Information giving

Question 1

What should the stages of explaining how to use an inhaler be?

Answer 1

1. Introduction, consent, open question
2. Ask the patient what they understand about asthma and inhalers; ask about their allergies
   
   1. Ask patient about any previous experience with them, possible reasons for poor technique
   2. explain how an inhaler works
   3. explain how to use an inhaler
   4. Ask patient to perform the procedure
   5. SAFETY NET - MAKE PT AWARE OF IN CASES OF OVERDOSE AND SEVERE ASTHMA
3. Ask patient what they understand about spacer devices
   
   1. explain what a spacer device is and why its required
   2. Ask patient to perform the procedure
4. Explain cleaning/storage of the device and importance of replacing every 6-12 months
5. SAFETY NET - MAKE PT AWARE OF IN CASES OF OVERDOSE AND SEVERE ASTHMA
6. Organise an asthma review appointment
7. Closure

Question 2

How is a blue inhaler used?

Answer 2

Reliever inhaler (BLUE):

Contains SABA

Given to every asthma patient

Taken to relieve symptoms of asthma, but doesn’t treat the underlying cause of the disease (inflammation)

Work by relaxing muscles surrounding the airways, allowing them to open up and making it easier to breathe again

Safe medicines with few side effects unless overused

They should rarely be necessary if asthma is well controlled, and a patient needing to use them 3+ times per week should have their treatment reviewed

Question 3

How is a brown/orange inhaler used?

Answer 3

Preventer inhaler (BROWN/ORANGE):

Contains ICS

Taken to help control symptoms and prevent disease progression

Work over time to reduce the amount of inflammation in the airways, prevent asthma attacks occurring and reducing the likelihood of long term changes to lung structure

Need to be used for some time before you gain full benefit, and may still occasionally need to use the reliever inhaler

Recommended if you have asthma symptoms 2+ times per week, wake up due to asthma symptoms or have to use reliever inhaler 2+ times per week

Question 4

how do you use an inhaler?

Answer 4

• Remove mouthpiece cover,*
• shake the canister for 5 seconds,*
• hold inhaler vertically with thumb with mouthpiece near mouth and index finger on top of inhaler,*
• breathe all the way out,*
• put mouthpiece in mouth with lips forming a tight seal,*
• take deep breath in and press firmly with index finger as you take a breath,*
• breathe in for as long and hard as possible, hold*
• breath for 10-15secs then breathe out normally,*
• repeat*

Question 5

What is a spacer device and how is it used?

Answer 5

• A spacer is a device to enable better control of asthma by allowing inhaler medication to reach deep into the lungs, whilst removing complexity of needing to have good coordination of depressing inhaler and inspiring at the same time.*
• It also reduces the risk of oral candidiasis.*
• It follows the same steps as previously mentioned- only put the mouthpiece of the inhaler into the spacer, put the spacer mouthpiece into your mouth, then push down once on the inhaler and breathe in slowly*

Question 6

What questions should you ask the patient even before you give information about inhalers?

Answer 6

1. Name and age
2. how often they take their inhalers
3. how much they know
4. what they would lke to know

Question 7

What does the GMC guidance say about the control and surveillance of serious communicable disease?

Answer 7

GMC says: You must pass information about notifiable diseases to the relevant authorities for communicable disease control and surveillance.

• you do not need to ask pt for consent to break confidentiality if required by law
• but should tell patient about intention to disclose personal information and consider their reasons for objecting
  
  • e.g. consider the minimum intrusion, timing/amount of info shared
• You should disclose anonymised information if practicable and as long as it will serve the purpose

Different diseases are notifiable in different UK countries and the reporting arrangements differ. You should follow the arrangements where you work.

• if you consider that failure to disclose the information would leave individuals or society exposed to a risk so serious that it outweighs the patients and the public interest in maintaining confidentiality - then disclose the relevant infor promptly to an appropriate person or authority
• patients with a serious communable disease should be explained how to protect others from transmission inc practical and then importance of informing them
• info can be disclosed to a person with close contact with the pt with SCD if you think
  
  • the person is at risk of infection that is likely to result in serious harm
  • the patient has not informed them and cannot be persuaded to do so
• when tracing and notifying people you should not disclose the identity of the patient if practiciable
• be prepared to jusify a decision to disclose personal informaiton without consent
• children should be protected, they may need testing inc vertical infection - if they refuse child testing then = safeguarding concern

Question 8

What are the notifiable diseases [under the health protection regulations 2010]?

Answer 8

The diseases notifiable to local authority under the Health Protection(Notification) Regulations 2010 are:

• Acute encephalitis
• Acute infectious hepatitis
• Acute poliomyelitis
• Anthrax
• Botulism
• Brucellosis
• Cholera
• Diphtheria
• Enteric fever
• Food poisoning
• Hemolytic uremic syndrome
• Infectious bloody diarrhoea
• Invasive group A streptococcal disease
• Legionnaire’s disease
• Leprosy
• Malaria
• Measles
• Meningococcal septicemia
• Mumps
• Plague
• Rabies
• Rubella
• Severe Acute Respiratory Syndrome (SARS)
• Scarlet fever
• Smallpox
• Tetanus
• Tuberculosis
• Typhus
• Viral haemorrhagic fever (VHF)
• Whooping cough
• Yellow fever

Question 9

What is a notifiable disease?

