Counselling Flashcards
How can you structure explaining a disease?
Normal anatomy/ physiology
What the disease is
Cause
Problems and complications
Management
How can you structure explaining a procedure?
Explain what the procedure is
Why you are doing it
Details of procedure- before, during and after
Risks and benefits
How can you structure explaining a treatment?
Check patients understanding of the condition
How the treatment works
Treatment course- when and how it is taken and for how long
Monitoring
Side effects
Contraindications
What are the contraindications for warfarin?
Pregnancy
Significant risk of major bleeding
Active bleeding
How can you explain how warfarin works to a patient?
Thins the blood to treat or prevent blood clots
It does this by blocking vitamin K which is the vitamin used by the body to make clots
How do you explain the treatment course to patients for warfarin?
Once daily
Dose changes take 2-3 months to take effect
Prescribed lifelong for AF, 3 months for DVT and 6 months for PE
What is the monitoring for warfarin?
Started at 5mg each evening
INR on days 3,4 and 5- warfarin dosing charts to adjust the dose
Regular INR checks by anticoagulation clinic
What are the side effects which a patient should be counselled about for warfarin and what things should the patient avoid?
Bleeding- seek medical advise if unusual or significant bleeding (long nose bleed, blood in urine/ stool/ vomiting)
Diarrhoea, rash, hair loss and nausea
Avoid: liver, spinach, leafy greens, cranberry juice, XS alcohol, NSAIDs and aspirin
What are the contraindications for DOACs?
Significant renal impairment
Significant risk of major bleeding
Active bleeding
How can you explain how DOACs work to patients?
Thins blood to treat or prevent clots
Many proteins are involved in making blood clot, this drug blocks one of these proteins from working
How do you explain the course of treatment for DOACs for patients?
Once or twice daily
Take with a full glass of water while sitting upright
Usually prescribed for 3 months for DVT, 6 months for PE and lifelong for AF
What is the monitoring required for DOACs?
None regularly
Check renal function before and annually
What are the side effects of DOACs that a patient should be made aware of?
Bleeding
GI disturbance
Irreversible if serious bleed occurs
How would you explain when to use an Epipen to a patient e.g. symptoms of anaphylaxis
Symptoms include feeling lightheaded or faint, breathing difficulties, wheezing, fast heart, sweating, collapsing or LOC. If you experience these symptoms then be prepared to use your Epipen.
What are some SE’s of steroids?
- Peptic ulcers (PPI to prevent this)
- Hypertension
- Osteoporosis (Vit D + Calc for prevention)
- Immune suppression
- Diabetes
- Weight gain
What is some important safety information to give when prescribing long-term steroids for a patient?
- Not to stop them suddenly - addisonian crisis
- Sick day rules
- Don’t take NSAIDs - risk of stomach bleed
How would you explain PrEP to a patient?
- stands for pre-exposure prophylaxis. A medication you take before and after sex which can help prevent you from being infected with HIV
- reduces chance of being infected with HIV via sexual intercourse by up to 99% if used properly
In what ways can PrEP be taken?
- Daily dosing - provides protection at all times
- Event-based dosing - pill taken before and after sex
What are the contraindications for levothyroxine you should check for when counselling a patient?
Aint none
How can you explain how levothyroxine works to a patient?
It is a man-made version of thryroxine which is a thyroid hormone. You are given it to bring your thyroid hormone levels from low back to normal.
How do you explain the course of treatment for levothyroxine to patients?
Once daily tablet before breakfast
Taken long term
Dose changes take 4-6 weeks to see an effect
What is the monitoring of levothyroxine?
TSH test every 2-3 months
What are the contraindications to statins?
Pregnancy
How can you explain how statins work to patients?
Statins stop the liver from making cholesterol. High cholesterol causes problems with your arteries which increases your risk of heart disease, stroke and kidney disease. It is also important to address other risk factors for CVD
How do you explain the course of treatment for statins to patients?
One tablet daily in the evenings
Taken long term
Decreases the risk over many years
How can you explain the monitoring of statins?
