Class 10 Flashcards
Your next patient is a 62 year old man who has recently been admitted due to shortness of breath. His shortness of breath was worse on walking up stairs and exercise. He has been cleared by the cardiologist. He has a family history of heart and lung disease. He is using Ventolin with minimal effect.
His BMI is 32. He has come to you today to discuss his investigations.
Tasks:
Explain the investigations to your patient
Counsel regarding management plan
Open-ended question
D: Hi, my name is _____. I’ll be taking care of you today. How can I help you?
Address concern
D: I understand that this can be concerning. But is it okay if I ask you a few question so I’ll understand the situation better, we’ll discuss your results and we’ll make the best management plan together.
Explain Spirometry
D: I have your results with me. A spirometry measures your lung function by assessing the amount of air you can breathe out. We look at two values, the FVC which is the total amount of air that you can breathe out forcefully after taking a deep breath in, and the FEV1 which is the amount of air that you can forcefully breathe out in 1 second after taking a deep breath in. we calculate the ratio of these values, and in your case, it is decreased which means that there is a narrowing in your airways. We call this an obstructive pattern.
Next is we look at the FEV1 before and after we gave you the puffer (Ventolin). As your FEV1 has increased less than 10%, you most likely have a condition called Chronic Obstructive Pulmonary Disease. COPD is the long-term damage of smoking to the lungs.
Explain ABG results
D: When you breathe in, oxygen moves into your blood and a gas called carbon dioxide is removed from the blood and you breathe it out. I can see that the amount of oxygen in your blood is lower than normal, and the amount of carbon dioxide is more than normal. This is most likely because of the narrowing in your airways and has led to your blood becoming acidotic.
Management
D: To manage your COPD comprehensively, we follow a few steps:
We first confirm the diagnosis with a lung function test. Sometimes we do a chest x-ray to rule out lung cancer. And the heart specialist has ruled out any problems with your heart.
We would like to optimize your lung function:
Pharmacological treatment: we will use some inhalers to improve the narrowing and improve your symptoms
Our first step is usually starting Ventolin as a reliever, to relieve symptoms. In your case, I can see that it has not helped. So I want to step up your treatment today.
I will start you on a long acting medication called a LABA such as salmeterol, use it twice a day regularly. Continue using Ventolin whenever you have symptoms, 1-2 puffs every 3-4 hours.
I will review you in 3 months, and if the symptoms are not controlled, I will add another medication called a LAMA such as tiotropium.
Non-pharmacological treatment: I need you to aim for a healthy lifestyle.
I need you to have a regular exercise as this will improve your lung function. I want you to do at least 150minutes moderate to high intensity exercise per week or at least 30 minutes/day for 5 days. I will send you to an exercise physiologist who can make an individualized exercise plan for you. He will gradually increase the duration and intensity of exercise to reach our goal of exercise.
Take a healthy diet. I’ll refer you to the dietician to help with this.
Aim to lose weight
I’ll refer you to the chest physiotherapist who will teach you some breathing exercises, coughing techniques that will improve your lung function
We would like to prevent deterioration of your COPD
Stop smoking
Refer to Quitline
Help with the cravings and withdrawal symptoms by giving NRT and varenicline
We would like to prevent lung infections
We’ll do regular vaccinations for influenza yearly, and pneumococcal vaccine now, in 1 year and in 5 years, and COVID vaccination
In certain situations, the specialist may consider giving you oxygen at home, but this is not for all patients and has a strict criteria
Develop Support
Key point! I will refer you to the Pulmonary Rehabilitation Program. This is a program which provides support, education, exercise classes and overall, they aim to help you improve your lifestyle and the understanding of your condition
I will also refer you to Lung foundation or COPD association, which are support groups of people with COPD
I will give you reading materials from lung foundation
Exacerbation
We want to make plan for any possible exacerbations that you may have. If you have any increase in your shortness of breath, cough, sputum production, this means that you are having an exacerbation. I will give you a written action plan that explains what steps you need to follow if you have an exacerbation
Increase the amount of Ventolin/blue puffer: use 4-8 puffs every 3-4 hours. If you need Ventolin more than this, or earlier than 3-4 hours, call the ambulance and go to the ED
I will give you steroid tablets. If you have an increase in symptoms, you can start 50mg prednisolone once a day for 5 days.
