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umesh

CASC - what worked for me

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thanx doctor for your invaluable hints and advices please keep on posting more info, Jan 2013 is coming soon.

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Hi Umesh

Thank you so much for your thoughtfulness. I really appreciate your courage to do this.

Thanks again.

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Any chance I can get hold of you via skype or mobile- I am doing it for the first time and have few burning questions after reading this forum.

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thank u very much for ur help i appreciate the effort u r doing here i took the exam last january i didnt pass i can see now how far i was from doing it i studied hard but i didnt grasp the whole picture as u r posting here i m preparing for january now with different strategy waiting for ur post it s really ll make alot of diffrence with me

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Hi Folks,

some more info.

learning disability patient - general points to remember.

1) try to know name and age of the patient....if not given in the task (like the station I had in my exam) ask the carer/nurse.

2) depending on the station, try to know degree of L.D - mild/moderate/severe

3) if they ask aetiology/risk remember to cover these points -

physical health - any infection/pain/constipation

mental health - mood/psychosis/anxiety

sensory impairment - hearing or vision problems

medication - if any, any changes, compliance

any changes in surrounding - in terms of accommodation (e.g change in room), change in carers (nurses), change in activities

info on family members - any change there

(there is a station where mother would have stopped attending care home due to her becoming unwell, leading to a change n behaviour of patient with other history of a new disruptive resident and discontinuation of gardening activity which would have made him unwell )

in terms of any behaviour itself, you need to cover - onset, duration, progression, what makes it worse, what makes it better, any other behaviours/symptoms. what is the view of the carer/nurse in terms of patients presentation.

common stations that come in exam are -

  1. disruptive behaviour - speak to nurse to explore aetiology (need to cover above pointers)
  2. L.D couples with mild or moderate degree (I am not sure) - wife pregnant but mother against it and wants them to have abortion - this is a linked station (will try to post info on this station some other time)
  3. 50 something patient with downs syndrome with memory problems

bottom line is, you will be speaking to parent/nurse in this station and main task is to get relevant history......however you need to be mindful of taking time to say some empathic sentences in-between as you are speaking to carers/nurse who are concerned about patient.

make sure you are thorough with the list under point (3) as this is what you will generally cover in L.D patient

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oh I forgot to add very important point in MCI station.........in the second station, the carer will ask, can you please prescribe him/her anti dementia drugs to prevent him from getting dementia....

main thing to say is its difficult to say who go on to get dementia and research has not shown any benefit in prescribing medication.....and antidementia medications cannot prevent or cure dementia........the main approach for someone with MCI is watchful waiting and support to enhance memory as i explained earlier.

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hi folks,

I posted a reply to a station in a different thread which I am copying here to add to the list of stations I am giving details about.

station - lady building fire in the back garden.Assess her delusional beliefs...content.Find out if they are primary or secondary?do a risk assessement

the lady will have delusion of poverty and no other symptom as such....royal college used to give a station with similar history but with nihilistic delusion in the past but this september it was about delusion of poverty.

history is - she is building fire outside the garden....as you ask her as to why she is doing it....she will say that she does not have money for funeral and hence she is building fire....you need to explore more about her belief of having no money and at the same time clarifying about any nihilistic delusion which she denies....when you ask if she thinks she is already dead, she denies this.

as for delusion of poverty.....you need to ask when did she first realise that she does not have any money.....to identify if it is primary or secondary....ask if she suddenly realised that she does not have any money or if something happened which made her to realise that.....she will say that nothing happened but she knows she is poor.....then you need to test the fixity and the truth of her belief....

for this you need to ask her a bit about her social situation, who does she live with (alone - so you are assessing risk as well), how long has she lived alone, does she work (no) , how much money she has in her bank (she says she has about 30000 or 40000 pounds in her bank) - this info will confirm that she is not poor and her belief is not real.....then test fixity of belief......ask her why she thinks she is poor in spite of having so much money in her bank, how sure she is that she is poor...could it be that she is unwell and she is thinking like this - she denies this.

then you need to assess risk - to her - risk of harm to self - selfharm/suicide thoughts, risk of fire, risk of self neglect, check her mood if depressed.

in the end summarise her belief.....that she thinks she is poor, which started suddenly a few weeks ago and inspite of having money in bank she thinks she is poor.