Review in 4 weeks and then every 6-12 months to see how well the blood is responding
LFTs before starting and then 3 and 6 months after starting because statins can cause a change in liver enzymes which needs to be monitored
What are the side effects of statins which patients should be made aware of?
Muscle pains
Headache
Itching
Nausea
Rhabdomyolysis- tell Dr if you are experiencing unexpected strong muscle pain
Some statins interact with grapefruit juice
What are the contraindications to metformin?
Significant renal impairment
Ketoacidosis
Low BMI
How can you explain how metformin works to a patient?
Increases your response to insulin so your cells can take up more glucose from food and reduces the amount of glucose which is made by the liver
How do you explain the course of treatment for metformin to patients?
Once, twice or three times daily tablet taken with meals.
Taken long term
What is the monitoring for metformin?
U&Es before starting, then annually
HbA1c every 3-6 months until stable and then 6 monthly at diabetic check ups
What are the side effects of metformin?
Nausea, diarrhoea, abdominal pain, weight loss
Lactic acidosis
Ho do you explain how iron tablets work to a patient?
Replace your body’s store of iron. Iron is needed to make RBCs
How do you explain the course of treatment for iron tablets to patients?
1-3 times daily tablet or syrup
Works best if taken without food
Takes 3-4 weeks for Hb to normalise and a further 3 months for stores to replenish
What are the side effects that patients should be aware of when prescribing iron?
GI irritation
Black/ green stool
Metallic taste
What are the contraindications of SSRIs?
Suicidal risk
Mania
How can you explain how SSRIs work?
Antidepressants alter the balance of chemicals in the brain
SSRI antidepressants affect a chemical called serotonin. A lack of serotonin is thought to cause depression
How do you explain the course of treatment for SSRIs to patients?
Once daily tablet
May be gradually stopped 6 months after feeling better
Effects are seen 4-8 weeks
What are the side effects of SSRIs?
GI
Appetite and weight change
Headaches
Drowsiness
Anxiety for 2 weeks
Withdrawal
May increase risk of suicide in younger patients
What are the contraindications of methotrexate?
Pregnancy/ trying for a baby (even if male)
breast feeding
Hepatic impairment
Active infection
Immunodeficiency
How do you explain how methotrexate works to a patient?
It is a ‘disease modifying agent’ which means it reduces inflammation and suppresses the immune system
Early use improves outcomes and the symptoms
How can you explain the treatment course for methotrexate to a patient?
Once a week tablet of methotrexate and once a week tablet of folic acid on a separate day
Same day each week
Build dose up slowly
Take long term if effective
Takes 3-12 weeks to work
What is the monitoring required for methotrexate?
FBC, U&Es LFTs- before starting, every 2 weeks until therapy is stable and then every 2- 3 months
What are the contraindications for lithium?
1st trimester of pregnancy
Breast feeding
Cardiac insufficiency
Significant renal impairment
How do you explain how lithium works to a patient?
Mood stabiliser
Exact mechanism unknown
Thought to interfere with neurotransmitter release and receptors
how do you explain the treatment course of lithium to a patient?
Once or twice daily tablet or liquid
Taken long term if effective
Takes 1-2 weeks to work
What is the monitoring for lithium?
FBCs U&Es TFTs BHCGs ECGs are done before starting treatment
Check lithium level after 5 days then every week until stable for 4 weeks and then every 3 months
Check TFTs, U&Es and Ca2+ every 6 months
What are the SEs of lithium?
GI pain and nausea
Metallic taste
Tremor
Toxicity
Kidney damage
What are the symptoms of lithium toxicity?
Diarrhoea, vomiting
Ataxia, dizziness
drowsiness
restlessness
What are the contraindications to atypical antipsychotics?
Hepatic impairment
Phaeochromocytoma
How can you explain how atypical antipsychotics work to a patient?
Schizophrenia is thought to be caused by problems with the dopamine receptors in your brain, atypical antipsychotics work by blocking these receptors
How can you explain the treatment course of atypical antipsychotics to patients?
Tablet daily or depot injection every 2-4 weeks
Dose is built up over a week or two
Dose is adjusted depending on response
Taken long term if effective
Takes several days or weeks to work
What monitoring is required for atypical antipsychotics?