If you have fever, and there is an increase in the amount of phlegm and a change in color of the phlegm, start antibiotics, amoxicillin 500mg TID x 5 days.
Your next patient is a 55 year old man, who is a known case of COPD and has come to you concerned of his recurrent falls. He is currently using budesonide inhaler. His GP prescribed prednisolone for 8 days whenever he has an exacerbation.
Tasks:
Explain results to the patient
Take history
Explain contributing factors and your management plan
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. How may I help you?
D: Is there any specific concern that you want me to address today?
Explain results to patient
D: Let’s discuss the investigations first. We have done a test for you called a bone mass densitometry which measures the bone density and strength. It checks 3 areas in your body, the spine, hip and the thigh bone. It gives us 2 scores, one is T-score which compares your bone density to a young person in the same sex; and the 2nd score is the z-score which compares your bone density to a person in the same age and sex.
D: I am looking at you T-score, as it’s between -1 & -2.5 in all 3 areas, you have a condition called osteopenia. This means that your bones are soft, but they are not at the level of osteoporosis which means being fragile and brittle.
D: I can see that your FBE, and the number of cells is normal. Your sugar levels are normal. Your kidney and liver function are both normal. Calcium which is a mineral in your blood is also normal. However, vitamin D which is an essential vitamin for having healthy bones, it is low.
History
D: Is it okay if I ask you a few questions?
D: Can you tell me more about your falls?
R: I’ve had 3 falls in the last 3 months. The last one happened at home. I’m concerned that I might fall and there is no one to help me.
Osteopenia
D: Do you take dairy products regularly?
D: How much sun exposure do you get?
D: How much exercise do you do?
D: Do you drink alcohol? How much?
D: Do you drink coffee? How much?
COPD
D: When were you diagnosed with COPD?
D: Are you compliant with your treatment?
D: Do you have regular follow-up and test with your GP?
D: How many flare ups do you get every 12 months?
D: Have you been admitted because of a flare-up?
D: Are you still smoking?
Falls
D: Can you please describe the falls?
D: Have you had any fractures?
D: Where did you have a fracture?
D: Any family history of fractures?
Risk Factors of falls
D: Do you have any vision or hearing problems?
D: Any joint pains that you have?
D: Any balance issues?
D: Do you have any stairs or any loose rugs?
Management
Most likely the main cause of your osteopenia and weak bones is the steroid medication that you have been taking. You’ve been taking steroids for 8 days during flare-ups which is too much as the recommended duration is only 5 days.
An uncontrolled COPD can also affect the bone density and cause osteopenia.
Osteopenia
Pharmacological
Because you do not have fractures, and you have osteopenia, I will calculate of the risk of a fracture using a fracture risk assessment calculator (FRAX calculator). If you have a high risk, I will give you medications.
We have options:
Alendronate tablets, this may give you a bit of tummy upset
Denosumab (Prolia), these are 6-monthly injections and you need to get it on time. We’ll just check your kidney function, calcium and vit D before we start it
If we start medications, please see your dentist for a dental check-up
Vitamin D supplements
Take 1-2 caps daily. Also take a calcium-rich diet, about 3-4 servings of dairy products every day.
Non-pharmacological
Do regular exercise
Adequate sun exposure outside of the high risk time (12:00 - 2:00 PM)
Cut down on alcohol and coffee
COPD
Stop smoking
I’ll send you to Quitline
I can help you with the craving and withdrawal symptoms with NRT
Refer to pulmonary rehabilitation program
Pharmacological
(patient is on budesonide); I will add a LABA like salmeterol, I’ll review you in 3-months’ time to see how you go
In your next flare-up, please take steroids for 5 days only
Falls
I’ll refer you to a fall clinic; they will check your vision and hearing
Physiotherapist: balance training
Occupational therapist: home review
Your next patient has come to your GP to discuss his results today. He is a known case of COPD and is using Symbicort. He has had 4 flareups in the last 12 months and he needed steroids for each flare up. He is a chronic smoker and has failed to stop smoking. NRT has been unsuccessful. No history of falls or fractures. He has a family history of hip fracture. He exercises only on the weekends and has inadequate sun exposure.
