Class 11 Flashcards
Your next patient is a 35 year old lady who had a thyroidectomy 4 hours ago and is now complaining of shortness of breath. Vitals are stable, O2 sat is 97%.
Tasks:
Explain the cause to the patient
Explain your immediate management and procedure (equipment)
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. How are you feeling now?
Address concern
D: I understand, I’m here to help you, and we’re going to do everything we can to address this.
Diagnosis
D: I am concerned about a rare but serious complication of the thyroid removal surgery, called hematoma. This is a bleeding under the surgical wound which gets trapped and creates a collection of blood which puts pressure on the surrounding tissue such as your main airway or windpipe (trachea). We usually monitor for this complication after surgery, I will quickly feel your neck and check if there is a firm and tense swelling under the wound.
D: As this can be a life threatening problem, and can block the airway completely, I will need to:
Notify the surgical team to come see you and to get ready for a small operation
We usually keep an emergency box with every patient who has had the thyroid-removal surgery which has a blade, scalpel, scissors, gauze and gloves and other equipment I may need
We need to act fast before the hematoma blocks the airway completely. We follow a guideline called SCOOP.
I’m going to remove the dressing and expose the Skin
I will cut the sutures and open the skin
I will open the superficial and deep layer of the muscles by gently spreading them apart
I’m going to pack the wound with some gauze and move you towards the operating theatre
By doing this, we’re creating some extra space for the hematoma, and relieve the pressure on your windpipe
D: We will then immediately take you the operating theater. The surgeon will search for the source of bleeding and try to stop the bleeding.
D: Do you have any concerns or questions about the procedure? Are you happy for me to proceed?
Your next case is a telephone appointment. A 68 year old lady who is a known case of varicose veins has just cut herself on the leg with broken glass and is bleeding. Her partner is on the phone.
Tasks:
Take history
Explain your immediate management to the partner
Open-ended question
D: Hi, my name is _____. How can I help you today?
Address concern
D: I understand this is a stressful moment for you, but I want you to stay calm so we can work through this together.
History
D: When did the bleeding start?
D: Has it stopped?
D: Is it getting worse?
D: Can you describe how she cut herself?
D: Are you seeing any pieces of glass in the wound?
Risk Factors
D: Is she on blood thinners?
D: Any medical condition that she has?
Assessment
D: Is she awake or unconscious?
D: Is she responsive or talking to you?
(We expect the answer to be yes, but if no, proceed with primary survey)
R: No
D: Can you check if she is breathing?
D: Is her chest moving?
D: Place your hand on the chest, it is moving?
D: Go close to her mouth and nose, can you listen for breathing sounds?
D: Is there any danger to yourself or to her at the moment?
D: When was her last tetanus vaccine?
Counselling
Ok John, please stay calm, I’m here to help you. I will ask the nurse to call an ambulance and send them to your address.
You can put me on speaker phone, or I’ll give you instructions and you can put the phone down, but I’ll be here if you need me.
Danger: First of all, please make sure there is no danger to yourself or to her, like any pieces of broken glass on the floor. Find a safe area and do the first aid there
Airway: If your wife is responsive and talking to you, this means that her airway is open and is breathing normally
Bleeding:
Lie her down, get a clean cloth and apply pressure to the wound and hold it firm
If the cloth gets soaked with blood, don’t panic, put another one on top of it and continue applying pressure
You can gently elevate the leg with a pillow under the leg and ask her not to move the leg
If you see any glass on the wound, do not remove it and just apply pressure around it
If the bleeding is severe, and not stopping, we can apply a tourniquet
Grab a belt or strip of cloth and wrap it around the leg above the bleeding area and tie a firm knot
Then just continue applying pressure
I have a car, do you want me to bring her to the hospital?
No, just continue applying pressure until the ambulance arrives. I want you to monitor your wife’s condition, make sure that she is breathing and responding to you. Once the ambulance arrives, they are going to apply a tourniquet or use a hemostatic bandage & dressing if the bleeding is ongoing and they will transfer her to the hospital
Your next patient is a 60 year old lady who has been admitted due to a diverticular bleed. She has been stabilized in the hospital. The surgeon is planning to do an angioembolization.
