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CCA BODID Revision Ebrahim Aldhafiri What We Will Cover ■ Station Types (histories, explaining, data, etc) ■ Go through previous & high-yield stations ■ Top tips for the CCA Disclaimer: - This is meant to be a high-yield revision session that covers the most likely things to come up, and NOT everything. - Always refer to university resources. CCA Layout: ■ A station on each specialty ■ Most likely: – Explanation->Dermatology – History->InfectiousDisease – Examination->Breast – SBAR->OncologyCCA Revision Breast Breast History (lump, redness, skin changes) HPC PMH & DH Communication • Open Questions first • Open question “tell me more” • Cancers then closed • Location • Breast screening? • ICE • Timeline • Mention Patient’s • LMP - ?COCP • Changes over time • Menopause - ?HRT name • Lump • Empathy statement • Breastfeeding • Body Language • Number • Sign-post • Texture • Medications • Fixed / mobile • Summarise • Allergies • Plan going forward • Other lumps (armpits) • Skin Changes FH Risk Factors • Cancers in the family • Erythema • Age >50 • Ulceration • Any other conditions? • Family history • Dimpling • Temperature SH • Nulliparity • Not breastfeeding • Any nipple changes or discharge? • 1STpreg > 30 • Pain (SOCRATES) • Smoking, alcohol, drugs • Early menarche / late • Systemic symptoms (weight loss, menopause night sweats, fatigue) • Occupation • HRT / COCP • Living situation • PMH of BC • Travel • Ionising radiation Obesity Breast History Differential Fibroadenoma Fibrocystic Disease Breast Cancer • Common in young women • Common in middle-aged • Hard irregular lump • May be associated with • Highly mobile non-tender women mass • Multiple tender small discharge • Separate “not-attached to lumps • May cause skin • Symptoms worsen before changes like dimpling breast tissue” menstruation or nipple inversion Lactational Mammary Duct Mastitis Fat Necrosis Ectasia • Hot tender mass • More common in obese • Most common around • Associated with females with large menopause age breastfeeding breasts • Nipple retraction + green • Can develop into • May happen after trauma discharge abscess (hot red mass) • Hard irregular painless • Associated with smoking lump Ductal Paget’s Disease Breast Eczema Papilloma • Eczematoid changes • Itchy red rash that • Blood-stained discharge to the nipple (red scaly starts on areola first without underlying mass itchy sensation) then to the nipple • A type of benign tumour • Associated with breast • Patient may have cancer systemic eczema Breast Cancer Screening Programme Background Why Mammogram? High risk patients • A 3 yearly service for • Not affected by tissue women aged 50-70 density • Referred under 2WW for triple • Mammograms every 3 • Can differentiate assessment years between calcifications, cysts and suspicious masses Numbers Counselling points • Of 100 women who had scanned, only 4 are • All mammograms are recalled for triple done by females • A type of x-ray that assessment and only 1 is visualises the breast found to have cancer (that might be in early • Minimal x-ray (few stages) months of background x- ray) • Breast cancer affects 1 in 8 women and early detection saves livesTriple Assessment Background Referral Criteria • Aged ≥ 30 with an unexplained breast (or • A 3-step system in women axilla) lump with or without pain with suspected breast cancer • Aged ≥ 50 with any of the following • Done within 2 weeks as part of the 2WW referral symptoms in one nipple only: discharge, retraction or other changes of concern • Involves clinical assessment, • Clinical assessment suggesting breast imaging and biopsy cancer (e.g. GP history & examination) • Recalled from breast screening 1. Clinical Assessment 2. Imaging 3. Biopsy • Full history • Both mammogram & USS • Fine needle aspiration • Mammogram is more • Core biopsy -> involves • Examination with chaperone more information like sensitive in older women Patient counselling • May order MRI as next step cancer markers Tips (not usually done) • Introduce yourself • Mention numbers and most cases • Take very brief medical history are benign • Ask about knowledge on procedure • Mention even if