Hands-on Guide to the Foundation Programme

Anna Donald, late of Bazian Ltd, London Michael Stein is Chief Medical Officer, Map of Medicine, London, and Medical Advisor, Hearst Business Media, Hearst Corporation, New York Ciaran Scott Hill is Neurosurgery Registrar, The Royal London Hospital, Honorary Senior Lecture in Neuroscience, Univesity College London, and Prehospital Care Physician, London Air AmbulanceSelina Chavda is NIHR Academic Clinical Fellow in Haemato-Oncology, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research

• Introduction xiiiHow to use this book xivAcknowledgements xvAbbreviations xvi1 Starting up 1Panic? 1People to help you 1Three basic tips 2Other useful start-up information 2Dress 2Equipment 3Geography 4Ward rounds 4Social rounds 5Night rounds 5Discharging patients 6Work environment 6Bibliography 62 Getting Organized or ‘The Folder’ 8Personal folder and the lists 8How to make a personal folder 8Keeping track of patients (List 1) 10List of things to do (List 2) 10Results sheet (List 3) 10Data protection and confidentiality 113 Paperwork and electronic medical records 12Patient notes 12Incident forms 13Blood forms and requesting bloods tests 14Discharge summaries (TTO/TTA) 15Handovers 16Referral letters 17Self-discharge 17Sick notes 174 Accident and emergency 19General advice 19Admitting and allocating patients 20Keeping track of patients 21Medicine 21Medical and surgical assessment units 22Fast-track patients 225 Becoming a better doctor 23Foundation Programmes (United Kingdom) 23Academic FoundationProgrammes 24Assessments 24Situational judgement tests 25Moving on from the Foundation Programme 26Information technology 26The internet 27Online medical databases 27Keeping up with the literature 28Evidence-based medicine 28Clinical audit 29Quality improvement projects 30Case reports 30Courses 30Professionalism 31Communication 31Consultants and senior registrars 32GPs 32Nurses 33Patients 34Patients’ families 35Confidentiality 36Exceptions to keeping confidentiality 36References 366 Emergencies 37Acute coronary syndrome 37Stroke 37DVT and PE 40Haematemesis 40Acute asthma 41Life-threatening asthma 42Acute severe asthma 42Brittle asthma 42Acute pneumothorax 42Anaphylaxis 43Meningitis 43Collapse or reduced mobility 45Overdose 45In general 46Treating the patient 46Surgery 487 Cardiac arrests and crash calls 49Cardiac arrest calls 49‘Do not resuscitate’ orders 528 Common calls 54How to use this section 56Considerations for all ward calls 56Abdominal pain 57Differential diagnoses 57Anaemia 58Arrhythmia 60Calcium 62Hypercalcaemia 64Hypocalcaemia 64Chest pain 65Confusion 66Differential diagnoses 66Constipation 68Differential diagnoses 68Diarrhoea 69Differential diagnoses 69Electrocardiograms 70Important ECG abnormalities to recognize 74Eye complaints 74The acute red eye 74Sudden loss of vision in one or both eyes 75Floaters 75Falls 75Differential diagnoses 75Fever 76Differential diagnosis 77The immunocompromised patient with fever 78Fits 78Differential diagnoses 78Intravenous fluids 79Upper gastrointestinal bleeds 81Lower gastrointestinal bleeds 82Glucose 82Haematuria 83Headaches 84Differential diagnoses and key symptoms 84Hypertension 85Peri operative hypertension 86Hypotension 86Differential diagnoses 86Insomnia 88Differential diagnoses and suggested management 88Management with benzodiazepines 88Itching 88Differential diagnoses (if no visible skin lesions or rash) 88Major trauma 89Minor trauma 90The moribund patient 91Nausea and vomiting 92Differential diagnoses 92Oxygen therapy 93Methods of oxygen delivery 93Pulse oximetry 94Phlebitis 94Management 94Potassium 94Hyperkalaemia 94Hypokalaemia 95Rashes and skin lesions 96Disease categories 1–10 96Shortness of breath 97Differential diagnoses 97The sick patient 98Sodium 98Hyponatraemia 98Differential diagnoses 99Transfusions 99Blood transfusions 99Platelet transfusions 100Urine: Low output (oliguria/anuria) 101Basic emergency routine 102Obstetrics and gynaecology calls 103Talking to the patient 103Gynaecological examination 103Obstetric examination 104Being a male 104Common gynaecological calls 105Termination of pregnancy 1069 Death and dying 107Terminal care 107Communication 107Breaking bad news 107Ongoing communication with dying patients 108Pain control 110Symptom control 110Prescribing for the dying 110Support for the dying and for you 111Death 111What to do when a patient dies 111Telling relatives about the patient’s death 112Religious practices on death 112PMs 112Death certificates 113Writing the death certificate 113Referring to the coroner (Scotland: Procurator fiscal) 114Cremation forms and fees 114To check for pacemakers 114Further reading 11410 Drugs 116General 116Prescribing drugs 116Drug charts 116Writing prescriptions 117Controlled drugs 117Verbals 118Giving drugs 118Drug infusions 119Prescribing drug infusions 119Intravenous drugs 120Specific drug topics 122Antibiotics 122Anticoagulation 122Digoxin 125Therapeutic drug levels 126Miscellaneous tips 12611 Handle with care 134Alcoholism 134Alcohol withdrawal 135Capacity 