Added Cases Flashcards
Your next patient is a 45 year old lady who underwent a laparoscopic cholecystectomy 4 hours ago. The surgeon detected a drop in the blood pressure and Hgb, and is suspecting an internal bleeding. The vitals are now stable and the patient is getting ready for an open operation for exploration.
Tasks:
Counsel the partner and answer his questions
Questions:
Why did this happen?
Was there any mistake by the surgical team?
Should we have been told about this before surgery?
What are you doing next?
*Expect an angry role player
Open-ended question
D: Hi, my name is ___. May I know your name?
D: I’m here to discuss your wife’s condition. May I know how much you known about her situation?
Let the role player complain at this point
D: I understand. Is there any other concern that you’d like me to address?
Empathy
D: I understand this is a stressful situation for you. I would like to reassure you that we will take good care of your partner and provide the best care to her.
D: I will explain about the procedure and why this has happened. If you have questions at any point, please don’t hesitate to ask me.
Surgery
D: Your wife underwent a keyhole surgery to remove the gallbladder. Once we remove the gallbladder, we block of the blood tubes and the ducts with some clips. This procedure has a rare complication that the clips slip of the blood tube and this causes bleeding in the stomach.
After any surgery, we observe the blood pressure and the vital signs closely for a few hours to monitor for complications and make sure there is no bleeding. We detected a drop of the blood pressure in your wife, and when we checked her blood, we noticed a drop in her hemoglobin which is part of the red blood cells.
We have already given her some blood and this is the reason that the surgeon is suspecting a slipped clip and an internal bleeding and has decided to perform an open surgery to find the source of bleeding and stop it.
Mistake
D: This is not a mistake by the surgical team. Although we try our best to avoid such complications, in a small number surgeries, complications are inevitable, but I would like to reassure you that we will try to provide the best care to her.
Been told before
D: Usually in our last consultation before the surgery, we discuss possible complications of surgery with the patient and provide you with a fact sheet and consent form which includes all the details of the procedure, including the possible complications.
D: I will keep you updated of the progress and if you have any questions or further concerns, I’m always here to help you
Your next patient is a 57 year old man who has come to your general practice complaining of tingling and numbness in both of his feet. It is worse at night. She has been drinking 5 SD of alcohol every night for the last 5 years and has stopped 6 weeks ago but symptoms are ongoing.
On PE: Decreased sensation on both legs, weak reflexes on both sides.
Investigations: + macrocytic anemia, BLS normal, vit B12 normal, GGT increased
Tasks:
Explain PE findings and investigation results
Explain diagnosis and differentials
Immediate and long-term management
Open-ended question
D: Hi, my name is ___. How can I help you today?
Explain PE and Investigation
D: On your PE, you had a decrease in the sensations of your leg. You also have a weak reflex which is a jerk or a sudden movement after a tap on the muscle. A weak reflex is another sign of a problem in the sensory nerves.
D: One of your liver enzymes is elevated, which is due to your chronic alcohol intake and this shows inflammation in the liver. We have RBCs that carry oxygen in our blood using a component called hemoglobin. In your case, the amount of hemoglobin is lower than normal, and the size of the RBCs have increased. You have a normal sugar level, kidney function, amount of vitamin B12
Diagnosis
Most likely you have a condition called alcoholic sensory neuropathy. Alcohol has damaged the nerves in your legs and this has led to numbness and pins and needles in your legs.
This damage is irreversible, but stopping alcohol will prevent further damage.
Differentials (Peripheral Neuropathy):
Diabetic sensory neuropathy
Vitamin B12 deficiencies
Hypothyroidism
Liver disease
Uremia (CKD)
Lumbar radiculopathy
Management
Immediate
I will refer you to the neurologist to do nerve conduction studies just to confirm the diagnosis and check the severity of it.
If the symptoms are too bothersome, we can start you on medications such as amitriptyline or gabapentin.
I will give you thiamine, which is a vitamin that decreases when you drink alcohol for a long time
Long-term
I appreciate that you already stopped drinking alcohol
Referral to podiatrist for foot care and education
Fall prevention: Refer to the fall clinic, physiotherapist, occupational therapist, check vision and hearing
Your next patient is a 30 year old man who has come to you inquiring about hemochromatosis. His brother was recently diagnosed with hemochromatosis.
Task:
Counsel the patient regarding the condition and management plan
Open-ended question
D: Hi, my name is ____. How can I help you today?
D: Do you have any specific concerns today?
D: How much do you know about hemochromatosis?
Counselling
Hemochromatosis is a result of excess iron storage in the body. It is caused by mutations in some genes which lead to an increased absorption of iron from the bowels. Since your body cannot excrete and get rid of the excess iron, it starts damaging your organs and causes symptoms. Iron needs to stay high for many years before damaging the organs and causing symptoms. Usually symptoms appear around the age of 30-60 years.
Symptoms:
The excess iron can damage your liver, pancreas, skin, and joints. You may experience joint pain ,tanning of the skin, tiredness, fatigue, decrease in sexual desire and erection problems. You may also develop heart disease, liver failure and high blood sugar level.
Diagnosis
We test the first degree family members using 2 tests:
Iron studies - in hemochromatosis, we expect a high transferrin saturation and ferritin level (iron storage)
Genetic studies - we check all the mutated genes and the two important genes are C282Y and H63D. For first degree family members, this test is Medicare rebated.