Answer 9

• A notifiable disease is one which that has to be reported to the government authorities as required by law.
• In the United Kingdom, notification of infectious diseases is a statutory duty for registered medical practitioners and laboratories, under the Public Health (Control of Disease) Act 1984 and the Health Protection (Notification) Regulations 2010.
• The registered medical practitioners shall notify such diseases in a proper form within 3 days, or notify v_erbally via phone within 24_ hours depending on the urgency of the situation.

Question 10

What is the format for a notifiable disease station such as a pt Dx with TB?

https: //www.cdc.gov/tb/topic/basics/tbprevention.htm
https: //www.cdc.gov/tb/topic/basics/tbinfectiondisease.htm

Answer 10

Notifiable disease

1) Intro

• Confidentiality line – (if you know it’s a notifiable).
  
  • Everything we speak about is completely confidential between you and the medical team, except if you or someone else it at risk.

2) PC

• symptoms
• how is it being managed
• social history – is anyone at home with you. sexual history (if STI) sexual history – are they having symptoms. have you told them

3) Mini History

4) Partner or Family at risk

• Do you mind if I ask why you haven’t told them (they’re scared)
• What makes you say that
• [Gague this before you say it:] ?You wouldn’t want your wife/children to go through the same thing you have

5) Why do they not want to disclose

6) Explain when confidentiality has to be breached

• TB is completely treatable, we can prevent them from getting it If they know now
• But only if we catch it in time e.g. latent period is much easier to treat even if they dont have symptoms
• you know we spoke earlier about confidentiality, this is one of those situations where others at risk. therefore, we will have to break confidentiality.

(if migrant – You and your health our our concern and not the immigration status. However, the people we tell are very well trained in this area and professionally trained in this situation. They will educate them in a way they know don’t be fired for this)

7) Negotiate and offer solutions

• How about we make an appointment and we can bring your family/partner in and tell them together
• How about you come in a few days time and we can go in from there

(often they will ask – are you going to tell the home office)

• we do have to tell the health authorities. However, you are kept completely anomanous.
• thye will sent an anomalous letter to your family notifying them they are at risk if you have not told them by then.
• that’s why we encourage you to try and tell them

This will be kept as anomanous as possible. It is completely curable.

If they say NO

• Empathy etc

Question 11

Who are the relevant authorities for communicable disease control and surveillance?

Answer 11

CCDC - Consultant in Communicable Disease Control. Within 3 days.

Pt Can be anonymised.

Question 12

What are the aims of a confidentiality station?

Answer 12

• empathise and be non-judgemental
• address the patients concerns and pick up on their cues
• address confidentiality: what is it, why it is in place, explain why it is in the patients best interests
• offer solutions to the patients problems
• do not breach confidentiality and know the rules!

Question 13

What are the rules of a confidentiality station?

Answer 13

• breach of confidentiality is only allowed when another person is at significant risk of harm
  
  • you can break confidentiality for blood borne STIs but not other
• if a patients partner is at significant risk you must take all measures to persuade patients to tell their partner before breaching confidentiality
  
  • and have multiple consults to do so
  • “you must respect the wishes of any patient who objects to information being shared with others providing care except where they would put others at risk of death or significant harm”
• you have a duty to advise the patient their behaviour is putting others at risk and the implications for someone remaining untreated
• if a patient lacks capacity you can speak to relatives with regards to their health unless you strongly suspect the patient would object

Question 14

What are the initial questions to ask in a Kaplan Meier or Forrest plot?

Answer 14

• 1. ‘Brief History and Empathy points’
  
  • Brief HCP
    
    • What has brought you in today?
    • When did this start etc
  • How is the patient coping- support at home, do they need more support
    
    • How are you since finding this out?
    • Do you have support at home?
      
      • ​State they don’t have to do this alone, as a medical team want to support them. Offer services like Macmillan etc.
  • What do they want to know from the consultation
    
    • What would you like to know from the consultation?
  • can you tell me what kind of symptoms you’ve been having just so I can understand what you’ve been going through?
  • What do they understand of their condition
    
    • What do you know of your condition?**If history is going on too long (eg. list of medicines). Thanks for that, I will look at that on the end
• 2. ‘Check level to pitch it at’
• just before we discuss the treatments, I have some data which I would like to show you, but before I do what do you know already about the treatment
• Is there anything in particular you would like to know about the treatment
• I’m going to show you a graph, how are you with numbers and graphs
  
  • Have you looked at graphs/statistics much before?
• 2 treatment options available- pros and cons of each

Question 15

how do you explain a kaplan meier curve?

Answer 15

3. Kaplan mier curve (If wincing, offer glasses)

(never say death in kaplain mier – say survival)

• Explain and show survival time
• Explain x and y axis
  
  • along the bottom we have time
  • along the left we have number of people with surviving
• Explain that at time 0, no one dies (everyone is still alive)
• The graph shows 1 study and 2 treatment groups
  
  • line 1 shows people with no chemotherapy
  • line 2 people with chemotherapy
• just to ensure I have explained the beginning part properly, do you want to tell me what you understand from this graph
• Explain the overall trend e.g. ‘group A is always higher than group B’
• Interpret the graph at 2 points
  
  • e.g.
  • If we look at 12m time: Out of 100 people just like yourself, this many people survive with chemotherapy. This many people will survive without chemotherapy.
  • If we look at (another time point): Out of 100 people just like yourself, this many people survive with chemotherapy. This many people will survive without chemotherapy.
• Emphasise that it is just a study and the patient might be completely different e.g. ‘this might not reflect reality but this is the best way we have of assessing the different treatment options for patients like yourself’

4. Summary and check understanding

• Just to check I’ve explain this properly can you explain it back to me

Question 16

How do you close/support with decision for kaplan meier curves or forrest plots?

