Page 1 of 2: FAQ: How to survive through your first SHO job after career gap

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

Hi all my IMG friends

when I started to work in uk, I did some mistakes and I wish the newcomers after me should not face the same problem. So I am goonna write how basically I survived through my 1st job with zero knowledge of nhs. pls correct me if I am wrong anywhere

druptodate · Credits: 401 Preparing for: MRCP Part 1 My Scrapbook

Ah yes excellent idea Suvie, please do tell and share your experiences!

Drstanilo · Credits: 18140 My Scrapbook

survie, I trust u ll be as honest as possible cos I know the quality of your contributions in this great RXPG site. Go on and tell your story as it really happened and others shall benefit from it.

zab · Credits: 2470 Preparing for: PLAB Part 1 My Scrapbook

Plz do tell us about ur experience, as it will greatly help all doctors who are starting out in the nhs.

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

sorry for delay, it may happen again because of my work schedule
anyway I think in the begining one must carry following documents with them everyday while going on ward round/seeing patient
1) List of most commonly prescribed medications with dosage and routes. In UK everywhere typical medications are prescribed and nobody questions dose and very handy when consultant asks u to prescribe on kardex while on ward round. I will try to put the list which helped me.
2) Carry the stepwise format of management ( UK way)for very common conditions which helps while clerking the patients quickly again typical scenarios u come across most of the time.
3) Tips regarding prescribing fluids which is commonly asked to do
4) Tips regarding prescribing painkillers which is very common as well
5) Important Tips for doing medical procedures including stepwise procedure details
6) very important NHS guidelines/ different scores for eg Pulmonary embolism- revised geneva score, TIMI score, Rockhall score
7) Format for referral letters
8) If you work as 1st on receiving, list of receiving jobs
9) As a SHO u have to do the dictation letters for secretaries to type. So carry a proforma initially to learn the tactics
10) If you just started working in a new hospital, go on collecting all the phone numbers u are contacting on a regular basis otherwise u do waste lot of time to find out especially fax no and contact no for various speciality referrals--I think one should always have his own small directory. I usually carry the one small chit kept behind my id card all the time
Now you would wonder how can u carry so many documents. But initially I did carry all of them The best way is to buy a box type clipper board which FY1 usually use. U can carry lot of documents in it including audit documents.
I would try to put the lists I have as soon as possible

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

To start working in NHS, 2 things are very important other than ALS, ALERT and registration and that is
1) Minimum 6 months experience
2) minimum 2 UK references/appraisals

Now both goes in vicious circle without UK job cant get reference-- no reference no UK job. I mean very difficult to get-- there could be few lucky ones
The way I tried to sort this out is--- to find a employer who would accept your country references. and agencies are the best in that way they accept even the email references including top agencies like medc.

Now next is to get reference/appraisals, (I would try to put the formats of both which you really struggle to find anywhere.) Once agency offers you the job try to go for at least 4 months. Now gain confidence of consultant and get him sign those forms when he is in good mood but make sure u work for at least 4 months less than that they are not usually happy to give one. Thats it-- another 4 months locum and u get ur 2 UK references.
now u are ready to knock NHS door as a regular staff

plabosce · Credits: 1127 Preparing for: PLAB Part 2 My Scrapbook

Hi Suvie ,

thank you very much for your valuable advices

......

good luck for your career...........

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

Hi
I have got an interview call for CT2 post was just searching for interview guide and CV preparation and came across these 2 websites seems to be very useful

Only RxPG members can see links here! Register or Login!

