination of ACE and CaChB is a good combination

You can combine the whole three to achieve better blood pressure control.

B-blockers and alpha blockers should be reserved for patients with persistently high blood pressure after using the whole three combined together.

Other pharmacological intervention

Aspirin 75mg, big debate about usage for primary prevention and current guidance is not in favour in UK.  I would recommend it though if you are sure there are no contraindications (Peptic ulcers and chronic kidney disease).

Statins should be considered for all of those patients with high cholesterol.

 Next antihypertensive medications, how to start, titrate doses and when to review for response

Please feel free to leave any comments

Please if you have a topic you want me to cover please leave me a note

Reference SIGN guidelines for hypertension management

Note that there would be new guidelines coming from NICE at the end of the year, I will give you an update as appropriate