Answer 16

• 5. Support with decision
• Now you have read these numbers of, what do you make of this?
  
  • (NEVER say therefore you should go for this – it is NOT OUT DECISION)
• yes the data does show that, however it does not take into quality of life or side effects, as everyone reacts differently
• are you aware of some of the side effects of chemotherapy
• explain side effects (if unsure refer to consultant)
• How are you feeling about all of this?/
• If they ask what you think?
  
  • chemotherapy is like every other medication, everyone reacts differently. Therefore, it is your decision, as a medical team we will try to support you. However, it is your decision to make
• Don’t worry you don’t have to make that decision right now. There has been a lot of information, go away have a think and we shall book an appointment in a weeks time.
  
  • Reassure:
    
    • It is your decision at the end of the day
    • take your time
    • weigh up, talk to your family/friends
• Offer leaflets/websites
  
  • Would you like a leaflet?
• Consolidate and set up future appointment:
  
  • I understand this is a lot of information to take in
  • and it might take you a while to process-
  • if you have any questions at any point, here is some contact information…
    
    • if you know you would like to come back to ask any questions , when are you available, these slots are available
• • Close

Question 17

How do you help someone interpret a forrest plot?

Answer 17

• Read title:
  • If we look at this it shows…
• If we just ignore those numbers from now and we can possibly come back to the end – lets focus on the left sid
• Methods of intervention compared
• Each row has a different study by a different author
• Size of the box correlates to sample size (amount of people in each study)- the bigger size, the better
• Blue bar represents uncertainty (something we call the confidence interval) of the trial
• Left side favours treatment
• Right side favours the control
  
  • these are loads of different studies that took place. the blue squares shows the average outcoe
  • look at line in middle
  • everything towards to the left side shows it favours chemotherapy over not having chmoetherapy
  • everything to the right side shows it doesn’t favour chemotherapy
• what do you make of this so far?
  • Line through 1 is the line of no effect
• Check understanding
• Choose a study to interpret and get them to interpret a study too
  
  • ‘I know this is quite confusing’
• Look at the diamond which shows the overall average result
  
  • yes that is what it shows, there is
  • these black lines show the best and worst outcome from the study and again want to look at it in relation to the line. If left, better with. If right, they did worse.
    
    • But the most important thing from thi sis the red diamond. The red diamond is adding all the different studies together. It lies on the left side of the line, overall it shows the studys facour chemotherapy.
• What do you make of that?
• Relate it back to the patient- ‘for you to take antibiotics would be more beneficial for you’
  
  • Relative risk- e.g. if 0.53= 47% fewer deaths on drugs than placebo
• It doesn’t inclue from side effects, quality of life, everyone reacts differently
• (Know what the numbers mean- incase they point)

OR – less than 1, means taking treatment is protective

LCL – lower lmit

UCL – upper limit

Weight – study size

Question 18

What are the rules in assessing capacity?

Answer 18

• patient has capacity until proven otherwise
• capacity is decision dependent e.g. a patient may not have capacity to make one decision but may have capacity to make another
• if a patient lacks capacity you must act in their best interests
• if a patient makes a strange or irrational decision this doesnt mean they dont have capacity

Question 19

What is the 2 step test to assass capacity?

Answer 19

*The patient only lacks capacity if the answer to both these steps is yes*

1. Does the patient have impairment/disturbance of brain function?
   
   • if no then the patient has capacity and you do not need to move onto step 2
2. If yes, does this mean they are unable to make a decision as a result?
   
   • Perform the consent test - if they can do all of the following then they still have capacity
     
     1. Understand
        
        • info relevant to decision
        • e.g. consequences, risk, benefits, alternatives
     2. Retain
        
        • the information (for long enough)
     3. Weigh up
        
        • the information to make a decision
     4. Communicate
        
        • the decision (by any means)

Question 20

What are the forms and documentation regarding capacity?

Answer 20

• all parts of your capacity assessment must be clearly documented and also why the patient does not have capacity for the decision in question
• if you are stopping a patient without capacity from doing things they want to e.g. leaving hospital you are depriving them of their liberties and must fill in a DoLs (Deprevation of liberty safeguards) form

Question 21

What are the key points of the mental health act?

Answer 21

• The mental health act allows you to detain a patient with a mental disorder who is at risk of harm to themselves or others –> nothing to do with capacity!
• it only allows you to treat that mental inllness without their consent!
• although it can cautiously be extended to treat disorders closely related to the mental disorder e.g. OD or self-harm lacerations

Question 22

How do you act in patients best interest if a patient is over 18 years old and lacks capacity?

Answer 22

• If a patient over 18 years old lacks capacity it is the doctors duty to make the decision on their behalf, acting in their best interest under the mental capacity act (not MHA)
• the relatives/friends have no legal right to make the decision unless they have power of attorney

To decide their best interests you must

• persuade the patient to be involved in decision
• take into account any of their beliefts / views
• consult anyone named by patient/carers to help determine what is in their best interests (but not make the decision)
• check for any lasting power of attorney
• consider if they regain capacity

Question 23

Explain to a patient how to reduce exposure to allergens including house dust and house dust mite

Answer 23

• House dust mites feed on old human skin scales and can be found in most homes (in pillows, duvets, mattresses, carpets, upholstered furniture)
• Mites produce allergens (in droppings), which allergic asthmatics are sensitised to, and exposure can cause airway inflammation and asthma attack
• To avoid mites-
  