Weight checks weekly for 6 weeks
Before treatment, then at 3 months, then annually: pulse, weight, waist circumference, ECG, HbA1c, fasting glucose, lipid profile, prolactin
What are the side effects of atypical antipsychotics which should be communicated to a patient?
Tardive dyskinesia
Constipation and dry mouth (anti-cholinergic)
Weight gain
Neuroleptic malignant syndrome (high fever and muscle rigidity)
Hyperprolactaemia (galactorrhea)
Agranulocytosis with clozapine (fever, chills, sore throat, weakness, bleeding gums)
Prolonged QT
What are the contraindications of Levodopa?
Glaucoma
How can you explain how levodopa works to a patient?
Levodopa is a replacement for a chemical called dopamine which your brain is no longer able to produce
This will help to reduce your symptoms, particularly the slowness and rigidity
How can you explain the treatment course of levodopa to patients?
3-4 times daily tablet with food
Taken as long as it works effectively
Fast-acting
How can you explain the monitoring of levodopa to patients?
None is required, review symptom changes in clinic and can ring up if problem
What are the side effects of levodopa which can be communicated to patients?
Psychosis
N&V
Dyskinesia
Postural hypotension
‘Wearing off’ phenomena
Impulsive behaviour
Dizziness
How can you explain how insulin works to a patient?
Insulin allows the cells of your body to take up glucose from the blood and use it for energy
This means insulin reduces the blood glucose level
In people in diabetes, insulin may be needed because the body cannot produce or use it effectively
How can you explain the treatment course of insulin to patients?
Depends on the type of regimen
Inject at 90 degree angle to skin. Inject areas of fat
Rotate sites: lower abdomen, outside of thighs, buttocks
What monitoring is required for insulin therapy?
Capillary glucose is required before each meal and before bed
Also check capillary sugar if there are any signs of low blood sugar (drowsiness, confusion, sweating, tachycardia)
What are the contraindications to bisphosphonate?
Pregnancy
Dysphagia
Recent peptic ulcer
Significant renal impairment
Unable to sit upright
How can you explain how bisphosphonate works to a patient?
Prevents bone from being broken down and helps to rebuild new bone
Lifestyle factors can also help with this- exercise, diet, not smoking and eating a well balanced diet
How can you explain the treatment course of bisphosphonate to patients?
Once daily or once weekly tablet
Swallow tablet with full glass of water
Take at least 30 mins before food or anything other than water
Be upright 30 mins after swallowing
Taken long term
What monitoring is required for bisphosphonates?
Regular dental check ups (osteonecrosis of the jaw)
What side effects of bisphosphonates should be communicated to the patient?
Headache
Heart burn, bloating, indigestion
Seek medical advise if: osteonecrosis of jaw, dysphagia, upper GI bleed or black stools
How can you explain a bronchoscopy to a patient?
Camera test to the airways leading to lungs
Before:
NBM for 2 hours before, 6 hours before= clear liquids only
Will need to stop blood thinning medications 1 week before, DOACS 48 hours before
During:
Will be given a midazolam anaesthetic- this means you will not be able to drive home
Lidocaine spray to nose, throat and windpipe
May be uncomfortable, may cause you to cough
After:
Arrange follow-up
No eating/ drinking 2 hours after because throat is still numb
No driving for 24 hours
Risks:
Lung damage, collapse
Infection
Bleeding
Sore nose/ throat
How can you explain a gastroscopy to a patient?
Camera test to look into your stomach
Before:
NBM 2 hours before, clear liquids 6 hours before
Stop acid suppressive meds 2 weeks before
During:
Lidocaine throat spray or midazolam sedative
Continuous suction
Air is passed through the scope so this will make you feel full and make you burp
After:
Arrange follow-up
If throat spray- no eating or drinking for 2 hours
If midazolam- no driving for 24 hours
Risks:
Perforation (<0.1%)
Bleeding
Infection
How can you explain a colonoscopy to a patient?