malignant, treatable • ICE with high success rate • Explain each step in a summarised • Be empathetic way in simple language • Chunk and check • Summarise at the endCCA Revision Oncology SBAR Oncology Metastatic Spinal Cord Compression • Compression of the spinal cord • Presents with sudden onset • Whole spine MRI is the key due to bony metastasis worsening back pain, may be worse investigation • Associated mostly with prostate, on lying down or coughing • High dose dexamethasone (16mg) is • Lower limb weakness, sensory given to reduce compression lung or breast cancers • Time is key as delayed treatment changes or autonomic dysfunction • Urgent oncological assessment for can result in permanent nerve • Can cause bilateral sciatica possible surgical intervention or damage radiotherapy Neutropenic Sepsis • Can be caused by line infections • Sepsis 6, start antibiotics before • Diagnosis is by clinical picture, waiting culture or WBC results • Life-threatening sepsis in observations (fever) and FBC • Broad spectrum agents (tazocin or patients on chemotherapy 9 • Time is key as delayed treatment (neutropenia < 0.5x10 ) meropenem can be used) can lead to septic shock • Patient can present with either • If not responsive to Abx can indicate specific organ symptoms or illness fungal infection or resistant bacteria and non-specific symptoms • Urgent oncology assessment Hypercalcemia of Malignancy st • Elevated calcium levels due to • Symptoms of bones, stones, groans • 1 line: IV fluids (aggressive) lytic bone lesions (bony mets) and psychiatric overtones • IV bisphosphonates • Bone pain, urination, thirst, abdo pain, • Consider IV diuretics if treated dehydration • Time is key as delayed treatment constipation, renal stones, delirium • Continuous monitoring can lead to hypovolemic shock • Diagnosed by high corrected calcium • Urgent oncology assessment • ECG can show short QT Tumour Lysis Syndrome • Can lead to seizures, arrythmias, renal failure • Chemotherapy leading to lysis of • Symptoms of N&V, diarrohea, • Treated by IV fluids and IV tumour & release of content cramps, fatigue, seizures, palpitations • Associated with leukaemia and • High potassium, high phosphate, allopruinol to reduce uric acid • Anti-hyperkalemic agent lymphomas high uric acid, high creatinine and • Monitoring: Obs, Bloods, ECG low calcium • Urgent oncology assessment SBAR Oncology Situation • Don’t: • Mention your name and position • Mention too much about • Confirm the person’s name, the next steps (obs, position and if ready for handover • Mention a 1-liner about the differentials, etc) possible diagnosis • Keep it concise and don’t spend too much time here • Mention the patient’s ID, name, location, number, etc Background • Admission details: date & • Don’t: symptoms • Mention too much about the presentation (summarise it in • Relevant PMH, DH & allergies your words) Assessment • Don’t: • Observations • Forget to mention the • Examination findings abnormalities in numbers (e.g • Blood tests & imaging BP of 90/62) • Treatment so far • Don’t mention every number • Tips: (just say normal or abnormal) • Stay calm • You have more than enough Recommendation time in this station • In the few minutes before • Diagnosis and possible differential ringing, write down each letter • Plan for investigation & treatment and your own SBAR in a • Why is this an urgent issue requiring their presence summarised way • Ask if they want u to do anything while waiting SBAR Oncology: Example Situation • Hello my name is Ebrahim, I’m • Are you ready to receive a one of the junior doctors in A&E handover? can I please speak to the • His name is Jane Smith, 64M oncology doctor on call? (DoB 8/April/1960), Hospital • Can I confirm who you are? number 12345 with new onset • I have a patient with suspected fever and feeling unwell. I’m sepsis I want to discuss with you. worried about neutropenic sepsis Background • She presented an hour ago with • This patient is a known breast fever, dry cough and feeling unwell. cancer patient who was treated with surgical excision of tumour • She has no other relevant PMH and chemotherapy. Last cycle • She is allergic to ibuprofen (rash) and only on