  • Encase mattress/duvet/pillows with mite-proof bedding
  • Wash bedding >55ᵒ
  • Replace carpets with smooth flooring
  • Vacuum frequently
  • Use vacuum cleaners containing a high efficiency particulate air (HEPA) filter and double thickness bags. Should be serviced by a non-asthmatic regularly
  • Place soft toys in freezer overnight/wash regularly

Question 24

Explain the diagnosis of COPD to a patient

Answer 24

• Chronic obstructive pulmonary disease (COPD) is the name for a group of lung conditions that cause breathing difficulties, and this includes
• Emphysema- damage to the air sacs in the lungs
• Chronic bronchitis- long-term inflammation of the airways
• Cause –>
• COPD is a common condition that mainly affects middle-aged or older adults who smoke. Many people don’t realise they have it
• The main cause is smoking, and the likelihood of developing COPD increases the more you smoke and the longer you’ve smoked
• However, the condition can sometimes affect people who have never smoked- some cases of COPD are caused by long-term exposure to harmful fumes or dust, or occur as a result of a rare genetic problem that means the lungs are more vulnerable to damage
• Symptoms –>
• The breathing problems tend to get gradually worse over time and can limit your normal activities, although treatment can help keep the condition under control
• The main symptoms of COPD are:
  
  • Increasing breathlessness, particularly when you’re active
  • Persistent chesty cough with phlegm (some people may dismiss this as just a “smoker’s cough”)
  • Frequent chest infections
  • Persistent wheezing
• Without treatment, the symptoms usually get slowly worse. There may also be periods when they get suddenly worse, known as a flare-up or exacerbation

Question 25

discuss treatment options for COPD with a patient including cessation of smoking

Answer 25

• Treatment –>
• The damage to the lungs caused by COPD is permanent, but treatment can help slow down the progression of the condition
  
  • Stopping smoking - the most important thing you can do
  • Inhalers and medications - help make breathing easier
  • Pulmonary rehabilitation - a specialised programme of exercise and education
  • Surgery or a lung transplant - this is only an option for a very small number of people
• The outlook for COPD varies from person to person. The condition can’t be cured or reversed, but for many people treatment can help keep it under control so it doesn’t severely limit their daily activities

Question 26

What are the steps in Counselling a patient regarding appropriate avoidance of drugs, foods and alcohol whilst taking warfarin?

Answer 26

• Explain need for warfarin
• Directions for taking warfarin
• Missed doses
• Monitoring warfarin
• Side effects
• Interactions

Question 27

Explain need for taking warfarin?

Answer 27

• Explain need for warfarin
  
  • Warfarin is an oral anticoagulant- a medicine that stops blood clotting
  • Clotting is a complex process involving substances called clotting factors, which are produced by the liver and help to control bleeding. They work with cells that trigger the clotting process (platelets) to ensure that blood clots effectively
  • To produce some of the clotting factors the liver needs a good supply of vitamin K, but warfarin works to block one of the enzymes (proteins) that uses vitamin K to produce clotting factors, meaning it disrupts the clotting process, making it take longer for the blood to clot.
  • Warfarin is prescribed for people who’ve had a condition caused by a blood clot, such as a stroke, heart attack, DVT or pulmonary embolism
  • Warfarin may also be prescribed for people at an increased risk of developing harmful blood clots such as those with a replacement heart valve, an irregular heart rhythm (atrial fibrillation), a blood clotting disorder known as thrombophilia or those at an increased risk of blood clots following surgery

Question 28

Explain directions for taking warfarin

Answer 28

Directions for taking warfarin

It is important to take warfarin exactly as directed and not to change the dose unless advised to (the aim of therapy is to decrease the blood’s tendency to clot, but not stop it clotting completely so the dose may be changed)

It is taken once a day, usually in the evening (and it’s important to take your dose at the same time each day, before, during or after a meal)

How long you take warfarin for depends on your condition

Question 29

explain missed doses of warfarin

Answer 29

Missed doses

If you normally take warfarin in the morning but forget to, take it as soon as you remember (however if it’s time to take your next dose don’t take a double dose to catch up)

If you normally take warfarin in the evening but forget to, take it if you remember before midnight (if not, leave it)

Question 30

Explain monitoring warfarin

Answer 30

Monitoring warfarin

You’ll have regular blood tests at your GP surgery or local anticoagulant clinic to make sure your dose is correct

The international normalised ratio (INR) is a measure of how long it takes your blood to clot. The longer it takes your blood to clot, the higher your INR. Your INR will be used to determine the dose of warfarin you need to take. INR needs to be 2-3

When you start taking warfarin, you may be given a yellow booklet about anticoagulants, which explains your treatment

Question 31

explain side effects of warfarin

Answer 31

Side effects

• Contraindicated in: pregnancy, severe hypertension, high risk of internal bleeding (e.g. stomach ulcer), bleeding disorders
• Bleeding (blood in urine/faeces, severe bruising, long nosebleeds, bleeding gums, cough up blood, unusual headaches, increased bleeding during period)- take care with shaving, brushing teeth, gardening, sewing, contact sports
• Skin rashes
• Hair loss
• Interactions
• Medications- alert HCPs before taking other medicines (avoid herbal medicines, supplements, aspirin/ibuprofen (paracetamol is ok))
• Diet- decrease foods with vitamin K (green leafy vegetables (spinach/broccoli), vegetable oils, cereal grains)
• Alcohol- do not drink more than 14 units per week
• Always inform dentists/surgeons
• Sports- avoid contact sports, martial arts and kick boxing
• Body piercings- not recommended