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

These are easy to remember tips I always carried with me and covers most of the clinical scenarios. take print out and carry if reqd

Cardiology

CCF—wt chart
Oxygen therapy see details of O2 therapy prescription
ECG
ECHO
Fluid balance chart / intake output chart
Diuretics
Fluid restriction to 1.5L
ACE inhibitors

ACS
High flow O2
GTN spray
Aspirin 300mg stat then 75mg –always rule out possibility of aspirin sensitivity/peptic ulcer optd as its very common in alcoholics
Clopidogrel 300mg stat then 75mg be careful while prescribing in elderly people
LMWH 1mg/kg BD until trop T level done. Always rule out bleeding contraindications
Cardiac monitor/Telemetry
Morphine 2.5mg IV max 10mg PRN
GTN infusion/nitrocine ( see drug list for dosage put in forum)
Calculate TIMI score in new onset patients to start on clopidogrel

AF
Digoxin
LMWH
B blockers-bisoprolol
ECHO

SVT
Rule out adverse signs, if present –DC shock
1 : 2 AV block- Adenosine give 6mg to start with very slowly. Inform pt prior to giving the dreadful feeling he may have. Usually with first 6mg pt may feel anxious with second dose of 12 mg may feel chest tightness third dose of 18mg may feel scared Avoid giving after 3rd dose if still not in SR. Tips—flush with saline fast after every dose of adenosine. Keep all the syringes ready loaded, continuous printing of ECG while giving adenosine. Check after every dose may not need more dose.
Other SVTs -IV metoprolol 5mg IV stat
Rule out causes like infection/drugs
Calculate CHADTS2 score to ascertain risk of TIA to start on prophylactic aspirin
Never forget to Carefully listen for heart murmur in all these patients
Also in all the cardiac conditions include routine investigations like ECG/Cardiac enzymes-Trop T/CK, TFTs/digoxin level if pt on any,INR if on warfarin,

RS
Inv— Chest xray, ABG, sputum C & S, pneumonia screen + viral PCR, peak flow chart, theophyllin level

O2 therapy
If severely breathless—10-15L O2 via trauma mask
Otherwise start with 24% O2 which can give max 4L if still breathless, change mask to 35% which can give maximum 6L
Nasal canula’s usually give 2L but cant monitor O2 concentration so not preferred in COPD pt. In COPD pt start with 28% maintaining SaO2 between 88-92%

COPD/bronchitis/Asthma
If wheeze +, start nebulizers-salbutamol + atrovent
O2 therapy as mentioned above
Steroids-prednisolone 40mg stat and OD
Carboceistein 750mg QID
Antibiotics as per protocol
Chest physiotherapy
Respiratory nurse review once stable

Pneumonia—calculate CURB-65 score

Aspiration pneumonia
Nil by mouth
IV antibiotics
SALT review
Chest physio

Pulmonary embolism- calculate revised Geneva score

CNS

Inv-CT brain, skull xray, AMT, MMSE

CVA
Withhold aspirin/warfarin/antihypertensives/steroids until CT brain
If infarct, immediate aspirin 300mg daily for 14 days +/- dipyridamole/LMWH
Physiotherapy
Soft diet/thin fluids/dietician
Swallow assessment
Know what is LACS/PACS/TACS/POCS

Dizziness/syncope—lying-standing BP, withhold antihypertensives, check for drugs causing, compression stockings, TILT test/R test, Midodrine in resistant cases

Meningitis—immidiate empirical antibiotics(ceftriaxone 2gm) after taking blood culture sample.
LP
CT brain to rule out raised ICP before LP
Fundoscopy
Seizures
Pabrinex
IV phenytoin/IV lorazepam
Na valproate level if pt on any
Rule out causes—Infection/Tumor/missed dosage/alcohol/new medications/injury/antidepressants

SAH
IVF 3L/24hrs
Nimodipine 60mg 6hrly
Neuro-obs
Stop aspirin/clopi
d/w neurosurgeons( know well before talking to them GCS level, prev mobility status, compression signs on CT with shift, coagulation status)
SDH—operate only if symptomatic/chronic

Endocrine

DM—BM 12 hrly

Hyperglycemia –may not always need sliding scale just rehydrate with patients regular antidiabetic drugs

DKA ( DM + urinary ketones + HCO3 less than 15)
Sliding scale insulin- insulin actrapid 50 U in 50ml NS
Bl glu 0-4 ( no insulin)
4.1-15 (3U insulin)
More than 15 ( 6U insulin)
Monitor K+/Mg/PO4
ABG
Fluids- 1lit/hr/2hrly
1lit/2hr/4hrly
1lit/4hr/8hrly
Catheterise if reqd
LMWH if not contraindicated