Camera test to look inside the bowel
Before:
Oral intake-
2 days before= low fibre diet
1 day before= clear fluids only after a light breakfast
2 hours before= NBM
Sodium picosulphate the afternoon before procedure to clear the bowel
During:
Midazolam sedative
DRE before scope insertion
Air passed through the scope which will make you feel bloated and like you need to go to the toilet
After:
No driving or alcohol for 24 hours due to sedative
Arrange follow up
Risks:
Perforation (0.1%)
Bleeding
Infection
Uncomfortable
How can you explain a flexible sigmoidoscopy to a patient?
Same as colonoscopy except:
Before:
NBM 2 hours before and phosphate enema 2 hours before
How can you explain a flexible cystoscopy to a patient?
Camera test to look into the bladder. A small, thin camera will need to be inserted through the hole you pass urine out of.
No prep needed
During:
Anaesthetic jelly
Water passed through the scope which will make you feel the urge to wee
After:
Can go home after passed urine
Arrange a follow-up
Risks:
Bladder damage
Bleeding
Infection
Dysuria
Retention
May need temporary catheter afterwards
Rigid cystoscopy is the same but NBM 2 hours before and 6 hours before clear fluid only. May need midazolam because its a bit more uncomfortable
What should be discussed when explaining an surgical procedure?
Wash hands, Introduce, Patient’s name and Explain why you are here (WIPE)
Ask what the know so far
Explain why the operation is required and what it is.
Before:
Pre-op assessment by nurse or anaesthetist to see if they are fit and well before surgery
No food 6 hours before, clear fluid up to 2 hours before, after NBM
Consent will be taken by the surgeon before
May need pre-op blood tests
During:
Taken to the anaesthetic room
Cannula will be put in
Anaesthetic will be done (explain the relavent type)
After:
Operation will be done and you will wake up in the recovery bay- might feel a bit groggy
There may be tubes in place which were not there before (catheter, drains etc)
Pain control will be prescribed, ask if you are in pain
VTE prophylaxis- injections and stockings
Physio and OT
Explain specific risks. When you say a risk, follow with how this is managed (eg bleeding, we will manage this with stopping the bleeding and replacing blood lost with fluid or transfusion if appropriate)
What are the risks associated with anaesthetic?
Teeth, lip, tongue or throat damage
Bleeding
Hypo/ hyperthermia
breathing problems
Infection
What are the risks associated with bowel operations?
Ileus
Anastomotic leaks
Stoma
Intrabdominal collections
Adhesions
Damage to local structures
What are the risks associated with biliary operations?
Infection
Bleeding
Damage to bile duct and surrounding structures
Bile leak
What are the risks associated with CABG/ stenting?
Reperfusion arrythmias
Post-op ACS
Inotropes are often needed post-op
What are the risks associated with vascular surgery?
Failure
Haemorrhage
Infection
Limb or organ ischaemia
Cholesterol embolism (trash foot)
What are the risks associated with thyroidectomy?
Airway obstruction secondary to haemorrhage
Nerve damage
Failure
Infection
What are the risks associated with any orthopaedic operation?
Infection of prosthesis
Loss of position/ failure of fixation
Non-union, malunion
Neurovascular injury
Compartment syndrome
What are the risks associated with TURP?
UTI
Retrograde ejaculation
Urethral sphincter damage
Stricture
TURP syndrome
What are the risks associated with breast surgery?
Infection
Need for re-excision
Bleeding
Lymphoedema if SNB or ANC
What are the steps for checking inhaler technique in a metered dose inhaler?
- Check expiration date
- Shake (the inhaler, not patient)
- Remove cap
- Stand or sit upright, hold inhaler upright
- Breathe out completely
- Form seal with mouth around mouthpiece
- Press down on top, simultaneously breathe in deeply and slowly (if using spacer take 5 breaths in and out)
- Hold breath for 10 seconds
- Replace cap
- Repeat after 1 min if necessary, if steroid inhaler then wash out mouth
What is the inhaler technique in dry powder inhalers?
Click to open
Exhale fully
Seal mouth around mouthpiece
Breathe in quickly and deeply
Hold breath for 10s
What vaccines should be given at 2 months?
