Week 12: Clinical Decision Making

Question 1

What is clinical decision making? (1)

Answer 1

Being able to use various resources and possess experience/knowledge to help you make a good decision in order to provide safe care.

Question 2

What essential skills do you need to make a reasonable decision? (4)

Answer 2

Info. gathering and knowledge
Evidence based + critical thinking (reflecting on experience)
Good communication
Team Working

Question 3

What information do we need to know when performing a thorough history taking? (6)

Answer 3

1. Patient details
2. Presenting Complaint (PC)
3. Hx presenting complaint (HPC)
4. Past Medical History (PMH)
5. Drug Hx and allergies
6. Biochemistry/clinical test results.

Question 4

What is a pharmaceutical problem? (2)

Answer 4

Related to a medical issue.
Appropriate/optimal treatment of a disease state.
- Prophylaxis
- Symptom control
- Risk/benefit decisions

Question 5

How do we know it’s a pharmaceutical issue? (3)

Answer 5

Consider:
- S/s of px
- What do the test results show? (Abnormalities?)
- Is there any add. info. needed?

Question 6

What are the possible solutions for a pharmaceutical problem? (6)

Answer 6

Review current tx:
- Rationalise (deprescribe?)
- Correct dose, frequency/timings
- Duration
- Interaction/C/i.
- Environment

Question 7

What factors do you need to consider when making a decision? (4)

Answer 7

1. Patient safety (paramount)
2. Conjunction with patient/team
3. Document accurately and clearly
4. Explain and justify reasons for actions.

Question 8

What is the main interaction between citalopram and tramadol? (1)

Answer 8

Tramadol + SSRI antidepressant = Serotonin syndrome (increases seizure threshold)

Question 9

Explain the interaction between Citalopram and Tramadol. (1)

Answer 9

Tramadol + SSRI antidepressants inhibits serotonin reuptake = Increases serotonin (5HT) levels.

Question 10

What is Serotonin syndrome? (1)

Answer 10

Levels of 5HT increases in the CNS.

Question 11

What are the signs and symptoms of serotonin syndrome?

Answer 11

1. Changes in mental state.
2. Autonomic hyperactivity (tachycardia, diarrhoea )
3. Neuromuscular abnormalities (hyperreflexia)

Question 12

Explain the appropriate actions to take for SSRI + NSAIDS and SSRI + Tramadol.

Answer 12

SSRI + Tramadol = avoided or use with caution

SSRI + NSAIDs = Increases GI bleeding risk (okay for short-term, not for long-term)

Question 13

What is the reference range for Lithium? (1)

Answer 13

0.4-1mmol/L

Question 14

If the patient’s lithium levels are low, what actions should be taken? (2)

Answer 14

1. Check compliance.
2. If compliant, dose change.

Question 15

Why does a patient prescribed lithium need their thyroid function testing regularly? (2)

Answer 15

Lithium can induce thyroid disorders = TFTs checked every 6 months.

Question 16

What counselling should a px prescribed lithium receive? (3)

Answer 16

1. Regular monitoring is considered = TFTs every 6 months etc.
2. Maintain adequate fluid intake (dehydration = reduces renal blood flow. Hence reduces renal excretion)
3. Avoid diet changes which can reduced or increase sodium intake. (Lithium toxicity worsens on low sodium)

Question 17

Why is Lithium a high risk drug? (2)

Answer 17

1. Lithium is a narrow therapeutic index drug (high risk drug)

Question 18

What lithium level is considered toxic? (1)

Answer 18

> 1.5mmol/L

Question 19

What drugs can interact with lithium? (2)

Answer 19

Affects renal function (ACEI, Diuretics, NSAIDs)

Can cause sodium depletion (Thiazide diuretics)

Question 20

What does the QT interval in an ECG represent? (1)

Answer 20

Duration of activation and recovery of ventricular myocardium.

Question 21

What is the normal range for the QT interval? (1)

Answer 21

0.33-0.44 sec

Question 22

What does a QT interval of > 0.44 sec indicate? (1)

Answer 22

Myocardial electrical instability - QT prolongation

Question 23

What are the possible complications for QT prolongation? (3)

Answer 23

1. Ventricular Arrhythmias
2. Syncope
3. Sudden Death

Question 24

What types of drugs can cause QT prolongation? (3)

Answer 24

1. Antipsychotic drugs
2. Citalopram/Escitalopram
3. Opioids (Methadone)

Question 25

What is shared decision making? (1)

Answer 25

Patient is involved in the decision making process.

Question 26

What does shared decision making comprise of? (3)

Answer 26

Risks, monitoring and informing px.
Giving info.
Listening to patient.

Question 27

What do you always need to do when it comes to making decisions? (3)

Answer 27

Reflect on decision made
Ensure adequate monitoring, follow-up and support is in place.
Be prepared to review your decision at a later date.