OSCE Finals Revision Flashcards
1
Q
Sexual hx
A
Intro
- some questions sensitive, will include details about sex / sexual partners
- stress confidentiality
HPC
- explore sx
- discharge (urethral / vaginal/rectal)
- dysuria
- swellings/growths/ulcers
- pain (anogenital/pelvic/dyspareunia)
- PV bleeding, menstrual hx
- testicular pain/swelling, penile changes/itching/swelling
- fever, malaise, wt loss, rash, swelling/tenderness of joints, conjunctivitis
Partners
- ?sex with men/women/both
- last sexual encounter, type of sex, contraception use etc
- was this regular/casual partner
- if regular - how long been with
- any other partners in last 3mo (then ask same qs again)
- feel safe with partner? Any violence / unconsensual encounters? Any procedures to genitals like cutting/piercing?
BBV risk assessment
- partners from countries with high HIV/hep prevalence
- MSM
- needle sharing / injecting drugs
- sex work - paying/paid
- partners known HIV+
- chemsex
- tattoos / piercings
PMHx
- previous STIs, tests
- HIV / hep B/C status
- vaccinations, inc hep B, HPV
- previous obstetric/gynae issues
DHx
- meds, allergies
- contraception, adherance
- PrEP use
SHx
- alcohol, smoking, recreational drug use
- sexual problems, eg premature ejaculation
2
Q
Gynae hx
A
HPC
- SOCRATES, explore sx
- PV bleed (intermenstrual, post-coital, post-menopausal),
- abdo/pelvic pain
- PV discharge,
- dyspareunia,
- vulval itching/skin changes,
- infertility
- urinary sx
- bowel sx
- abdo distension
- fever, fatigue, wt loss
- chance of pregnancy
(4 Ps - PV bleed, PV discharge, pain, pregnancy)
PMHx
- menstrual hx
- obstetric hx
- sexual hx
- date last cervical smear, results
- surgical hx
- previous gynae issues
- previous STIs
DHx
- contraception, HRT
- meds, allergies
FHx
- breast, ovarian, endometrial cancer, diabetes, bleeding disorders
SHx
- wt change
- occupation, home, smoking, drinking, diet, exercise
3
Q
Menstrual hx
A
- length of cycle, ?regular
- duration of period
- volume of bleed - eg heavy
- dysmenorrhoea - more painful than usual
- LMP
- menarche
- date of menopause if post
4
Q
Obstetric hx
A
HPC
- N+V, fetal movts, PV bleed, abdo pain, PV discharge, headache/visual disturbance, oedema, pruritis, unilateral leg swelling, chest pain/SOB, fatigue/fever/wt loss
Previous obstetric hx
- gravidity, parity
- gestation at birth, mode of delivery, birth weight, complications, neonatal support, midwife/obstetric care, IVF etc
- current children - ages etc
- any previous miscarriages - causes
- previous TOP, type
- previous ectopics - site, management, cx
Current pregnancy
- LMP, when had +ve pregnancy test
- gestational age
- folate use
- estimated date of delivery - birth plans
- scans / screening results - eg 20 wk scan, Down’s
- any problems / admissions in this pregnancy
PMHx
- as per
DHx
- allergies, meds
- immunisations
FHx
- eg SCA, CF
SHx
- thoughts about pregnancy
- occupation, home, family, smoking/drinking
- domestic abuse
5
Q
Breast / breast lump Hx
A
6
Q
Fertility hx
A
“I understand you’ve been having some difficulty getting pregnant, can you tell me more about this please?”
General
- how long been trying - regular, unprotected sex
- previous Ix
- previous medical tx
- previous IVF
Sex
- frequency of sex
- difficulties with sex
- relation to fertile days?