Tasks:
Take a short history
Explain the procedure to the patient
Address her concerns
Open-ended question
D: Hi, my name is ___. How are you feeling now?
D: I’ll be explaining about the procedure that the surgeon has recommended, but I’ll need to ask you a few questions first. Do you have any concerns that you’d like me to address?
R: They told me that they’re going to do an angioembolization, I’m just wondering why they don’t want to do a surgery for me
D: I understand your concern, let’s have a chat about it, but I’ll need to ask some questions first, is that alright?
Bleeding
D: When did the bleeding start?
D: Was it fresh or dark blood?
D: How much was it, just a few drops or a gush of blood?
Symptoms
D: Are you feeling dizzy and tired?
D: Any chest pain or shortness of breath?
D: Are you taking any blood thinners?
D: Do you have any medical conditions?
Diagnosis and Management
You have been diagnosed with bleeding from some pouches in your bowel which we call diverticula. They are usually caused by long-term constipation and that causes some pouches in your bowel walls. These pouches sometimes become inflamed and painful, they can sometimes burst and rupture, or sometimes it can cause some bleeding, such as in your case. We have 2 main options to treat this bleeding:
Doing a surgery, which is an invasive and complicated procedure. We might need to remove a part of your bowel. In this case, you will need to stay in the hospital for a longer time, and it has a higher risk of complications like bleeding, infections.
The second option is angioembolization. The surgeon has recommended this procedure for you.
We will initially do a scan called CT angiography to find the blood tube which is bleeding
The procedure aims to block the bleeding vessel and we do this by injecting an absorbable gel or a coil-like device, and sometimes we might give some medication that narrows the blood tube
For this procedure, we make a small cut in your groin and insert a small tube in the blood tubes. We then travel close to the bleeding vessel and we usually use some thin tubes at that point. As I told you, we either inject gel or the coil-like device to block the vessel and stop the bleeding
This procedure is easier and has a lower risk of complication and has a shorter hospital stay
Cons of this procedure are: there is a risk of re-bleeding after the procedure, and at that point, we will need to proceed to a surgery to stop the bleeding; rarely, we have a condition called bowel ischemia after the procedure, which means that the bowel are not receiving enough blood
Patient-centered Approach
I understand your concern. I can ask the surgeon to come and talk to you. He can also explain the pros and the cons of this procedure so you can decide about which option you prefer and give us an informed consent
Your next patient is a 27 year old lady admitted in the surgical ward due to a ruptured appendix. She underwent a surgery yesterday. The surgeon has recommended 72 hours of observation before discharge. She is currently on LMWH, IV antibiotics. Today is her 2nd day post-surgery and patient wants to go home.
Tasks:
Take history
Explain vital signs chart to the patient
PE findings will appear on the screen
Counsel regarding discharge
Open-ended question
D: Hi, my name is ___. How are you feeling now?
D: I was told that you have requested to leave the hospital earlier than your surgeon has recommended. May I know why?
D: Is there any way I can help you and support you in this situation?
D: Are you aware of the complications after surgery and why we want to keep you in the hospital for a little longer?
Abdominal Complications
D: Are you having any abdominal pain?
D: Any fever that you’ve had?
D: Any nausea and vomiting?
D: Have you started eating and drinking? Any problems with this?
D: Have you passed wind and bowel motions since surgery?
Post-op complications
Pneumonia
D: Do you have any cough? Any shortness of breath?
Atelectasis
D: Are you in pain? Are the pain killers helping?
UTI
D: any burning or pain on passing urine?
DVT
D: Have you noticed any swelling or pain in your legs?
Surgical wound
D: have you noticed any discharge or redness around the wound area?
D: Have you noticed any redness around the cannula insertion sites?
Version 1
No symptoms
Vitals normal
UDT normal
No abdominal complications
Counselling
I’ve checked your vital signs and asked about possible complications which may happen after surgery, and everything seems to be fine.
