Counseling Workshop

Question 1

Diabetes Counseling

Answer 1

1. Intro - ICE
2. Explain Results
   - RELEVANT Q- any symptoms (tiredness, polydipsia, polyuria) : asymptomatic vs symptomatic DM
   *asymptomatic need to repeat test ASAP to confirm
3. Complications: Target end organ damage, micro and macro vascular complications KNIVES (Kidney Nerves Infection Vascular Eyes Skin)
4. Management (OPTIONS)
   -Pharmacological 1. start metformin or lifestyle modification with an aim of FBS 4-7, Hgba1c<7
5. Lifestyle
   -diet: cereals, whole grains, 1.5 serving of dairy daily, fruits and veggies, limit saturated fats, reduce salt intake
   -regular mod intensity exercise 150 mins per week , resistance exercise 2-3x/week total 60 mins
   -weight loss 5-10% (options orlistat, ozempic,naltrexone, bupropion)
   -safe alcohol levels
   -smoking cessation
6. MDT endo, DM educator, exercise physio, dietician
7. Review:
   eyes: ophtha
   kidney egfr annually cvs-lipid profile

Question 2

T1DM Counselling

Answer 2

History
1. DM Hx- treatment and compliance in detail, Complications of insulin therapy (Uncontrolled DM Complications)
2. Lifestyle- Diet, exercise, alcohol, OTC meds/herbals
3. Occupation esp if driver
4. Pyschological Assessment - mood and stress
Management
*patient does not like too many injections
1. change to long acting or insulin pumps GOAL FBS 4-7 RBS 5-10
2. MDT
3. Driving -patient please notify the driving authority (not MD), BSL should be >5, small snacks every 2 hrs
KEYPOINT
Hypoglycemia
1. symptoms (hunger, nausea, dizziness, loss of consciousness)
2. RF: alcohol and missed meals
3. MANAGEMENT:
<4 6 jellybeans, 1/2 glass of fruit juice, 1 tsp of honey and recheck after 15 mins
>4 take complex carb: banana, apple, sandwich
- Glucagon shot/ hypo kit
4. Sick day management plan
-more frequent BSL 4-6x/day
-do not stop insulin
-hydration
5. Support Groups : NDSS, Diabetes Victoria
GENERAL INSULIN ADVICE
1. unopened insulin in fridge, opened room temp
2. Cloudy, lumps and flakes do not use
3. proper disposal of needles
lipodystrophy

Question 3

Hypertension Counseling

Answer 3

1. Condition HX
   TX?- Side effect- postural hypotension, ankle swelling-amlo
2. Hypertension Complications: retinopathy : BOV HF S/Sx: chest pain SOB, leg edema, orthopnea, CKD: change or decreased urination?
3. R/O secondary causes of HTN
   OSA- snore and gasp, recent weight gain,
   Drugs and alcohol
4. CVS risk factors- alcohol, smoking, stress and occupation, exercise family Hx, diet
   MANAGEMENT
   BP not controlled
   best thing to do is to add second low dose med and discuss possible s/e
5. ACE /ARB
6. Thiazide
7. Lifestyle
8. FF up and review lipids

Question 4

DVT causes COSTVMP

Answer 4

C-contraceptive
Obesity
Surgery/immobilization
Travel
Varicosities
Malignancy
Past/FHx of DVT
Pregnancy/Postpartum

Question 5

General Lifestyle Advice

Answer 5

1. Diet: Varied, rich in fruits and veggies, whole grains and cereals, lean meat fish and poultry
2. Fats: Limit saturated and trans fat
3. Salt <6g/day but if HTN <4g/day
4. alcohol <2 SD/day
5. Physical Activity at least 30 min daily most days of the week
6. Weight loss 5-10% or BMI <25 WC <94/M<80/F
   7 Smoking Cessation

Question 6

CVS RISK FACTORS
(ABCDEFS)

Answer 6

A- Alcohol
B- BP and BMI - Hx of HTN, if they know weight/overweight
C- Cholesterol - ever diagnosed with high lipids
D- Diet and DM - healthy diet? take away? Fast foods?
-ever been Dx with high blood sugar
E- Exercise and lifestyle - occupation, sedentary, what exercise? how much?
F - Family History of DM, HTN, IHD, Stroke, CKD

Question 7

Muscle Cramps (S/E of Statins)

Answer 7

explore the muscle pain : where? how bad? anything makes it better or worse? how long after starting med?

