OSCE communication skills Flashcards
Explain what clozapine is
Clozapine is an antipsychotic medication used to treat schizophrenia in patients who haven’t responded to first line treatments, or don’t tolerate them for whatever reason
““Sometimes, we find that despite trials of different medication people still struggle with some of the symptoms of schizophrenia; such as hallucinations, paranoia, disorganization or unusual beliefs. This can make it difficult for people to live the lives they would like to
When people have tried at least two different antipsychotic medications and continue to experience symptoms we often refer to this as ‘difficult to treat schizophrenia’ or ‘treatment-resistant schizophrenia’.”
Explain how to take clozapine
Clozapine is available as a tablet or in liquid form
We prescribe it first at a low dose, and then gradually increase this dose up over a few weeks, to work out the dose that works for you
It’s important that you don’t miss any doses, as if you do we will need to start you from the low dose again and repeat the titration process
Advantages of clozapine
6 out of 10 people with treatment-resistant schizophrenia benefit from clozapine
Common side effects of clozapine
- sedation (take at night)
- constipation (diet, laxatives)
- tachycardia (refer to cardio, or β blockers)
- weight gain (diet, metformin)
- hyper-salivation (time)
- BP (hypo and hyper)
- hyperglycaemia (meds)
Rare but serious side effects of clozapine
Agranulocytosis (<1%), neutropenia (3%)
- increased risk of severe infections
- seek urgent advice if pt develops flu-like sx
Seizures
- lowers seizure threshold
- increased risk at high doses
- coprescribe anticonvulsants (valproate) at high doses
Cardiac
- refer any pt with tachycardia at rest, CP, arrhythmias, HF
GI hypomobility
- associated w constipation side effect
- higher risk of ileus + obstruction
Monitoring of clozapine
Baseline:
- ECG
- BP
- BMI
- FBC, U&Es, HbA1c, lipids, troponin
Monitoring:
- weekly bloods for first 18w
- then fortnightly until 1yr
- then monthly after 1yr
Important other information when prescribing clozapine
- Clozapine levels rise significantly if pt stops/reduces smoking
Structure of a clozapine counselling station
- ICE
- Focused history
- Explain what clozapine is (∴ advantages too)
- Explain how to take it
- Common side effects
- Explain the monitoring, and therefore the risks, and safety net for flu-like sx
Focused history for clozapine counselling
- Sx of schizophrenia
- Current management
- Previous hospital admissions
- Previous medications trialed (inc efficacy, compliance, and adverse effects)
Focused history for statin counselling
- Ascertain if it’s for primary or secondary prevention
- CVD risk factors (smoking, alcohol, hypertension, sedentary lifestyle)
QRISK (treat if 10%+)
- smoking
- diabetes
- heart disease in 1DR <60
- CKD
- AF
- BP treatment
- migraines
- RA
- SLE
- severe mental illness
- atypical antipsychotics
- regular steroids
- erectile dysfunction
10% = 1 in 10 chance of CVD in 10 years
Explain what statins are and how they work
“Cholesterol is essential for life as it is used in many processes within the body. However, too much of the ‘wrong sort’ of cholesterol can increase the risk of potentially fatal cardiovascular events such as heart attack or stroke.”
“Statins work by limiting the production of new cholesterol within the body, as well as clearing ‘bad cholesterol’ from the blood. This aims to reduce the total amount of bad cholesterol circulating in the body and, in doing so, reduces the likelihood of future heart attacks or strokes.”