Address Concern of patient:
I understand your concern and why you need to leave and go home. I can offer help and support. I can arrange for social workers.
I can provide a medical certificate to provide time off work
The reason that we prefer to keep you in the hospital is that we are concerned of some complications after surgery.
We have done a surgery on your bowel and we need to make sure that the bowel is functioning properly before we let you go. We need to make sure that you’re eating, drinking, passing wind and bowel motions properly.
We are worried about infections, which is why you are on antibiotics to prevent these.
We are also worried about clots in your leg, which is why we are giving you a blood thinner.
At the same time, we will monitor for lung infections, cannula site infections, urinary tract infections
I can give you some time to think about this. If you have any questions, you can ask me. If you have any other concerns, you can share it with me.
I want to reassure you that we will help arrange for support in any way we can so we can work through this together.
You can let me know what your final decision is after you think about it.
If you still decide to leave:
Red flags: in case of any fever, abdominal pain, vomiting, pain and swelling in the legs, discharge from the surgical wound, please come back to the ED so we can check it for you
Before you leave, you will need to sign a form called discharge against medical advice, which states that you have understood the risks, but still decide to leave, and we respect your decision.
Version 2
I feel a slight burning when I pass urine
VS chart: + fever
PE findings: UDT + nitrites, +1 leukocytes, +1 blood
Counselling
I understand your concern and why you need to leave and go home. I can offer help and support. I can arrange for social workers.
I can provide a medical certificate to provide time off work
On your examination, you have a mild fever, and on the urine test, you have signs of a urinary tract infection. If we don’t treat it, it may spread to your kidneys and to your blood and cause a severe infection. This is why we prefer to keep you in the hospital so we can provide treatment and monitor the response to treatment. Overall, staying in the hospital will be a safer option.
Other reasons that we prefer to keep you in the hospital is that we are concerned of some complications after surgery.
We have done a surgery on your bowel and we need to make sure that the bowel is functioning properly before we let you go. We need to make sure that you’re eating, drinking, passing wind and bowel motions properly.
We are worried about other infections, which is why you are on antibiotics to prevent these.
We are also worried about clots in your leg, which is why we are giving you a blood thinner.
I can give you some time to think about this. If you have any questions, you can ask me. If you have any other concerns, you can share it with me.
I want to reassure you that we will help arrange for support in any way we can so we can work through this together.
You can let me know what your final decision is after you think about it.
If you still decide to leave:
I will give you oral antibiotics, but watch out for worsening of symptoms, abdominal pain, vomiting, fever, pain and swelling in the legs, discharge from the surgical wound, please come back to the ED so we can check it for you
Before you leave, you will need to sign a form called discharge against medical advice, which states that you have understood the risks, but still decide to leave, and we respect your decision.
Your next patient is a 25 year old lady who presented to your general practice complaining of bilateral hand pain. You prescribed her with diclofenac which did not improve the pain. The blood tests you arranged show a +RF and a +anti CCP. Her mother also has RA.
Tasks:
Explain results and the most likely diagnosis to the patient
Explain the course of the disease
Discuss initial management plan with her
Open-ended question
D: Hi, my name is ___. I’ll be taking care of your today. Can you tell me what has happened so far?
D: Do you have any concerns that you’d like me to address today?
Explain results & Diagnosis
D: As I can see on the notes, you have pain on both hand an on multiple joints, and your mother also had rheumatoid arthritis, this is why the doctor decided to check for RA factor in your blood test. The results of the rheumatoid factor and anti-CCP blood tests are positive, which confirms that you have a rheumatoid arthritis. The anti-CCP is very specific to rheumatoid arthritis, and once it’s positive, it confirms the diagnosis.
D: How are you feeling now?
D: I’m really sorry, I wish I had better news today.
D: RA is an autoimmune condition, which means that your immune system starts attacking your own body. In RA, it mainly affects the joints causing pain, inflammation, swelling and redness. It also affects other areas in your body including your eyes, heart, lungs, and the nerves in the leg.
