Lec 5- Decision making skills Flashcards
What is a clinical decision
- Problem => Though process => Decision/Recommendations
Format of the session
- A clinical scenario will be presented on the screen
- A range of answer options will appear
- You will make a decision on the treatment plan or drug choice for the given scenario that you believe is the best option and vote via Tophat
- Time allocated will be dependent on the complexity of the question
- Resources will be used as advised
- Student answers will be displayed and discussed in the lecture
- Answers that would attract a red flag
Pharmaceutical care
- The responsible provision of drug therapy for the purpose of achieving the definite outcome that improves patient quality of life
- Drug dose or choice
- Indications
- Compliance
- ADR
- Interactions
- Education
- Monitoring
Pharmaceutical care issue
Newly diagnosed with high BP and started on ramapril 5mg OM 5/7 ago and is feeling dizzy and GP would like you to have the initial consultation with her in your HTN clinic. You have found out she is an occasional drinker “heavy” smoker, is not eating healthy and is living off junk food due her recent break up with her boyfriends
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Pharmaceutical issue HTN
Q1) which of the following care issues would you like to discuss first in your consultation with miss AW
A) smoking cessation B) Why split from boy C) Side effects of ramapril D)Monitor BP E) Eating more fruit F) Signpost to support group
- C) The side effect of ramipril
- Ramipril dosing should be given at night for first few days as can cause postural hypotension and this could be why Miss AW feels dizzy
- Other side effects (ca ough) discussed with Miss AV
- Lifestyle advice given at every opportunity (Alc intake, smoking and diet)
- BP monitoring
Pharmaceutical care issue- Asthma
PC: sob, wheezy DHX: Salbutamol 100mcg 2p prn Treated in hospital with IV hydrocortisone, salbutamol and ipratropium nebs and IV salbutamol infusion 3/7 post admission Josh is ready for discharge. He has been started on Clenil 50mcg 2p BD, prednisolone 20mg OM for 2/7, salbutamol 10 puffs QDS and to reduce as per weaning plan.
Clinical care issue
Q2) what are the main care issues you would want to discuss with Josh and his parents at this stage of his career
A. Make appointment to see the Gp to get inhaler counselling
B. Discuss the use of the new Clenil® inhaler and side effects
C. Self management plan discussion
D. Inhaler technique checked and assessed
E. Monitor U/E’s as was on IV and nebulised salbutamol
F. Check patients respiratory distress
- Answers= B, C, D
- Josh is going home on new inhaler so need to check if he can use brown inhaler correctly and knows difference between blue and brown
- Counsel to rinse mouth with water after using inhaler= oral thrush
- Self management plans are given out on discharge and parents need to be aware of “reliever and preventer” therapy and when to increase blue inhaler dose
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Short Term Goals
- What would you like to achieve in the Short term? relate it to the PC-what the patient has been admitted for
- If we take HTN we want to achieve a consistent BP of <140/90 mmHg, with a few agents as possible and minimum side effect
- When a flare up develop : want to clear up symptoms, to cause a remission of the disease
Long Term Goals
- What are we trying to achieve in the LONG term future/Ultimately
- If we continue with HTN we want to reduce the risk of CV morbidity and mortality
- Other examples
- When a flare-up has settled: prevent any further flare-ups
- Patient encouraged on getting more exercise
- Patient encouraged to start smoking cessation programme
- Realistic, Achievable, Individualised
GI short term goals
- Answer = B,D
- Short term goals
- Treat NSAID GI ulcer
- Treat deficiency Fe anaemia
- Long term goals
- Manage patients back pain with appropriate analgesia
- Avoid risk factors including lifestyle advice for re-occurrence of ulcer
- Healthy eating plan specific for vegetarians
Gastroenterology
- Answer D= Stop and switch to regular paracetamol
- Stop NSAID
- Serious GI toxicity >Bleed
- Educate on avoiding NSAID’s and the risks
- Concomitant use with SSRI also increases the risk of Upper GI bleeding
- Switch to suitable analgesia paracetamol (+/- codeine)
- Could add on topical treatment and/or heat patches
Gastroenterology
- Answer D: ferrous sulphate 200mg TDS
- First-line option: most common used Fe salt; Cost-effective; High F (bioav)
- Ferrous fumerate, gluconate or liquid preparations can be started as alternative- but mainly used if ferrous sulphate is not tolerated.
- MR Preps not recommended as no therapeutic advantage
- NB: Parenteral Fe reserved for use when oral is unsuccessful
- Patient cannot tolerate oral Fe
- Non-compliant
- Malabsorption
- Continual blood loss
Angina Long term
- Short term goals
- Relief of angina symptoms i.e. chest pains
- Long term goals
- Optimise angina therapy
- Prevention of future cardiac events and improve survival
- Education on the importance of compliance to a treatment regime
- Stabilise patients depressive mood
Angina
- Answer= NO
- Identify interaction between Simvastatin and St Johns Wort
- STOP St Johns Wort reduces plasma concentration of simvastatin
- If simvastatin switched to atorvastatin then advise to go to GP for low mood as no real evidence for use and more risk due to being on other medication for long term conditions
- Advise not to take herbal medicines before checking with the GP or pharmacist
- Explore and address issues around impact of stress, anxiety or depression on angina
- Offer/Sign post for support groups, CBT, GP
Angina
- Answer C
- Discuss with Mr AM his smoking patterns and if he has tried to stop smoking before
- Identify what stage Mr AM is in the cycle if change
- Discuss pattern of smoking: craving in the morning? Has he tried stopping before? if so what products has he tried
- If Mr AM willing to try and give up then NRT discussed and offered
- If Mr AM not willing to make changes then issue leaflets (+/-) signposting to local support groups