MANAGEMENT OPTIONS
1. lower dose
2. alternate day dosing every other day
3. change medication to ezetimide

DONT FORGET TO DO CK LEVELS if > 5x dose, alternate or lower can resolve in 6-8 weeks

Question 8

Migraine Counseling

Answer 8

Migraine happens when there is dilatation of blood tubes in your brain
Management
!!!STOP OCP!

-Pharmacologic -
1. paracetamol, ibuprofen
2. metoclorpramide/ odansetron -nausea
–if this does not work
3. Sumatriptan (wafers, tablets, nasal sprays)
LONG TERM
If headaches is >2-4 times per month: prophylactic meds
1. Propanolol
2. Pizotifen
3. amytriptiline
-NON Pharmacologic-
-dark quiet room
-neck stretching exercises
-cold pack on forehead
-heat packs on shoulders and neck
General Treatment Advice
1. Trigger Avoidance- Migraine Diary
-food (cheese, chocolates), missing meals
-alcohol, stress, lack of sleep
-periods
2. Regular sleep patterns
3. meals on time
4. plenty of water, avoid coffee, caffeinated drinks
Red Flags
-more severe, neuro deficits , sudden severe pain
Support Group
Refer to neuro if TRIPTANS does not work

Question 9

Chlamydia Counseling

Answer 9

1. Confidentiality
2. Explain results good bad good
3. MANAGEMENT - GIVE OPTIONS
   - Chlamydia - azithro 1 dose vs doxy BID x 7days S/E GI irritability and photosensitivity
   - no sex for 7 days or sex with partner undiagnosed and untreated
   - patient delivered partner therapy
   4 Contact tracing partners in the last 6mos : a. patient, b. website, c. sexual health clinic

Review in 1 week for tx compliance and symptom resolution

Question 10

Chlamydia and Gonorrhea Counseling

Answer 10

1. Confidentiality
2. Explain results good bad good
3. MANAGEMENT -
4. Pharmacological GIVE OPTIONS
   - Chlamydia - azithro 1 dose vs doxy
   - Gonorrhea Im injection
5. Non Pharma
   -no sexual contact for 7 days
   - no sex with partners from the last 3 mos until tested and treated
6. NOTIFICATION
   -DHS- gonorrhea
   -partner notification : 1 patient, 2 website 3. sexual health clinic
7. OTHER STI testing
   - test of cure 2 weeks after tx completion AND 3 mos after for 1. HIV and gonorrhea
   REVIEW in 1 week: tx adherence, symptoms resolution and notification
8. General advice
   -safe sex: condoms
   -consider PrEP
9. Redflags

Question 11

Preoperative Counseling

Answer 11

1. Open ended Q
2. concern
3. Operation: what kind? what has been the problem
4. PMHX/ MRA
   any condition
   - Heart: MI/ Angina Hx of CABG/ Valve dse or sx/ PCI, any echo ecg
   - Chest pain SOB, orthopnea, PND
   - Exercise and functional class
   -Lungs: Smoking, COPD Asthma, Sleep apnea use medical devices during sleep
   -Endo: High BSL or thyroid problems
   -Kidneys: any kidney problem? abnormal kidney tests dialysis?
   - Blood: any hx of tiredness ,anemia,? any bleeding problems or episodes? any blood tests done before Clots in legs
   - Liver: liver problems, abnormal liver tests , alcohol
   -Brain: history of strokes
   - Drugs and allergies
   any allergies to medications?
   taking any blood thinners? INR? insulin, steriods?
   * above criteria checks HASBLED AND CHADSVASC score
   MANAGEMENT
5. acknowledge patients concern
6. Calculate risk of bleeding and clotting
   ***WARFARIN:
7. stop 5 days before the sx, check it after 24 hrs and if INR < 2
8. start on LMWH or enoxaparin then stop day prior the sx
9. After the SX the surgeon will decide if warfarin can be resumed or maintain on heparin
   PRACTICAL ADVICE:
   bowel surgery- bowel prep hydration