Tasks:
Explain investigation results
Explain risks and counsel regarding management
Explain risks
You have osteopenia and there is a risk of a minimal-trauma fracture if you have a fall. This means that you may break your bones with a simple fall or injury that normally should not cause a fracture.
Management
Osteopenia: same as ver 1
COPD
Respiratory physician + spirometry
I will add an inhaler called a LAMA like tiotropine
I’ll do influenza and pneumococcal vaccination
I’ll refer you to the pulmonary rehabilitation program
Stop smoking: Quitline, NRT like varenicline
CBT for the cravings
Falls
Refer to fall clinic to reduce the risk of falls in the future
OT: home review
Check vision, hearing
Medication review
Your next patient is a 70 year old lady who was admitted due to a hip fracture and underwent surgery. She is planned to be discharged soon. The occupational therapist has done an assessment:
Patient can do basic activities of daily living such as going to the toilet or taking a shower but she has problems with cooking and needs assistance.
She has balance issues so had to hold on to something to walk and has poor mobility
Not safe to discharge to home unless support is available.
Tasks:
Discuss the report with the son
Discuss discharge planning
Open-ended question
D: Hi, my name is ___. I’m so sorry to hear that your mother has been unwell lately. Can you tell me what has happened so far?
D: Can you please describe her living arrangements and if she has support at home?
R: She lives alone, I live 1 hour away. I cannot stay with her and she cannot stay with me.
Summarize
D: Let me summarize your mother’s condition at the moment. As you are aware, she had a fracture in her hip which is a serious fracture as it can affect walking and her daily activities for some time. We have done a surgery to repair the fracture, but hip fracture has a long rehabilitation phase and the recovery time can take at least 6 months to return to the normal function.
Problem List
D: We have a few concerns with your mother’s situation.
We are concerned about her ability to perform her daily activities such as dressing, cooking, showering and going to the toilet. She will require some support for some time and as the occupational therapist has done an assessment, I can see that she is able to take a shower by herself, able to go to the toilet, but she needs help cooking.
Pain: The pain continues after surgery and we will need a pain management plan to control the pain upto the level which she will be able to do her activities of daily living. We will need to balance the benefits and risks of painkillers as some can make her drowsy and increase the risk of falls. This is why, I will send her for a medication review with the pharmacist, and the pain clinic to have a proper pain management plan.
Balance: after the fracture and the surgery, she can have some problems with balance and some weakness when walking, and this increases the risk of fall. I will refer her to a physiotherapist for balance training and give her some exercises to improve the muscle strength and also the balance. We can provide her some walking aids such as a single-point walking stick, 4-point walking stick, or a walker depending on her mobility needs.
Home safety: our main concern is having another fall. Having a poor lighting, having stairs and uneven surfaces, having pets, having slippery floors, or loose rugs all increase the risk of a fall. I will ask the occupational therapist to do a comprehensive home review. They will do a home risk assessment first and identify the dangers or risky points at home, and they will give us some recommendations. For example they might give advice about appropriate lighting, securing rugs with non-slip flooring, need to install grab bars and handrails in the toilets and stairs, non-slip mats in the shower and toilets, and education on proper use of the assistive devices.
I can arrange an aged-care assessment. I will request a review on the My Aged Care website. They will assess her condition and the support she has, and they will offer support either through social workers, or providing government-funded residential aged care.
Geriatric screening: we will monitor your mother’s situation closely. We’re going to see her in the fracture clinic to make sure her fracture is healing well. We will check her mood and do a mental health check. We’ll do a MMSE to assess her memory. Regarding meals, we can get some support from meals on wheels.
Key points:
Your mother has had a minimal trauma fracture, there is a chance that she has osteoporosis, meaning that her bones are fragile. I will send her for a bone mass densitometry, and start treatment.
She will also need blood thinners for a certain time to prevent clots in her legs as she is moving around less than usual.