paracetamol for headaches was a week ago. Assessment • We have given oxygen, started • Observations: BP is low (105/73), PR is antibiotics and put a catheter 112 weak regular, RR is 26, oxygen in. sats 92% on room air, Temp 39.1 • We’re waiting the bloods (FBC, • She appears unwell, with mild U&Es, CRP, lactate. Cultures) sweating and extra breathing effort Recommendation • Can I ask you to come and review • I think she most likely to have her urgently as she is having a neutropenic sepsis, in light of her symptoms and PMH of possible oncological emergency? chemotherapy. • Is there anything u want me to do • We’ve started her on IV tazocin while waiting? (pipercillin and tazobactam)Clinical Trial Explanation Background Phases Positives • A scientific system done for tens of • 0. Experiment on very small number of humans years (or animals) to understand how the body reacts • Patients are the reason medications approved & • Ensures both safety and to the drug. millions of lives saved effectiveness of medications • 1. Determines side effects. Done on healthy • It is the way most medications are individuals to confirm safety • Chance of regular follow up by developed • 2. Involves a small number of patients to assess specialists using examinations, tests & scans • Multiple types, but this one is how effective it is in diseased patients. • If it’s phase 3, you are either randomised controlled trials • 3. Involves 100s-1000s of patients as part of RCT to compare the new treatment with current getting the standard treatment regimens. or something better Negatives CCA Tips Example Station • Long and may require months • Get brief background history • Most likely to be phase 3 • Explain in lay terms (medication already safe) or even years • Explain a phase 3 trial to a • You have to come up regularly • Be empathetic for test • Mention the positives and patient and answer any • There can be rare unexpected negatives clearly questions. • Eventually tell them it’s their • Possible questions: side effects that develop after years (re-assure after) decision • Am I a rat that you • Expect difficult questions from try on me? patients and take your time in • How do you know the medication is not answering harming me?CCA Revision Dermatology Skin Rash HPC PMH & DH Communication • Open Questions first • Open question “tell me more” • Skin conditions then closed • Location • Atopy (asthma, • ICE • Timeline hay fever) • Mention Patient’s name • When did it start and what • Medications • Empathy statement happened since then • Any specific event around (including • Body Language topicals) • Sign-post onset of rash (new soap, • Summarise detergent, etc) • Allergies • Plan going forward • Describe what can you see FH Risk Factors • Redness • Coloured: Silver, etc • Skin conditions in the • Sun Exposure • Ulceration family • Discharge • Any other conditions? • Outside working • Use of immunosuppressant • Feeling (rough, smooth, etc) SH (SCC) • Other skin symptoms (itch, • Light skin discharge, pain, etc) • Smoking, alcohol, • Not using sunscreen drugs • Tanning • Systemic symptoms (fever, fatigue, N&V, etc) • Occupation • Sunbeds • Living situation • Travel • Stress • Pets • Macule: Flat small lesion (<10mm) • Papule: Flat large lesion (>10mm) • Patch: Raised small lesion (<10mm) Skin Rash Differentials Terminology • Plaque: Raised large lesion (>10mm) • Nodule: Raised lesion that is deep Seborrheic Eczema Psoriasis Dermatitis • Red itchy dry skin, more • Flaky plaques with silver • A subtype of dandruff • Eczematous lesions on common on flexor surfaces scales in extensor surfaces • Associated with personal or • Better w sun exposure scalp and oil-rich areas FH of hay fever of asthma • May be associated with (eyebrows, ears) arthritis • Flaky in nature Contact Ringworm Urticaria “Hives” Dermatitis • Pale pink raised • Well-defined red itchy • Allergic reaction (T4HS) to circular rash specific agents (nickel, areas of skin • Caused by fungal detergent, etc) • TH1S secondary to allergy (e.g infection • Appear as itchy red rash in area of contact medications) BCC SCC Melanoma • Pearly nodule with • Painful firm nodules • Most Aggressive form that have crusting