Explain the course of disease
D: RA is a chronic and long-term condition that occasionally will flare up and get worse. The repeated inflammations damage the joints and create deformities, and also damage other organs. We need to prevent these flare-ups.
Initial Management
Pharmacological: We will need to control the symptoms of pain and swelling in the joints
We can give some anti-inflammatory painkillers called NSAIDs, like ibuprofen. However, side effects of using this long-term are tummy upset or ulcers in the stomach, and it can affect your kidneys
We may start you on corticosteroids, especially in the initial stage of treatment, like oral prednisolone. Pros of steroids are, they have a rapid onset of action and it relieves your symptoms fast, but cons are, it increases your blood pressure, your blood sugar level, can cause a bit of weight gain and tummy upset
Key point: I will refer you to a rheumatologist to start you on a special medication called disease modifying antirheumatic drugs (DMARD), like methotrexate. This medication suppresses the immune system and decreases the inflammation in your body. When you’re started on this medication, we will have to do regular blood tests like FBE, LFTs. We’ll also check your immunization history and do some vaccinations as needed, and we’ll start you on folic acid supplements.
Non-pharmacological
We are going to treat you as a multidisciplinary team
I will send you to a physiotherapist. They are going to teach you stretching and strengthening exercises of your hand. In the long run, this will reduce the symptoms and pain in your hands
I will refer you to the occupational therapist. They will help you with making splints for your hand
I can refer you to a psychologist. If you feel emotional about your diagnosis, they can help you with cognitive behavioral therapy to help you cope with the stress.
Lifestyle
Regular exercise and healthy diet are helpful
Cut down alcohol and smoking
Support
Support groups and Reading materials from Arthritis Australia, myRA
Question:
I am a professional pianist, should I stop playing?
Your symptoms of pain and swelling in the hands can interfere with playing the piano.
If we start appropriate treatment of DMARDs, doing PT exercises, there is a chance that you might be able to continue playing the piano
However, avoid playing when you have a flare up: pain, swelling, redness in the joints
I will follow-up your condition and see how we go in the future
In the future, I can give you a letter to find a suitable occupation/role
Methotrexate Counselling
Your next patient is a 45 year old patient who has been diagnosed with RA. He was started on Methotrexate by the specialist. He has come to you very angry as he found out that methotrexate is a carcinogenic medication.
Tasks:
Explain management of RA to him
Explain what he needs to check when on methotrexate
Counsel him and convince him to take the medication
Open-ended question
D: Hi, my name is __. How can I help you today?
Explain management
D: I totally understand your concern and why you are angry. But please calm down, I’ll explain everything to you and we’ll make a plan together.
D: RA is an autoimmune condition, which means that your immune system starts attacking your own body. In RA, it mainly affects the joints causing pain, inflammation, swelling and redness. It also affects other areas in your body including your eyes, heart, lungs, and the nerves in the leg.
D: We have 2 main concerns:
If this inflammation happens over and over again, it will damage the joints and create an irreversible deformity in the joints
This repeated inflammation will damage other organs, especially the lungs, hearts, eyes, nerves in the leg, etc
D: Treating RA aims to prevent repeated inflammations and decrease the risk of irreversible damage to the joints and the organs
D: Any medication has side effects. Whenever we use methotrexate, we consider the benefits and also consider the risks and side effects. In your case, the benefit of controlling RA outweighs the possible risks of taking methotrexate. RA itself increases the risk of cancers such as lymphoma. Methotrexate may increase the risk of cancer slightly, but overall, we have noticed that methotrexate can decrease the risk of cancer by controlling the inflammation of RA.
D: While you are on methotrexate, you may experience some side effects like nausea, tummy upset, dry skin, thin hair, tiredness, inflammation in the lungs and liver. But we’ll give you folic acid supplements that will decrease the risk of side effects.
D: we usually monitor your FBE and LFTs every 2-4 weeks for the first few months, then repeat it every 1-3 months.
D: We’ll make sure that you’re upto date with your vaccinations before starting methotrexate, like whooping cough, influenza and hepatitis B.
