Consent and drug counselling

Question 1

How do you consent for a bronchoscopy?

Answer 1

Preparation: 4h clear fluids, 2h NBM. Do clotting test and stop aspirin/ warfarin 1 week before.

During: Can use midazolam as a sedative and lignocaine gel for airways

After procedure: No E+D for 2h as throat is numb . No driving, alcohol or heavy machinery for 24h and get picked up with sedative.
Arrange F/U.

Risks:
Sore throat.
Haemoptysis next day if biopsy
Lung collapse

Question 2

Consent for an OGD?

Answer 2

Before: 8h no fluids before
4h before NBM
Stop anatcids 2 w before

During: Midaxzolam as sedative and lidocaine spray with continuous suction, air is passed through which may make you feel full/ gassy

After: No alcohol, driving or heavy machinery for 24 h and someone picks you up with sedative
F/U with GP

Risks: 
Perforation (will get pain, high temperature, breathing difficulties - may be able to mix with just abx, may need surgery)
Bleeding 
Infection 
 sore throat

Question 3

Consent for Colonoscopy

Answer 3

Before:
3d no bran
1d before clear fluids only
4h before NBM 
Laxative Sachets morning and night before 

During:
Midazolam sedative
Pain relief - IV or gas and air 
Takes 30-45 mins of actual scoping
Air passed through scope which may make you feel bloated and like you need to go to the toilet 

After:
Are taken to a recovery room since have been given sedative
No driving, alcohol, heavy machinery, get picked up for sedation
F/U 2-3 weeks for results of biopsy

Risks: Perforation, bleeding, infection, abdominal pain, failure to complete procedure
Red flag sx: Excessive PR bleeding, temperture

Question 4

Consent for cystoscopy?

Answer 4

Before:
NBM for 2h

During: May have sedative or anaesthesia
anaesthetic jelly used

After:
No alcohol, driving, heavy machinery, need pick up if sedative

Risks:
Bleeding
Infection
Mild pain with urination
haematuria if biopsy

Question 5

Consent for chest drain?

Answer 5

Done under local anaesthetic
Insertion of plastic tube to collect fluid content in chest
Is diagnostic (sample sent to lab) and therapetuic
Drain bottle is kept under bed to allow to drain

Risks: Bleeding, infection, pain, risk of lung damage

Investigations would ask for: pH, protein, LDH, gram stain. MCS

Question 6

Consent for lumbar puncture?

Answer 6

Use local anaesthetic
Needle inserted into space between vertebrae of back, goes in about 1-2cm, very small amount of the fluid that surrounds the spinal cord is collected which will be sent to the lab. Will need to lie flat for 4 hrs after to stop CSF leak and subsequent headache.

Risks: bleeding, infection, meningitis, CSF leak

Investigations would ask for from sample: MCS, cell count, glucose, protein, PCR

Question 7

Consent for blood transfusion?

Answer 7

Benefits: Relieves symptoms and stops damage to organs from anaemia, allows quicker recovery

Risks: 1 in 10,000
Reactions (allergies, anaphylaxis - monitored during to deal with this quickly)
Build up of fluid causing SOB
Infection (low due to our screening, 1 in a million chance)
Formation of antibodies
Can get delayed reactions (Delayed haemolytic reaction, graft versus host, infections)

During: small sample of blood needs to be taken before to check blood group, this will be tested in the lab, a cannula is then put in your arm, you will have your details checked many times to check this is the right match for you. It usually takes 2-4 h to tranfuse the blood, vitals will be monitored during.

Question 8

Consent for NGT?

Answer 8

CI: Basal skull #

Process: Measure distance first, Lubricate tip NGT, insert horizontally, give water to keep swallowing

Question 9

Consent for NGT?