Question 32

Advise a patient on DVT/PE prophylaxis during travel

Answer 32

• Patients at risk
  
  • History of DVT/PE, cancer, stroke, heart disease, inherited tendency to clot (thrombophilia), recent surgery (pelvic region/legs), obesity, pregnancy, hormone replacement therapy
• Before you travel
  
  • See your GP before you travel (don’t leave this until the last minute in-case you need to buy medication, compression stockings etc)
  • Compression stockings significantly reduce your risk of DVT and leg swelling, by applying gentle pressure to the ankle to help blood flow. They come in a variety of sizes at different levels of compression, but it is vital they are measured and worn correctly, therefore take advice on size and proper fitting from a HCP
• During travel (journey >6hrs)
  
  • Wear loose, comfortable clothing
  • Wear elastic compression stockings
  • Drink plenty of water
  • Avoid drinking excessive amounts of alcohol because it can cause dehydration
  • Avoid taking sleeping pills because they can cause immobility
  • Perform simple leg exercises (regularly flex your ankles)
  • Take occasional short walks when possible (down plane aisle if flying, or by stopping at service stations if driving)

Question 33

Explain to a patient how to take sublingual GTN in the event of chest pain

Answer 33

• Spray- when pain develops, spray 1-2 times under the tongue, close mouth immediately and pain should ease within 1 minute
• Tablets- when pain develops, place 1 tablet under the tongue, allow to dissolve and pain should ease within 1 minute
• If 1st dose doesn’t work, take a 2nd dose after 5 minutes
• If pain continues for 15 minutes, call an ambulance
• Administration PRIOR to exercise will provide better relief than administration AFTER onset of pain
• Spray/tablets should be carried at all times
• Spray is preferred to tablets due to a longer shelf life
• Side effects include headache and flushing (due to vasodilation)

Question 34

What are the stages of explaining to a patient what happens when they go for an upper GI endoscopy?

Answer 34

1. What is a gastroscopy?
2. Who has a gastroscopy?
3. What happens during a gastroscopy?
4. What preparation is required?
5. What happens after a gastroscopy?
6. How reliable is a gastroscopy?
7. What are the side effects of a gastroscopy?

Question 35

explain what is and who has a gastroscopy?

Answer 35

• What is a gastroscopy?
• A common routine test where a HCP looks into the upper part of your gut- this includes the oesophagus (gullet), stomach and duodenum- using an endoscope
• An endoscope is a thin, flexible telescope (as thick as the little finger) which is passed through the mouth, into the oesophagus and down towards the stomach and duodenum
• The endoscope tip contains a light and a tiny video camera so the HCP can see inside the gut
• The endoscope also has a side channel, down which various instruments can pass, for example the HCP may take a small sample (biopsy) from the inside lining of the stomach by using a thin grabbing instrument passed down a side channel
• Who has a gastroscopy?
• It is advised if you have symptoms such as recurring indigestion, recurring heartburn, upper abdominal pain, vomiting, difficulty swallowing, or other symptoms thought to be coming from the upper gut
• Conditions that can be confirmed/ruled out include-
  
  • Oesophagitis- redness on the oesophagus lining
  • Duodenal and stomach ulcers- small red craters
  • Duodenitis and gastritis
  • Cancer

Question 36

Explain what happens during a gastroscopy and what prep is required?

Answer 36

What happens during a gastroscopy?

• The HCP numbs the back of your throat using local anaesthetic spray
• You may also be given a sedative injection to help you relax- this can make you drowsy but doesn’t put you to sleep like a general anaesthetic
• You lie on a couch, have a plastic mouth guard between your teeth (for protection), and will be asked to swallow first section of the endoscope before the HCP pushes it further down
• The video camera at the endoscope tip sends pictures to a screen, which the HCP observes for abnormalities
• Air is passed down the endoscope to make images easier to see (can cause feelings of fullness/belching)
• Samples of the inside lining of the gut (biopsies) may be taken depending on why the test is done and what they see- these are sent for laboratory testing
• The endoscope this then gently pulled out
• The procedure usually takes 10 minutes- however allow 2hrs for the whole appointment (preparation, sedative, procedure itself and recover)
• The procedure doesn’t usually hurt but may feel slightly uncomfortable

What preparation is required?

• The hospital department will send you instructions before the procedure occurs
• You shouldn’t eat 4-6hrs, but small sips of water are allowed <2hrs before the test
• If you have a sedative, you will need somebody to accompany you home
• Medication may need to be temporarily stopped

Question 37

Explain what happens after a gastroscopy, how reliable are they and what are the side effects?

Answer 37

What happens after a gastroscopy?

• Most patients can go home after resting for 30mins after the procedure
• If a sedative has been used, you may wait slightly longer, and you cannot drive/drink alcohol/operate machinery for 24hrs
• The HCP will write a report and send it back to your GP- biopsy results take a few days to process

How reliable is a gastroscopy?

• Helpful for seeing abnormalities of the upper gut, however it may not detect a small number of cases of early ulcers/cancer
• Sometimes a repeat procedure is advised if persistent/worsening symptoms

What are the side effects of a gastroscopy?

• Mild sore throat
• Feeling tired (if sedative was used)
• Occasionally, the endoscope causes some damage to the gut leading to bleeding/infection/perforation
• Immediately consult a doctor if any of the following occur <48hrs-
  
  • Worsening abdominal pain
  • Fever
  • Difficulty breathing
  • Vomiting blood
• A small number of people have a heart attack or stroke during/after a gastroscopy. These tend to be older people who are already in poor health. These serious complications are rare in most people who are otherwise reasonably healthy.