6 in 1, rotavirus, Men B
What vaccines should be given at 3 months?
6 in 1, rotavirus, pneumococcal
What vaccines should be given at 4 months?
6 in 1, Men B
What vaccines should be given at 1 year?
MMR, pneumococcal, men B, hib, men C
What vaccines should be given at 3 years and 4 months?
MMR, 4 in 1
What vaccine should be given to 12-13 year old girls?
HPV
What vaccine should be given to teens?
3 in 1, men ACWY
What are the benefits of vaccinations?
Prevents serious diseases with serious consequences
Maintains eradication of diseases that can kill and disable millions of children
Safer to have the diseases than not have them
What are the risks of vaccines?
Side effects of: swelling, redness, lump, fever, small chance of allergic reaction and anaphylaxis
What are the contraindications to vaccines?
Being ill with a fever
Avoid live vaccines (MMR, BCG, varicella and nasal flu) in immunocompromised
Flu vaccine CI in egg allergy
How do you structure counselling for contraception?
Start off with a very short history:
Age
Relationship status (regular partner, multiple partners)
Menstrual history
Previous contraception and chance of pregnancy
Post-partum/ breastfeeding
PMHx- particularly STIs and obs/ gynae Hx, previous ectopic pregnancies
DHx
Contraindications to COCP (smoking + age>35), Hx/FHx of VTE, breast/cervical cancer, migraine with aura
Have they got any thoughts about what they would like? Ask about ability to remember to take pills, would injections or procedures be acceptable
Describe the procedure in more detail - how it works, treatment course, side effects/risks
Briefly mention some alternatives
Summarise, offer leaflet, follow-up to start contraception
How can you counsel someone for emergency contraception?
Introduce etc
HPC:
Details - when, with whom (regular partner)
Current contraception?
Menstrual hx (last period, cycle length, estimated day of ovulation e.g. 2 weeks before next menstrual period)
Discuss why they want emergency contraception
Discuss options (CuIUD 5 days, ella One 5 days, levonelle 3 days)
PMHx & DHx - for contraindications
Future contraception
Risk of STIs
ICE
Leaflet
Advise them to come back in 3 weeks
What are the options for termination of pregnancy?
- Medical abortion - Mifepristone followed by Misoprostol (prostaglandin) - causes bleeding, small % need surgical intervention if unsuccessful
- Surgical Abortion - Dilatation and suction OR evacuation - anaesthetic required
How would you explain autosomal dominant inhertiance?
if a parent is affected, there is a 1 in 2 chance of the child being affected
How would you explain autosomal recessive inheritance
Need two copies of abnormal gene (1 from mother and 1 from father) to cause disease.
If one parents is affected and the other is a carrier, there is a 1 in 2 chance the child will be affected.
If both parents are carriers, there is a 1 in 4 chance of the child being affected.
What are the 6 main autosomal dominant conditions
- Huntington’s
- Myotonic dystrophy
- Von Willebrand
- PCKD
- Hypertrophic obstructive cardiomyopathy
- Hereditary spherocytosis
(safe to assume everything else is recessive)
What are the 3 main X-linked recessive conditions
- G6PD deficiency
- Haemophillia A/B
- Duchenne muscular dystrophy
What is the screening used for Down’s, Edwards and Patau’s syndrome?
Combined test:
-scan and blood test (10-14 weeks)
-Blood test shows decreased pregnancy associated plasma protein, increased beta HCG
-Nuchal translucency scan (11-14 weeks) - would show as increased
Quadruple blood test (14-20 weeks):
- decreased alpha fetoprotein, unconjugated estradiol and increased beta-hcg, inhibin A
Non-invasive prenatal testing >10 weeks- only offered to mums with high risk (>1 in 150) - but also avaliable privately
If screening shows high risk then invasive testing is offered- amniocentesis, chorionic villus sampling
How do you structure a conversation about birthing options?
Introduce and congratulate (do they know gender, do they have a baby name yet)
Hx:
Previous births- delivery method? any complications? How many?
Current pregnancy- any complications? position? twins?
Maternal factors- diabetes, pre-eclampsia, age, anaemia?