Answer 9

CI: Basal skull #

Process: Measure distance first, Lubricate tip NGT, insert horizontally, give water to keep swallowing if no risk of aspiration, once reach desired length fix with dressing.
Check local guidance but generally is aspirate pH <5.5 is fine –> if can’t get aspirate then lie on left for 30 mins and retry. Otherwise CXR which must show NGT passing vertically down the oesophagus until the diaphragm, does not follow bronchi, tip NGT visible 10cm beyond gastro-oesophageal junction

Question 10

Summarise SSRI counselling

Answer 10

Action: Antidepressants alter balance of chemicals in brain, alters levels of serotonin

Timeline: OD

How taken: Tablet

Length: stop 3-6 months after feel better

Effects: 4-6 weeks

Tests: None

Important Side effects: GI, headache, drowsy, anxiety at first, ED

Complications/ CI: Suicide risk - need review in 2 weeks of starting

Question 11

Summarise Methotrexate counselling

Answer 11

Action: DMARD which suppresses inflammation and immune system

Timeline: Once weekly with folic acid

How taken: Tablet/ infection

Length: Long-term

Effects start: 4-6 months

Tests: FBC, LFT, UE at start, 2 weeks until established then every 2-3 months

Important SE: alopecia, headaches, GI distrubance, myelosuppression so beware anaemia, bleeding/ brusing/ infections

Complications: myelosuppression, liver toxicity (careful alcohol), pulmonary toxicity

CI: Pregnancy (male too), hepatic impairment, breast feeding, infections, immunodeficiency

Supplementary advice: Need annual flu jab, no NSAIDs

Question 12

Summarise Lithium counselling

Answer 12

Action: mood stabiliser

Timeline: OD

How taken: tablet/ syrup

Length: lifelong usually

Effects start: 1-2 weeks

Tests: FBC, UE, TFT at start and every 6m+ bHCG, ECG baseline. lithium levels every week until stable then every 3m

Effects: GI, fine tremor, thirst, polyuria, wt gain

CI: pregnant, breast feeding, cardiac disease, significant renal impairment, addisons

Complications: lithium toxicity (dysarthria, dizzy, coarse tremor, ataxia, muscle twitch, speech/ vision problems, N+V+D)
Renal toxicity
diabetes insipidus
hypothyroidism

Supplementary advice: brand lithium is important

Question 13

Summarise atypical antipsychotics

Answer 13

Action: blocks receptors in brain

Time: OD tablet or depot 2-4 weeks

How taken: tablet/ depot

Length: long term

Effect taken after: days/ weeks

Tests: LFT, ECG

Important SE: anti-dopaminergic (tardive dyskinesia, tremor, movement disorder); anti-cholinergic (constipation, dry mouth); anti-histamine (wt gain, dizzy); QT prolongation; gynaecomastia ; ED

CI: liver failure, phaeochromocytoma, need advice in pregnancy

Complications: liver failure, NMS (high fever and rigid muscles), agranulocytosis

Question 14

Summarise Levodopa counselling

Answer 14

Action: Replaces dopamine in brain which helps with rigidity and slow movements

Time: 3-4 times daily with food

How taken: PO

Length: As long as it works effectively

Effect taken after: Straight away

Tests: None

Important SE: Psychosis, N+V, dyskinesia - can use domperidone and selegiline to help with this

CI: glaucoma

Question 15

Summarise bisphosphonates counselling

Answer 15

Action: Prevents the bone from being broken down and helps rebuild new bone

Time taken: once weekly

How taken: tablet, wait at least 30 minutes before food and stay upright

Length: long term but can eventually try a bisphosphonates holiday

Tests: dental check up

Important SE: heartburn, GI SE

CI: pregnancy, stomach ulcers, dysphagia, severe renal impairment

Complications: osteonecrosis of the jaw, atypical #s, oeseophageal irritation

Question 16

Summarise Warfarin counselling

Answer 16

Action: Thins the blood by blocking vitamin K

Time taken: OD, same time every day

How taken: Tablet

Length: 3/6 months for DVT, 6 months for PE, lifelong AF

Effect starts: 2-3 days

Tests: INR needs to be taken regularly

Important SE: Bleeding (look out for bruises, epistaxis, haematuria, bleeding gums, dark stools etc); N+V+D; interactswith CYP450 drugs and steroids

CI: pregnancy, haemorrhagic stroke, ORBIT score high, surgery

Supplementary advice: Carefu alcohol binges, NSAIDs, keep diet the same. Need yellow anticoagulant book, tell doctors you’re on warfarin as has lots of interactions and before surgery!!, dont double up on warfarin doses

