OPIC History Taking and Management Flashcards
What key things must you ask in every elderly medicine history?
Social History
How do they usually manage day to day?
Work/ retired?
Where do they live and who with?
How do they mobilise? Walking aids? Stairs in the home?
Any assistance at home e.g. carers?
Drive?
Do relatives feel concerned that their family member is at risk?
Assess for carer strain
it can be very stressful as a family member when something like this happens - how are you coping yourself?
ASSESS RISK
How can you assess risk in an OPIC history?
Risk to themselves:
Self-neglect – are they remembering to wash and dress themselves and eat 3 meals a day?
Are they remembering to take their medications? Remembering to order repeat prescriptions? Taking anything twice?
Remembering to lock doors? Accidentally leaving the hob on?
Finances OK? Missed paying any bills? Direct debit set up?
Any risk of falls?
Any risk of self-harm or suicide?
Risk to others:
Do they drive?
Are they irritable, aggressive?
Involved in childcare? Pets at home?
What should you ask in a history of a fall?
How did it happen? What were they doing at the time? Did they report feeling any different before they fell?
Do you have any ideas about why they fell? Had they recently been ill? Had they been started on any new medications?
Did they hurt themselves when they fell?
Did they lose consciousness or become unresponsive? How long were they down for?
Did they bite their tongue? Did they lose continence?
Did they recover straight away after their fall?
Have they fallen before? Are they prone to falling?
How is their balance generally?How do they normally mobilise?
Any problems with blood pressure or feeling dizzy after standing up too quickly?
How is their vision?
What specific symptoms prior to the fall should you screen for in a falls history?
Weakness
Change in sensation
Headache
Dizziness, light-headedness, feeling drowsy
Change in vision / hearing
Changes to speech? Drooping of the face?
Fever , Neck pain?
Did they have any cardiac symptoms? Palpitations, chest pain, SOB?
How should you investigate someone who has fallen?
Cardiac investigations:
Lying and standing bp- orthostatic hypotension
ECG - arrhythmias
Urine dip for infection
FBC - anaemia/bleeds, WCC and CRP for infection, U&Es for any electrolyte derangement, bone profile for deranged calcium and osteoporosis (risk of fracture on falling)
AXR- faecal impaction
CT head- subarachnoid haemorrhage
CGA - general frailty and functional ability
Timed up and Go Test, Turn 180 Test
Which members of the MDT can get involved in managing falls risk?
Pharmacist- review TTOs
Physios - improve strength and mobility
Occupational therapists- ADLs
GP follow up
How can you manage postural hypotension?
Hydration
Review polypharmacy
Reduce adverse outcomes from falls (e.g. fall alarm, soft flooring)
Behavioural changes (e.g. rising from sitting slowly, calf pumping before standing)
Compression stockings
Midodrine
What should you ask in a confusion history?
When did this all start? What is the course of symptoms over time? Is there a significant change from their normal?
Triggers:
Been poorly recently? High temperatures?
Change in waterworks or bowel habit?
Eating/drinking? Alcohol?
New stress? Change in environment?
Associated symptoms:
Cognitive disturbance: change in speech? Memory?
Low mood
Reported seeing or hearing things that you can’t see or hear?
Change in their behaviour? Agitated? Disinhibited?
How are they sleeping?
Impact on day-to-day life? What is your main concern after what has happened? What has triggered you to come in now? What are you hoping that we do in the hospital for your family member?
How can you investigate a patient with new confusion?
Confusion Screen Bloods:
Glucose: hypoglycaemia can commonly cause confusion
FBC: Anaemia / bleeds
U&Es: electrolyte derangement
Bone Profile (Calcium): hypercalcaemia can cause confusion
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
ABG if suspected hypoxia
ECG
Infection:
Urine dip
Blood culture
CXR
CT/MRI head
How can you manage a patient with delirium?
Reassurance
Consistency
Orientation
Avoid transfer between wards
Minimise sensory deprivation/overload
Safe wandering
Sleep hygiene – scheduled med rounds, avoid overnight interventions
Consider haloperidol 0.5 mg or lorazepam if PD
How would you answer a patient who asks ‘ can my daughter force me to go into a care home?’
No, nobody can make you do something you don’t want to do.
We know there are situations where people do have to go into care homes, but I don’t think we’re at that stage with you…
And if that was to happen in the future you would be very much in the driving seat of that decision and involved in all of the conversations.
Explore ICE
How would you approach a family member of a an acutely unwell patient who is for palliation who says “It’s not what he would have wanted he would’ve wanted everything” ?
Explain likely outcome with link back to symptoms
He was a poorly man before, with symptoms such as … Which suggest he was coming to the end of his life before this admission
Out investigations show that he currently has … which is a life threatening condition, and I believe he is highly likely to die as a result of this
We have the option to bring him in and treat him very aggressively which is not very comfortable … He is very unlikely to recover and is likely unfortunately to die anyway, either from his condition or from the treatment itself…
Our other option is to recognise these symptoms and recognise that he is dying, and support him to be as comfortable as possible
But this is a two way discussion, I want to hear what you think and what is important to you
It is a decision between yourselves and the medical team to decide what is in their best interests
How would you approach a memory history?
When you say memory issues what do you mean?
Issue with short term memory or long term?
Difficulty remembering names (semantic) ? Faces (visuospatial)? Do you ever struggle with doing things in the right order (procedural memory)? Do you ever forget what you’re doing part way through a task (procedural memory)?
When did it start? Sudden or gradual onset?Any other symptoms at time of onset? Progression over time? Does it fluctuate?
Functional impairement? Dementia has to be severe enough to impact on quality of life
Screen for hallucinations and delusions
Screen for difficulties mobilising and tremor
Screen for urinary incontinence
ICE
Screen for depression
RISK ASSESS!!!
How would you explain a diagnosis of dementia to a patient?
All of these changes you have been experiencing such as … are consistent with a diagnosis of dementia
Dementia is an umbrella term for damage to the brain, and it is categorised based on the underlying cause of the damage
We can’t fix it and unfortunately it will get worse over time
We can slow symptom progression but we can’t stop it
How would you calculate risk of osteoporosis?
Bone profile bloods
DEXA scan (hips and lumbar spine)
FRAX score