D: I’ll give you some reading materials about RA and methotrexate and its side effects. I will arrange a joint meeting with the rheumatologist so we can discuss your concerns with him. But if you still decide to stop this medication, we can talk about other options, like NSAIDs, corticosteroids, or other DMARDs.
D: Non-pharmacological
We are going to treat you as a multidisciplinary team
I will send you to a physiotherapist. They are going to teach you stretching and strengthening exercises of your hand. In the long run, this will reduce the symptoms and pain in your hands
I will refer you to the occupational therapist. They will help you with making splints for your hand
I can refer you to a psychologist. If you feel emotional about your diagnosis, they can help you with cognitive behavioral therapy to help you cope with the stress.
Lifestyle
Regular exercise and healthy diet are helpful
Cut down alcohol and smoking
Support
Support groups and Reading materials from Arthritis Australia, myRA
Your next patient is a 67 year old man who is scheduled for knee replacement surgery of OA. She is a known case of COPD, IHD and mild CKD.
On her pre-anesthesia assessment, the anesthesiologist has reported that surgery has a high risk for the patient and has sent the patient back to you.
List of medications given.
x-ray and spirometry given.
Low hemoglobin and other investigations given.
Tasks:
Take history regarding the knee osteoarthritis and other conditions
Discuss risks and benefits of surgery
Do not talk about alternative management options
Open-ended question
D: Hi, my name is ___. How can I help you today?
Address Concern
D: I understand that that can be concerning. Is it okay if I ask a few questions and I’ll explain what the report tells us, and why we’re not happy to proceed with the surgery.
Osteoarthritis History
D: When were you diagnosed?
D: What treatments are you taking? Are you compliant?
D: Are you having regular follow-ups with your GP and specialist?
D: Complications
D: Are you able to attend to or do your daily activities at home?
D: How is OA affecting your life?
D: Have you had any falls?
D: Do you experience pain regularly? Can you scale the pain for me?
COPD History
D: When were you diagnosed?
D: What treatments are you taking? Are you compliant?
D: Are you having regular follow-ups with your GP and specialist?
D: Are you still smoking?
D: Any shortness of breath, cough or wheezing?
D: How many flare ups have you had in the last 12 months?
D: Have you ever been admitted because of a flare up?
IHD History
D: Do you have any chest pain on exercise?
D: Do you have any swelling in your legs?
D: Any shortness of breath when you lie down?
Cardiorespiratory Fitness
D: Are you doing regular exercise?
D: How much can you walk before you get tired?
D: Can you tell me what is the heaviest exercise or physical activity that you can do?
D: Can you climb 2 flights of stairs or walk 4 blocks?
Surgical/Anesthesiologic Assessment
D: Have you had any surgeries before?
D: Any history of difficult intubation or airway management?
D: Any nausea/vomiting or problems after surgery?
D: Any history of allergies to anesthesiologic medication?
D: Any family history of allergies to anesthesiologic medication?
D: Any allergies to egg, soy, or peanut?
Counselling
We do an assessment before any surgery to consider the possible risks of the surgery and anesthesiology.
Based on the report and my assessment, you have a high risk of complications during and after surgery. As you have ischemic heart disease, this increases the risk of heart attacks during and after surgery. As you have COPD and have a lung condition, this increases the risk of lung problems like atelectasis and pneumonia after surgery. CKD increases the risk of CVD and heart disease after surgery, and it also increases the risk of mortality after surgery.
During a surgery, your body will be put under significant stress as you lose blood, given some medications, and given some fluids. Because of this stress, we need a functioning heart, lungs and kidneys. However, in your case, having IHD, COPD, CKD (mention the positive points in the history here as reasons) increases the risk of problems during and after surgery.
Overall, we have decided that we don’t want to proceed with the surgery, as the risks outweigh the benefits.
Do you have any specific concerns that you want me to address?
If patient still not happy:
I will arrange a joint meeting with your surgeon, anesthesiologist, and your GP to discuss this further with you