prominent vessels • Associated with • Looks like a mole with • May ulcerate & bleed immunosuppression ABCDE feature • In sun exposed areas • Important to differentiate (face) from Seborrheic keratosisSkin Conditions Explaining General Tips • Always take a breif history • Explain the normal skin • Explain what they can do (and what you • SH is important in derm, function then the can do) so ask in detail condition • Explain triggers (including stress) (occupation, pets, • Explain in lay terms • Eczema and psoriasis are associated smoking, etc) • Chunk and check with smoking & alcohol intake • ICE before explaining • Empathy • Safety netting • If it’s a cancer diagnosis, • Ask if they have any • Leaflet and NHS website they already know (it’s questions • Summarise not breaking bad news)Skin Conditions Explaining Eczema Psoriasis Cancer • Mention normal skin function (the skin is • Mention normal skin function (the skin is • Mention normal skin function (the skin is made up of multiple layers to keep us made up of multiple layers to keep us made up of multiple layers to keep us warm ,the skin moist & sun protection) warm, the skin moist & sun protection) warm, the skin moist and to protect us • As part of the layers, we have cells called • As part of the layers, we have cells called from the sun) “immune cells” to protect us from bugs. “immune cells” to protect us from bugs. • As part of the layers, we have cells called • In Eczema, these cells become extra • In Psoriasis, these cells become extra “basal/squamous/melanocytes” which active and attack the skin. This can be active and attack the skin. We don’t have different functions (melanocytes related to other conditions (asthma, hay know the exact cause, but it may be produces melanin which protect us from fever) or for genetic causes. associated with our genes, other the harmful sun damage) • This attack causes the skin to be dry, conditions (Crohn’s, obesity, etc) or • In your case, with many years of sun irritated and severely itchy. certain medications exposure and your skin being light, this • The condition mostly affects children but • This attack causes the skin to be dry and had damaged this cells and caused can affect adults. extra thick, causing flaky painful skin. them to appear differently from other • It is chronic in nature with periods of • The condition can affect older or cells (a cancer) relapses (gets worse) and remissions younger people. • Because we caught it early, we are going (gets better). • It is chronic in nature with periods of to refer you urgently to a dermatologist • Many patients have a trigger for their relapses (gets worse) and remissions to the skin cancer removed. eczema (certain soaps, smoking, (gets better). • They are going to do tests to make sure animals) it has not spread (including a scan of • Emollient Cremes: This is used to restore the water layer and prevent your body) itch and dehydration. Use generously when needed. • You are advised to wear a sunscreen, • Steroid Cremes: This is only used at times of flare ups. It reduces the especially in the summer and avoid Creams redness and the immune cells from overworking. 1 fingertip per 2 tanning. palms max. Overusing this crème can cause the eczema/ psoriasis worsen so be careful. Max twice a day. • Vitamin D analogue cremes: For every patient psoriasis • Biologics: tablets can be used in resistant psoriasis CCA Revision Infectious Disease Fever in a returning traveler HPC • Open question “tell me more” PMH & DH Communication • Open Questions first • Describe how you feel • Previous • Timeline then closed • When did it start and what conditions • ICE • Regular meds • Mention Patient’s happened since then name • Any specific event around • Vaccination status • Empathy statement onset of rash (new soap, • Allergies • Body Language detergent, etc) • Sign-post • Fluctuation of fever FH • Summarise • Systemic symptoms (headache, • Plan going forward vision problems, hearing problems, • Any conditions in the family Risk Factors dizziness, pain anywhere, difficulty breathing, bowel habit, N&V, • Anyone on the same travel • Recreational drugs is also sick? waterworks, skin changes, fatigue, • Unhealthy