Question 12

Abdominal aortic Aneurysm Counseling

Answer 12

1. Explain condition - dilation of blood tubes due to weakening of the blood vessel wall
2. Risk/ Contributing Factors
   - Smoking, HTN, Alcohol, unhealthy diet, sedentary lifestyle, T2DM, hyperlipedemia, stress
3. Complication : Rupture- bleed-die

MANAGEMENT
1. Lifestyle Modification to lower CV RF
2. Smoking cessation
3. BP Control- high bp can make it worse
4. Diet and exercise
5. Alcohol <2 SD/day
6. Regular follow up and referral to vascular sx
7. UTZ 3.9-q24,5-Q6 mos
8. family screen > 50 y/o
9. red flags
-back pain
-abdominal pain
-injuries to abdomen
ED ASAP

Question 13

Hemachromatosis Counseling

Answer 13

1. Open ended Q
2. Concern
3. Explain Hemochromatosis- happens when there is excess iron in the body. It tends to run in families and caused by a mutation in the gene leading to an increased absorption of iron
   - our body does not usually have a way to get rid of the excess iron and when iron stays in the organs it can damage it, it usually takes years before it causes symptom- long term organ damage
   Organs Involved
   -liver- tiredness, liver failure
   -pancreas- diabetes
   -skin- tanning
   -heart
   -joints esp the hands
4. Diagnosis- Blood tests: Iron studies and genetic testing (C282Y, H63D- AR both parents/partners ) if positive will need regular follow up depeding on # of genes present
5. Management OPTIONS
6. Life long blood donations- weekly until normal iron stores then every 3-4 mos
   *Ferritin <100 T-sat <50%
7. Medications: Deferoxamine : chelating agent- attaches to iron and make it easier to remove from the body
   GOAL IS TO LOWER IRON STORES BEFORE IT DAMAGES THE ORGANS
8. Treatment advice
   -Avoid Vit C
   -avoid alcohol
   - low iron not really needed no role

Question 14

Melanoma Counseling
Biopsy: Superficial Spreading Melanoma, Clear margins, Breslow depth 0.25mm Clark Stage 2

Answer 14

1. Open Ended Q- Can you tell me what has happened so far?
   -did the doctor explain to you what are we looking for?
   -any concerns? ideas? worries?
2. I have the results are you happy to talk about that? How much do you w
   . WARNING SHOT- Unfortunately I don’t have good news. Would you like anyone to be with you at this moment?
3. MEDICAL CONDITION- Biopsy results showed Melanoma a type of skin cancer
   EMOTION- ADDRESS-give time to process, angry cry..pause, tissue , glass of water silence COUNT to 10
   EMPATHY - I’m so sorry that I have to give you this news, I can only imagine how difficult or overwhelming it must be to process this right now, but it is also important for you to discuss what we are going to do next. are you okay to proceed or if you want we can arrange a family member to be with you or another consult
4. EXPLAIN CONDITION
   - Cells in the skin that produce pigments call melanocytes when they get damaged usually by UV/sun exposure they grow out of control and causes skin cancer
   GOOD NEWS we caught it early and it has involved the top layer of the skin and it is not too deep which has less chance of spreading
5. FURTHER MANAGEMENT
   A. Refer back to specialist for
6. Re-excision : based on the depth of the margin around the lesion we need to remove a few extra skin to be on the safer side (1cm)
7. Sentinel Node Biopsy - they will inject a dye and see which lymph node picks up the dye first and take a biopsy to check for spread
8. CT scan of chest brain abdomen for spread
   B. SKIN CHECK
   -makes you at risk to develop other skin cancer (10x more) full body check of lesions ABCDEF
   C. General treatment Advice
   - most impt RF is sun exposure 5S
   -family check for lesions
   REVIEW every 3 mos for 2 yrs then every 6 mos for 2 yrs then annualy
   -RED FLAGS- new lesions: growing, change in color, itching, bleeding to touch see GP
   -REFER!! Support Group CAncer nurse, psychologist