Question 38

Explain to a patient the procedure of PEG tube placement including the risks and potential complications

Answer 38

• Feeding tubes can be used to provide nutrition while you’re recovering your ability to swallow. They may also be required in severe cases of dysphagia that put you at risk of malnutrition and dehydration, and they can make it easier for you to take the medication you may need for other conditions.
• There are 2 types of feeding tubes-
  
  • Nasogastric (NG) tube- a tube passed through your nose and down into your stomach
  • Percutaneous endoscopic gastrostomy (PEG) tube- a tube is implanted directly into your stomach
• Nasogastric tubes are designed for short-term use, and the tube will need to be replaced and swapped to the other nostril after about a month. PEG tubes are designed for long-term use and last several months before they need replacing.
• PEG tube-
  
  • Pros- hidden under clothing, need replacing less often than NG tube
  • Cons- breathing problems, internal bleeding, bowel perforation, inflammation/infection, blockage
  • Before procedure- HCP discusses the procedure, risks, benefits, questions
  • The procedure- takes 20-30mins and occurs in endoscopy unit. Sedative is given, mouth guard put in the mouth, endoscope passed through the mouth guard over back of tongue and into the stomach, antiseptic cleans the outer skin over the stomach, PEG tube inserted, once in place a small plastic disc inside the stomach stops the tube being pulled out and another plastic disc on the outside stops the tube falling into the stomach
  • After procedure- feed can be given 4hrs after insertion

Question 39

Explain to a diabetic patient how to prevent the development of foot problems

Answer 39

• Diabetes can reduce the blood supply to your feet and cause a loss of feeling known as peripheral neuropathy. This can mean foot injuries do not heal well, and you may not notice if your foot is sore or injured
• Risk of complications can be greatly reduced if you are able to control blood sugar levels, blood pressure and cholesterol levels
• Foot care tips-
  
  • See the NHS podiatrist at least once a year
  • Keep your feet clean and free from infection
  • Wear shoes that fit well and don’t squeeze or rub (ill-fitting shoes can cause corns and calluses, ulcers and nail problems)
  • Never walk barefoot, especially in the garden or on the beach on holidays to avoid cuts and try to avoid sitting with your legs crossed so you don’t constrict your blood circulation
  • Cut or file your toenails regularly
• Urgent help should be sought if-
  
  • Breaks in the skin of your foot, or discharge seeping from the wound
  • Skin over part/all of the foot changes colour and becomes more red, blue, pale or dark
  • Extra swelling in your feet where there was a blister or injury
  • Redness/swelling around an ulcer or in an area where you’ve previously been warned to seek immediate attention

Question 40

Advise a patient with diabetes on diet, exercise and smoking habit

Answer 40

Dietary advice-

• There is no longer a diabetic diet and patients should be able to continue to enjoy a wide variety of foods as part of a healthy diet
• Eating 3 meals a day- avoid skipping meals, and space breakfast/lunch/evening meal out over the day to help control appetite and blood glucose levels
• Include carbohydrates in your diet, but as all carbohydrates affect blood glucose levels be conscious of the amounts you eat. Healthier options include wholegrain bread, whole-wheat pasta and basmati/brown/wild rice as they are generally more slowly absorbed (they have a lower glycaemic index) and help to keep your digestive system working well
• Cut down on fats (particularly saturated fats) which are found in foods made of animal products like butter, cheese, red/processed meats, palm oil, coconut oil, ghee, cakes and pastries
• Eat more fruit and vegetables (5 portions a day)
• Include more beans and lentils
• Aim for at least 2 portions of oily fish per week
• Limit sugar and salt intake by limiting the amount of processed foods
• Drink alcohol in moderation (all alcohol contains calories so cutting back further can help with weight loss)
• Newly diagnosed patients can be referred to a dietician for more specific advice and guidance if necessary

Exercise-

• Regular exercise is especially important for people with diabetes because it helps with blood sugar control, weight loss and high blood pressure
• People with diabetes who exercise are less likely to experience a heart attack or stroke than those who do not exercise regularly

Smoking-

• Giving up smoking is one of the most positive things a person can do to both improve health and reduce the risk of long term complications associated with diabetes
• If patients feel ready to quit, can be given information about the stop smoking service

Blood pressure-

• High blood pressure is related to an increased chance of complications, particularly in people with diabetes, and these include problems with the eyes, kidneys, and heart (stroke, MI)
• The symptoms of blood pressure may not show unless blood pressure becomes very high and so it is important that your blood pressure level is checked each year
• Blood pressure targets for diabetes are <135/85mmHg for T1DM and <140/80mmHg for T2DM

Question 41

Explain to a patient taking insulin how to recognise and prevent severe hypoglycaemia

Answer 41

• A hypo is when your blood glucose level is too low (<4mmol/L), which can happen if the balance of diabetes medication you take (especially insulin), food you eat and physical activity you do sometimes isn’t right
• Testing blood sugar regularly can help to stop a hypo before getting symptoms
• Symptoms and signs-
  
  • Trembling/shaking, sweating, anxious/irritable, pale, palpitations, tingly lips, blurred vision, hungry, feeling tearful, tiredness, headache, lack of concentration
• Causes-
  
  • Missing/delaying a meal or snack, not having enough carbohydrate at your last meal, doing a lot of exercise without having extra carbohydrate/reducing your insulin dose, taking more insulin than required, drinking alcohol on an empty stomach
• Prevention methods-
  
  • Change eating routines or adjust insulin (if there is a pattern)
  • Adjusting insulin during stress/illness