- pain
Consider in partners (each)
- age
- occupation
- BMI
- previous children - same/different partner
- smoking / alcohol
- current meds
- PMHx
Woman’s gynae health
- gynae systems review
- PCOS sx - hirsutism, obesity, infrequent periods
- prolactinoma - galactorrhoea
- miscarriages, TOPs, any previous births (primary/secondary failure to conceive)
- menstrual hx
- obstetric hx
- sexual hx
- cervical smears, contraception hx
- vaccinations - eg MMR
PMHx
- abdo/pelvic ops, STIs/PID, previous subfertility
DHx
- folic acid, allergies, meds
FHx
- eg genetic problems, blood problems (SCA, thalassaemia)
- fhx of early menopause
SHx
- smoking, drinking, vaping, recreational drugs
- diet, exercise, occupation
7
Q
Paediatric hx
A
HPC
- SOCRATES, explore sx
- fever, activity/behaviour, rashes
- cough +/- sputum, runny nose, SOB, cyanosis
- vomiting, diarrhoea, abdo pain
- wet nappies, dysuria, frequency, haematuria
- seizures, fits, headaches, abnormal movts
- sore throat, ear pain
Birth
- any problems in pregnancy
- place of birth, gestation, weight, mode of delivery, complications, neonatal requirements
Growth
- weights - the Red Book
- puberty
Feeding
- eating / drinking, how much / how many bottles
- frequency of wet nappies / stools, consistency
Development
- any concerns
PMHx
- previous medical / surgical problems, previous hospital visits
DHx
- meds, allergies, immunisations
FHx
- as normal
SHx
- who’s at home, siblings/parents
- any smokers
- social services input
- housing, hobbies, school, pets
ICE
8
Q
Back pain hx idk
A
9
Q
Derm hx
A
HPC
- SOCRATES
- Where, when it appeared, how it’s changed
- Sx – itch, pain, rash, skin lesion, bleed, discharge, blisters, fever, malaise, wt loss, arthralgia
- Exacerbating / relieving factors
- Tx tried
- Recent contact, stress, illness, travel
- Hx of sunburn, use of tanning machines
- rheum system review
PMHx
- Atopy – asthma, allergic rhinitis, eczema
- Skin cancer, suspicious skin lesions
FHx
- Skin disease
SHx
- Occupation (inc skin contacts at work)
- Improvement of lesions when away from work
- alcohol, drugs, smoking
- home environment
- changes in diet
DHx
- Inc OTC
10
Q
Derm examination
A
Inspect
- general
- site, no of lesions
- pattern of distribution
Describe - SCAM
- Size, Shape
- colour
- Associated secondary change
- Morphology, Margin
Pigmented lesion - ABCDE
- Asymmetry
- irregular Border
- > 1 Colours
- Diameter >6mm
- Evolution - change in size/shape/colour
Palpate
- surface, consistency, mobility, tenderness, temp
Systemic
- nails, hair, mucous membranes, scalp
11
Q
ENT Hx
A
HPC
- SOCRATES
- general - fever, chills, wt change
- ear - tinnitus, vertigo, hearing loss, pain, discharge
- nose - congestion, rhinorrhoea, epistaxis, decreased smell
- throat - pain, dysphagia, odynophagia
- larynx - hoarse, voice change, noisy/difficulty breathing, pain speaking
- neck - swellings, pain, lumps
- face - sinus pain, pressure, swelling, numbness
PMHx
- previous surgery, eg head/neck
DHx
- meds, allergies
SHx
- smoker, alcohol
FHx
- anything in the family
12
Q
Ophthal hx
A
HPC
- SOCRATES, explore sx
- sudden vision loss
- change to vision - nature, onset, duration
- red eye
- eye discharge / watering
- gritty / dry eyes
- itchy eyes
- photophobia
- swelling / tenderness of eyes
- eye pain / pain on eye movt - SOCRATES
- double vision
- flashing lights
- headache/fever
- bleeding / trauma to eye - nature of injury, mechanism, FBs
- abnormal pupil reactions?
- temporal tenderness / jaw claudication
PMHx
- previous eye surgery, laser, trauma, contact lens/prescriptions
- chronic / autoimmune conditions
DHx
- eye drops?