Question 15

Epilepsy (DRIVING)

Answer 15

1. Open ended Question
2. Concerns
3. Condition : Epilepsy since when, tx, compliance, side effects? last seizure attack ff up with specialist?
   ***if non compliant: was it explained why? need? complications and consequences of non adherence
4. risk factors of seizure
   -alcohol, drugs
   -medications- drug interactions
   -sleep if enough and regular
5. PMHx/FHX
   Management
6. Acknowledge and address the concern BUT for safety of pt and other people
7. Criteria for conditional license (seizure free for 6mos and compliant to meds)
8. Risk factors avoid alcohol
9. medication compliance : follow up in 2 mos, review and consult with neuro if seizure free for 6 mos can recommend conditional license with yearly review

Question 16

Asthma Counseling

Answer 16

1. open ended Q
2. Concern- address
3. Symptoms of uncontrolled Asthma
   -recent noisy breathing /wheezing
   -# days per week with symptoms
   -# of days per week needing inhaler?
   -night symptoms or awakening
   - any limitation to exercise or activity
4. Risk Factor esp smoking and 2nd hand exposure to smoke
   -Home/work environment: pets dusts carpets?/fumes
5. Comorbidities
   - GERD- heartburn, weight gain
   -Psych- mood? Stress?
6. Hx of Life threatening asthma
   -any visits to ED? ICU admission
   MANAGEMENT PLAN
   **asthma is not controlled/partial>1 or poorly >3
   ++we need to step up treatment
   OPTIONS
7. Add LABA to current ICS
   OR
8. change to ICS+ LABA
   review in 3 mos

Non Pharma
-smoking cessation
-regular exercise
-Refer to respiratory clinic

Asthma Action Plan 6x6x6 (pedia 4x4x4)
reading material
redflags 000

Question 17

COPD Counseling

ver 1 spirometry
ver 2 xray
ver 3 ABG

tasks
1. explain condition
2. explain management

Answer 17

1. Explain COPD - happens when you smoke this causes damage to your lungs causing narrowing of the airway
   Management: COPDX
   *C-onfirm Dx (already in stem: xray/spirometry)
   *O-ptimize lung function :
   -pharmacotherapy 1. LABA OR LAMA (review in 6 weeks)
   -refer to chest physiotherapy : breathing exercises and cough techniques
   -SNAP: weight loss, diet, exercise physio
   *Prevent deterioration and worsening condition
2. SMOKING CESSATION
3. vaccination : influenza and pneumococcal, covid
4. Mucolytics as decided by specialist
5. Oxygen therapy
   * Developing Support
6. referral to pulmonary rehab
7. Support group Lung foundation Aus
8. Reading Materials
   *X - Exacerbations
9. red Flags -worsening sx, increase cough or SOB
   ACTION PLAN!
10. Ventolin 4-8 puffs repeat every 3-4 hrs and seek advice at GP if fever plus increase or change in phlegm color:
11. antibiotics (amox) and steroids (predx 5 days)

Question 18

COPD + Osteopenia + Hx of recurrent falls
BMD:-1 to -2.5
on oral steroids for 8 days after exacerbation and on budesonide
Invx Vit D 30 (NV>50)