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hi all i can how much i m gratefull for ur help it really make a difference about the bonfire station i attend spmm course 1 week ago n they ve the scenario that the lady think she s dead because she saw an angel 2 dayys ago that told her she s dead so she decide to sit fire in backyard i m not sure about other details as far as i can remember that she s depressed but not really cooperative about talking do u think there s 2 different scenariofor this station?

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Thanks a LOT, Umesh. I am sure everybody appreciate your time & hardwork. Please keep going as you know this is the time we will all be looking fro help & hope.

To answer to DrKoukou- the 2 stations are different in terms of different Delusions ie Delusion of Poverty & Nihilistic Deluisions (SPMM).

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Hi Folks,

some more info. thought will write some general points related to some tricky stations.

station - mother of Schizophrenia patient angry about over hearing a nurse talking about her son being diagnosed with schizophrenia. Son is an inpatient with psychosis and diagnosed with SCZ...urine drug screen negative (if I remember right). talk to mother and address her concerns

the main task in this station is to 1) manage an angry carer, 2) give info on Scz and 3) acknowledge the mistake of nurse

1) managing angry mother - the moment you enter the station and introduce yourself, mother who will be standing will start speaking in a high tone showing her irritability about the news of her son being diagnosed with SCZ.....the main thing to do here is to allow her to vent her anger (or allow actor to finish her script) and once she does, acknowledge the mistake done by the nurse (task 3) by saying...."well Mrs Smith, its unfortunate that you had to hear about your sons condition like that...I am sorry about it...I will look into this matter....HOWEVER (this is a very useful word in CASC exam as it helps you to acknowledge the patient/carer perspective but allows you to add in your views after that to steer them towards accepting your view) I am here to let you know more about your Son's Diagnosis/condition/illness and address any concerns or questions you have about him and his illness....after this request her to sit down..."can you please take a seat (or do you want to sit down) so that we can discuss further about this".....she may or may not sit...but you have done your bit by asking.....then you go ahead and sit in your chair and continue the conversation...she will eventually sit and ask you questions.

her questions are - "are you sure its SCZ...I think its drug related" - you need to let her know that although illicit drugs do increase the risk of some one having psychosis, if it is due to drugs the symptoms go away if they do not take drugs....in her sons case urine drug screen is negative...so its not due to drugs and its more due to SCZ.

"Why did he get it...am I to be blamed" - here you need to reassure her that it is not her fault in anyway...something like "no Mrs Smith, its not your fault....its difficult to say who gets SCZ...there is no one reason for it...many factors addup...like chemical imbalance, illicit drugs, social stress and if someone in family has SCZ it increases risk"

"will he be able to continue his college...have a family"

here you need to reassure again but avoid giving false hopes.....actually in any station when you are speaking to a carer/patient asking about any illness you need to sugarcoat it and say it in a reassuring way and at the same time not giving false hopes and reassurances (here use of word HOWEVER comes in handy...e.g someone with Dementia.....unfortunately there is no cure for this...however our goal will be to improve his quality of life as much as possible and provide good support both for him and you)

so as for the question - you need to say something on the general lines talking about the illness nature and about how people respond to it...."this is his first episode......its too early to say how his illness will affect his life....HOWEVER generally there are many people with SCZ who do manage doing well in their life inspite of the illness and also have family....if he takes his medication regularly and with good support from his family, friends and our team, I dont see any reason why he will not be able to do them...but again we will have to wait and see"...if you want you can tell the rule of third....1/3rd improve and dont have any more episodes.....1/3rd get better but have episodes inbetween....1/3rd get worse.(I think you can use this rule in general to any mental health condition)

what are you going to do now - tell about management plan - he is on medication....once he improves...we will give him some leave..and once he recovers from this episode...he will be discharged form the ward...and we will continue to see him in clinic regularly, once in few months....a nurse will see him at home...if need be we can provide other support as well.

