Class 9 Flashcards
Your next patient is a 40 year old lady who presents to your general practice complaining of cough and shortness of breath. She is a known case of asthma and is using Ventolin and steroid inhalers. She is compliant to her medication and the asthma educator has checked her inhaler technique. She is concerned of her worsening symptoms and her frequent use of her reliever inhaler. Vitals are stable.
Tasks:
History for 3 minutes
Explain the possible contributing factors
Explain your 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 your concern, I know how difficult that can be. But let me ask you a few questions to better understand your situation, then we’ll make the best management plan for you.
Key point 1: Symptoms of Uncontrolled Asthma
D: How many days per week do you need to use Ventolin?
R: I almost use it every day
D: How many days per week? Do you have daytime symptoms of coughing and wheezing?
R: Everyday
D: Any nighttime symptoms that wake you up?
R: Yes
D: Have you noticed any limitation on exercising?
R: Yes
Key point 2: Risk Factors for Uncontolled Asthma
D: Do you smoke? Anyone smoking at home?
D: May I know your occupation? Any exposure to dust or fumes at work?
D: Do you have any pets at home?
D: Do you have any carpets?
D: Have you had any recent weight gain?
D: Any loss of weight? Have you ever coughed up blood?
D: Have you had any recent heartburn?
Assess Severity of Asthma (if with extra time)
D: How many flare ups have you had in the last 12 months?
D: Any admissions because of a flare up?
Positive Findings:
Smoking, 15 cigarettes/day
Management
Your asthma is currently poorly controlled. As you are using your Ventolin more than 2 days per week, you’re having daytime symptoms more than 2 days per week, you have nighttime symptoms, and you find it difficult to exercise.
A well-controlled asthma is when you don’t have nighttime symptoms, no limitation on exercise, and less than 2 days per week of daytime symptoms and Ventolin use. The most possible cause of your worsening asthma is your current smoking.
Pharmacological
I will need to step up your treatment plan and add another medication that we call a LABA. We have two options:
I will change your preventer to Seretide/Symbicort BID. This prevents the symptoms from happening. But I still want you to use Ventolin if you need it when you have symptoms.
There is a new option. I can give you Symbicort which is a combination of steroid and LABA. Use it as a preventer BID, and if you have further symptoms throughout the day, you can use the same Symbicort as a reliever.
We will continue this treatment for 3 months and I will review you. You can use a spacer to maximize the effect of the medication.
Non-pharmacological
Smoking will make your asthma worse, and I need you to stop. I can refer you to Quitline, support you in stopping smoking by giving you medications to reduce the cravings and withdrawal symptoms such as nicotine replacement therapies.
Please vacuum your carpets regularly, avoid dust, pollen, pet dander.
Please do regular exercise. If you get symptoms during exercise, you can take 1 puff of Ventolin before you start.
I will arrange for a spirometry. This test assesses your lung function.
I will give you an action plan, this is a written plan that tells you what to do in case you are having a flare up.
I will give you reading materials from Lung foundation about asthma, triggers, risk factors.
If you get more coughing, wheezing, shortness of breath, please come back to me for reassessment.
Your next patient is an 80 year old woman, admitted in the hospital and diagnosed with lobar pneumonia and heart failure. She has been started on antibiotics. She is a chronic smoker and has become restless and agitated and is shouting Greek.
V/S: Sat 93% on 4 liters of oxygen
Bloods done: Na 132 (135-145)
Tasks:
Explain condition to next of kin
Explain possible reason
Explain management plan (behavioral and management plan)
Open ended question
D: Hi, my name is ____. I’m taking care of your mother today. How can I help you?
Address Concern
D: I understand that this is a distressing, and overwhelming situation. But I’d like to reassure you that we’ll support you and your mother and provide the best care to your mother.
D: Just before we start talking about your mom’s condition, do you have your mother’s consent to discuss about her condition?
D: Do you have any concerns that you’d like to address today?
Explain the diagnosis
Your mother is having a condition called delirium which is an acute change/impairment of the awareness and consciousness and it causes confusion, agitation, restlessness and disorientation.
Delirium is usually multifactorial and has multiple causes. There are a few possible causes in your mother’s case. It can be the low salt in her blood, a low oxygen in her blood, an infection in her lungs, or her heart failure as problems in her heart can also cause delirium. There can be other causes as well such as drugs and medication such as painkillers, high or low sugar in the blood, withdrawal from use of regular alcohol, medication or drugs if she’s been on it for quite some time; other infections like blood or urine infections, reduced sensory input like having hearing and vision problems, strokes and brain tumors, urinary retention or constipation, and heart attack, pulmonary embolism or clots in the lungs.
Management
Key point 1: whenever we want to treat delirium, we need to treat the cause. To find the cause, we will need to do further investigations.
