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kris

Kris tips for CASC

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Thought of starting separate thread so that candidates find it useful now and days before the exam too!!!

I take candidates have had some time to reflect on the feedback.

I would like to share with the candidates about a book I read borrowing from local library which helped enormously in my preparation for CASC. Below is the link from amazon (I do not get any commission)

http://www.amazon.co.uk/dp/033523870X/?tag=hydra0b-21&hvadid=9550933749&ref=asc_df_033523870X

I request candidates to focus on active listening which will be tested again and again in various stations in the CASC exam.

Will chip in with more tips as my time permits!!

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Regarding preparing for the actual exam, after making sense of feedback (I will try and discuss my drawbacks and what I did to improve later) and understanding active listening (I will try and discuss my understanding of active listening later), I thought about what is it I should do and know to appear confident in the actual exam.

As this was my third attempt, I had some idea about stations to expect but never did I make any assumptions.

Basic rules I followed (learned the hard way!!!)

1. Reading the instructions carefully and understanding what is the actual task (MSE, History, Risk assessment,only symptoms, only physical examination, addressing concerns, discussing or not discussing diagnosis, discussing or not discussing management, seeking or not seeking consent). Based on the actual task each and every information on the instructions is there for a reason, so try and make use of it to get going in the station. For instance, history taking in 70 year old will clearly indicate that the candidate should focus on illness commonly occuring in the elderly. I know this is basic stuff but given that College is looking for "experts" who can deliver in given time, we have to be on top!!!

2. Try and figure out what is the clinical situation from the instructions, for instance, are you seeing the patient in A&E/ward/clinic/home etc as this will give an idea about the severity, nature etc of the actual problem. It will also help you to jump in to the role quickly and develop rapport accordingly.

3. Try and figure out the mindset of the patient/carer/colleague in the particular clinical situation before entering the station from the instructions. For instance, if it says the carer has been waiting to see you, most likely carer will be annoyed so just apologise straightaway and you have developed rapport or if it says the patient has been brought by police to A&E, what it most likely means is the patient lacks insight and must be either confused about everything or angry with police. So acknowledge that fact with the patient and ask him/her to give his/her perspective of the situation. That solves the problem as you have developed rapport and have got him talking. If the instruction says address concerns of angry mother, I will not be surprised to see an angry mother most likely we would not see in usual clinical practise but College wants to check if candidate can deal with extreme scenarious!!! So switch yourself to active listening mode, that is don't react to what the mother is saying for instance if she says "you are not doing anything to help my son" just acknowledge that the mother is upset!! What I would do is ask the mother gently as to what is it she is clearly upset about. (these techniques are taught to local graduates hence they pass easily but as an IMG I had no clue as to how to deal with this situation till I understood active listening) and by doing so, you are encouraging the mother to verbalise the actual problem and she feels comfortable as you have offered to listen to her. What the candidate should not do is go in to denial saying "it is not my fault" "we are doing everything we can" or become frustrated thinking once again my colleagues have not done their best (not everybody does their job in NHS) but that does not mean the candidate takes all the responsibility. What it means is accept unacceptable behaviour, acknowledge, give hope to carer that things will be put right, seek their help and clarify their expectations etc etc

I will try and chip in with more if time permits.

On a lighter note, my wife has agreed to allow to me to spend 10-20 minutes a day on superego, as I have passed the exam now!!!!

Edited by kris
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hahahhaha@ the last bit Kris. we men know where ure coming from

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hahahhaha@ the last bit Kris. we men know where ure coming from

Peechoo - i dont think it is relevant to ALL men though... ;)

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Thought one would be able to chill out after passing the exam but never in this profession and in this country!!!

Below is the draft I used repeatedly in any history taking station to make sure I did not miss anything in the actual exam due to nerves.

If the scenario states take a history from the patient/ carer- it implies History of presenting illness with associated risks generally. However be mindful if the scenario is single station or complex, so then the information you gather would depend on the time allocated. Generally College makes it easier for the candidate by stating obviously what is the task and you will be able to finish the task in given time if you ration appropriately for the tasks with out deviating too much or looking for something not obvious or trying to think actor/ college is deliberately trying to trick you!!! and as a result candidate will dig his/her own grave!!!

