History and Counselling: Clearing Some Confusions

Discussion in 'Plab 1 and 2 forum' started by guest2011, Nov 5, 2012.

  1. guest2011

    guest2011 Moderator

    What are HIGH RISK factors?

    1. Deep Injury
    2. Visible blood on device which caused injury
    3. Terminal HIV related illness in the source patient
    4. Injury with a needle which has been placed in a source patient's artery or vein

    This takes us to another scenario: injury to a nurse/doctor/health worker.
  2. guest2011

    guest2011 Moderator

    INVESTIGATIONS:
    Blood for HIV, Hep B, Hep C from injured worker and also the concerned patient. RECHECK HIV status 3 months later and Hepatitis serology 3 and 6 months later.
    LFT checked and repeated 3 and 6 months later.
    Female workers checked for ßHCG.
    Fill out Accident book and Complete Critical Event Audit.
  3. guest2011

    guest2011 Moderator

    You have to ensure adequate follow up of both care worker and donor.

    If Preliminary Risk Assessment shows significant risk of HIV, POST EXPOSURE PROPHYLAXIS (PEP) needs to be started as soon as possible (IDEALLY within 1 hour).

    May be appropriate to give first dose of PEP before a fuller assessment, after HIV status of donor is known.
  4. guest2011

    guest2011 Moderator

    There may be a scenario where the Doctor/Nurse has got a needle stick injury while taking blood from a child. Therefore you need to take blood from the child again to send for the serology: HIV, Hep B and C. So, you need to talk to the mother to take her permission for that.
    This scenario would be like dealing with a 'dissatisfied' patient. Mother would be unwilling, and it would be difficult to convince her.
    Here you would need to emphasise the fact that 'this is for greater good' because 'in case the doctor/nurse/health worker is unknowingly infected', they might spread that to many other patients while taking care.
  5. guest2011

    guest2011 Moderator

    Just highlight the benefits. She obviously feels good, but she would benefit much more if she quits:
    1. Protect her loved ones from passive smoking
    2. Better/Improved Smell and Test
    3. Less tiredness, More energy
    4. Easy Fighting off cold and Flu.
  6. guest2011

    guest2011 Moderator

    WHEN SAYS THAT FATHER IS STILL ALIVE IN SPITE OF SMOKING ALL THESE YEARS:

    Say that it is by chance and she should not take that chance.
    Smoking is the single greatest avoidable risk factor for cancer. It causes one in four of all deaths from cancer in the UK.
    Worldwide, smoking has caused an estimated 100 million deaths in the last century.
    Around half of all regular smokers will die from the habit.
    Smoking causes 90% of lung cancers in men and up to 86% of cases in women.
  7. guest2011

    guest2011 Moderator

    1. Is it ADDICTIVE?

    You have to say it is not addictive.

    In this, you have to mention that the medicine cannot be withdrawn ABRUPTLY. If done, it MIGHT cause WITHDRAWAL SYMPTOMS, but that is not due to any addiction. This problem can be dealt with by GRADUALLY REDUCING THE DOSE BEFORE COMPLETELY STOPPING THE MEDICATION>
  8. guest2011

    guest2011 Moderator

    2. When would it START working?

    It might take 3-4 weeks to start working. You should be able to feel the improvement by that time. If you do not feel any improvement, we or your GP would review the medications.
  9. guest2011

    guest2011 Moderator

    3. Would I be on this medication LIFELONG?

    Usually the medication is advised to carry on for AT LEAST 1 year after COMPLETE RECOVERY. So, it all depends on the progress, and more on this issue can only be told during the FOLLOW UP.
  10. guest2011

    guest2011 Moderator

    4. Patient says "I have read the side effects".

    Ask patient what are the concerns. Also ask if the patient wants any of the side effects to be discussed. Also ask if the patient wants you to tell him/her the side effects again.
  11. guest2011

    guest2011 Moderator

    In adults:

    microcytic anaemia - MCV < 76 femtolitres
    normocytic anaemia - MCV = 76-96 femtolitres
    macrocytic anaemia - MCV > 96 femtolitres
  12. guest2011

    guest2011 Moderator

    MICROCYTIC ANAEMIA:

    The most common cause of microcytic anaemia is iron deficiency anaemia.