GI

Inv
P/R
FOB/ Colonoscopy
Liver sreen
Amylase, urinary amylase, U & E
Stool c & s/ stool chart
Abdo Xray
USS abdomen
NG tube

Colitis-Antiemetics/steroids-IV hydrocortisone

Upper GI bleed- crossmatch & Transfusion ? urgent OGD
Calculate Rockhall score

Anemia- FBC/ Crossmatch/ Hematinics/ iron studies/ celiac serology/ OGD/ Colonoscopy/MSSU/ FOB/ MCV/Blood film

Ascites
Fluid restriction/low salt diet/ high protein diet/ dietician/ daily wt/alcohol liaison/ spironolactone/ daily wt/ascetic tap/ USS abdomen ? SBP—ciprofloxacin
Ascitic drainage + 20% albumin

Alcohol Excess/ withdrawl
Ethanol levels
CIWA
Pabrinex
Antiemetics + PPI
Addiction liaison team

PCM overdose

PCM/salicylate levels
LFTs
Coagulation ( prescribe vit K if high )
Parvolex
Pabrinex
CIWA
4 hrly BM
Psychiatrist opinion

IVDA/ drug abuse
Urine for drug use
Avoid morphine as painkillers if on methadone, try NSAIDs

Kidneys

ARF—rule out causes-nephrotoxic drugs, UTI, Rhabdomyolysis-check CK,hypotension, dehydration
Withhold diuretics/ ACEs
IV fluids/ Fluid challenge
Catheterise ( if hypotensive/if retention/ severe ARF)
Fluid balance chart
MSSU
USS KUB
Hb
24 hr urine proteins/ protein –creatinine ratio—more than 4gm s/o nephritic syndrome
Complete renal survey—U & E, Ca, PO4, ESR, CRP, Skeletal survey-bone scan, Se electrophoresis, Bence-jones pr,
USS, CxR
Myeloma screen

Joints
Xray
Painkillers
Uric acid
NSAIDs + PPI if no contraindications
ESR,
Autoimmune screen

Sepsis—at least 2 ( T more than 38 or less than 36/ HR + 90/RR + 20/ WCC -4 + 12)
Blood culture if temp spikes
Septic screen—culture urine/sputum/blood/CxR
Cellulitis-wound swab, antibiotics, tissue viability nurse r/v
MRSA screen

Neutropenic sepsis + lymphadenopathy
ESR
Autoimmune screen
Se ACE
Blood film
EBV/CMV serology
Haematologist opinion

Electrolyte imbalance

Hyponatremia
N saline very slow ( can cause cerebral edema) 125ml/hr
Rule out SIADH—urinary Na, urine osmolality, se osmolality
TFTs
Synacten test
Drugs-respiradone

Hypocalcemia
Adcal
If no response to oral calcium, give Alfacalcidol 1microgm daily/ 500 nanogm elderly
Check PO4, PTH, Vit D
Rule out clinical signs-tetany

Hypercalcemia
Check PO4, Ca, PTH, Mg, Vit D
Bone scan,
Myeloma screen

Hypomagnesemia
Oral magnaspartate 1 sachet
IV Mg sulpahate

Hypokalemia
Sando K
IV KCL 20mmol

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

Alcoholic Hepatitis
check LFT/coagulation
vit K if reqd
Full liver sreen
USS abdomen to rule out ascites
Sepsis screen
GAHS score If more than 9--prescribe prednisolone for 7 to 10 days

Urinary retention
MSSU
Bladder scan
catheterise
P/R to rule out constipation
laxatives if reqd
PSA

unknown Wt loss

CT chest/abdp/pelvis
Wt chart
Dietician
PSA
FOB/colonoscopy
Stool for amylase
Myeloma screen

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

Full LIVER SCREEN

IMMUNOGLOBULINS
IgG
IgA
IgM

Caeruloplasmin
Alpha 1 anti-trypsin

AUTOANTIBODIES
ANA
LKM
Smooth muscle ab
Mitochodrial ab
Gastric parietal cell
TTG