Always go with the flow of the patient/ carer to start with. Common sense states candidates taking CASC should have some sense of what might be the likely condition the patient might be suffering based on the scenario even before he/she talks to the patient.

For instance if the patient is psychotic, he would be reluctant to discuss his symptoms but on the other hand a manic patient would be all over you. Good candidate would pick on this very quickly and adjusts his style of interview to pass the station. The approach also applies to a carer, for instance if the carer is angry, expect to be bombarded with questions and lot of anger but on the other hand if the carer is there to take bad news, you are required to do the talking by setting the scene and responding appropriately to the carers emotions.

Back with taking history-

Focus on chief complaint and immediately establish time line as to when it started to be sure if it is acute/ chronic/ intermittent.

If psychotic patient with persecutory beliefs about neighbours- ask when did he/she become aware of neighbours wanting to cause harm or if depressed patient states does not feel like doing anything- ask since when he started to feel that way. It is also important to have some idea of the patients best level of functioning before they developed complaints. I know we all do this day in and day out in routine clinics but the problem in the exam is if the candidate misses one step for instance misses the timeline he will completely deviate in his history and ask for symptoms which he/ she will not be able to elicit and then come out and shout on the forum saying that the actor was "difficult." College is very clever to set traps and they love it.

Example: scenario would be 65 year old man not looking after himself, GP concerned. Possible causes for the problem are numerous and the candidates responsiblity is to find out the most likely cause in 7 minutes!! College instructions might be that the person is depressed or psychotic or demented or delirious or etc Hence it is important for the candidate to go with open mind and follow the logical sequence.

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After understanding the nature of chief complaint, onset, age and bit of circumstances of presentation, the candidate by now would have possible diagnosis in his/her mind.

For instance, if it is depression, check for triggering factors by asking a general question- did you have any worries around that time for eg, family, personal, money, work etc etc

Next, you need to establish if the patient is really suffering from depression, so use ICD-10 criteria. Generalise, stating when people have had such and such stress, it is also likely that they might experience other symptoms or problems, seek permission if it is ok to check and then screen through ICD-10 criteria. Just brief questions like- how is your mood- the way you feel in yourself, what about energy levels, motivation etc etc again generalise before you ask any sensitive question- for eg- when people feel low in mood, they can also have thoughts of wanting to kill themselves, have you had any of such thoughts.

By now, you have roughly established the possible diagnosis.

say you know by now what might be the problem, but just want to make sure you are not missing anything and hence would like to check if there are any other symptoms- screen for co-morbid conditions- in this case screen for anxiety, OCD, paranoia or ideas of reference, alcohol problem- just ask one question and move on- patient might not have much to say!!

Next is establising severity of the condition- generalise saying when people feel low, they can have various problems, drink alcohol to cope, do you see yourself drinking more than usual, also ask how the condition is affecting their life and family members life.

Next ask patient their understanding of the problems, family's understanding of the problems

Ask patient what they have done to help themselves, if anything, has it helped.

Lastly ask what they would like to happen now.

That covers History.

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Approach to station where you are asked to conduct MSE. It will involve mostly 2 scenarios ie psychosis or mania. The stations can be just single or linked depending on the additional task. So you have to be flexible with time management.

What do we know of the mindset of a patient who is psychotic or manic. I am sorry to be sounding so basic but my goal is to help people pass the exam. Please try and think for yourself.

This is what I will do in manic station-

  1. get the patient talking- he will definetly talk about his beliefs/ exeperiences (which will most likely be grandiose, bizarre, persecutory, psychotic experiences etc), appear interested to know more about his beliefs- gently ask him when did he become aware of the belief or experience- then switch to appearing curious- ask simple questions like- when, how, where, what find a balance don't dig deep but establish bizarreness etc etc- by now you would have picked on the bizarre nature of the belief or experience
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Hi Afterlife

Thanks. Please let me know if I can be of any help with your CASC practice.

I would gladly do my best because of all the people, I would like you to pass this exam.

Best of luck.

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Many thanks Kris, I shall let you know if there is anything.