    Causes of Iron Deficiency Anaemia:
    *Monthly periods
    *Pregnancy
    *Gastrointestinal blood loss
    -NSAIDs
    -Stomach Ulcers
    -Angiodysplasia
    *Chronic Kidney Disease
    *Other Causes
    -Inflammatory Bowel
    -Oesophagitis
    -Nose Bleeds
    -Haematuria
    -Malabsorption(Coeliac Disease & Gastrectomy)
    -Diet
  13. guest2011

    guest2011 Moderator

    Normocytic Anaemia:

    The most usual cause is anaemia of chronic disease. However, if there is a reduced white cell count or reduced platelet count then suspect bone marrow failure - diagnosis will require the performing of a bone marrow biopsy.

    Macrocytic Anaemia:

    The commonest causes of macrocytic anaemia are vitamin B12 and folate deficiency, both of which cause megaloblastic haemopoiesis on the bone marrow examination.

    Normoblastic haemopoiesis is seen in the other causes of macrocytic anaemia such as alcoholic liver disease, hypothyroidism and acute blood loss.

    NORMOCYTIC ANAEMIA:

    CAUSES-

    acute haemorrhage
    haemolytic anaemia
    bone marrow failure
    anaemia of chronic disease
    mixed iron and folate deficiency
    pregnancy
    chronic renal failure
    riboflavin deficiency

    MACROCYTIC ANAEMIA:

    CAUSES-
    1.Megaloblastic Anaemia(Vit B12 & Folate deficiency)
    *vitamin B12 deficiency
    PERNICIOUS ANAEMIA
    -being 60 years of age
    -being female
    -having a family history of the condition
    -having another autoimmune condition, such as Addison’s disease or vitiligo
    DIET- Vegans
    GASTRECTOMY
    INFLAMMATORY BOWEL
    PPI like medications
  14. guest2011

    guest2011 Moderator

    *Folate Deficiency
    DIET- Weight Losing diet
    MALABSORPTION- Coeliac Disease
    EXCESSIVE URINATION
    -Congestive Heart Failure
    -Ac. Liver Damage
    -Long Term Dialysis
    -Medications- Barbiturates etc.
    -Pregnancy
    -Malignancy
  15. guest2011

    guest2011 Moderator

    What to do during a seizure?

    *Place them in the recovery position. Lay them on their side, on a soft surface, with their face turned to one side. This will stop them swallowing any vomit. It will keep their airway open and help to prevent injury.
    *Stay with your child and try to make a note of how long it lasts.
    *If it is your child's first seizure, or it lasts longer than five minutes, take them to the nearest hospital as soon as possible or call 999 for an ambulance. While it is unlikely that there is anything seriously wrong, it is best to be sure.
  16. guest2011

    guest2011 Moderator

    What to do during a seizure? (Continued)

    *If your child has had febrile seizures before and the seizure lasts for less than five minutes, phone your GP or NHS Direct on 0845 4647 for advice.

    *Try not to put anything, including medication, in your child’s mouth during a seizure as there is a slight chance that they might bite their tongue.

    *Almost all children make a complete recovery, and there is not a single reported case of a child dying as the direct result of a febrile seizure.
  17. guest2011

    guest2011 Moderator

    High temperature (FEVER)

    Reducing a high temperature can help to make your child feel more comfortable, but DOES NOT AFFECT the chances of a seizure.

    Paracetamol and ibuprofen have been shown to be effective in reducing a high temperature. Removing any unnecessary clothes and bedding will also help to lower your child’s temperature.