Question 17

Summarise Levothyroxine

Answer 17

Action: Increase hormone in body that thyroid usually makes

Time taken: OD

How taken: tablet

Length: lifelong

Effects start: few weeks later

Tests: TFT every 2-3 months until stable and after that annually

Important SE: Usually none as replacing a hormone but if become hyperthyroid may get N+V+D, heat intolerance, palpitations/ hypothyroid sx

Question 18

Summarise statin counselling

Answer 18

Action: stops the liver making cholestrol which predisposes to clots in blood

Time taken: OD at night

How taken: tablet

Length: lifelong

Effects start: decreases the risk over the years

Tests: LFTs at start, 3m and 12m

Important SE: muscle pains, N+V+D

CI: pregnancy

Complications: Rhabdomyolysis

Supplementary advice: Avoid grapefruit juice and clarithromycin

Question 19

Summarise Metformin Counselling

Answer 19

Action: Lowers blood glucose by increasing sensitivity to insulin

Time taken: OD with meal

How taken: Tablet

Length: Lifelong if works

Tests: U+Es before starting and then annually

Important SE: GI distubances

CI: Renal impairment, low BMI, ketoacisosis, stop before general anaesthetic

Complications: Lactic acidosis

Question 20

Summarise Iron tablet counselling

Answer 20

Action: Replaces body’s store of iron which is needed to make blood cells

Time taken: OD-TDS, with food

How taken: Tablet

Length: usually 4 months

Effects start: 3-4 weeks

Tests: FBC in 3-4 weeks

Important SE: GI irritation (N+V+D, dark stools), tablets taste bad

Question 21

Explain inhaler technique

Answer 21

Explain that inhalers are to relax the tubes in the lungs, they need to reach quite deep down so need to stay in lungs as long as possible. Explain when to use and that 2 puffs should be taken.

1) remove mouthpiece
2) shake cannister
3) breathe all the way out
4) form a tight seal with mouth around mouthpiece
5) take a deep breath in and press firmly down on the cannister
6) breathe in for as long as you can
7) hold your breath for 10s then breathe out normally
8) repeat

Question 22

Summarise HRT counselling

Answer 22

Action: replacess oestrogen and progesterone which have gone down with menopause which will help reduce hot flushes, vaginal dryness, OP, CVD

Time: OD

How taken: gel, cream, PO or patch - patch if VTE risk, combined if have uterus, cyclical if perimenopausal and continous if menopausal

Length: as long as symptoms need controlling

CI: breast cancer, PV bleed, breast feeding, VTE

Supplementary advice: contraception needed until 1 yr post final period

Question 23

Summarise COCP counselling

Answer 23

Action: stop you from getting pregnant by stopping periods and thickening mucus of womb to stop sperm entering, also improves PMS and reduces risk of ovarian and endometrial cancer

Time: OD, same time every day, 21 days on, 7 days off

How taken: PO (also have depot proverra, patch, coil and implant)

Length: As long as wish not to be pregnant

Effects start: After 7 days unless taken in day 1-5 of period cycle

Tests: BP check

Important SE: headaches, sore breasts, low mood, low libido, breakthrough bleeding, skin changes, raised BP, blood clots

CI: VTE, breast cancer, pregnant, migraine with aura, 35+ smoking 15+ cigarettes a day; relative = BMI 35+

Complications: cervical cancer, breast cancer

Supplementary advice:
99% effective if taken correctly
Does not protect against STIs 
Retake if D+V
Stop before surgery (4 weeks)
May interact with abx 
Missed pill rules: 
If miss one take another on same day, if miss two still take the other and then if there are less than 7 pills in the pack do not take your break and use condoms for 7 days. If there are over 7 use condoms for 7 days and still have your withdrawal bleed

Question 24

Summarise steroid counselling

Answer 24

Action: Reduce inflammation

Time: OD

How taken: PO

Length: depends

Important SE: wt gain, skin thinning, acne, mood change, proximal myopathy

CI: NSAIDs
Complications: peptic ulcers, htn, infections, OP, DM, cataracts

Supplementary advice: Sick day rules, dont suddenly stop
Need bisphosphonates and PPI, NSAID CI