SHx
- smoking
13
Q
Ophthalmic examination
A
Inspect
- face, eyebrows, asymmetry
- globe position, proptosis
- facial swelling/erythema/rashes
Vision
- acuity - Snellen’s / newspaper
- Ishihara plates
- visual fields
Eye movts
- ?diplopia, pain, nystagmus
Pupils
- shape
- direct / indirect reflexes
- RAPD
- accommodation
Lid/lashes
- lumps, swellings, erythema, cellulitis, ptosis
Conjunctiva
- red, discharge, purulent
Cornea
- eg abrasions, ?fluorescein stain
Anterior chamber
- hypopyon, hyphaema
Direct ophthalmoscopy
- red reflex, optic disc, retinal vessels, retina, macula
14
Q
Psych hx
A
HPC
- explore sx - nature, onset, tx, severity (functional impact), exacerbating/alleviating, duration/progression - impact on life
- psychosis - hallucinations, delusions, thought disorder - irrational thoughts, seeing/smelling things, feel targeted
- depression - low mood, anhedonia, sleep/energy, hopelessness…
- mania - periods of elation, out of character
- cognition - memory loss/forgetful
- anxiety, panic attacks, phobia
- unhappy about bodyweight / can’t control eating
- insight
Risk assessment
- intention to harm self, anyone else
- suicidal thoughts
- action on these thoughts
- risk of harm from anyone
PMHx
- psych issues - dx, tx
- past contact with mental health services
- previous self-harm/suicide attempts
- medical hx
DHx
- meds, allergies
- compliance
FHx
- psych issues, suicide
SHx
- alcohol, smoking, drugs
- current home, relationships, dependents/children, work, education
- forensic hx - police, jail, criminal record
- upbringing hx - childhood, school, inc child abuse
15
Q
Self-harm / suicide hx
A
HPC
- before - eg life events, depression
- planning - how long for / impulsive
- suicide note / tell anyone?
- precautions to avoid being found
- any alcohol/drugs
- truly intend to end life?
- when / where / how - eg specific OD details, self-harm injuries, where they got meds from etc
- how were they found / how did they get here
- feelings after the event - angry/regret
- current mood
- anything stopping them commit suicide?
- If they went home what would they do?
- any future plans for suicide
- happy to accept tx?
- depression screen - low mood, anhedonia, sleep/energy…
- psychosis - hallucinations, delusions…
- anorexia - problems with eating habits / body image
- safe at home? any risk from others?
PMHx
- conditions, inc psych
- past suicide attempts/self-harm - methods, help sought
DHx
- meds, inc allergies
FHx
- self-harm/suicide, psych conditions
SHx
- drug / alcohol, social stresses, relationship/family, jobs, living situation, hobbies
16
Q
Psychosis hx
A
17
Q
Depression hx
A
18
Q
Mania hx
A
19
Q
Eating disorders hx
A
20
Q
Psych risk assessment (self-harm/suicide)
A
- any thoughts of self-harm
- any thoughts of harming others
- any suicidal thoughts
- any harm from others?
- any attempts to self-harm / commit suicide
- what stops you acting on these thoughts
- made plans for suicide? What are they?
- how do you feel afterwards?
- take steps to ensure not found?
- support system at home
- any triggers for these feelings?
- any dependents?
21
Q
Capacity assessment
A
Requirements
- Any impairment of brain/mind - eg dementia, injury, intoxication - if NO then pt has capacity, if YES then follow point below
- can the patient understand, retain, weight up, communicate decision
- capacity is decision specific
- assume pt has capacity unless proven otherwise
- illogical decisions don’t mean pts don’t have capacity
Consultation
- intro, purpose, consent
- “can you tell me a bit about why you are in hospital”
- “do you understand what the options are for managing…”
- look for demonstration of requirements
- document clearly in notes
If pt lacks capacity
- find least restrictive option
- DoLS if decision infringes on pt’s ability to leave, or if they are controlled / supervised in any way they don’t consent to
- make decisions in best interests of pt - involve pt, take own beliefs into account
- ensure that ADRT / LPA are accounted for
22
Q
NAI / safeguarding
A
…
23
Q
Domestic abuse
A
Intro
- intro, purpose, consent
- build rapport
- emphasise privacy, safety, confidentiality
Approaching the issue
- general hx
- “how are things at home?”
- Establish abuse types - physical / sexual / emotional
- “has your partner ever hurt you”, “does your partner make you do sexual things you don’t want to?”, “how does your partner make you feel?”
- who is it, nature of relationship
- pattern - when it occurs, how long it’s been occurring, any escalation
- any alcohol/drugs involved
- coping? anything to try to stop it?
- who else lives at home?
- any weapons in the house?
- construct emergency safety plan - call police
Risk assessment
- currently feel in danger?
- mood? self-harm / suicide?
- children / vulnerable adults at risk?
- any previous psych hx, alcohol/drug use, previous divorce….
Closure / management
- ICE
- establish support - friends/family
- counselling support - eg national domestic violence helpline, WomensAid.org.uk - give leaflet
- refuge
- referrals - police, local domestic abuse services, counselling/support services, social services (if at risk children/adults)
- offer follow up
24
Q
CAGE / alcohol hx
A
HPC
- current use - what, how much, type, when, where (pub/home), why, who with
- anything happen in past?