    Aspirin should NEVER be given to children under 16 years old. There is a small risk that the medication could trigger a condition called Reye’s syndrome, which can cause brain and liver damage.
    The use of cold sponges or fans is NOT RECOMMENDED for treating a high temperature. There is little evidence that they are effective, and they may cause your child discomfort. Your GP can give you additional advice about treating the underlying cause of your child’s high temperature.
    It is also important to prevent dehydration during a fever by ensuring that your child drinks plenty of fluids.
  18. guest2011

    guest2011 Moderator

    AMNESIA of events -- ANTEROGRADE(post traumatic) -More than 30 mnts before impact (Remember, RETROGRADE amnesia never occurs without anterograde)--

    if PRESENT----> CT

    if ABSENT----> Any amnesia or loss of consciousness since the injury? ----> YES---->Are any of the following present?

    ▲ Age ≥ 65 years
    ❋ Coagulopathy (history of bleeding, clotting
    disorder, current treatment with warfarin)
    ▲ Dangerous mechanism of injury
    – pedestrian or cyclist struck by a motor vehicle
    – occupant ejected from a motor vehicle – fallfrom>1m or 5stairs
    ***YES----> DO CT
    ***NO
  19. guest2011

    guest2011 Moderator

    ***NO----> NO IMAGING REQUIRED

    Any amnesia or loss of consciousness since the injury?-------> NO

    **NO IMAGING REQUIRED

    ▲ Imaging should be carried out within 8hours of injury, or immediately if patient presents 8 hours or more after the injury.

    **If patient presents out of hours and is ≥ 65, has amnesia for events more than 30 minutes before impact or there was a dangerous mechanism of injury, it is acceptable to admit for overnight observation, with CT imaging the next morning, unless CT result is required within 1 hour because of the presence of additional clinical findings
  20. guest2011

    guest2011 Moderator

    ❋❋Selection of children (under 16) for CT scanning of head❋❋

    **Are any of the following present?

    ● Witnessed loss of consciousness lasting > 5 minutes
    ● Amnesia (antegrade or retrograde) lasting > 5 minutes
    ● Abnormal drowsiness
    ● 3 or more discrete episodes of vomiting
    ● Clinical suspicion of non-accidental injury
    ● Post-traumatic seizure but no history of epilepsy
    ● Age > 1 year: GCS < 14 on assessment in the emergency department
    ● Age < 1 year: GCS (paediatric) < 15 on assessment in the emergency
    department
    ● Suspicion of open or depressed skull injury or tense fontanelle
    ● Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes,
    cerebrospinal fluid leakage from ears or nose, Battle’s sign)
    ● Focal neurological deficit
    ● Age < 1 year: presence of bruise, swelling or laceration > 5 cm on the head
    ● Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from > 3 m, high-speed injury from a projectile or an object)
  21. guest2011

    guest2011 Moderator

    ❋CRITERIA FOR ADMISSION❋

    -Difficult to assess (Child, Post octal, Alcohol Intoxication)
    -CNS signs
    -Severe Headache or Vomiting
    -Fracture

    ❋❋LOSS OF CONSCIOUSNESS DOES NOT REQUIRE ADMISSION IF WELL, AND A RESPONSIBLE ADULT IS IN ATTENDANCE
  22. guest2011

    guest2011 Moderator

    Complications:
    EARLY---> Extradural/Subdural Haemorrhage, Seizures
    LATE----> Subdural, Seizures, DI, Dementia. Parkinsonism

    DROWSY TRAUMA PATIENTS "SMELLING OF ALCOHOL": Alcohol is unlikely cause of coma (unless > 44mmol/L).
    NEVER ASSUME SIGNS ARE JUST ALCOHOL.
  23. guest2011

    guest2011 Moderator

    BINOCULAR DIPLOPIA:

    1. Ophthalmoplegia- 3rd/4th/6th Nerve Palsy

    Causes-
    *Raised ICT- Tumour
    *Mono neuritis- Diabetes
    *Cavernous Sinus lesions/Thrombosis
    *Stroke
    *Aneurysm

