nov2013h

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anna1983
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184251
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nov2013h
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2012-11-18 17:02:59
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nov13
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nov13
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  1. DEPRESSION things to ask?
    • Concentration
    • Attention
    • Diurnal variation
    • Appetite
    • Sleep
    • Libido
    • Weight
    • Thoughts about the future and suicidal ideations
    • Support network, how is it affecting their life?
    • DRUGS/ ALCOHOL
    • RISK assessment
    • Follow up- within 2 weeks, ooh number in case
  2. Tx depression
    • Exercise/lifestyle
    • Talking therapies-CBT/ counsellor
    • Antidepressants
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  3. Hearing loss history
     
    • Can you tell me more about the hearing problems you have been experiencing?
    •  
    • HPC:
    • When did the hearing problem first start? Did it occur suddenly?
    • Does it affect both ears?
    • What sounds are you able to hear if any?
    • Have you noticed any ringing in your ears ?( red if unilateral)
    • Any problem with your balance? (red flag)
    • Have you experienced any pain in you ears?
    • Do you suffer with dizziness/vertigo?
    • Any previous trauma/injury to ears?
  4. history hearing loss (pmh.dh.sh)
    • PMH:
    • Any prev problems with ears?or any prev ear operations?Many ear infections in the past?Any hx of mumps/ meningitis?
    •  
    • DH: Any regular medications? Have you taken gentamycin in the past?
    • FH: Any FH hearing problems?
    • SH: smoking/alcohol/illicit drugs/occupation/who lives with you
    • ICE: Do you have any idea what might be causing the hearing loss?How has the hearing loss affected life at home and work?
    •  
  5. Examination hearing loss
    • Otoscopy
    • Whispered speech test
    • Rinne/webers
    • Further I: formal hearing test
    • MRI if indicated
    •  
  6. Explanation hearing loss
    • Conductive deafness – from failure in any of the ways in which move the sound waves through the outer ear, eardrum or bones of inner ear
    •  
    • Sensorineural- from a problem in inner ear, esp cochlea where sound vibrations are converted into nerve signals or in any part of the brain that subsequently processes these signals
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  7. Obstructive sleep apnoea
     
    • HPC: could you tell me more about the breathing problems you are having at night?
    • PMH: When did you first start experiencing these episodes?How many in typical night? 
    • Anyone witnessed? What happens exactly? 
    • Do you feel tired during the day as a result? 
    • Do you usually snore?Do you have difficulty concentrating during the day?

    • Pmh: any prev M probs, any ENT surgery.
    • DH: regular meds/sleeping tablets
    • SH: smoking/drugs/alcohol/ occupation, who at home, do you drive?
    • What specific concerns about this sleep problem?
  8. Examination obstructive sleep apnoea
    • Ex weight ENT tonsils and nasal passages
    • I-                    Epworth sleep score
    • II-                  Formal sleep study
    • DO ~NOT DRIVE UNTIL ON Tx
    •  
  9. Tinnitus
    • Can you describe the noises in your ears youve been experiencing?
    •  
    • HPC: when start? What specific noises? Do you hear them all the time?
    •            Do you hear the noises in both ears or just one? (red flag if unilateral)
    • Are the noises coming from inside/outside you ear?
    • Have you tried anything so far to get rid of the noise?
    • PMH: prev med prob, prev surgery?
    • DH regular medications?
    • SH: smoking/alcohol/drugs/occupation/who at home?