If you have 2 copies of the C282Y gene, there is a high risk of developing hemochromatosis. If you are worried about your children, we can test your partner.
If you have one C282Y or one or two H63D gene, there is no need for follow-up unless symptomatic
If you have one C282Y and one H63D gene, we need to monitor your iron levels every 2-5 years
Management
If we confirm HC, we have 2 options:
Our preferred option is lifelong regular blood donations to remove the excess iron from your body. We will start with weekly blood donations until the iron storage is normal and then we’ll repeat it every 3-4 months (ferritin <100, TS<50%)
Our second option is a medication called desferrioxamine. This attaches to the excess iron and removes it from your body. It’s not as effective as blood donations and it may have side effects.
If iron storages are lowered before damage to the liver and other organs happens, you may have a normal life expectancy.
Treatment advice:
Avoid alcohol
Avoid vitamin C
There is no role for a low iron diet, but it can decrease the frequency of blood donations
I will review you once the results are ready. I will give you reading materials about hemochromatosis.
You are working in a general practice. A 24-year old man with chronic diarrhea had a recent colonoscopy for the investigation of his diarrhea. For the previous 6 months, he was passing bloody stools 6 to 7 times per day without any mucus or slime. He was told he had inflammatory bowel disease but could not remember any specific names. The specialist who did the colonoscopy did however give him a copy of the photographs taken of the colon and told him that the appearance was similar for the whole of the large bowel.
Tasks:
Interpret the colonoscopy illustrations
Advise the patient which disease you believe is likely and what treatment is likely to be required
Open-ended question
D: Hi, my name is ____. How can I help you today?
Explain the colonoscopy results
D: You can see the inner layer of your large bowel. And you can see some ulceration and redness in the inner layer which is not normal. This happens in a condition called inflammatory bowel disease. In IBD, the layers of your bowel become inflamed and this is the cause of your symptoms. This is an autoimmune condition and your immune system is responsible for causing this inflammation.
D: There are two types of IBD: Ulcerative colitis and Crohn’s disease. Although the appearance on the photo is suggestive of UC, we will wait for confirmation by the biopsy and samples that have been taken.
D: Ulcerative colitis involves the large bowel especially the end of the large bowel called the rectum. It just involves the superficial layers of the bowel. Crohn’s disease involves both the small and large bowel. It involves all layers (entire bowel wall). It can also cause ulcers & abnormalities around the back passage.
D: In terms of complications, in Crohn’s disease, sometimes you get flare-ups and inflammation in the bowel which causes abdominal pain, bloody diarrhea and fever, ulcers and fistulas around the back passage, and it can cause obstruction of the bowel. In Ulcerative colitis, it can cause dilation of the bowel and cause fever and severe pain in a condition that we call toxic megacolon. It also increases the risk of having bowel cancer.
D: This condition is usually controlled well with medications. The medication aims to suppress the immune system and decrease the inflammation in the bowel. We have a few options:
steroids have a fast response but we cannot continue them long term due to side effects
Special medications such as sulfasalazine or mesalazine
Immunomodulatory drugs such as methotrexate, infliximab
Before starting these treatment, we will do some blood tests to check for TB, hepatitis, and we will give some vaccinations such as influenza, pneumococcal and hepatitis vaccine if needed.
If you don’t respond well to medications, we may need to do surgery.
D: Having IBD, we will check for some nutritional deficiencies such as iron deficiency anemia. IBD also increases the risk of osteoporosis. For Ulcerative colitis, we need to do regular colonoscopy for follow-up as there is a higher risk for cancer.
Your next patient is a 65 year old man who has recently been diagnosed with Alzheimer’s disease. His son is here to discuss about his father’s condition. CT scan shows mild degeneration of brain and MMSE is 25/30.
Tasks:
Take history
Address son’s concerns
Explain management plan
Son’s concerns:
Son is not happy to take care of his father since they have a bad relationship
Wife died 9 months ago, dad is depressed
Open-ended question
D: Hi my name is ____. I’ll be your GP for today. From the notes I can see that your father has recently been diagnosed with Alzheimer’s disease, can you tell me more about it?
D: Do you have any specific concerns that you want me to address today?
Explore the presenting complaint: memory issues
D: When did you first notice that your father has been having memory problems?
D: Is it getting worse?
D: Does your father get irritated and agitated more frequently?
D: Any problems with his sleep?
D: Any changes in his social engagement?
D: Has he ever got lost in the streets? (risky behavior)
D: Any accidents or incidents at home? (risky behavior)
Risk Factors of Dementia
D: any vision or hearing problems?
D: Does he drink any alcohol? How much?
D: Does he use any drugs?
D: Does he take any medications?
Geriatric Screening
D: Any recent falls?
D: Who does he live with? Does he have enough support? Who takes care of him?
D: Is your father able to do his daily activities himself?
D: How is his diet? Who cooks for him?
D: How is his mood?
D: How is his sleep?
D: How is his appetite?
D: Any suicidal ideas?
Rule out Differentials of Dementia
D: Any head injuries?
D: Any history of stroke?
Past Medical History/Family History
D: Any personal or family history of other medical or mental illnesses?
Diagnosis
Your father has recently been diagnosed with Alzheimer’s disease. This is a degenerative brain disease and brain cells are affected, and this causes memory problems, affects thinking and behaviors.
Management
Aged Care Assessment