Explain how to take statins
Once daily tablet
Taken at the same time (simva/prava should be taken at night)
If a tablet is missed, take it ASAP, but do not take two in one day
Monitoring of statins
Pre-treatment cholesterol levels and LFTs
Follow-up test after 3m and 12m
Explain that the patient won’t feel any different, but it’s important they continue to take the medication continuously for maximum benefit
Side effects of statins
- myalgia (not a cause for concern)
- muscle toxicity (severe myalgia, must be reported)
- nausea
- constipation
- diarrhoea
- flatulence
- headaches
Reassure pt that statins are well-tolerated, and long-term safety is very well proven (lots of negative media coverage causing reduced adherence)
Interactions with statins
- grapefruit
- some abx
- some immunosuppressants
- some fibrates
Key point: “consult your Dr before starting any new medications”
Lifestyle advice for statins
Statins work by reducing your risk of cardiovascular events, but you can also make some lifestyle changes that will reduce this risk even further. This includes:
- regular physical activity (moderate intensity, 30m a day, 5d a week)
- healthy foods (can provide advice on food pyramid, dietician referral, etc)
- smoking cessation
- reducing alcohol intake
Structure of a statin counselling station
- ICE
- Pt history
- Explain what statins are and why they are prescribed
- Monitoring
- Side effects
- Interactions
- Lifestyle advice
Focused history for levothyroxine counselling
- Sx of hypothyroidism
- Current medications (for interactions)
Explain hypothyroidism and thus the need for levothyroxine
“Your thyroid sits at the base of your neck and produces a hormone called thyroxine that regulates many aspects of your metabolism, such as heat control, weight and energy levels. When your thyroid doesn’t produce enough thyroxine, we call this hypothyroidism.”
If pt mentioned their sx of hypothyroidism in focused history, integrate these into your explanation, e.g.
“You mentioned that you have been feeling tired recently, which we know is one of the symptoms of hypothyroidism.”
“Levothyroxine is a medication that can be used to top up the level of thyroxine in people whose bodies are unable to make enough thyroid hormones on their own. By using this medication, we can restore normal levels of thyroid hormones and prevent you from experiencing the symptoms associated with hypothyroidism.”
How to take levothyroxine
OD, 30mins before breakfast
(coffee + food reduces absorption)
Lifelong medication which pt should not suddenly stop taking or adjust their dose without consultation first
Missed dose: take ASAP, but do not double dose
Monitoring of levothyroxine
2-3w after first starting
2-3m after a dose change
Annually thereafter
Side effects of levothyroxine
‘Over’dose = hyperthyroid
- heat intolerance
- weight loss
- insomnia
- fine tremor
‘Underdone = hypothyroid
- cold intolerance,
- weight gain
- low mood
- dry skin
- constipation
Other information with levothyroxine counselling
- free prescriptions for life
- give a leaflet
Indications for PrEP
not part of counselling per se, just illustrative
- MSM
- trans women having anal sex (condomless)
- anyone having condomless sex with someone known to be HIV+ (unless partner is non-transmittal)
RFs, consider PrEP:
- anticipated high-risk sexual behaviour
- bacterial rectal STI or hep C in past year
- use of PEP in past year
- unable to use condoms
- IVDU
Contraindications for PrEP
HIV+
PrEP is only PART of the HIV tx, meaning if the pt was HIV+, only receiving 2/3 drugs could lead to resistance
Explain what PrEP is
PrEP is a combination of 2 anti-retroviral drugs, which work by preventing HIV from multiplying within T cells
Evidence shows significant reduction in HIV infections in those prescribed PrEP, up to 99% if taken properly
“PrEP stands for pre-exposure prophylaxis. It is a medication that you take before and after sex which can help prevent you from being infected with HIV.”
“It is a combination of two medications which stop the virus infecting your cells. We have been using these drugs to treat HIV for a long time.”
“Studies have shown that if PrEP is taken reliably, it reduces the chance of being infected with HIV via sexual intercourse by up to 99%.”