To check for low salt in her blood, I will examine your mother and check if she has any swelling in her legs, and check her urine output.
We’ll also do FBE, ESR, CRP, blood culture, urine MCS, ECG, brain CT scan, UEC, FBS, LFTs.
I want to review her medication chart and her vital signs chart.
I can see that your mother has a low sodium in the blood. We will have to find the cause of this and if we confirm that the cause is excessive fluid in her body, we will restrict her fluids and monitor the urine output. If the sodium drops further and goes below 120, then we’ll start her on IV fluids and start her on normal saline and slowly replace the sodium.
We will continue the intravenous antibiotics for her lung infection. We will be monitoring her oxygen levels. If the O2 saturation falls further, we may support her breathing by placing a tube in the airway.
Non-pharmacological
We will closely monitor your mother. We’ll monitor her vital signs. We’ll ensure her safety and your safety.
We will create a familiar environment for her. You can stay with her. We encourage family members to be present. We will allocate the same nurse every day. Encourage regular communication.
We’ll keep the room quiet, with good lighting and temperature. We’ll place a calendar and a clock. We’ll create a safe environment for her.
We’ll monitor her medications and avoid medications that can make this worse. If she is in pain, we’ll give her pain relief.
In case she wears glasses or hearing aids, please bring that for her
If she gets worse, as a last resort, we can give medications to calm her down such as haloperidol; if we become concerned of her safety, we may use physical restraints, although we try to avoid it as much as possible
Questions:
Do you want me to talk to mom in English or Greek?
I want you to talk to your mother with whatever language she is more comfortable with
Your next patient is a 45 year old man who is admitted in the hospital and had a total knee replacement 3 days ago. He has developed confusion and agitation today. He is a heavy alcohol drinker and used to drink 25 SD every day.
PR 120 Temp 37.8
PE: no organomegaly, no features of ascites, no cannula site infection
Inv: raised AST, ALT, GGT
Macrocytic anemia (Hgb low and MCV increased)
Tasks:
Explain the blood test results to the son
Explain the possible causes and your diagnosis
Explain your management plan
Open-ended question
D: Hi, my name is ____. I’m taking care of your father. How can I help you?
Address Concern
D: I understand that this is a distressing, and overwhelming situation. But I’d like to reassure you that we’ll support you and your mother and provide the best care to your father.
D: Just before we start talking about your dad’s condition, do you have your father’s consent to discuss about her condition?
D: Do you have any concerns that you’d like to address today?
Explain Results
D: On his liver function test, his liver enzymes are elevated, which is most likely because of the damage of heavy, long-term alcohol use to the liver.
D: The red blood cells in his blood are larger than usual (high MCV) and they contain a low amount of hemoglobin which is responsible for carrying oxygen in the blood. This can also be a side effect of heavy, long-term alcohol use
D: Your father is having a condition called delirium which is an acute change/impairment of the awareness and consciousness and it causes confusion, agitation, restlessness and disorientation.
Delirium is usually multifactorial and has multiple causes. There are a few possible causes in your father’s case. The most likely cause in your father is alcohol withdrawal. When you use alcohol in large amounts and for a long time, your body gets used to it. And if you suddenly stop drinking, it causes confusion, agitation and even sometimes, seizures. We call this alcohol withdrawal.
D: Your father has a mild grade fever. This can be a sign of infection such as lung infections, urine infections, surgical wound infection, etc.
D: He also has a high pulse rate. I am concerned about problems in the heart such as heart attack, or problems in the lungs such as a clot in the lung called pulmonary embolism.
D: His liver enzymes are also high, which can be possible for a hepatic encephalopathy.
D: There can be other causes as well such as drugs and medication such as painkillers, high or low sugar in the blood, withdrawal from use of regular alcohol, medication or drugs if she’s been on it for quite some time; other infections like blood or urine infections, reduced sensory input like having hearing and vision problems, strokes and brain tumors, urinary retention or constipation, and heart attack, pulmonary embolism or clots in the lungs.
Management
Management of Alcohol Withdrawal:
Key point 1: whenever we want to treat delirium, we need to treat the cause. To find the cause, we will need to do further investigations.
We’ll also do FBE, ESR, CRP, blood culture, urine MCS, ECG, brain CT scan, UEC, FBS, LFTs.
I want to review her medication chart and her vital signs chart.
Give thiamine
Supportive care:
Non-pharmacological
We will closely monitor your mother. We’ll monitor her vital signs. We’ll ensure her safety and your safety.
We will create a familiar environment for her. You can stay with her. We encourage family members to be present. We will allocate the same nurse every day. Encourage regular communication.
We’ll keep the room quiet, with good lighting and temperature. We’ll place a calendar and a clock. We’ll create a safe environment for her.
We’ll monitor her medications and avoid medications that can make this worse. If she is in pain, we’ll give her pain relief.