    2. Myasthenia Gravis

    3. Multiple Sclerosis

    4. DM

    5. HTN

    6. Head Injury

    7. Thyroid Ophthalmoplegia

    8. Stroke

    9. Drugs
  24. guest2011

    guest2011 Moderator

    DIZZINESS is a non specific term which can be categorised into FOUR different subtypes according to symptoms described by the patients:

    1.VERTIGO

    2.PRESYNCOPE: the feeling of impending faint, caused by reduced total cerebral perfusion

    3.DISEQUILIBRIUM: feeling of unsteadiness or imbalance when standing

    4.LIGHT HEADEDNESS: also known as giddiness or wooziness.
  25. Neha Gupta

    Neha Gupta Active Member

    Patient with gastric erosion on endoscopy. Alcoholic history. Explain and discuss management.

    or

    Male patient who on endoscopy was diagnosed with gastric erosion due to long history of alcohol intake..take history n tell him life style management.

    In history he had 20yrs of alcohol intake n long history of nsaids intake.

    This is the station we would discuss now.
  26. Neha Gupta

    Neha Gupta Active Member

    GASTRIC EROSION:

    We have to first remember a few points to tackle this station.

    Causes include:

    NSAIDs
    alcohol
    stress - trauma, major surgery, septicaemia
    helicobacter pylori
  27. Neha Gupta

    Neha Gupta Active Member

    GASTRIC EROSION:

    Clinical features of ACUTE erosive gastritis include:

    epigastric or central pain
    vomiting
    acute upper gastrointestinal haemorrhage
    Endoscopic examination reveals a widespread reddening of the mucosa. The inflamed mucosa may be awash with bile.
  28. Neha Gupta

    Neha Gupta Active Member

    GASTRIC EROSION:

    The following lifestyle advices may be of some help:

    *Cut down on the amount of coffee and tea you drink. This can increase the amount of acid your stomach produces. Try herbal teas instead.

    *Drink milk and eat milk-based foods, such as yoghurt and cheese. Milk is thought to coat the stomach and neutralise the effects of stomach acid.

    *Lose any extra weight you are carrying.

    *Eat little and often. This could help reduce the build-up of stomach acid between meals.

    *Limit your intake of alcohol. Too much alcohol can irritate the areas of inflammation in your stomach.
    Avoid spicy or excessively rich foods if they make your symptoms worse.

    *Quit smoking. It may put you at greater risk of developing an ulcer and impede your recovery.
  29. Neha Gupta

    Neha Gupta Active Member

    So, the approach to the station would be:

    1.Ask the patient what does he know.
    2.Tell him about the finding.
    3.Explain to him in non-medical term what gastric erosion is.
    4.Ask him again what is his idea about the condition.
    5.Take a brief history of the risk factors.
    6.Enumerate the life style advices
  30. The treatment options available for alcohol misuse depend on:
    *whether your drinking is hazardous, harmful or dependent,
    and
    *whether you are trying to drink less or give up drinking completely.
  31. Hazardous drinking

    If you are drinking hazardous amounts of alcohol, it is likely that you will be referred to a short counselling session, known as a brief intervention. This may be following an alcohol-related accident or injury.
    A brief intervention lasts around 10 to 15 minutes and covers the risks associated with your pattern of drinking, advice on reducing the amount of alcohol you drink, alcohol support networks available to you and any emotional issues around your drinking.
    You may be advised to keep a "drinking diary" so that you can record how many units of alcohol you drink a week. You may also be given tips on social drinking, such as alternating soft drinks with alcoholic drinks when you're out with friends.


    Harmful drinking

    If you are drinking harmful amounts of alcohol, you will first have to make the decision about whether you want to reduce your alcohol intake (moderation) or give up drinking alcohol altogether (abstinence).
    Abstinence will obviously have a greater health benefit, although moderation is often a more realistic goal, or at least, a first step on the way to abstinence.
    Ultimately, the choice is yours, although there are circumstances where abstinence is strongly recommended. These include:
    if you have liver damage, such as liver disease or cirrhosis
    if you have other medical problems that can be made worse by drinking, such as heart disease
    if you are taking medication that can react badly with alcohol, such as antipsychotics
    if you are pregnant or are planning to become pregnant
    Abstinence may also be recommended if you have previously tried to achieve moderation and been unsuccessful.
    If you choose moderation, you will probably be asked to attend further counselling sessions so that your progress can be monitored and further treatment and advice provided if necessary.
    You may also have regular blood tests so the health of your liver can be carefully monitored.