water drinking tingling, weakness, etc) • Animals bite • Travel SH • Unprotected sexual activity • Country of travel • Country, duration, reason • Smoking, alcohol • Immunosuppression • Precautions (vaccines, insect • Recreational drugs repellent, mosquito tents, etc) during travel • Activities (water drinking, food, • Occupation IVDU, sexual, tattoos, animals) • Living situation • Systemic symptoms (fever, fatigue, • Travel N&V, etc) Fever in a returning traveler: Differentials Malaria Viral Haemorrhagic Hepatitis Fever • Usually caught in African countries (not • Acute hepatitis from travel is caused always) secondary to mosquitoes bites by hepatitis A • Examples: Ebola, dengue, yellow fever, • Cyclical fever (comes & goes) • Unclear water or food etc • Fever, joint pain, fatigue, petechial rash • Associated with malaise, joint pain, • Flue-like prodrome, fever, RUQ pain, headache, anorexia, abdo pain, jaundice, fatigue • May cause bleeding (haematemesis, jaundice • Vaccine available before travel conjunctival haemorrhage, epistaxis, etc) • Diagnosed by blood film (thin and thick swabs) • Treatment is supportive Tuberculosis HIV Glandular Fever • Usually chronic in nature • Flu-like symptoms (sore • Caused by EBV • More common in south Asian throat, myalgia, diarrhoea, • Sore throat, fever, countries (Pakistan, India, etc) runny nose) lymphadenopathy • Source from travel is blood • On-Off fever, night sweats, cough • Management is (blood-stained), fatigue (IVDU, tattoos) or sexual supportive • Diagnosed by sputum culture • Frequent fungal infections • Can happen without • Treated with RIPE for 6 months • Presents 3-12 weeks after travel infection (unlikely to be straight after travel • Meningitis • Travel diarrhoea Others • Typhoid • Lyme disease • AmoebaEthics: Confidentiality Background Breaking Confidentiality • Always maintain confidentiality • You can only break confidentially if You can only break confidentially if bloodborne STI (HIV, hepatitis) not others bloodborne STI (HIV, hepatitis) not (chlamydia, gonorrhea, etc) others (chlamydia, gonorrhea, etc) • Can break if partner consented (the partner • Consent from partner is a must for must be present) breaking most medical diagnoses. Patient counselling Tips • Don’t just say no, try to frame it in a • If they have an STI and won’t disclose: • Explore reason for visit more formal way • Explain the importance of telling the • Explain role of a doctor and how • DO NOT disclose the information partner confidentiality work • Provide them with alternatives like • Explain serious health risks (infertility • Explore their concerns you can test them or discuss it with from STI, death after years from HIV) • Acknowledge their concerns and be their partner • Offer solutions, such as bringing the empathetic • If HIV, explain other possible partner and talking with you • Ask about any symptom they have methods of transmission not just • Explain condition is easily treatable sexualEthics: Confidentiality (Example Stations) Example 1 Example 2 • You are the FY1 in GP • You are the FY1 in GP practice. Please Speak to practice. Please Speak to James smith. James smith. • James asks you that his • James has just been girlfriend came from travel 3 diagnosed with HIV and weeks ago, and he is worried the GP asked him to tell about her transmitting an his wife. He refused. infection to him. He asks if you can check her medical records and tell you about any diagnosed infections Tip • Actors are really good at acting • Be careful of falling into their trap and disclosing information (breaking confidentially) Things to Read on ■ Explaining chemotherapy & radiotherapy: their mechanism, side effects and benefit ■ Explaining CENTOR criteria for sore throat, and the need (or not) for antibiotics ■ SBAR: SJS & TEN ■ Hepatitis Explanation ■ Breast Examination CCA Tips ■ Read on the previous CCA stations ■ Focus on the high-yield stuff that comes up frequently ■ Practice (especially histories & explanations) with someone ■ Don’t focus too much on knowledge, rather on skills ■ Don’t forget to be empathetic in explaining & history taking ■ Have a structures approach for each station Questions