In case she wears glasses or hearing aids, please bring that for her
If she gets worse, as a last resort, we can give medications to calm her down such as haloperidol; if we become concerned of her safety, we may use physical restraints, although we try to avoid it as much as possible
Your net patient is a 90 year old man who has been admitted due to lobar pneumonia and has been started on antibiotics. He has been having episodes of hypoxia and hypotension. He has an advanced care directive for no CPR and no enteral feeding. The consultant has suggested palliative care and has asked you to discuss this with the family members. The patient’s daughter is here to talk to you and she is the next of kin and has consent to discuss about her father’s condition.
Tasks:
Talk to the daughter and explain measures being done
Explain what you can do further
Initiation Phase
D: Hi, my name is ___. I’m one of the doctors taking care of your father. I’m so sorry to hear that your father has been unwell lately.
Open-ended question
D: Can you tell me how much you know about your father’s condition?
D: Are you the medical decision maker for your father?
D: Do you have any specific concerns that you want me to address?
Explain the situation
D: Let me explain more about the current situation of your father. Your father is diagnosed with lobar pneumonia, which is a lung infection caused by some bugs and it usually causes cough, fever, shortness of breath, and sometimes, drowsiness.
As he has low oxygen and low blood pressure, we categorize this as a severe pneumonia. We have started him on IV antibiotics and are also giving him oxygen and fluids.
D: We have been monitoring his condition closely, but unfortunately, he is not responding well to the treatment and has had episodes of low blood pressure and low oxygen.
We are concerned that his condition might worsen and his situation may deteriorate, but I want to reassure you that we’ll do everything we can for him and we will continue providing the best care to him.
D: If his condition worsens, our next steps would be to consider placing a tube in his airway and assist him with breathing. But I have become aware about your father’s advanced care directive and his wishes for end of life care. He has refused any resuscitation and chest compressions and also feeding with a tube.
D: The consultant has asked me to have a discussion about palliative care with you, which is a possibility in your father. This is a special type of treatment that focuses on making the patient comfortable and pain-free at the end of life. It provides physical, emotional and spiritual support for people who have serious illnesses.
PEPSI COLA:
Physical: we will do our best to treat any symptom your father has such as for pain, we’ll give painkillers, if he has vomiting, we’ll give anti-vomiting medications. We will make sure he is comfortable and pain-free
Emotional: I understand that this is a difficult and emotional time for you and your family, but I’m here to support you. We can have a family meeting to discuss different possibilities and have clear expectation of his current condition.
Personal: if you require any spiritual or religious arrangements, I can help you with that.
Support: if you require any support, I can help you with Centrelink forms and support. I can refer you to support groups like Palliative care Australia. They also have a hotline that you can call for support.
Information/Communication: we will try to have clear communications and I will update you about your father’s condition regularly. We will involve you in the decision making and I can also arrange a meeting with the consultant if you need further discussion and support.
Control: We will respect his wishes in his advanced care directive and not to resuscitation and chest compressions if his heart stops beating. If at any point, we need help in the decision making, we will involve you as the medical decision maker.
Is everything clear up to this point? Do you have any questions?
Empathy:
We will be taking care of your father as a team. We’ll try to provide the best care to him. If you have any concerns, you can always contact me. I’ll be here for you and your family.
Your next patient is a 57 year old lady who is brought to the ED after an MVA. Primary and secondary survey has been done. A CT scan was done as part of the trauma assessment and an incidental 1.5cm homogenous opacity was seen in the left adrenal.
Tasks:
Take history for 4 minutes
Explain your diagnosis and differentials
Explain further investigation to the patient
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. How are you feeling now?
D: We did some scans on your stomach to make sure you had no injuries to the organs, and I’m happy to confirm that there is no injury. However, we saw a small lump on a gland above your kidney called the adrenal gland. Is it okay if I ask you a few questions?
Explore Differentials
Malignancies
D: Any recent loss of weight?
D: Any recent loss of appetite?
D: Any tiredness and night sweats?
D: Any abdominal pain and bloating?
D: Any changes in your bowel motions, like diarrhea or constipation?
Metastasis
D: Breast: Are you doing your regular mammograms? Have you ever had a breast lump before?
D: Lung: Any long-term cough? Have you ever coughed up blood?
Pheochromocytoma
D: Have you had long-term headache?
D: Have you experienced any racing of your heart?
D: Have you noticed any flushing and sweating?
D: Have you noticed any shakiness in your hands?
Cushing’s Disease
D: Have you had any recent weight gain?
D: Have you noticed any bruising in your body?
D: Have you noticed any weakness in the muscles?
Hypertension
D: Have you ever had a high blood pressure before?