    Dependent drinking

    As with harmful drinking, you will need to choose between moderation and abstinence. Abstinence will usually be recommended for people with moderate to severe dependency.
    Whatever your level of alcohol dependency, it is recommended that you spend a period of time free from alcohol so that your body can recover from its effects.
  32. Neha Gupta

    Neha Gupta Active Member

    Detoxification

    How and where you attempt detoxification will be determined by your level of alcohol dependency. In mild cases you should be able to detox at home without the use of medication because your withdrawal symptoms should also be mild.
    If your consumption of alcohol is high (over 20 units a day) or you have previously experienced withdrawal symptoms, you may also be able to detox at home with medication to help ease withdrawal symptoms. A tranquiliser called chlordiazepoxide is usually used for this purpose.
    If you have severe dependency, you may go to a hospital or clinic to detox as the withdrawal symptoms will also be severe and are likely to need specialist treatment.
  33. Neha Gupta

    Neha Gupta Active Member

    Withdrawal symptoms

    Your withdrawal symptoms will be at their worst for the first 48 hours. They should gradually start to improve as your body begins to adjust to being without alcohol. This usually takes between three and seven days from the time of your last drink.
    You will also find that your sleep is disturbed. You may wake often during the night or have problems getting to sleep. This is to be expected and your sleep patterns should return to normal within a month.
  34. Neha Gupta

    Neha Gupta Active Member

    During detox, you should drink plenty of fluids – about three litres a day. However, avoid drinking a large number of caffeinated drinks, including tea or coffee, because they can make your sleep problems worse and cause feelings of anxiety. Water or fruit juice is a better choice.
    Try to eat regular meals even if you are not feeling hungry. Your appetite will return gradually.

    If you are taking medication to help ease your withdrawal symptoms, you should not drive or operate heavy machinery because the medication will probably make you feel drowsy. Only take your medication as directed.
  35. Neha Gupta

    Neha Gupta Active Member

    Detox can be a stressful time. Ways that you can try to relieve stress include listening to music, going for a walk or taking a bath. Read more about stress management.
    If you are detoxing at home you will regularly see a nurse or other health professional. This might be at home, your GP practice or at a specialist NHS service. You will also be given the relevant contact details for other support services should you need additional support.

    Withdrawal from alcohol is an important first step to overcoming your problems with alcohol. However, withdrawal is not an effective treatment by itself. You will be advised to undergo further treatment and support to help you in the long-term.
  36. Neha Gupta

    Neha Gupta Active Member

    Abstinence

    Several treatment options are available for abstinence. These often differ in effectiveness depending on the individual, so if you feel that a certain treatment is not working for you, you can discuss alternatives with your care team or your GP.


    Medication

    There are several medications recommended by NICE to treat alcohol misuse:
    acamprosate
    disulfiram
    naltrexone
    Before being prescribed medication you will have a full medical assessment, including blood tests. These medications are discussed in more detail below.


    Counselling

    Self-help groups
    Many people with a dependence on alcohol find it useful to attend self-help groups, such as Alcoholics Anonymous.

    Twelve-step facilitation therapy
    Twelve-step facilitation therapy is based on the programme devised by Alcoholics Anonymous. The difference is that you work through the stages on a one-to-one basis with a counsellor, rather than as a group.
    Twelve-step facilitation therapy may be your preferred treatment option if you feel uneasy or unwilling to discuss your problems in a group setting.
  37. Neha Gupta

    Neha Gupta Active Member

    Cognitive behavioural therapy (CBT)
    Cognitive behavioural therapy (CBT) is a talking therapy that emphasises a problem-solving approach to alcohol dependence.