HEPATITIS SCREEN
A
B
C
E

IRON STUDIES
Iron
% Sat
TIBC
Ferritin

ABDO U/S

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

Handy (UK type) proformas to get references. I used these ones

APPLICANT NAME:

CANDIDATE IDENTIFICATION NUMBER:

APPLICANT GMC NUMBER:

SPECIALTY AND LEVEL APPLIED FOR:

EDUCATIONAL/CLINICAL SUPERVISOR NAME:

DESIGNATION :

INSTITUTION ADDRESS:

GMC NUMBER:

DATES YOU WERE EDUCATIONAL/CLINICAL SUPERVISOR FOR THIS APPLICANT:

From………………………To…………………………

Please rate the applicant’s performance against each of the criteria listed in the following table by ticking the appropriate box. You should base your ratings on workplace assessments and reports completed while the trainee was under your educational/clinical supervision. You may subsequently be asked for evidence to support your ratings.

Performance ratings:
1 = Less than satisfactory for level at which applying
2 = Satisfactory but below average performance
3 = Satisfactory and average performance
4 = More than satisfactory, above average performance

PLEASE SIGN AND DATE EACH PAGE OF THIS REPORT

APPLICANT NAME :…………………………………………………………………

CANDIDATE IDENTIFICATION NUMBER:……………………………………….

CRITERIA 1 2 3 4
Capacity to apply sound clinical knowledge & judgement & prioritise clinical need.
Technical ability and potential for developing strong and complex clinical/diagnostic skills
Capacity to operate effectively under pressure & remain objective in highly emotive/pressurised situations.
Awareness of own limitations & when to ask for help
Capacity to communicate effectively & sensitively with others, able to discuss treatment options with patients in a way they can understand
Capacity to think beyond the obvious, with analytical and flexible mind.
Capacity to bring a range of approaches to problem solving
Capacity to monitor and anticipate situations that may change rapidly
Demonstrates effective judgement and decision-making skills
Capacity to work effectively in a multi-disciplinary team & demonstrate leadership when appropriate.
Capacity to establish good working relations with others
Capacity to manage time and prioritise workload, balance urgent & important demands, & follow instructions.
Understanding of importance & impact of information systems
Commitment to professional integrity in all actions and behaviour
Willingness to take responsibility for own actions
Awareness of ethical principles, safety, confidentiality & consent.
Awareness of importance of clinical governance & responsibilities of an NHS employee
Motivation and commitment to self-directed learning
Fitness to practise safely
Understanding of the basic principles of audit
Completion of audit projects
Understanding of the basic principles of research and evidence-based practice, with potential to contribute to research
Evidence of ability to communicate knowledge and understanding to others
Overall professionalism

Clinical supervisor name
signature
date

druptodate · Credits: 401 Preparing for: MRCP Part 1 My Scrapbook

Suvie,

Thank you very much from the bottom of my heart

. Very kind and generous of you to share your experience.

Syl · Credits: 1201 Preparing for: PLAB Part 2 My Scrapbook

Thank you very much Suvie. I will definitely follow it out while I get into my job. Share somthing more about how did you overcome, of course when u r free.

llr · Credits: 2091 Preparing for: PLAB Part 1 My Scrapbook

Hi Suvie

Thanks for your valuable information. Good luck for you in the future also.

helpmepassplease · Credits: 201 My Scrapbook

i dont think anyone could than you enough, thats amzing!

suvie · Credits: 2292 Preparing for: PLAB Part 2 My Scrapbook

one must know dosage of these medications to start with. have a personal copy of BNF. please correct dosage if any wrong

cvs

IV

Furosemide 40/80mg
Amiodarone 300mg over 1 hr
Metoprolol 5mg IV for SVT
IV digoxin 50mg OD
Nitrocine infusion 20mg drug in 20ml dilutent = total 20mg as 1mg/ml
Or 50mg in 50ml of NS= total 50mg as 1mg/ml
Start as 0.6 mg/hr
Then 1.2mg/hr
2.4mg/hr
5mg/hr
To be prescribed on infusion pump prescription chart
Clexane 40mg/20mg sc od ( rule out bleeding contraindications)
Oral