Positive Findings in History
Episodic headaches
High blood pressure
No palpitations, no sweating
No red flags for cancer
Explain Diagnosis and Differentials
Whenever we do a scan and we find an incidental mass in the adrenal gland, we call it an adrenal incidentaloma. There can be different causes of this mass:
Adrenal cancer
Other cancers spreading to the adrenal such as a breast cancer, bowel cancer
Pheochromocytoma
Steroid-producing mass which cause Cushing syndrome
Masses that produce a hormone called aldosterone, causing hyperaldosteronism or Conn’s syndrome
Adrenal hemorrhages
Benign adrenal adenomas
Investigations
Pheochromocytoma: serum and 24-hour urinary metanephrines
Cushing disease: 1mg dexamethasone suppression test; we’re going to give you a tablet and you take it a night, and we’ll do a blood test in the morning to check your cortisol levels
Hyperaldosteronism: aldosterone/renin ratio
Further investigations: MRI/CT scan with contrast
If we are concerned about the spread of the cancer to the adrenal, we may need to take a sample with a needle called a fine needle aspiration biopsy
Your next patient is a 60 year old lady who was admitted after a MVA 1 week ago and has now been discharged. She had a CT scan of the chest, abdomen, and pelvis. On her chest CT scan, an incidental breast mass was seen.
Tasks:
Explain CT scan results to the patient
Explain your management plan
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. How are you feeling now?
Explain CT-scan
D: We did some scans on your chest, abdomen, and pelvis to make sure you had no injuries to the organs, and I’m happy to confirm that there is no injury. However, we saw a small lump on your breast. Is it okay if I ask you a few questions?
D: Do you have any history of breast lumps? Are you aware about this?
D: We need to find out what kind of lump we are dealing with, as the management can be different.
Differentials
D: This lump can be a benign lump like fibroadenoma, a breast cyst, fat necrosis, or it can be a malignant cancerous lump.
Explain Triple test
D: We evaluate any breast lump with 3 tests, that we call the triple test.
For the first step, I will ask you some questions and I will examine your breast to check the characteristics of the lump. I can arrange a chaperone during examination. It will involve looking at your breast, feeling your breast and armpit.
For the second step, we need to another type of imaging called a mammography to look at the characteristics of the lump
For the third step, we may need to take a sample from the lump which we call a core biopsy or a fine needle aspiration. This usually happens under the guide of an ultrasound.
Conclusion
D: Once the results are ready, and we have identified the type of the breast lump, we can plan further treatment. If it’s a benign lump, we are reassured that it’s not a cancer, we’ll observe it and follow it up. But if it’s a malignant cancer, I will need to refer you to the breast surgeon.
Your next patient is a 60 year old man who has come to you today to discuss his results. He did a CT aortogram for stroke and an incidental thyroid nodule was seen.
Tasks:
Take history from the patient
Explain the investigations you would request
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. How can I help you?
D: I have your results with me. We have seen a lump in your thyroid gland in your neck. Is it okay if I ask you a few questions?
D: Have you had a previous history of thyroid nodule or disease?
Symptoms
D: Have you noticed any swelling in front of your neck?
D: Have you noticed any pain/discomfort in your neck?
D: Have you noticed any changes on your skin on the neck?
D: Do you have any weather preferences? Any heat intolerance?
D: Any changes in your bowel motions? (diarrhea)
Red Flags
D: Have you lost any weight? Any loss of appetite? Any lumps and bumps in the neck?
D: Any difficulty in swallowing?
D: Any changes in your voice?
Risk Factors
D: Any previous history of radiation or imaging to the neck?
D: May I know your occupation?
D: Any previous history of any cancer?
D: Any family history of thyroid cancer? Breast and bowel cancer?
Past Medical History (if there is extra time)
D: When did you have a stroke?
D: What treatment are you on? Are you compliant with medications?
D: Do you have regular follow-up with your GP and specialist?
D: Any weakness/numbness in the body?
Counselling
On your scan, we found a thyroid nodule, which is a growth in the thyroid gland.
It can be a benign growth like inflammatory or hyperplastic nodules, thyroid cysts, and follicular adenoma, or it can be malignant like a papillary thyroid CA, follicular thyroid CA, or metastasis from breast or lung.
I will examine you, examine the nodule and check the characteristics, and I’ll also check the glands and lymph nodes in your neck.
I will then arrange for a blood tests that checks the thyroid function called TSH. If your TSH is low, we will proceed to a radioactive iodine scan. We will inject you with a medication and do a scan assessing if the thyroid picks up the radioactive iodine. (if the thyroid picks up the iodine, it’s a hot nodule, meaning it’s functioning; if it does not pick up the iodine, it’s a cold nodule, it’s non-functioning, not a good sign)
If your TSH is normal or high, I will send you for an ultrasound to further examine the nodule. If there are concerning features on the ultrasound scan, we will take a sample with a needle that we call a FNAC.
And based on the results, I will arrange the most appropriate management plant. Is that okay?