How to take PrEP
Daily dosing: single pill every day
- appropriate for anyone
- protection from 72hr for anal sex
- protection from 7d for vaginal sex
Event-based dosing: tablet before and after sex
- appropriate for anal + vaginal sex, but more complicated + requires pre-planning
- 2 pills 2-24hr before sex, 1 pill 24 hr after 1st dose, another pill 24hr after 2nd dose (FOUR PILLS IN TOTAL)
Side effects of PrEP
Mild + settle w/i a few weeks:
- headache
- nausea
- GI upset
Rare:
- ↓ CrCl (mild, non-progressive, reversible)
- ↓ bone density (no ↑ risk of fractures)
Monitoring for PrEP
Baseline tests before starting
- HIV test (within last 45 days)
- Renal function
- Hep B (if +, refer to hepatology + must use daily-dosing)
Regular monitoring:
- HIV test (3monthly)
- Urine dip (3monthly)
- STI test (3monthly)
- Renal function (annually)
Missed pills in PrEP
- Efficacy drops with missed doses
Daily-dosing: 1-2 missed pills are okay if it has been taken correctly for at least 7 days prior
Event-based: seek help for PEP, take a pill each day until PEP
Additional info for PrEP
- does not affect contraception
- no evidence to suggest teratogenic (but sample size is small so seek doctors advice)
- safe when breastfeeding
- will not affect hormone treatment for trans people
What is the structure recommended when explaining a diagnosis?
Brief history Understanding Concerns (ICE) Explanation (NWCPM) Summarise
NWCPM (normally we can probably manage): Normal anatomy/physiology What disease is Cause Problems/complications Management
Three questions to ask for the ‘B’ in BUCES
- What has brought the pt in today?
- What are their sx?
- Any risk factors?
How might you ‘signpost’ an explanation of epilepsy?
“I’m going to begin by explaining how our brains normally work (N), then I will explain what epilepsy is (W), what might cause it (C), and how we can best manage it to suit your needs (M)”
Epilepsy counselling:
Explain normal brain physiology (N)
“Our brain controls how we move, what we say and do, our memories and emotions, and how we see, feel, and hear things. It does this by firing lots signals constantly all over our brain. These signals go both ways: so when we are seeing/hearing/feeling/etc, the signals go from the outside world INTO our brain, and when we move, our brain sends those signals to our muscles.”
Epilepsy counselling:
Explain what epilepsy is (W)
“Epilepsy is a condition that affects the brain and causes a person to have an increased tendency to have something called epileptic seizures. There are different types of epilepsy and the symptoms of each differ significantly.”
“A seizure is an event that occurs when there is a chaotic burst of signalling that interferes with the brain’s normal function, resulting in epilepsy symptoms. Most seizures only last a few seconds to one minute. Some people have warning signs before they experience a seizure. This pre-warning is called an aura and can be anything from a sound you hear, a warm feeling in your stomach, a smell or any other type of sensation.”
TAILOR TO THEIR TYPE OF SEIZURES
Epilepsy counselling:
Explain causes of epilepsy (C)
“Epilepsy does not have one specific cause. Some people are born with epilepsy, and some develop it later on in life. It may be caused by events that happen before you are even born or during the process of birth. Epilepsy can develop later in life as a result of head injury, infection, brain tumour or a stroke. In many cases, however, the cause of epilepsy remains unknown.” 4
“There are certain circumstances and substances that increase the risk of people with epilepsy having a seizure and we call these triggers. Some examples of triggers include heavy alcohol use, dehydration, lack of sleep, use of certain medications, recreational drugs, fevers, flashing lights and missing doses of epilepsy medication.”
Epilepsy counselling:
Explain problems/complications of epilepsy (P)
- Impact on life (swimming alone, extreme sports, driving if seizures uncontrolled)
- Status epilepticus (carry emergency medicine)
- Sudden unexplained death in epilepsy (SUDEP) (emphasise medication adherence)
- Medication SFx (e.g. valproate in child-bearing potential)
Epilepsy counselling:
Explain management of epilepsy (M)
“The primary goal of treating your epilepsy is to reduce the number of seizures you experience. It may take some time to find out what works for you, and we will work together to optimize your treatment to allow you to live your life as normally as possible.”