Aspirin 75mg OD( rule out allergy)
Doxazocin 2mg at night for resistant Hypertension
Simvastatin 40 mg HS
GTN spray 2 puffs S/L PRN
Dipyridamole MR 200mg 12 hrly
Propranolol 40/80mg OD
Captopril 6.25-12.5mg BD
Carvedilol 3.125-6.25-12.5 BD
Bumetanide 2mg/1mg BD
Candesartan (losartan) 2/8/32mg
Bisoprolol 2.5/5mg OD
Nicorandil 10mg BD/TDS
Metoprolol 25mg TDS
Digoxin 500microgm stat 250microgm after 6h-8hrs 125microgm/62.5 microgm daily

Pulmonary Embolism
175U/kg SC OD x 6days
1.5mg/kg SC OD x 5days or till oral anticoagulant take over
IV heparin 5000IU if bleeding risk or IVC filter

RS

Spiriva 18 mcg OD
Salbutamol inhaler 200mcg/400mcg 1-2 puffs PRN
Salbutamol nebuliser 5mg 6hrly
Atrovent 0.5 mg 6hrly
Seretide 1-2puff 12hrly
Codeine linctus/pholcodeine 10ml TDS for dry cough
Carboceisteine 750 mg TDS

GI

H pylori eradication—Amoxycillin 1gm BD + clarithromycin 500mg BD+ PPI
( omeprazole 20mg BD)
IV PPI-40mg omeprazole in 100ml NS 5hrly over 72 hrs ( differs as per hospital policy)
Lanzoprazole 30mg OD
Omeprazole 20/40mg OD
Peptic liq 10ml PRN/TDS
Gaviscon liq 10ml HS/PRN/TDS/QID
Creon 10,000 U 8hrly for pancreatic insufficiency
Asacol 1gm 8hrly/ 800mg 8hrly
Merbantyl- ms relaxant for ulc colitis pt 10-20mg tds ( CI in BPH )
Pentoxyphyllin 400mg tds
Cholestyramine 4gm sachet OD/BD/TDS
Pentasa enema
Predfoam enema for IBD
Laxatives
Movicol 1 sachet HS/BD
Senna 2 tablets at night
Lactulose 10-15ml BD/TDS
Antiemetics
Metoclopramide/domeperidone 10 mg TDS
Cyclizine 50mg IV/IM/oral 8hrly
Onandesetron 4mg BD
Prochlorperazine 12.5mg IM NEVER IV or oral 5-10mg 8hrly for labyrinthitis
Spironolactone 100/200mg OD
Metformin 500mg BD/TDS ( withhold if renal impairment)

Hong Kong protocol in GI bleed
IV 80mg omeprazole stat then 8mg /hr for 72hrs can change as per local policy basis is high pH can stabilize the clot
Hepatorenal syndrome
Telipressin 0.5-1mg IV QID +/-
albumin 1U over 2 hrs—2-3units
Glypressin 0.5-1mg IV QID

Urinary retention
Taphyn MR retention

Painkillers
Co-dydramol 10/500 – 2tab QID
Paracetamol 1gm QID/PRN
Cocodamol 30/500 or 8/500—2 tablets QID
Dihydrocodeine 30-60mg QID/PRN
Tramadol 50-100mg
Sevredol 10mg PRN work out daily requirements and then prescribe MST 10/20/30mg BD
Inj morphine 2.5/5/10mg IV
Fentanyl patch 25 microgm every 72hrs

Always avoid prescribing NSAIDS, if very necessary then rule out all contraindications and give cover with PPI
Palliative drugs
Oromorph 5-10mg/2.5-5ml 1 to 2 hrly
Oxynorm 30mg s/c pump over 24hrs or 5mg s/c PRN
Buscopan 20mg IV PRN or 10mg oral
Hyocine butylbromide 20mg stat/ subcut infusion 400microgm 6hrly