Adjusting insulin during temperature changes

Question 42

Explain the long term effects of high blood pressure to a patient- counsel them on the importance of lowering blood pressure and lifestyle changes

Answer 42

• Blood pressure is recorded with 2 numbers
  
  • Systolic pressure (higher number) is the force at which your heart pumps blood around your body
  • Diastolic pressure (lower number) is the resistance to the blood flow in the blood vessels
• As a general guide, high blood pressure is >140/90mmHg, ideal blood pressure is between 90/60mmHg and 120/80mmHg, and low blood pressure is <90/60mmHg
• If blood pressure is too high, this puts extra strain on your blood vessels, heart and other organs such as the brain, kidneys and eyes
  
  • This can increase risk of life threatening conditions such as heart disease, heart attacks, strokes, heart failure, peripheral artery disease, aortic aneurysms, kidney disease and vascular dementia
• If you have high blood pressure, reducing it even a small amount can help lower your risk of these conditions
• Lifestyle changes-
  
  • Reduce the amount of salt you eat and have a generally healthy diet
  • Cut back on alcohol if you drink too much
  • Lose weight if you’re overweight
  • Exercise regularly
  • Cut down on caffeine
  • Stop smoking
  • Try to get at least six hours of sleep a night

Medications can also be used if lifestyle adjustments do not improve blood pressure

Question 43

Explain to a patient how HIV is transmitted and preventative measures to avoid infection and the distinction between HIV positivity and AIDS

Answer 43

• HIV vs AIDS
  
  • HIV (human immunodeficiency virus) is a virus that damages the cells in your immune system and weakens your ability to fight everyday infections and disease.
  • AIDS (acquired immune deficiency syndrome) describes a number of potentially life-threatening infections and illnesses that happen when your immune system has been severely damaged by the HIV virus.
  • AIDS cannot be transmitted, but HIV can
  • There’s currently no cure for HIV, but there are very effective drug treatments that enable most people with the virus to live a long and healthy life
• Transmission-
  
  • Found in body fluids e.g. semen, vaginal and anal fluids, blood, and breast milk
  • Anal/vaginal sex without a condom
  • Sharing needles, syringes or other injecting equipment
  • Transmission from mother to baby during pregnancy, birth or breastfeeding
• Prevention-
  
  • Using a condom for sex
  • Post-exposure prophylaxis
  • Pre-exposure prophylaxis
  • Treatment for HIV to reduce the viral load to undetectable
  • If you use drugs, never share needles or other injecting equipment (syringes, spoons, swabs)
  • In pregnant HIV positive women, give anti-viral therapy, elective caesarean section and advise against breastfeeding

Question 44

Counsel a patient for HIV testing

Answer 44

• Introduction, consent, confidentiality
• Ask permission to discuss HIV testing
• Reason for taking test
  
  • Routine for patients at GUM clinic, otherwise ask if specific reason patient has asked for the test
• Ever had a test before
  
  • When, what was the result
• Exposure risk
  
  • Have you had any sexual experience that you would consider putting you at high risk of getting HIV?
  • When was the last time you had sex?
    
    • Male/female partner
    • Type of sex: oral, vaginal, anal
    • If anal: receiving or inserting
    • Contraception used
    • Condoms used
  • For men: Have you ever had sex with men?
  • How many partners have you had in the last 3 months?
  • Have your partners been tested for HIV?
  • Where were your partners from? (high-risk area?)
  • Have you had sex with someone who was HIV positive?
  • Have you ever worked as a sex worker?
  • Have you ever received a blood transfusion?
• Basics of the test
  
  • How the test works
    
    • Point of care test- antibody test which is a finger prick blood test, gives results in a few minutes, result is either negative or reactive (if reactive must be confirmed with antigen blood test), 99% accurate
  • When they will receive the result
    
    • Window period- the test will not show whether you have contracted HIV within this period (past 1-3months). You should still have a test today but if you have had high-risk activity within the last 1 or 3 months then you should come back for another test if this one is negative.
  • How effective it is
    
    • False positives/negatives- rare but can happen
• Benefits and risks of the test
  
  • Does the patient have an expectation of what the result will be
  • Advantages- prolonged good healthcare, reduced anxiety, treatable and manageable condition
  • Disadvantages- stigma, rejection from partners/family/job
  • How would they cope with a positive result? (do they have appropriate support)
• Agreement to test
  
  • Summarise what you have said
  • Check they have understood everything and ask if they have any questions
  • Are you happy to have an HIV test today?

Question 45

Explanation of osteoporosis

Answer 45

• Introduction and check name and consent
• Explain results of DEXA scan and blood tests, ask what patient knows about osteoporosis
• Explain osteoporosis- condition affecting bones causing them to be weak and brittle and more likely to fracture
• Suggest causes- high dose steroids, post menopausal, lack of calcium/vit D in diet, eating disorder, FHx
• Lifestyle changes- diet high in calcium, exercise (weight bearing and resistance exercises), quit smoking, reduce alcohol, medical management (Ca/vit D tablets, bisphosphonates)
• Bisphosphonates- how they work, why they are used (slow rate that cells break down bone)
• Administration- tablet or injection
• Side effects- oesophagitis (sit up when swallowing tablet), jaw necrosis
• Actively involve patient
• ICE

Question 46

How does information giving work?

Answer 46

Preparation

• Consider the patient, aims, objectives, info needed & approach.

Check agenda

• Check the patient’s agenda. What do they know already? How much information do they want or need today?