- Medication adherene
- Status epilepticus emergency medicine
- Non-pharmacological (e.g. avoiding triggers)
- Tell your friends
Focused history for lithium counselling
- Pt’s symptoms (helps to emphasise importance of adherence)
- “Do you have any questions about your diagnosis so far?”
Explain what lithium is and how it works
- Mood stabiliser
“Changes the way your brain processes signals which helps to stabilise your mood. The exact mechanism is not fully understood, but this is a medication that has been used for decades with excellent evidence to support its use.”
Explain how to take lithium
- Liquid or tablet (“are you able to swallow tablets?”)
- Swallow with plenty of water
- Take at same time every day, ideally night
- Do not stop suddenly or change dose without consultation
- If pt misses a dose, do not double up, take next as normal
- Pt will receive a lithium record book which they should keep with them at all times
Monitoring of lithium
- Weeks-months to notice the effects
- Explain they will need a WEEKLY blood test at beginning of tx to measure the level in the blood
- Once stable, blood tests reduce to monthly, then 3monthly
- 6 monthly TFTs, U&Es, and calcium (can cause hypOthyroid, U&Es to prevent toxicity)
Normal side effects of lithium
LITHIUM
- Lethargy
- Insipidus (diabetes)
- Tremor; fine
- Hypothyroidism
- Insides (GI upset)
- Urine (increased)
- Metallic taste
All usually self-limiting, so if they don’t resolve with time, pt should inform Dr
Signs of lithium toxicity
- confusion
- drowsiness
- vision problems
- loss of appetite
- speaking difficulties
- seizures
- excessive thirst/urination
Risk of toxicity is reduced by taking medication at same time every day, and attending all blood test appts
Avoid NSAIDs (↑ lithium levels in blood)
Lithium during pregnancy
Explain teratogenic effects of lithium
- birth defects in first trimester
- also passes into breastmilk
Emphasise importance of reliable contraception
Encourage pt to discuss with psychiatrist if they are wanting to start a family
- may need to use a different medication
Focused history for bisphosphonates counselling
- Find out why they are being prescribed it (fracture or osteoporosis on DEXA scan?)
- Drug history
- Acid reflux?
- Osteoporosis RFs (smoking, alcohol, steroids, post-menopausal)
Should take no more than 2minutes in an OSCE
Explain what bisphosphonates are and how they work
- Group of drugs to treat ‘thinning bones’
- Slow down bone breakdown by osteoclasts to allow osteoblasts to continue strengthening the bone
- Explain that it will take around 6 months for them to work
“Osteoporosis is a condition that involves thinning of the bones, which increases the risk of fractures. Bisphosphonates work by preventing the thinning of the bones, allowing the bones to gain strength over time and ultimately reducing the risk of future fractures.“
“It takes roughly 6 months for the bisphosphonate to start strengthening your bones. You will most likely not feel any different in yourself, but it is important to keep taking the medication to keep your bones strong. This will be a long term medication and your GP will review it annually.”
How to take bisphosphonates
Most commonly prescribed is ALENDRONIC ACID PO once weekly
- take tablet on same day each week
- take with a large glass of water
- stay upright for 30 mins
- if a dose is missed, take ASAP but do not take two together
Side effects of bisphosphonates
- Oesophageal irritation ⇒ heartburn (hence sitting upright)
Self-limiting SFx:
- Abdominal pain
- Nausea
- GI upset
- Myalgia, arthralgia
Rare, but serious:
- Jaw osteonecrosis (must attend annual dental checkups) (mouth ulcers, pain, swelling)
Lifestyle advice to give during bisphosphonate counselling
- Diet and exercise for bone health
- The more they use their bones, the stronger they will get
- High calcium foods: dairy, leafy greens, soya beans, nuts, bony fish
- Calcium + vit D supplement
- Smoking cessation
Blood transfusion counselling: benefits
- Relieve anaemia symptoms
- Prevent damage associated with anaemia (e.g. MI)
- Allows for earlier mobilisation + quicker recovery
Blood transfusion counselling: risks
Overall risk of a serious problem occurring = 1 in 10,000
- Identification error (why pt ID is checked many many times)
- Reactions (fever, rash)
- Fluid build-up (breathlessness)
- Infection (BBV, less than 1 in 1M)
- Antibodies (only a problem for future transfusions)
- Iron overload (if frequent transfusions)
- Future pregnancy complications (antibodies causing foetal anaemia)
Also no longer eligible to donate blood
Remind pt that they will be closely monitored before, during, and after transfusion
“Donated blood is carefully tested and processed, so the risk of infection due to bacteria or viruses like hepatitis or HIV is tiny – less than 1 in a million. We have to check carefully that we match the right blood for you, so you need to wear an ID band and you will be asked to state your name and date of birth before starting. Occasionally, people develop a reaction during the transfusion, such as a temperature or a rash. Rarely, these can be serious. There is a small risk that fluid could build up in your circulation, making you feel short of breath.”