then talk about providing leaflet on SCZ....again acknowledge that it must have been difficult for her to hear about her son the way she did....again apologise...ask if she wants to complain she can...end the station by asking if she has any more questions and if not tell her that if she has in the future to get back to you and you will be more than happy to address them.

in summary...the main skills tested in this station are 1) angry person - acknowledging the emotion (I think this is a very important skill you need to use in many stations wherein you need to acknowledge how you think the patient is feeling...e.g I can see you are upset/angry, I can understand you are not happy/ you are sad, I can see that you are really struggling with your social situation, I can see that you are restless and agitated (EPSE pt), I can see you are quite restless and active..is this normal to you (manic patient)

2) acknowledging the error from the nurse 3) giving details of the illness - in a reassuring manner 4) leaflets/will see again if need be.

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Hi Folks,

some more info.

people advice about dress code, body language and various techniques you need to use during stations. I think these are totally irrelevant...dont waste time worrying about what you will wear or how you will sit as nobody has time to observe these things during the exam, be it the examiner or the patient or you for that matter....everyone has their own worries to think about.....you worry about what to ask, actor worried about remembering the script and probably the examiner will be thinking something in his personal life and all he wants is the exam to get over and all he is bothered is how is your communication style, how well do you establish rapport and show empathy to patient and how much have you covered in the checklist he has for the station......yes the examiner has a checklist....apparently all the examiners sit together in the morning and agree to a list of things that needs to be covered in each station and agree on what are the most important points to cover.....process facilitated by the co-ordinator for the day..........the exam itself is such a fast paced scenario that before you realise, the morning session is over and the afternoon session gets over even sooner as it is just 7 minute stations. so as long as you wear something presentable and sit comfortable it should be ok.

what you need the most is a checklist for yourself in each station.......checklist of things that are important in that particular station....but during the first 1-3 minutes you need to go with the flow of the patient as they will have a script and they will tell you things initially which you need to pick up and ask further questions based on that....so initial 1-2 minutes dont be in a hurry to ask your own specific questions....rahter sit back and hear to what the actor has to say....he is there to help you.....what I have seen is, but for 1 station where the actor is told to be difficult purposefully, in the rest of the stations they are very helpful and forth coming with relevant info.

so where the checklist comes in handy is the later part of the station when you can go methodically asking the questions in your list and at the same time making sure it is not abrupt, blunt or significant deviation from the previous question..........one good thing to remember is to find some link to your next question from previous question.....e.g so you told me you are struggling with sleep...what about your appetite?....rather than asking "how is your sleep....after they ans...how is your appetite....it comes across as blunt and mechanical....as long as you avoid coming across as mechanical...it doesnot matter how you ask your questions.

e.g - guy with morbid jealousy.............you need to have a list something like this.....1) some questions on his beliefs...2) conviction of belief 3) behaviours to find proof 4) future plan 5) ACCESS TO WEAPON (most important) and any thoughts of harm to her or her alleged partner 6) child protection issues (if they have kids....then have they witnessed any domestic violence...verbal or Physical aggression) 7) alcohol history (most common cause) 8) past history of - forensic/previous relationship/similar relatrionship issues

so if you have these pointers in your mind when you enter the station, you will be able to cover significant portions of these (if not all) and you should pass this station.....asking questions to the actor will also be easy as you have stock of questions to ask next, rather than being led by patient completely throughout the station....as I said earlier, during initial 1-3 minutes you need to go with the actor and as he gives more info, you need to cover your checklist points asking relevant questions based on what he says...but during later part of interview you need to ask direct questions to info you want to know...that way you come across as someone who build the rapport with patient initially itself and also covered all major points and have more chance to pass the station.

probably this shoud be the general approach to most stations....have checklist...use it during later part of interview.....initially go with patient for 1-3 minutes

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Hi Umesh

Could you help us with the station mentioned below.