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Please find below stations from last CASC exam Sept 2012.

CASC stations Sept 2012

Day 1

Linked stations

1. Collaborative history from nurse about patient with chronic schizophrenia

who has been recently discharged from the hospital

2. Discuss with patients father and address his concerns

3. History, MSE of a old age farmer brought by son to A&E

4. Discuss diagnosis and management with son and address his concerns

5. Collaborative history from mother of 35 year old Romanian lady who

presented mute and not eating.

6. Discuss management with nurse on medical ward and address her

concerns.

7. Relevant history from patient who complains of sudden loss of vision

during funeral of his father. Conduct eye examination to look for vision, eye

movements and ophthalmoscopy.

8. Discuss diagnosis, aetiology and address concerns of patients mother.

Single stations

1. MSE of young adult found shouting on the street at 3am. Brought to A&E

by police.

2. Relevant history to establish diagnosis of mental disorder in a young lady

who has set fire. Also elicit features of conditions associated with risk of fire

setting.

3. 35 year old lady with chronic schizophrenia, recent prolactin 728 (normal

500) on Risperidone 6mg od. Previously on Depixol depot for more than 10

years. Assess symptoms relevant to hyperprolactinaemia. Discuss

relevance of high prolactin levels.

4. Elderly man found wandering in the city centre brought by police to A&E.

Conduct cognitive examination.

5. Middle aged heroin user. Take history to establish current drug use. Elicit

extent and nature of the problem.

6. Middle aged lady with OCD not responded to ERP. Discuss medication

option and address her concerns.

7. 25 year old moderate to severe LD attending day hospital. Key worker

concerned. Also patient suffers from epilepsy. Collaborative history to elicit

cause of the presentation.

8. Middle aged man dropped out of therapy after attending 4 sessions. Take

history to establish reasons and discuss transference reaction.

Day 2

Linked stations

1. Assess a man who has assaulted someone. Do take history, MSE & RA

Discuss with student nurse - management

(New station, patient psychotic)

2.Take history from AOT nurse (repeat from yesterday)

3. Heroin & pregnancy

4.Dementia - History taking from carer (BPSD- wife stopped visiting, not

invloved in gardening)

Speak to the angry son- Olanzapine

Single stations

1) 16 year old girl was brought to A&E by her parents as she is "out of

control". She wants to speak to you without parents as they don't understand

her. Arrive to diagnosis

2) Erotomania. Old station with stalker of nurse Fiona

3) The female patient who was admitted 3 days ago and has ds of

Schizophrenia, complicated with drug abuse. She went on leave today and

on return displayed unusual behaviour: was observed responding,

distractable etc. She refused to have Urine Screen. Please talk to her about

the urine screen. Do not take history or MSE.

4) Cognitive assessment with accent on frontal lobe

5) Elderly lady, who tried to set fire in the gardent. Assess delusional beliefs,

their contents. Find out if they are primary or secondary. Risk assessment

6) OCD, had 12 sessions of ERP. Please discuss drug treatment, address

concerns.

7) young male, attended A&E. 3 days ago he was prescribed

Trifluo....Presented agitated and restless. He flushed the tablets down the

toilet. Assess why the medication was prescribed. Explain what is the cause

of his problems. Address concerns and discuss management

8) Male with depression and job loss. Had 4 sessions of treatment notspecified.

Find out if there is transference phenomena. Help the patient to make

decision.

Day 3

Linked stations

CASC Stations on Thursday 13/09/2012

Linked

Footballer for cognitive distortions assessment

Speak to Manager Re Management

Assess Patient on the Ward Re assault on another Patient

Speak to Student Nurse Re management

Assess old lady on medical ward with confusion ,temperature,infection

Speak to Student Nurse re management

Assess lady with memory problems

Speak to Husband re management,today it was MCINTYRE

SIngle Stations

Lady who started a bonfire in her front lawn

Assess Patient re home leave

Pain in the backside, assess

Depression not responding to Fluoxetine and Venlafaxine, management

options

Mother demanding that Son be discharged Home,Son has Schizophrenia and

on Clozapine

Akathisia after GP commenced him on Trifluo , management.