“Events such as these are unlikely and we will check you regularly during the transfusion. It is very important to tell a member of staff if you feel unwell at any point, so we can deal with any problems quickly. Sometimes, after one transfusion your immune system can make antibodies against the donor blood cells. These won’t affect you, but they can make it harder for us to find blood that is a match for you if you needed another transfusion.”
Blood transfusion: alternative treatments
- Iron replacement (slower)
- Cell salvage (pts own blood loss is collected and given back to them)
- EPO injections
- Nothing
Medications to avoid possibly needing a transfusion (e.g. like after a surgery with expected blood loss):
- Tranexamic acid (reduce amount of blood lost)
- Iron supplement
Explain blood transfusions to a patient
“Before the transfusion, a small sample of your blood needs to be obtained to check your blood group. This will be sent to a lab for testing. A small needle called a cannula will be put into a vein in your arm or hand. You will be asked to give your name and date of birth and this will be checked against your ID band and the details on the bag of donor blood selected for you.”
“The blood will flow slowly from the bag via a plastic tube into your vein. It usually takes 2 to 4 hours for each bag of blood to be transfused. Your temperature, blood pressure and pulse will be checked before, during and after the transfusion.”
GET CONSENT + ASK ABOUT ALLERGIES
Safety netting instructions for a blood transfusion counsel
Within 2 weeks (usually within 24h) of transfusion, if they feel unwell they should contact their GP
Sx to look out for:
- chest pain
- back pain
- SOB
- skin colour change
- urine colour change
Smoking cessation station: focused history
Explore pt’s smoking history
- how long they’ve smoked
- how much they smoke (pack years)
- what they smoke (cigars, cigarettes, vape, etc)
- what situations they smoke in (only social, all, etc)
- how smoking makes them feel / why they do it
- how it affects their life and relationships
- how they finance their habit
- how much they’d save if they quit
- have they tried to quit, why they relapsed
- withdrawal sx
PMH:
- pre-existing lung disease
- cardiovascular disease
- previous hospitalisation/surgery
Medications:
- previous nicotine replacement
- its efficacy
FHx:
- malignancy
- lung disease
SHx:
- alcohol intake
- recreational drug use
- psychosocial aspects of health, inc stressors at work or home
5 A’s approach to smoking cessation discussion
Ask: about the pt’s smoking status
Advise:
- commend pt for taking this first step
- advise on the risks of smoking and the long-term effects
- reassure that they will be supported throughout process
Assess:
- pt’s understanding of consequences of smoking
- explore pt’s views of smoking cessation and current motivation
- attempt to quantify it (“on a scale of 1-10, how motivated do you feel?”)