Go through options, advantages and disadvantages of each place:
- Hospital - safest option
- Midwife lead - more comfortable, may need transfer if complications, can’t have epidural
- Home - may need to be transferred, no epidural, higher risk for first birth
- Water - same risks as home birth
Pain relief - epidural, spinal (for c-section), opioids, entonox (laughing gas)
Vaginal vs C-section - patients can request one, but if they don’t need one, try to find out why e.g. pain worry
Concluding - ask about concerns, leaflets and website, give time to think and book follow up
How would you structure a conversation about HRT?
- Confirm age and confirm menopause (ask about bleeding)
- Discuss symptoms and their effect on quality of life
- Relevant PMH and FHx - contraindications & do they have a uterus
- Ask if there is anything they already know and what they want to discuss
- What HRT is and how it helps, including risks and benefits, types of HRT and how it can be given
- Mention contraception (women can still be fertile for 1 year after last period, or 2 years if <50y) - options are barrier, POP, mirena coil
What are the contraindications to HRT?
Undiagnosed PV bleeding
Pregnancy/ breastfeeding
Oestrogen- dependent cancer
Acute liver disease
Uncontrolled HTN
Hx of breast cancer
Hx of VTE
Hx of stroke/ MI/ angina
What are the benefits of HRT?
Relief of symptoms:
-vasomotor symptoms
-Psychological sx
-Reduced libido
-Urogenital atrophy
Reduction of osteoporosis
Reduction of colorectal cancer
What are the risks of HRT?
VTE (no risk with transdermal)
Stroke
Breast cancer (small increase)
Ovarian cancer (small increase if use >5years)
Endometrial cancer (combined therapy greatly reduced this risk)
What are the side effects of HRT?
Oestrogen-> breast tenderness, leg cramps, nausea and bloating
Progesterone -> premenstrual syndrome
Bleeding PV
What are the stages of capacity assessment?
can the patient understand?
Retain?
Weigh-up?
Communicate their decision?
What are the three criteria that are required for consent to be valid?
Consent must be:
-Informed
-Voluntary
-The patient must have capacity
What are the consent rules for children aged 16-18 years old?
Presumed to have capacity and treated like adults. However, treatment refusal can be overridden in some circumstances (by person with parental responsibility or court)
What are the consent rules for a child aged under 16?
Can consent to medical treatment but not necessarily refuse treatment. Gillick competency is judged if ‘they have sufficient maturity and judgement to enable them to fully understand what is proposed’
Two scenarios that a settled by court are if:
- a competent child refuses treatment in their best interest
- if a clinician disagrees with a parent
What are the fraser guidelines for prescription of contraceptives?
A doctor can prescribe contraception to a child under 16 if:
- the child understands the advice
- they cannot be persuaded to tell their parents
- they are likely to continue having sex without the contraception
- the child’s physical/mental health may suffer without the contraception
- the child’s best interests are that they should receive it
Bear in mind the age of the partner (sexual abuse)
How long are you unable to drive after a first unprovoked seizure?
6 months if normal licence, 5 years if HGV licence
How long are you unable to drive after a stroke/ TIA?
1 month on a normal licence and 1 year if HGV licence (but do not need to inform the DVLA if no residual symptoms)
How long are you unable to drive after a unexplained syncope?
6 months for normal licence and 1 year for HGV licence
Explain the SPIKES protocol for breaking bad news
- Setting - ensure you are in a comfortable and confidential room
- Perception - outline events leading up to current situation, ask them what they already know/understand
- Invitation - check if the patient would like to know the results now and if they would like someone to be present
- Knowledge - give a warning shot, chunck and check, okay to be silent. Do not launch into explanation, let the patient lead to consultation
- Emotions and Empathy - listen and acknowledge, don’t try to solve the problem
- Strategy and summary - agree on plan, summarise concerns
What is the key structure for dealing with strong emotions e.g. anger
- Acknowledge it ‘I can imagine you’re feeling very fustrated right now’
- Gather information
- Repeat back the reasons
- Ask if there is anything else
Avoid saying ‘I understand’!!