I will refer her to the fall clinic to help prevent and reduce the risk of another fall.
Your next patient is a 47 year old lady who presented to your general practice concerned of bowel cancer. Her father has been diagnosed/has history of bowel cancer.
Tasks:
Take history
Counsel the patient accordingly
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. How can I help you?
Address concern
D: I understand your concern. Thank you for coming in for an assessment. Let me ask a few questions so we can make the best management plan together.
D: How is your father doing?
D: May I know at what age was he diagnosed with bowel cancer? (<60 years)
Symptoms
D: Have you lost any weight lately?
D: Any loss of appetite?
D: Any lumps and bumps around the body?
D: Any tiredness and night sweats?
D: Any abdominal pain?
D: Any diarrhea or constipation?
D: Any vomiting? Any bloating?
D: Any dark stools or any blood in the stools?
D: Have you ever been screened for bowel cancer?
Risk Factors
D: Do you drink alcohol?
D: Do you smoke?
D: Can you describe your diet?
D: Do you take a lot of red meat?
D: Do you eat a lot of vegetables?
D: Any history of having polyps in the bowel or inflammatory bowel disease?
D: Any family history of other cancers?
Metastasis
D: Any cough or shortness of breath?
D: Any yellowish discoloration of skin?
D: Any headaches?
*If patient has symptoms:
We’re not doing a screening, please do a colonoscopy now to make sure there is no cancer. If there is no cancer, then we’ll put you back on screening.
Lifestyle advice:
Healthy diet
Cut down on red meat, processed meat and BBQ
Cut down on alcohol
Stop smoking
Regular exercise, healthy weight
Red Flags:
Symptoms we asked on history taking
Reading material: cancer council
Review depending on category risk
Your next patient is a 60 year old lady who has come to the ED after a fall on an outstretched arm. X-ray shows a Colles fracture with minimal displacement. A below elbow cast (plaster of Paris) has been applied.
The patient is about to be discharged.
Tasks:
Explain care of cast at home
Explain follow-up care plan
Explain the Fracture
D: You have had a Colles’ fracture which is a fracture in the radius bone in the wrist/forearm. When the fractured part moves upwards, we call this a Colles fracture.
D: The cast will immobilize the broken bones and keep them in a proper position to allow healing of the bone. We need to keep this for 6 weeks. We’re going to see you in 1 week at the fracture clinic to review the fracture, if all is well, we’ll leave the cast for 6 weeks.
Care of Cast
D: I’ll give you painkillers that you can take regularly. Some of them may cause drowsiness, so please don’t drive while taking them.
D: mild swelling of the forearm is expected in the first few days, but to reduce the swelling, we have to do a few things:
Keep the cast elevated and above the level of your heart. During the day, put it on a sling, and at night, place it on top of a pillow.
You can apply a bag of ice wrapped in a thin towel to the cast every few hours
D: keep the cast dry. If you are taking a shower, wrap it with 2 plastic bags and tape the bag to your skin. In case the cast becomes wet, use a blowdryer in the cold setting to dry it
D: Keep the cast clean. Don’t apply any powder, lotion or oils close to the cast. If it becomes itchy, don’t stick items inside and underneath the cast as it can injury your skin. Don’t pull on the padding inside.
D: Regularly move your fingers to keep the blood flow circulating and to avoid stiffness in the fingers. I will print out a fact sheet for the finger exercises as soon as you are pain free.
Key points:
Red Flags (Compartment syndrome, Infections)
If you have any fever, blisters, rash, redness on the skin, or any bad smell, go to your GP or emergency department
If your pain is not responding to painkillers, unable to move your fingers, if you start having pins and needles and numbness, or your fingers go pale/blue, rush to the ED because we will need to remove the cast
Once we remove the cast in 6 weeks’ time, we’ll make a rehab plan and refer you to physiotherapy as we expect some stiffness in your wrist. We’ll do some strengthening and stretching exercises
As you’ve had a minimal trauma fracture, there is a risk of osteoporosis. I will send you for a scan called a DEXA scan to assess the bone mass density.