L.D couples with mild or moderate degree- wife pregnant but mother against it and wants them to have abortion - this is a linked station .

I am unsure as to what they are looking for in this station

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Hi Folks,

some more info.

people advice about dress code, body language and various techniques you need to use during stations. I think these are totally irrelevant...dont waste time worrying about what you will wear or how you will sit as nobody has time to observe these things during the exam, be it the examiner or the patient or you for that matter....everyone has their own worries to think about.....you worry about what to ask, actor worried about remembering the script and probably the examiner will be thinking something in his personal life and all he wants is the exam to get over and all he is bothered is how is your communication style, how well do you establish rapport and show empathy to patient and how much have you covered in the checklist he has for the station......yes the examiner has a checklist....apparently all the examiners sit together in the morning and agree to a list of things that needs to be covered in each station and agree on what are the most important points to cover.....process facilitated by the co-ordinator for the day..........the exam itself is such a fast paced scenario that before you realise, the morning session is over and the afternoon session gets over even sooner as it is just 7 minute stations. so as long as you wear something presentable and sit comfortable it should be ok.

what you need the most is a checklist for yourself in each station.......checklist of things that are important in that particular station....but during the first 1-3 minutes you need to go with the flow of the patient as they will have a script and they will tell you things initially which you need to pick up and ask further questions based on that....so initial 1-2 minutes dont be in a hurry to ask your own specific questions....rahter sit back and hear to what the actor has to say....he is there to help you.....what I have seen is, but for 1 station where the actor is told to be difficult purposefully, in the rest of the stations they are very helpful and forth coming with relevant info.

so where the checklist comes in handy is the later part of the station when you can go methodically asking the questions in your list and at the same time making sure it is not abrupt, blunt or significant deviation from the previous question..........one good thing to remember is to find some link to your next question from previous question.....e.g so you told me you are struggling with sleep...what about your appetite?....rather than asking "how is your sleep....after they ans...how is your appetite....it comes across as blunt and mechanical....as long as you avoid coming across as mechanical...it doesnot matter how you ask your questions.

e.g - guy with morbid jealousy.............you need to have a list something like this.....1) some questions on his beliefs...2) conviction of belief 3) behaviours to find proof 4) future plan 5) ACCESS TO WEAPON (most important) and any thoughts of harm to her or her alleged partner 6) child protection issues (if they have kids....then have they witnessed any domestic violence...verbal or Physical aggression) 7) alcohol history (most common cause) 8) past history of - forensic/previous relationship/similar relatrionship issues

so if you have these pointers in your mind when you enter the station, you will be able to cover significant portions of these (if not all) and you should pass this station.....asking questions to the actor will also be easy as you have stock of questions to ask next, rather than being led by patient completely throughout the station....as I said earlier, during initial 1-3 minutes you need to go with the actor and as he gives more info, you need to cover your checklist points asking relevant questions based on what he says...but during later part of interview you need to ask direct questions to info you want to know...that way you come across as someone who build the rapport with patient initially itself and also covered all major points and have more chance to pass the station.

probably this shoud be the general approach to most stations....have checklist...use it during later part of interview.....initially go with patient for 1-3 minutes

A great few posts I must say. A lot of good advice and guidance for others. Good work Umesh and Congrtaz on passing the exams.

Though I agree with most of what you have said, I don’t agree with the part in red. I believe the examiners do notice these things, yes it’s irrelevant but if your initial impression is good you have a more favourable chance of passing the station(s). The reason why I say this is because (admit it or not - right or wrong, beside the point) there is a certain expectation from doctors; we have to be courteous, well dressed and empathic etc (kind of the parcel and package for us). After all this is a professional exam where we need to dress and act the part if we want to be looked at favourably and thus improve our chances of passing this ridiculous drama (read CASC)

;)

Having said that this is not the only thing that will help you pass so ofcourse you need the knowledge,manners and ability to back it up.