Assist: STARR approach
- Set a quit date (ideally abruptly, i.e. a few weeks, as it’s proven to be more effective)
- Tell family and friends
- Anticipate challenges
- Remove tobacco products
- Recommend programmes and therapies to help (discuss pharmacological and non-pharmacological options here)
Arrange:
- arrange follow-up within 1-2w
Pharmacological therapies to aid smoking cessation
Nicotine replacement therapy (NRT)
- first line
- patches or sprays
- caution in cardiovascular disease and ACS
Bupropion
- C/I in epilepsy, eating disorders, hypersensitivity rxns
- start 1-2w before quit date
Varenicicline
- most effective
- C/I in hypersensitivity rxns
Non-pharmacological therapies to aid smoking cessation
Lots of available counselling options:
- brief intervention (f2f behavioural therapy)
- individual counselling
- group counselling
- telephone counselling
What are the categories of features of an MSE?
- Appearance and behaviour
- Speech
- Mood and affect
- Thoughts (stream, form, delusions, risk assessment)
- Perception (dissociation, illusions, hallucinations)
- Cognition
- Insight
MSE: appearance and behaviour
Build / distinctive features:
- clothes (unkempt, hygiene)
Gait / posture:
- psychomotor activity (i.e. hyperactivity, hypoactivity)
- facial expression, body language
- eye contact, rapport
- level of arousal (e.g. agitated, calm, abrupt)
MSE: speech
Rate:
- rapid or pressured ⇒ mania
Rhyme:
- words linked (e.g. hair and bear)
- punning (2 words with the same sound, e.g. male and mail)
Tone:
- monotonous ⇒ depression
Volume
MSE: mood and affect
Mood = subjective emotion over time, pt’s own words
- nature (e.g. high, low, anxious)
- variability (e.g. continuous, variables, ups and downs)
- severity (e.g. “anxiety was worse than it has ever been” ⇒ ?panic attack)
Affect = verbal and non-verbal indications of their mood
- quality (e.g. angry, hostile)
- range (e.g. restricted, labile)
- intensity (e.g. blunted, flat, elevated)
- incongruent (inappropriate in context of speech content, e.g. laughing when saying they are suicidal) or congruent (in keeping with content of speech, e.g. crying when describing depression)
MSE: thoughts
Stream = abnormality of amount and speed of thought
- pressure: unusually rapid, abundant, varied (⇒ mania)
- poverty: unusually slow, few, unvaried (⇒ severe depression)
- thought blocking: mind becomes suddenly empty of thoughts, speech is suddenly halted, confirm by asking the patient “what just happened there?” (⇒ paranoid schizophrenia)
Form = abnormality in way thoughts are linked
- flight of ideas: thoughts are moving so quickly that it is difficult (albeit not impossible) to follow train of thought (⇒ mania)
- Knight’s move thinking: lack of logical connection between thoughts (⇒ schizophrenia)
- perseveration: persistent repetition of one thought (⇒ frontal lobe dysfunction, stroke)
Delusions = false, unshakeable idea/belief that is firmly held despite evidence to the contrary, which is NOT in keeping with cultural, educational, or social background
- persecutory: people are trying to hurt them
- of reference: objects/events/people have special significance (e.g. news reporter is talking to only them)
- grandiose: self-exaggerated importance
- worthlessness: belief that they have done something shameful based on innocent error (⇒ psychotic depression)
- control: actions, impulses, and thoughts are controlled by external agency
- possession of thoughts (inc. insertion, withdrawal, broadcast) (⇒ all first rank sx of schizophrenia)
Self-harm/suicide risk
MSE: perception
Dissociative symptoms:
- de-realisation: feeling as though the word is not real
- de-personalisation: feeling detached from oneself
Illusions = misinterpretation of real stimulus in context of emotional state (e.g. shadow on wall is an intruder in house)
Hallucinations = perceptions without external stimulus
- auditory: 2nd person (voices talk TO pt ⇒ psychosis), or 3rd person (voice talk ABOUT patient ⇒ paranoid schizophrenia)
- visual
- tactile: feeling as though they are being touched
- gustatory/olfactory
MSE: cognition
Pt’s current capacity to process information
MSE: insight
Pt’s awareness and understanding of their mental illness, treatment options, ability to comply with tx, and ability to identify reality from their sx