Electrolytes/Nutrients

Actimel/yakult ( lactobacilli) 1 carton BD
Inj hydroxycobalamine 1mg IM 3 times a wk initially x 2wks then once in 3 months
Enoxaparin / clexane 20-40mg s/c OD ( 6pm ) for DVT prophylaxis
Vit K 10mg IV stat
Alendronic acid 75mg wkly
Pabrinex ( vit B inj) I + II IV 8 hrly
Thiamine 100mg TDS
Vit B co strong TDS
Sando K 2 tab TDS
Magnaspartate sachet 1 TDS
Sandocal 1000 – 2tablets at night
Iron dextran 1500mg IV as per instructions of company

Antibiotics

IV—clarithromycin 500 BD for RTI
Vancomycin as per chart/ CrCl in penicillin sensitive pts/neutropenic sepsis
Levofloxacin 500mg BD
Coamoxixlav 1.2 gm 8 hrly
Flucloxacillin 1gm/2gm 6 hrly
Benzylpenicillin 1.2 gm/2.4 gm 6hrly (make sure pt is not allergic before prescribing this –one dr has been jailed as pt died due to reaction)
Metronidazole 500mg 8hrly
Tazocin 2.25/4.5gm 8 hrly/6hrly for neutropenic sepsis
Gentamycin once daily as per chart/CrCl
check levels after every dose- after 1st dose should be less than 2 later doses should be between 5-12
Ceftriaxone 2gm BD for meningitis/SBP
Ciprofloxacin 400mg BD
Flucanozole 400mg OD for GIT fungal infection
IV daptomycin 400mg ? 6hrly

Oral
Clarithromycin 500mg BD
Amoxicillin 500mg TDS
Metronidazole 400mg TDS
Coamoxiclav 625/375mg TDS as per renal function
Penicillin V 500mg 6hrly
Doxyxyxline 200mg stat 100mg OD
Tetracycline 250mg/500mg 6hrly
Rifampicin 300mg 12hrly
Flucloxacillin 500mg 6hrly
Trimethoprim 200mg BD—can cause deranged LFTS

Oral switch over for following IV antibiotics

IV vancomycin to tetracycline/rifampicin
IV amoxy/genta/metro to ciprofloxacin + metronidazole

MRSA

Throat-chlorhexidine spray BD
Skin—chlorhexidine 1% topical application QID
Nose

Miscellaneous

Betahistine 16mg 8hrly
Metanium oint for contact dermatitis
Lacrilube 1 drop QID for dry red eyes in coma pts
Aqueous cream BD for dryness
Piriton (Clorphenyramine maleate) 4mg QID

CNS

Seizures- lorazepam 4mg IV
Phenytoin 750mg IV over 1hr as loading dose with cardiac monitoring
Then 100mg IV 8hrly—check phenytoin level after 24hrs before next dose
Regular dose—phenytoin 300mg oral OD

Dexamethasone 8mg BD ? 8am/12pm
Mirtazepine 45mg at night-antidepressant
Zopiclone 3.75/7.5mg at night
Gabapentin 300mg 8hrly
Levetiracetam 2.5ml BD
Haloperidol 0.5-1mg IM ? IV not to be given
Diazepam 2mg 8hrly
Lorazepam 0.5mg IV prn max 2gm in 24hrs
Lormetazepam
Midzolam
Dipyridamol MR 200mg BD

wld write about how to do dictation and tips on practical procedures soon

Renu27 · Credits: 733 Preparing for: PLAB Part 1 My Scrapbook

Hello Doctor,

Thank you very much.It will be very useful for me.

plabosce · Credits: 1127 Preparing for: PLAB Part 2 My Scrapbook

that`s really nice to help other plab candidates suvie , thank you very much

all the best for your future

Renu27 · Credits: 733 Preparing for: PLAB Part 1 My Scrapbook

Hi Suvie,

you please do reply,if you have time...

I am planning to do my clinical attachment,so i like to get advice from experienced person like you.What are the things they expect and what are the things we need to know before going?

Many thanks in advance.

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