Dementia in Downs syndrome, Hx from Mother

Social Hx in Alcohol dependance

Day 4

Linked stations

Stations from 14th Sep:

Linked:

1) 16 year old girl referred by GP. Assess her mental state and take history to

come to possible diagnoses. You will be discussing management with

consultant in the next station

2) Overdose by teacher (64 Paracetamol) found by friend (Overdose

assessment/risk/social history)/ Talk to friend and address her concerns

3) Lady with memory problems, History and cognitive examination/ Talk to

husband re: MCI

4) Adult ADHD, Judo player, Confirm diagnosis and Medication issue/ Talk to

coach

Single:

1) Eating disorder stable now( but assess for good and poor prognostic

factors)

2) Talk to mother of a son who has diagnosis of Schiz. and due to be

commenced on Clozapine on a ward

3) Explain Alzh. risk to relative

4) Pain disorder

5) Lady in therapy (Psychodynamic) wants to stop sessions

6) Examination for Cerebellar function in an alcoholic person

7) Dementia drug explanation to relative

8) 18 year old brought by father after a festival, concerned about mental

health. Perform mental state examination. Single stations

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Please find below youtube links for some of the physical examination stations

Physical Examination Stations for CASC

Thyroid Examination

Upper Limb Neurological Examination

Lower Limb Neurological Examination

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Ophthalmoscope

Ophthalmoscopy Examination

Cranial Nerve Examination

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Other interesting and helpful videos

Desensitisation

CBT

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Thanks alot Kris.I'm preparing for the first attempt of CASC and your tips helped me to feel the exam conditions more closely. if you have any additional advices, descriptions or tips I'll be grateful to know from you.

What are your plans now after finishing your MRCPsych?

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Thanks a lot Kris .you've been extremely helpfu!

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Thank you friends.

I have been working hard on compiling all my CASC study material for easy reading to help lot more candidates in future. I am very optimistic it will be helpful to all and definitely more helpful to IMG's.

I would appreciate views of prospective candidates on two points below

1. Would you prefer the notes only in soft copy with no set charges but would encourage you to donate (whatever amount) directly to charity in India i have started Chiguru Foundation (for details visit Facebook page and please click like to help the message reach many) to provide free mental health care and conduct mental health awareness campaigns? Or

2. In the form of textbook, where you may have to buy from publishers (hope somebody publishes) and pay for it?

I appreciate all your views as early as possible.

Please vote option 1 or option 2 in your message to keep it easy and simple.

Many thanks

Krishna Thalagavara

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Kris,

Many thanks for ur kindness and willingness to help us in our plight to pass this casc.I think the first option would be better as sending material to publishers might take a lot of time and we only have 5 months preparation time left for next exam. I would be very happy either to pay u for ur materials or to donate as per ur wishes.

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Dear Friends

 

I am pleased to inform that the work on CASC booklet is going smoothly and I am hoping to complete and have booklet for circulation by mid May 2013.

 

I am happy to post couple of chapters here for all of you to have a read soon. In the meanwhile, I would encourage candidates to send personal message expressing their interest to obtain a copy along with their address.

 

Hope to be of help to lots of you.

 

Many thanks

 

Regards

 

S R Krishna Thalagavara

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in your blog one of the Q&A is

 

What causes Autism?

The most common cause is abnormal or defective ‘genes’ passed on from parents to the child.

 

will parents don't feel upset and guilty if you put it so bluntly to them.is there any better way of answering this question?

 

 

Please follow my blog below for explanation on Autism in simple language

 

http://krishnathalagavara.wordpress.com/

 

Kind request, please like and share Chiguru Foundation Facebook page.

 

Thanks

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i hope your CASC booklet doesn't contain similar answers like autism Q&A posted above

Dear Friends

 

I am pleased to inform that the work on CASC booklet is going smoothly and I am hoping to complete and have booklet for circulation by mid May 2013.

 

I am happy to post couple of chapters here for all of you to have a read soon. In the meanwhile, I would encourage candidates to send personal message expressing their interest to obtain a copy along with their address.

 

Hope to be of help to lots of you.

 

Many thanks

 

Regards

 

S R Krishna Thalagavara

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