Gather info

• Gather important info needed about the patient for concordance*

Context

• Explain purpose/context of information. Give an indication of your agenda: ‘I would like to speak to you about three things today…’

Chunking

• Give small amounts of information at a time. If it occurs to you that you might be speaking too much; stop and check…

Frequent checks

• Periodically check: ‘how you feeling about this?’ or ‘what do you think about this so far?’ etc. This is to allow the person ‘processing’ time, to check understanding and fit info to patient needs

Interaction

• Encourage conversation and questions e.g. ‘please stop me if you don’t understand something’; Listen to the patient!

Linking

• Try if possible to address what the receiver already knows/ understands/ does / believes - and identify any dilemmas/difficult

Language

• Calibrate to the patient. Check whether you share the same understanding of terms and use some of their words if possible. Avoid or explain jargon

Check pacing

• ‘How is this going for you so far?’, ‘Am I going too fast?’

Check what has been understood

• Ask the person to summarise what they have understood/remembered in order to check you’ve explained correctly

Cue recall

• Ask the person to re-cap important aspects discussed (‘what about the side effects?’)

Invite questions

• What other information would be helpful?

Additional help

• Drawings/diagrams/prepared leaflet/support group/referrals etc…

Question 47

What are the side effects of the different inhalers?

Answer 47

ICS/preventer: Inhaled steroids have fewside effects, especially at lower doses. Thrush (a yeast infection in the mouth) and hoarseness may occur, although this is rare. Rinsingthe mouth, gargling after using the asthma inhaler, and using a spacer device with metered dose inhalers can help prevent these side effects. Thrush is easily treated with a prescription antifungal lozenge or rinse.

SABA/reliever ‘taken too much’: You may notice that your heart beats more quickly than normal and that you feel shaky. These side effects aren’t dangerous, as long as you don’t also have chest pain. They usually go away within 30 minutes or a few hours at most

Question 48

What is the pneumonic ATHLETICS in explaining a treatment?

Answer 48

• Action
• Timeline
• How to take
• Length of treatment
• Effects - time before seen
• Tests
• Important SEs
• Complications
• Supplementary advice

Question 49

How do you counsel a patient (start)?

http://oscestop.com/Explaining.pdf

Answer 49

• Start
  
  • introduction and explain why you are there
  • build a rapport before launching into explanation
  • ask if the patient knows why they are here
    
    • ask them to talk about what has happened up until this point
  • assess their prior knowledge - ask WHAT they know about condition/Tx already
  • describe what you are going to talk about e.g. your structure and if that would be helpful? and ask if they want to discuss anything else?

Question 50

How do you counsel a patient (middle)?

Answer 50

• Consider diagram
• CHUNK AND CHECK
  
  • important! explain small bits at a time and check they understand the info and ask if they have any questions; pausing after each section
• speak slowly and clearly and empathetic and listen for/to patient concerns

Question 51

How do you counsel a patient (end)?

Answer 51

• Summarise what you have talked about and make a plan
• check they’ve understood everything
• always offer something e.g. a leaflet, wesite, specialist nurse contact, follow up appointment

NB: let the patient guide the consult and decide what they want to talk about, follow cues and ask what they want to know and their worries. ICE! Avoid med jargon, be aware if you maybe breaking bad news (empathy, considerate)

Question 52

How do you structure a disease explanation?

Answer 52

• normal anatomy/physiology
• what the disease is
• cause
• problems is causes and complications
• management

Question 53

How do you explain a procedure (e.g. scope)?

Answer 53

• explain what it is
• reason for it
• explain procedure details (before, during, after)
• risks and benefits
  
  • if asked to get consent then check their understanding, get them to weigh up pros and cons & ask them why they chose their answer

Question 54

How do you explain a treatment?

Answer 54

• first, briefly check for any contraindications to the treatment
• check condition understanding
• how treatment works
• treatment course and how its take
• side effects
• (ATHLETICS)

Question 55

How do you explain bisphospohates to a patient?

Answer 55

A - prevents bone from being broken down and by helping to rebuild new bone; but also lifestype factors such as exercise, no smoking (we can help) and eating a well balanced diet

T - 1x weekly or smaller dose daily

H - swallow tablet with full glass of water; >30mins before food or anything other than water & be upright for 30 minutes after swallowing

L - long term

E - N/A

T - dental checkups before starting them regularly (osteonecrosis of jaw risk)

I - SE = headache, heartburn, bloating, indigestion, GI (d&C, black stools, abdo pain)

C - jaw osteonecrosis & CI = preg, dysphagia, stomach ulcers; severe renal impairment

S- website e.g. www.Nos.org.uk

Question 56

How do you explain warfarin using ATHLETICS?

http://oscestop.com/Common_drugs_to_explain.pdf

Answer 56

A- thins the blood (blocks vitamin K, the vitamin used by the body to make proteins that cause the blood to clot)

T - once daily (usually in the eve)

H- tablets

L - DVT=3 months, PE = 6 and AF = life

Effects - time before; 2-3 days

T- 5mg for 4 days then test INR on Day 5 & 8 adjust dose accordingly. Started concomitantly with LMWH if immediate effect is required. regular INR checks by anticoag clinic - regularity determined by INR stability

I -mportant SE = bleeding (1-2%)- come back if any unusual bleeding e.g. bruises, dark stools, cuts taking long to heal. Also D, N, rash, hair loss.

Reacts with CYTOP450 interactors, steroids.

Contra: pregnancy, haem stroke, sig bleeding, and caution in pts with high falls risk

S- supplementary advice: avoid liver, spinach, cranberry juice, alcohol binges; no NSAIDs/aspirin, given anticoag boook