- tried to cut down?
- treatments / detoxes
- relapse reasons
- ?tolerance
- any tremors, sweating, N+V, palpitations
- agitation, headache, hallucinations, seizures, insomnia
- affect on mood - assess risk of self harm / suicide / harming others
- how important is drinking to you?
CAGE
- felt the need to cut down?
- feel annoyed by people complaining about your drinking?
- feel guilty about drinking?
- ever drink an eye opener in morning?
SHx
- effect on self - injuries/medical conditions
- effect on family/friends, work, finances, police, driving, crime
- given up on hobbies/friends?
- recreational drug use, smoking
- family/living/working situation
- gambling?
FHx
- family alcohol use
DHx
- allergies, meds
PMHx
- eg ALD, UGIB, memory loss, PUD
- anxiety / depression
25
Q
Smoking cessation counselling
A
- (smoking causes CV disease, stroke, lung cancer, PVD)
- intro etc
- ICE about smoking / cessation
Smoking hx
- how long, how much
- what type - tobacco/nicotine
- where
- how does it make you feel, any effect on relationships
- how do they finance, how much would they save if stopping
- previously tried to quit? Relapses and why?
- withdrawal sx - craving, dizziness, low mood, fatigue, insomnia
PMHx
- COPD, asthma, pulm fibrosis, CVD / RFs
DHx
- any nicotine replacement now/before
FHx
- eg malignancy
SHx
- alcohol, drugs
- stressful life?
- employment
5 A’s approach
Ask
- ask + record smoking status
Advise
- risks of smoking, long-term effects
- advise to quit
Assess
- assess understanding of consequences of smoking with their own health
- explore pt’s views on cessation, if they feel motivated
- quantify motivation 1-10
- use stages of change model to guide assessment - precontemplation/contemplation/preparation/action maintenance/relapse
Assist - STAR
- Set quit date (2-4wks)
- Tell family + friends
- Anticipate challenges + how to overcome
- remove all tobacco products - recommend counselling / pharmacological therapies
Pharmacological therapies
- Nicotine replacement therapy - patches, spray
- Bupropion
- Varenicline
- all reduce cravings
Non-pharmacological therapies
- brief intervention (face-to-face therapy)
- individual counselling
- group counselling
- telephone counselling
Arrange
- follow up in 1-2 wks
- reassure about relapses - part of process
Closure
- check understanding, chunk + check
- any qs/concerns
- direct to leaflets / websites - NHS SmokeFree National Campaign
26
Q
Mental state examination
A
Appearance/behaviour
- build, dress, hygiene, self-neglect
- engagement, eye contact, anxious, disinhibited, gait/posture
Speech
- rate (eg pressured), rhythm, tone (eg monotonous), volume
Emotion (Mood/Affect)
- subjective - pt’s view of own mood
- objective - your assessment of their mood
- affect - their outward expression of their emotions
Perceptions
- illusions
- hallucinations - auditory, visual, tactile, gustatory, olfactory
- derealisation/depersonalisation
Thoughts
- stream - pressure, poverty, blocking
- form - flight of ideas, loosening of associations, perseveration
- content - delusions, obsessions, over-valued ideas
- self-harm / suicide
Insight
- aware of own mental illness?
- willing to comply with treatment?