    ICE: what were you hoping we could do to help?How affecting you in terms of day to day life?Has it stopped you from anything you usually do?
  10. Examination in tinnitus
    • Ex: otoscopy/whispered speech test/ cranial nerves
    • I: formal hearing test if indicated.MRI if indicated
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  11. BPH
    • Do you mind telling me more about your urinary symptoms?
    •  
    • HPC:
    • Have you been passing urine more frequently ?
    • Have you had to rush to the toilet to pass urine?
    • Have you had any hesitancy when trying to pass urine?
    • Or Has the stream of urine been poor?  FRSH
    • Any dribbling at end of stream of urine?Have you ever been unable to pass urine?
    • Do you wake up at night to pass urine? If so how many times?
    • Have you noticed any weight loss, bone pains or blood in the urine?
    • Erectile problems?
  12. Hx BPH and Ix
    • PMH: Any other medical conditions?
    • DH: Any medications/diuretics?
    • SH: smoking/alcohol/drugs/occupation?
    • FH: Any FH bladder problems?
    • Do you have any worries/concerns about your bladder symptoms ?
    •  
    • Ex: prostate-chaperone, abdo exam- check bladder/kidneys
    • Ix: urine dip- haematuria, PSA, UEC, blood count, voiding diary, IPSS
  13. BPH explanation
    Produces fluid which protects and enriches sperm. A tube like structure called the urethra carries urine from the bladder to penis and this runs through the middle of the prostate. Urethra can be narrowed if the prostate enlarges and this is what causes the urinary symptoms
  14. Treatments for BPH
    • Conservative watch and wait
    • Dopuble voiding
    • Reduce alcohol and caffeine
    • Bladder training
    • Stop smoking
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  15. Drugs for BPH
    • Alpha blockers- tamsulosin-relaxes smooth muscle of the prostate
    • 5alpha reductase  inhibitors- finasteride- blocks the conversion of an enzyme in the prostate that is responsible for the enlargement
    • Surgery-TURP- transurethral resection of prostate or prostatectomy
    • Safety NET- IF NOT IMPROVING RETURN TO GP
    •  
  16. Prostate cancer
    • Ix PSA biopsy of prostate (urologist)
    • ‘Cells in the prostate become abnormal and multiply out of control, most common over 65, cmnest uk cancer’
    • RF: ageing, FH, ethnicity (afro Caribbean higher risk) diet, environmental
    • Refer under 2 week wait active surveillance and safety net, surgery radical prostatectomy, radiotherapy or chemotherapy, hormone- goserelin
  17. RF testicular cancer
    • FH, undescended testes, mumps, env.
    • 1% male cancers, commoner under 35, curable in 95%
    •  
  18. Testicle lump
    Can you tell me more about this testicular lump you have noticed?

    • HPC: when did you first notice the lump? Painful?inc is size recently?
    • Any pain/discomfort in groin? Any urinary symptoms? ANY weight loss/bone pain?RED
    • Any SOB/coughing up blood?RED
    • PMH: undescended testes/mumps? FH testicular problems
    • Occupation, smoke alc

    Was there anything you were concerned about, how symptoms affecting you?

    • Ex testicles, abdo,  LNS
    • Ix scrotal USS, tumour markers AFP, HCG, LDH
  19. COCP how does it work
    By preventing ovulation

    Thickening cervical mucus to prevent  fertilisation

    • Thinning the lining of uterus to prevent implantation. 99% if used correctly
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  20. Pill hx
    • Why cocp?
    • When LMP?
    • Periods regular?
    • Are you currently using any contraception?
    • Heavy periods?
    • Do you ever suffer with migraines? If so do you experience any warning signs beforehand e.g. flashing lights- RED?
    • Any prev STI? Suggest chalamydia screening!!!
    • PMH- HTN, Liver disease, breast cancer/DVT?
    • FH breast cancer, stroke, DVT or heart disease?
    • DH: Any regular medications? St john wart?enzyme inducers- carbamaepine/rifampicin?
    • SH: do you smoke?Who does she live with?
    • ICE: what do you know about the pill? Ex: BP, BMI
    • I THINK IT WOULD BE SENSIBLE TO TELL MUM AND DAD..... 
  21. Peripheral vascular disease
    • Can you describe the pain in the calf you have been experiencing?
    • When did it first start?
    • Do you experience the pain at rest – RED?
    • How far can you walk before the onset of the pain?
    • Have you experienced any cramping of the legs?
    • Are both legs affected?
    •  
    • Have you noticed any colour changes in the foot-RED?
    • Have you noticed any calf swelling- RED?
  22. PAD history 2
    • PMH: Heart disease/HTN/high cholesterol or diabetes?
    • DH: any regular medications?
    • FH heart disease/DM
    • Smoking.alc.drugs.occ. stairs at home?
    • Does this problem stop you doing things you normally be able to do?
    •  
    • PAD
    • Ex- BP, CVR, examine leg- pulses temp colour
    • Blood- FBC.uec,fasting lipids, glucose. ECG. ABPI. Doppler USS.
    •  
  23. Explanation PAD
    • Narrowing of one or more arteries. Mainly affects the arteries supplying blood to legs. It is due to fatty plaques developing on inside lining of the blood vessels.
    •  
  24. Mx PAD
    • Smoking cessation, exercise, WL, reduce alcohol
    • clopidogrel/statins consider