Edited by Insane in da Brain

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Hi Insane in da Brain,

I respect your views....totally valid.....and when I said do not worry too much about it, what I meant was dont spend too much time thinking about it....especially body language....because in the exam, you do not have time to think consciously as to how you are sitting and what is your body language...as for dress code, I am sure everyone will wear some neat ironed clothes to look comfortable......what I meant was, you dont have to go and buy some new clothes just for the exam....again, if you want to spend money and want to wear some new clothes to look the best and to feel more confident then its absolutely fine as well isn't it....bottom line is you (candidates taking CASC) choose what is best for you.....I was just giving pointers from my own experience of taking exam 3 times.

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linked station - LD patient, wife pregnant 1) talk to him 2) talk to mother

to briefly summarise the whole task, before I explain in detail, the main task in 1st station is - getting more history about the situation and to reassure him about the whole situation (bearing in mind not to overdo it and give false reassurance) that just having L.D will not make Social service to take the child away.

in 2nd station - its about a) being clear to the mother of your views and the current situation and at the same time B) showing a lot of empathy towards mother, acknowledging her important role in caring for her son over the years and reassuring that she is not expected to do it again and a lot of support will be given to her son/daughterinlaw

station 1 - you need to get more history, in terms of how old is he and her (this is important in terms of making decisions for themselves), degree of L.D for both, where do they live (if I remember right, they live in a residential/supported accomodation), how many weeks pregnant, was it planned or accidental, his and her views on pregnancy to know their commitment/motivation in caring for the baby......you need to ask his concerns/worries as well......he will say that he is worried that social service will take the child away.....if I remember right, he would have been agitated sometime recently, due to his worry. I am not sure if his partner had past history of illicit drugs but none at present (I am not sure about past history but there will not be any current history).

you need to clarify about their commitment/desire to go ahead with the pregnancy and to check with him, "do you think you will be able to manage caring for the child as it is a big responsibility (bearing in mind you ask this question in a way to check his understanding of the responsibility, rather than in a negative way referring to his L.D).

as you go along this station, you need to reassure him a few times inbetween as he will be visibly worried, probably saying that you are there to get more info on his situation and you will see how best they can be helped.....saying, just having L.D will not make S.S to take the child away......if the parents are motivated to care for their child, if L.D is mild (which will be in this station I think...I am not sure...even if it is moderate you need to say on the same lines...it will not be severe L.D in the exam) and if there are no major risks or issues, then S.S do support parents to care for their children as it is the best option for both parents and the baby......they will provide relevant support in parenting as well.

after you say this line, you should add that "however if there are any concerns then they will do an assessment of the situation and may decide otherwise for the welfare of the baby".......this is so that you dont give false reassurance but you are giving factual details to him. you need to end by saying that S.S will do an assessment during pregnancy and after delivery and then make a decision about parenting....just having L.D will not automatically make then to take away the child.....then reassure him that its early stages...lets hope everything works well and they will be able to care for their child....so it doesnot matter what you say to him, the main thing is to reassure him about the situation but at the same time not giving false reassurance

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2nd station - here initially mother will be irritable and angry...saying "can you arrange for sterilisation as I do not think they will be able to care for the child.....they have L.D......I cared for so many years for my son....it will come on me again to care for the child."

so here she is distressed in 2 ways....that her son and DIL cannot care for the child......that she will have to care again.

initial few seconds/minutes you need to just listen to what she says.....then clarify about what she says if need be....is that you main concern that they may not be able to care for the baby? why do you want them to have a sterilisation....have you spoken to them about your views?.....she will reply with answers wherein she shows her irritability/anger or other emotion....that is normal reaction....dont get too worried about it....just carry on asking questions....say something on the lines of "I understand your concerns about the situation....I understand you are not happy about it....I can see you are upset about it."....then say...."I have spoken to your son....they seem to be happy with the situation and they want to continue the pregnancy and looking forward and quite motivated to care for their baby in future.....as they are adults (you have asked the age in previous station), they have the freedom and rights to make the decision for themselves and we cannnot force them to decide otherwise....also sterilisation is an irreversible process (most important point to say in this station) and due to this we cannot decide for them and they will have to make the decision for themselves.