Answer 18

task 1 (explain quickly)
We have done a BMD scan, it measures the strength and density of bones
T score compares to young same sex
Z same age and sex
as it is -1 to -2.5 it means osteopenia: softer than usual but not yet osteoporosis
task 2 Hx
1. Open ended Q
2. Concern
3. Fall Hx- # of episodes? any relation to sudden changes in position? any Hx of broken bones or fractures (if yes what bone did you break)
4. fall Risk
- vision prob?
-balance prob/issues?
-weakness/numbness in legs
-Home environment: stairs,rugs, lighting, slippery surface
5. COPD Hx since when tx what inhaler compliance ff ups. **How many times did you need to take steroids in the last 12 mos
6. Osteoporosis RF
-alcohol,smoking,coffee,diet(dairy), sun exposure,malignancy (LOW/LOA/bone pains)
Task 3 management
calculate fracture risk GARVAN FRACTURE RISK CALCULATOR
if high risk we will treat you with medications
OPTIONS
1. Bisphosphonates : oral-alendronate, IV zolendronic acid- esophagitis and ostenecrosis of the jaw, flu like s/sx
2. Denosumab every 6 mos but need to check Ca levels
3. Estrogen like meds : raloxifene
Osteoporosis prevention advice
-vit D supplementation and adequate sun exposure
-calcium -increase dairy in diet or supplementation
-regular exercise and physio for balance training
-decrease alcohol, smoking, caffeine/coffee
-Fall Prevention clinic
-occupational therapist for home review
-medication review with pharmacist : polypharmacy and drug interactions
**COPD- add LABA/LAMA refer back to specialist

Question 19

Colle’s Fracture
60y/o fall on an outstretched arm

Answer 19

Colle’s fracture - fracture in the radius bone and fractured part titlts and moves upward

CAST CARE
- immobilize the broken part to facilitate healing for 6 weeks
-mild swelling is common-elevate the limb above the heart and pillows in bed
-can apply bag of ice wrapped in towel
-keep cast dry esp when taking a bath: cover with 2 plastic bags and tape to skin
-in case it gets wet- dryer in cool setting
-keep cast clean do not apply lotions or powders near the cast
-if it becomes itchy_do not stick any items inside or underneath the cast as it can injure the skin- dryer on cool setting is the best thing you can do
-regularly move fingers to keep blood flowing/ circulating and avoid stiffness

KEY POINT= RED FLAGS
**Infection, ulcer, compartment syndrome, neurovascular compromise
1. Fever/blister/ rash/ bad smell
2. pain not relieved by pain killers or unable to move fingers(compartment)
3. Blue/pale discoloration of fingers
4. Pins and needle sensation

FF UP PLANS
-review in 24 hrs for compartment
-review in 1 week at FRACTURE CLINIC
-cast removal at 6 weeks and physiotherapy after

-Arrange BMD scan- minimal trauma fracture- to check for osteoporosis
support and home environment assessment
***rehab exercises -move fingers

Question 20

Delirium

Answer 20

Always multifactorial
Delirium - acute impairment of consciousness and leads to restlessness agitation, hallucination and disorientation

Causes : DELIRIUM
Drugs- opioids and benzo
Electrolyte imbalance and sugar
Lack of drugs/withdrawal
Infection
Reduced sensory input (vision/hearing impairment)
Intracranial -stroke/trauma
Urinary retention & fecal bowel impaction
Myocardial & Pulmonary (MI/HF/PE/Pneumonia)

MANAGEMENT
1. Investigate underlying cause: Blood: FBE UCE LFT ABG BSL, Blood culture, Trop CT brain scan ECG CXR urine toxicology
2. Medication review (Abx esp carbapenems can cause delirium)
3. Chart- VS and temp O2 sats
Non Pharma
1. close observation
2. Quiet room and appropriate lighting
3. Encourage family members to sit and be with patient
4. Calendar and clock in the room
5. If she has glasses and hearing aids it can help and lessen disorientation
6. maintain regular sleeping patterns
WHEN we are concerned for her safety we can give medications
-haloperidol,olanzapine