136Children 137Depression 137Elderly patients 138Haemophilia patients 139Taking blood 139For theatre 139HIV/AIDS 140Taking blood 140HIV testing 140Jehovah’s Witnesses/Christian Scientists 141Pregnant women 141Sickle cell anaemia 142The patient on steroids 142Side effects of steroids 142Managing ill patients on steroids 143Treating common side effects 143Withdrawing steroid therapy 143Haematological and oncological emergencies 144Spinal cord compression 144Superior vena cava obstruction and airway compromise 144Raised intracranial pressure 145Tumour lysis syndrome 145Hyperviscosity 14512 Approach to the medical patient 147History and examination 147Getting to know the disease 148History and examination 151Clinical stalemate 151Preparing patients for medical procedures 151Cardiac catheterization 152Elective DC cardioversion 152Upper gastrointestinal endoscopy 153Colonoscopy 154Flexible sigmoidoscopy 154Liver biopsy 155Pacemaker insertion 155Renal biopsy 156Specialist referrals and investigating the medical case 156Cardiology 157Gastroenterology 158Haematology 159Neurology 160Renal medicine 161Respiratory medicine 161Rheumatology 16213 Practical procedures 163General hints 163Interpreting ABGs 165Bladder catheterization 167Men 168Women 169Blood cultures 169Venepuncture 169Cannulation (Venflon/line insertion) 170Problems with temporary and tunnelled central lines 173Using central lines 173Chest drains 173Managing a chest drain 174How to remove a drain 175DC cardioversion 175Electrocardiogram 176Exercise stress test 176Relative contraindications (discuss with senior) 176The procedure 176Injections 177Subcutaneous 177Intramuscular 178Joint aspiration/injection 179Aspiration 179Injecting joints 180Local anaesthesia (for any procedure) 180Lumbar puncture 181Contraindications (get help) 181Mantoux test 184Nasogastric tubes 184Peritoneal tap (paracentesis) 185Pleural aspiration 185Indications 185Pulsus paradoxus 188Respiratory function tests 188Spirometry 188Peak expiratory flow rate 189Sutures 19014 Radiology 191Requesting investigations 191Minimizing radiation 192Common concerns about X-rays 192Pregnancy 193Plain films 193Chest X-rays 193Abdominal films 194Ultrasound 194Computed tomography 195General 195CT head – Some emergency indications 195Radioisotope scanning 19615 Approach to the surgical patient 198Introduction 198Preoperative care 198Clerking 198Preoperative tests 199Requesting blood preoperatively 200Preoperative fasting 200Consent 201Marking 203Booking theatre lists 203WHO checklist 205Perioperative prescribing 205Anti-emetics 205Analgesia 205Laxatives 205Bowel preparation 205Thromboprophylaxis 207Insulin infusion 207Post-operative care 207Wound checks 208Stoma care 209Enhanced recovery after surgery 209Theatre 210Further reading 21016 General practice 212What you can and cannot do 212You can 212You cannot 212Referral letters and note keeping 212General points 212Public health and health promotion 213Risks 213Benefits 213Condoms 214Intrauterine system 214Intrauterine device 214Contraceptive injection 214Contraceptive implants 214Smoking 215Lifestyle advice 215Notifiable diseases 215Vaccinations 215Breast screening 215Cervical screening 215Sexual health 216The hidden agenda and health beliefs 216Follow-up 216Home visits 21717 Self-care 218Accommodation 218Alternative careers 218Bleep 219British Medical Association 219Car insurance 219Clothes (laundry/stains) 220Contacting medical colleagues 220Contract and conditions of service 220What you need to know about your contract 220Doctors’ mess 225Making money for the mess 225Insurance (room contents) 225Jobs 225Curriculum vitae 225The interview 226Consultant career prospects 226Locums 226Meals 227Medical defence 227Money 228Income protection if long-term sick or disabled 228Student debt 228Mortgages 228Payslip deductions 228Pensions 229Tax 229Telephone and online banking 230Needlestick injuries 230If the patient is known to be HIV positive 231If the patient is known to be hepatitis positive 231Not coping 231Part-time work (flexible training) 232Representation of junior doctors 232Sleep and on-call rooms 232When things go wrong 233Bullying and psychological stress 233Whistle-blowing 233Appendix I: Scoring systems 235Cardiovascular 235CHA2DS2 VASc 235HASBLED score 235GRACE score 235TIMI Risk Index 236NYHA scoring system (New York Heart Failure Association Scoring System) 236Neurology 236TIA-ABCD2 scoring 236AMTS (abbreviatedmental test score) 237AVPU score 237(GCS) Glasgow Coma score 237Anaesthetics 237Mallampatti classification for intubation 237BMI 238Calculating anion gap 238Calculating serum osmolality 238Respiratory 238Gastroenterology 239Child Pugh classification 240Renal 241Trauma 241Barthel score 242Bathing 242Bladder 242Bowels 242Dressing 242Feeding 242Grooming 242Mobility 242Stairs 242Toilet 242Transfer 242Appendix II: Useful tests, numbers and other information 243Addresses 243Mental Health Act 243Notifiable diseases 244Results 244Haematology 244Biochemistry 245Useful biochemical formulae 245Fitness to drive 246Further resources 248Index 249