Cognition
- MMSE / AMT
27
Q
AMT
A
28
Q
Disease explanation
A
Intro
- intro, purpose
- check prior knowledge
- ICE
Explaining disease
- normal anatomy / physiology
- what disease is
- causes
- problems, complications
- management
- chunk/check, can use diagrams
Closure
- ICE
- check understanding, answer questions
- summarise discussion
- further consultations / leaflets / websites
29
Q
Drug counselling
A
Intro
- intro, purpose, consent
- check understanding about condition
- check understanding about medication
- ICE
ATHLET(I)CS
- Action - indication, mechanism, diagrams
- Timeline (frequency) - when to take
- How to take (route) - eg oral/topical
- Length of tx
- Effects / SEs - esp common/serious
- Tests (monitoring) - eg blood tests
- Contraindications
- Supplementary advice - offer leaflet
Closure
- ICE
- double check understanding, answer questions
- summarise info given
- offer follow up…
30
Q
Corticosteroids counselling
A
- reduce inflammation + suppress immune system
- normally produced by adrenal gland
- tablet, OD, in morning same time (insomnia if taken later)
- take with meal
- may need long-term (goal is least amount of time)
- tale missed dose asap, but not 2 in one day
- sick day rules - double dose
Tests
- BP, BMI, eyes, HbA1c, lipids, K
- regular BP/BMI checks, lipids/K every 6-12mo, HbA1c every 3mo
S/Es
- insomnia
- wt gain
- mood changes
- long-term - Cushing’s, osteoporosis, proximal myopathy, HTN, high BMs, infections, adrenal insufficiency, peptic ulcers, cataracts, psychosis/depression
- never stop suddenly - risk of adrenal crisis - lethargy, weakness, N+V, abdo pain, diarrhoea, dizziness, wt loss, loss of appetite
- have steroid emergency card if on long-term
CIs / cautions
- acute systemic infections
- hepatic impairment
- unhealed wounds
- stomach ulcers
- HF, HTN, DM, epilepsy
- hx of mental health problems
- may be risky in breastfeeding/pregnancy
- avoid NSAIDs
31
Q
Antipsychotics counselling
A
- schizophrenia - overactivity of chemical messengers in brain - antipsychotics block receptors (dopamine) that cause this
- tablet OD, or injection every few weeks
- start low dose, gradually build up, take long-term, takes a few weeks to start effect
S/Es
- weight gain, diabetes, stroke, heart attacks - healthy diet
- restless legs, muscle spasms, eye movt problems, tremor, stiffness
- constipation, dry eyes, dry mouth, trouble urinating
- drowsy/lightheaded
- hot / shakey + very stiff muscles - see doctor
- sore throat / fever (clozapine) - see doctor
Monitoring
- clozapine - weekly FBC for 18wks, then every 2 wks for first yr
- 3mo HbA1c, lipids, BMI, BP, ECG, prolactin
Cautions
- CVD, Parkinson’s, Lewy body, epilepsy, DM, MG, previous jaundice
- hepatic impairment, phaeo
32
Q
Lithium counselling
A
- stabilises mood
- tablet OD, same time, continue long-term, takes a few weeks to take effect
S/Es
- damage to kidney, thyroid - bloods to check
- tremor, thirsty, polyuria, weight gain, swelling, drowsy, abdo pain
- teratogenicity in women
- OD is dangerous - D+V, coarse tremor, urinating lots, slurred speech, unsteady walking
Monitoring
- weekly lithium levels to start, then every 3mo once stable
- 6mo - U/E, TFTs, Ca
Contraindications
- 1st trim pregnancy
- breast feeding
- renal impairment / hypothyroid
- hyponatraemia (untreated)
- cardiac insufficiency / rhythm disorder
33
Q
SSRI / SNRI counselling
A
- depression imbalance of chemicals in brain - SSRIs re-adjust this (mainly serotonin)
- tablet OD, same time, usually morning (affects sleep)
- if working, continue for 6mo after sx resolve
- no effect for 4-6 wks, but keep going, may feel worse in wk 1-2 - follow up appt
S/Es
- anxious, jittery, suicidal - talk to us if this happens
- insomnia, headaches, wt gain/loss, D/V, loss of libido - see us if so
- don’t stop suddenly - withdrawal
Monitoring
- Nil, appt in 4-6 wks to follow up
CIs
- poorly controlled epilepsy
- manic phase
- suicidal risk
- don’t take MAOi / triptans
34
Q
Bisphosphonates counselling
A
- osteoporosis is where bones become brittle as cells break them down
- bisphosphonates slow these breakdown cells, help bone become denser
- tablet once a week - first thing in morning, empty stomach, with full glass of water, sit upright for 30 mins (don’t eat)
S/Es
- acid reflux
- bloating, indigestion
- change in bowel movts - diarrhoea / constipation / abdo pain
- headache
- may cause damage to bone in jaw - have regular check ups with dentist - watch out for pain / loose teeth
Tests
- nil
CIs
- pregnancy, stomach ulcers
- renal impairment
35
Q
Donepezil counselling
A
….