second part of station is reassuring her about future....tell her that, there are couples with mild L.D who have cared for their children effectively with good support from Social service and from the team.....however S.S will assess them during pregnancy and after delivery in terms of their ability to care for the child and if they have any concerns then they will look into other options like foster care with regular contact.....then add, I am aware that you have cared for your son through out your life, which is very commendable and no one can expect you to do it again for your grandchild if you do not wish to (this bit is the second most important point in this station that you have to say to pass the station)

end the station, asking if she has any other concerns or questions.

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Hi Umesh,

This is very helpful, thank you so much for sharing your experiences and very useful tips. Do you mind throwing some light on the station about an inpatient lady (still psychotic) asking to go on leave as she wanted to go near mud, delusional ideas??

What they are expecting in this station after eliciting the delusional beliefs?

Also if you could explain how to go about the station on refeeding synd in Anorexia Nervosa?

Many thanks,

Manish

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Hi Manish,

as for psychotic lady wanting to go on leave (I had this station in september 2012 and I passed this station).....the main task is 2 part.......1) psychosis - to elicit her fixed delusional belief......so you spend some time exploring her belief and then confirming its fixity (that she has strong firm belief) 2) risk - eliciting history indicating that she wants to bury herself in the sand to cleanse herself (by jumping from a bridge) and that she had tried it during previous leave.

the lady will be cooperative and gives info easily depending on how you ask the questions. if I remember the exam question correctly, the lady was admitted to ward under MHA (no specifics though understandably as its different in scotland and England) with psychosis a few days ago and now she wants to go on leave.

after initial introduction, you need to set the scene using the info from the question....something like....."i understand you want to go on leave.....i would like to ask you a few questions before we can make a decision on your leave.....is that ok with you?"

(since it is a 7 minute station, you need to make sure you move on with your questions quickly)......you need to ask questions on why and when she was admitted to hospital.....she will tell you about her delusional belief.....I dont remember what actually.....not sure if it is something about others able to read her thoughts....don't remember and don't want to give wrong info....hopefully someone who knows will pitch in with the right info......then you need to explore it further like any other delusion...about its fixity....falseness and conviction........

then ask about leave to know the risk - what she would do whe she goes on leave......I think you need to really ask some specific questions to explore the risk here....otherwise she will not give you full history and minimise the whole thing.....if I remember right, she will say something about wanting to go near the river/stream/canal so that she can purify herself......you ask how would she purify herself....she will say that she will use the sand.....you explore further...what will she do specifically....she will say that she will bury herself in the sand upto her neck.....then you ask her how would she bury herself......then she will say that she will go to a near by bridge and jump from there to bury herself in sand.....you explore her understanding of the risks involved in jumping from bridge....."dont you think you will get hurt badly if you jump from bridge?.....she will say nothing will happen.....if I remember right she will say that when she was given leave last time she had gone near the canal/stream to bury herself.

so in this station, you need to elicit her delusional belief....ask questions to confirm it is fixed unshakable belief......then elicit history about her plans to bury herself if given leave......jump from bridge to bury (she will not give this history until probed further as to how she would bury in mud/sand.....then elicit past history of similar intentions during previous leave or previous admission (I am not sure which one but there will be positive past history)

in the end you need to tell her that you feel that she is still unwell in her mental health....that you are concerned about her safety from what she has told....and you would not recommend leave at this point in time but it will be looked at in later stages when she is better......and for now you would advice her to stay in the ward.

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as for re feeding syndrome in anorexia......SPMM notes has very good info on this....its concise and gives all relevant info.....you just need to mug it up. will try to give info soon from what I remember.

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