    tx identifiable causes- HTN/ DM

    safety return if symptoms worsen or not improving

    vascular urgently if rest pain, absent foot pulses, pallor/evidence of gangrene.
  25. symptoms/signs of Delerium tremens
    Tremor, confusion, fits, visual hallucinations.
  26. ASK under 16s when coming for contraception
    • How OLD is your partner?
    • Was the sex consensual or did you feel coerced/forced?
    • Are your parents/ carer aware of your sexual activity?
    • Are your parents/carer aware that you are here to see me today?
    • Do you feel able to tell your parents/carer?
    • Have you ever been drunk or under the influence of drugs whilst having sexual intercourse?
    • Any hx depression/ mental health problems?
    • UNDER 13- CHILD PROTECTION REFER URGENT, +- SS/police
  27. Mental state exam brief
    • 1.age
    • 2.time
    • 3.Address 42 west street(recall for later)
    • 4. year
    • 5. name current location
    • 6. identification 2 ppl
    • 7. DOB
    • 8. Year world war 1
    • 9. 20 to 1 count down
    • 10 recall address from earlier
    •  
  28. Recessive gene e.g. cf
    • For a person to suffer with this condition must get two copies of the defective gene. For a child to suffer with this both parents must be carriers of the affected gene.The child could get just one copy of the defective gene which would make them a carrier.If 2 ppl with the recessive gene- 25% chance their children will suffer 25% that they will not have the condition or carry the gene and a 50% that they will be carriers.
    • Test is done on blood/saliva not 100% accurate.
    •  
  29. Haematuria
    Assymptomatic NVH- 2 of 3 dipstick positive—Check BP, creatinine and eGFR and send urine for ACR and PCR.

    • Refer if any one of : eGFR<60ml/min, ACR>30 PCR> 50 BP>140/90- nephrology referral
    •  
  30. Scenario:  I want slimming pills!!
    • Man BMI 17.5, wants to slim.
    • Start open Q- why do you think these would be useful for you?

    • Whats been going on in your life?
    • What are you doing to try to lose the weight?
    • Exploring concerns and Ideas, important because of....
    • Can you tell me what you eat going through a normal day please....
    • Who do you live with? Have you spoken to them about how youre feeling, job, depression
    • ‘your BMI is a measure of what is a normal and healthy weight in relation to height- yours is below what is considered normal and healthy. This could be harmful as your body will not be getting the nutrients it needs.’
    • Alcohol/smoking/Do you take anything else- laxatives etc??
    • Empathy- Im sorry that you view yourself in this negative way.
    • I want to help you as I think you have a negative body image and I think you need some help from a specialist in this condition. Also I could refer you to a dietitian for further dietary advice.What do you think about this?
  31. Giles 62years heavy alcohol intake-Sent by my wife who is concerned.
    • HPC/ PMH/FH/ SH/ DH
    • Can you tell me what you drink and how much on a typical day from when you get up until when you go to bed...
    • How much per week- work out units...
    • Weekend more??
    • Assess mood...
    • JOB/ DRIVING>>SHOULDN T drive dangerous+++
    •  
    • Challenge his beliefs- Giles I feel you are drinking above the recommended safe level, this could cause lots of problems with your health
    • Clarify why you cant give him a note. Use what he likes to help him- I know your wife is v concerned perhaps if you cut down your alcohol this may help your marriage.
    • Thanks for telling me that.
    • Alcohol dependant – needs to be referred specialist team how does he feel about this?
    •  
  32. Dyspepsia red flags
    Weight loss

    Stool dark

    Difficulty swallowing

    Examine abdomen- epigastric mass
  33. Richard Williams – ED BMI 25, 42yrs no pmh
    • How can I help? clarify why he is here
    • How long has it been going on?
    • Is it difficult getting/ maintaining?
    • Morning erections?
    • Masturbation ok?
    • Sexual partner/more than one??
    • LUTS
    • Make him feel at ease- This is a very common problem.

    • Causes smoke, alcohol, psychological, pvd. Assess mood how affecting relationship?
    • Invite wife- marriage counselling

    Did you have anything in mind to help this ?? How do you feel about that ? Pick up cues!!
  34. Sarah 41yrs pmh nad
    • Open Q
    • Why stressed? Vomiting and stress in work
    • Concentration/sleep/libido/ appetite/ social support/ relationships/ how is it affecting her body?
    • Explore vomiting – when ? pattern/blood/ food/ LMP? PREGNANT
    • Folic acid/smoking ask/ cant give you tablets as youre pregnant
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