36
Q
Warfarin counselling
A
- thins the blood (decreases levels of factors in blood that trigger formation of blood clots, blocks vit K)
- tablet, take in evening, same time each day
- start low dose, adjust based on blood results
- duration depends on indication - 3mo DVT, 6mo PE, lifelong AF
S/Es
- risk of bleeding
- avoid activities which risk injury/bleeding
- if big bruise / bleeding heavily / black stools - see doctor
- avoid ibuprofen/aspirin - stomach ulcer risk
- avoid lots of alcohol
- mention to drs you are on warfarin
- avoid grapefruit juice / spinach
Tests
- blood levels 2x a wk for 2wks, then every wk until stable
- then check every 6-8wks
- check more frequently if out of range
CIs
- teratogenicity in women
- active bleeding / risk, haemorrhagic stroke
- 48hrs post-partum
37
Q
DOAC counselling
A
- thin blood, prevent clots
- block a protein involved in clot formation
- OD/BD tablet / capsule
- take with full glass of water sitting upright
- 3mo for DVT, 6mo for PE, lifelong for AF - but varies
S/Es
- bleeding - see doctor if head injury, bleeding, headaches, blood in urine/stool/vomit, black stool, bruising
- GI disturbance
Tests
- none regular
- renal function before, annually
CIs
- renal impairment
- risk of bleed / active bleed
38
Q
Levothyroxine counselling
A
- synthetic version of thyroxine - hormone from thyroid gland - works to bring thyroid activity back to normal
- tablet OD before breakfast
- 4-6wks for effect, take long term
Tests
- TSH every 2-3mo until stable, then annually
S/Es
- when stable, S/Es rare
- hyperthyroid - D+V, headache, palpitations, heat intolerance if too high
- Hypothyroid - cold intolerance, constipation if too low
CIs
- none
39
Q
Statin counselling
A
- decreases level of bad cholesterol in blood - reduce risk of heart attacks/strokes
- tablet OD, in evening
- take for long period of time
S/Es
- muscle aches / pain - usually mild, fade with time
- severe muscle pain, urine dark - see doctor
- headache, tummy upset
Tests
- LFTs at start, 3mo, 1yr
- cholesterol levels every 6mo
CIs
- pregnancy
- avoid grapefruit
- macrolides interact
40
Q
Methotrexate counselling
A
- dampens immune system, stopping it attacking our own cells, also reduces inflammation
- tablet, once a week
- take same day every week
- folic acid tablet other day
- effect in 3-12wks, continue for long term
S/Es
- hair loss, headaches, stomach upset
- serious (rare) - bone marrow suppression - bruising/bleeding, tired/breathless/fever - see doctor (avoid aspirin/ibuprofen)
- liver damage - avoid excessive alcohol
- lung damage - breathless/cough - see doctor
Tests
- FBC, U/E, LFT every 2wks until dose stable, then every 3mo
CIs
- if trying to get pregnant - tell us, med is damaging to baby, will need swapping
- breastfeeding
- active infection, immunodeficiency
- ascites, pleural effusion
- hepatic impairment
41
Q
Levodopa counselling
A
- replaces dopamine in brain (lacking in parkinson’s)
- helps to reduce sx, eg rigidity, slow movts
- tablet 3-4/day, take with food (reduce nausea)
- give with carbidopa
- see effects quickly, continue for long term, may have to add other meds later
- never stop taking / miss dose - worsens sx
Tests
- none
S/Es
- tell dr if you have any S/Es
- tummy upset, light headed, vivid dreams, nightmares
- seeing/hearing things
- dry mouth
- involuntary movts - on-off effect, end of dose, dyskinesias
CIs
- glaucoma
42
Q
Insulin counselling
A
- allows cells to take up glucose from blood, reducing blood glucose level
- various regimens
- inject wit injection pen at 90 degree angle
- rotate injection sites
S/Es
- weight gain
- sharp injuries
- hypoglycaemia
- lipodystrophy
Tests
- BMs before each meal and before bed
- check if sx of high/low blood sugar
CIs
- none
43
Q
Metformin counselling
A
- decreases blood sugar by increasing amount of sugars taken up/stored by liver, also increases insulin response (so cells take up more glucose)
- tablet, OD, gradually increase dose
- take in morning with food, same time each day
- continue for long term
S/Es
- if troublesome - tell us - can change type
- diarrhoea, wt loss, tummy pain, nausea
- rarely - increase acid levels in blood - if feel unwell - see doctor urgently
Tests
- U/E every year - just to check we can still give it
- HbA1c every 3-6mo until stable, them 6mo at diabetic check ups
CIs
- acute metabolic acidosis
- eGFR<30 / Cr>150
- low BMI
44
Q
Iron tablets counselling
A
- replace body’s store of iron - needed to make RBCs
- tablet 1-3 times/day, or syrup
- take without food
- 3-4mo for Hb to normalise, then 3mo to replenish stores
Tests
- Hb in 3-4 wks to assess response
S/Es
- nausea, sickness, diarrhoea, constipation, abdo pain
- black/green stools
- metallic taste
CIs
- none
45
Q
Procedure counselling
A
Intro
- intro, purpose, consent
- focused hx if needed
- check understanding of condition / procedure
- ICE
Procedure explanation
- what it is
- reason for it
- details - before, during, after
- risks / benefits
- alternative treatments
- if consenting - ensure pt has capacity - understand/retain/weigh up/communicate
Closure
- summarise
- check understanding, answer questions
- offer leaflet, follow up, eg specialist nurse
46
Q
Breaking bad news
A
Setting
- confidential room, comfortable, tissues to hand, sat down
- family with if they want
- turn off bleep
Perception
- what do they know already
Invitation
- check what they want to know
- “I have the result here today, would you like me to explain it to you now?”