Question 21

BCC Counseling
margins not clear

Answer 21

Hidden agenda patient does not want re-excision

1. MOH’s Microsurgery- remove small pieces of skin and check it under the microscope to make sure it is clear of Ca cells- minimal skin removed best for face nose
2. cryotherapy -freeze Ca cells with liquid nitrogen
3. Radiotherapy- kill Ca cells with targeted radiation
4. Photodynamic therapy -cream applied and exposed under special light
5. Imiquinod- applied to skin but can also damage normal cells around the area

I will refer you to a dermatologist who can extensively discuss the options so you can make a more informed decision

KEYPOINT #2 skin check full body
KEYPOINT #3 Sun protection 5S
RED FLAGS - ABCDEF

Question 22

Squamous Cell Ca Counseling

Answer 22

1. Re-excision if margins not clear
2. Lymph node exam
3. CT scan of the body
   4 Full regular skin checks
4. Sun protection
5. Red flags
6. Cancer nurse, support group psychologist

Question 23

Prostate Cancer Counseling

Answer 23

1. open ended Q - can you tell me what has happened so far?, did the specialist tell you what we were looking for?
   BREAK BAD NEWS
2. Explain results : prostate walnut shaped gland just below the bladder and secretes fluid as part of semen. Gleason is how aggressive the tumor is if > 8 highly, spread of cancer
   Urine culture-infection we need to treat that w/ antibiotics. PSA
   MANAGEMENT: OPTIONS
   -options depend on the age the cancer stage how aggressive it is
3. Wait and watch -regular ffup and PSA- >70 y/o it is a slow growing cancer
4. Surgery- Total removal of prostate either keyhole or radical (cut in the skin) or robotic surgery
   **main complication is erectile dysfunction and retrograde ejaculation
5. Radiotherapy - External-focused beam radiation or Brachytherapy small radioactive seed to the prostate
6. Hormonal therapy - bilateral orchidectomy 2. Injection leuprolide

4Rs

Question 24

Alzheimer’s Disease Counseling

Answer 24

1. Consent/ MPA to discuss the condition
2. Open ended Q- can you tell me more , any concern you would like me to address
3. Explore Complaint: Memory Problem
   when did you first notice? getting worse?
4. Associated S/SX of Alzheimer’s
   -irritable/agitated
   -sleep disturbance
   -change in social engagement
   -risky behaviors : getting lost risky incidents at home like falls leaving the stove on
5. Risk factors
   - vision and hearing problem
   -recent/recurrent falls
6. Support
   -who does he live with?
   -who takes care of him?
   -is he able to do his daily activities on his own ?
   -who cooks for him?
   7 Medications: sedatives, anticholinergics
7. alcohol and drugs
8. DDX
   Head injury - any recent head injury ?
   Vascular -hx of stroke or high BP
   Pseudo dementia- mood and anhedonia
   Frontotemporal/parkinson - slowed movement, stiffness, balance
   fever?

Alzheimers- degenerative brain disease causes problem in memory thinking sometimes behavior
Management
1. MDT- Geriatrician, nurse, social worker
2. Invx- TFT Vit B12 LFT UCE- if there are any contributing factors that can make memory worse
3. Pharmacological - right now it is mild but can progress
Donezepil, rivastigmine, memantine
4. Risk reduction - medication review, correct vision and hearing problems, occupational therapist at the home, is depressed SSRI and psychologist

CRITICAL KEY POINT
we would like to provide care for your father as it seems he does not have much support
1. aged care assessment

2 options:
1. social worker to help him at home with meals on wheels
2. Residential aged care facility

DRIVING- license authority until patient can be assessed
- Plan for advanced care directive
dementia support group
decrease alcohol stop smoking
sleep hygiene