Knowledge
- build up to result, give warning shot
- be direct, use plain language
- chunk and check
- wait for them to respond after delivering news
- slow pace, respectful tone, give pt time to react after news
Emotions / empathy
- acknowledge their emotions
- eg “I can see this news is a big shock”
- respond to non-verbal cues
- am I going to die - “I can’t answer that at the moment….we’re still gathering information…I want to stress that you’re in the best possible hands…”
Strategy/Summary
- check understanding of everything, any questions
- plan, when to meet again, next steps
- ?refer to specialist
- leaflet, Macmillan nurses, websites etc
- offer to contact family to inform them
- any religious preferences, eg chaplain
47
Q
DNAR / respect form conversation
A
Background info
- DNAR is a medical decision
- <20% survive in hospital cardiac arrests, 10% survive to discharge, rates lower if co-morbidities / frail
- take a SPIKES approach
Consultation
- “here today to talk about your health, perhaps some plans for the future”
- focused history
- check prior understanding of illness / prognosis
- “any thoughts about if things were to get worse / patient’s heart stops beating”
- check understanding about resuscitation, what it involves
- “any thoughts about how you want to spend the final moments of your life?”
- check understanding about RESEPECT form / DNAR
- explain procedure, low success rates, reasons for DNAR (CPR likely futile, poor outcomes, reduced quality of life afterwards)
- allow for more natural death, maintain quality of life
- not giving up on patient (DNAR is only relevant if heart stops)
- focus on alleviating symptoms, prioritising comfort - eg pain, nausea, agitation….
- chunk/check
Closing
- check understanding, answer questions
- if disagree - give time to mull over, come back later with senior
- offer leaflet, offer further discussions
- spiritual support?
Organ donation / post-mortem / brain-stem death / invasive procedures
48
Q
SBAR handover??
A
49
Q
Angry patient / relatives
A
intro
- introduce self, consent, calm manner
- private location, position self close to door
- clear boundaries if pt aggressive/rude
Dealing with pt
- allow to vent feelings uninterrupted
- validate feelings, apologise early, don’t collude - “I’m sorry to hear you feel that way”
- focus on pt - explore concerns, acknowledge them
Explaining to pt
- try to give some info
- reassure you’ll look into the matter, escalate to senior colleagues
- stress complaint is being taken seriously
- make clear, realistic plan
- follow-up
- inform of right to complain - practice manager at GP, PALS at hospital
50
Q
Dealing with complaints
A
51
Q
Patient wants to self-discharge
A
52
Q
Dealing with / explaining medical error
A
Stabilisation
- make sure pt is safe - A-E
- escalate care as required
Post-incident
- SPIKES approach
- inform patient + relatives
- apologise
- explain how error occurred
- document well in notes
- inform seniors
- Fill out Datix
- reflect + learn from error
- offer chance for complaint - PALS
- summarise + plan
Near miss
- report, even if no harm (could have potentially led to harm)
53
Q
Death verification
A
54
Q
Lump examination
A
55
Q
Skin lesion examination
A
56
Q
Testicular exam
A
57
Q
Breast examination
A
58
Q
Obstetric abdo exam
A
59
Q
Speculum examination
A
60
Q
Bimanual examination
A
61
Q
NIPE
A
62
Q
Acute stations
A
63
Q
A-E assessment
A
64
Q
Falls assessment
A