    Family therapy
    Alcohol dependence doesn't just impact on an individual – it can also affect a whole family. Family therapy provides the opportunity for family members to:
    learn about the nature of alcohol dependence
    support the family member who is trying to abstain from alcohol
  38. Neha Gupta

    Neha Gupta Active Member

    *hazardous drinking: drinking over the recommended limits
    *harmful drinking: drinking over the recommended limits and experiencing alcohol-related health problems
    *dependent drinking: feeling unable to function without alcohol
    Many people who have alcohol-related health problems aren't alcoholics.
  39. Neha Gupta

    Neha Gupta Active Member

    Units of alcohol

    Alcohol is measured in units. A unit of alcohol is equivalent to 10ml of pure alcohol, which is roughly half a pint of normal strength lager, a small glass of wine or a single measure (25ml) of spirits.
    The recommended daily limits for alcohol consumption are:
    no more than three to four units a day for men
    no more than two to three units a day for women
    For both men and women, it is also recommended to include some alcohol-free days each week. You are putting your health at risk if you regularly exceed the recommended daily limits.
  40. Neha Gupta

    Neha Gupta Active Member

    Am I drinking too much alcohol?

    Some signs that you could be misusing alcohol include:
    feeling that you should cut down on your drinking
    other people have been criticising your drinking, which may annoy you
    feeling guilty or bad about your drinking
    needing a drink first thing in the morning to steady your nerves or get rid of a hangover
  41. Neha Gupta

    Neha Gupta Active Member

    Some signs that someone you know may be misusing alcohol include:
    if they regularly exceed the recommended daily limit for alcohol
    if they are sometimes unable to remember what happened the night before because of their drinking
    if they fail to do what was expected of them due to their drinking – for example, missing an appointment or work because they were drunk or hungover
  42. Neha Gupta

    Neha Gupta Active Member

    The short-term risks of alcohol misuse include:
    alcohol poisoning, which may include vomiting, seizures (fits) and unconsciousness
    accidents and injuries requiring hospital treatment, such as a head injury
    violent behaviour that might lead to being arrested by the police
    unprotected sex that could potentially lead to unplanned pregnancy or sexually transmitted infections (STIs)
    loss of possessions, such as a wallet, keys or phone, leading to feelings of anxiety
  43. Neha Gupta

    Neha Gupta Active Member

    Long-term alcohol misuse is a major risk factor for a wide range of serious conditions, such as:
    heart disease
    stroke
    liver disease
    liver cancer and bowel cancer
    As well as health problems, long-term alcohol misuse can lead to social problems such as unemployment, divorce, domestic abuse and homelessness.
  44. Neha Gupta

    Neha Gupta Active Member

    Screening Tests/Diagnosis:

    This is usually done by using a screening test that consists of a series of questions. It is important to be truthful when you answer the questions so that you can receive the right treatment.

    Alcohol Use Disorders Identification Test (AUDIT):

    One widely used screening test is the Alcohol Use Disorders Identification Test (AUDIT). This test involves answering 10 short questions about your drinking habits to help assess the effects it could have on you.
  45. Neha Gupta

    Neha Gupta Active Member

    Fast Alcohol Screening Test (FAST)

    The Fast Alcohol Screening Test (FAST) is a simpler test that you can use to check whether your drinking has reached hazardous levels.
    FAST consists of four questions which are listed below. The number after each answer is that answer's score.
    1. How often do you drink eight or more units (men) or six or more units (women) on one occasion?
    never – if this is your answer you can stop the test
    less than monthly – 1
    monthly – 2
    weekly – 3
    daily or almost daily – 4
    2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
    never – 0
    less than monthly – 1
    monthly – 2
    weekly – 3
    daily or almost daily – 4
    3. How often during the past year have you failed to do what was normally expected of you because you had been drinking?
    never – 0
    less than monthly – 1
    monthly – 2
    weekly – 3
    daily or almost daily – 4
    4. In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested that you cut down?
    no – 0
    yes, on one occasion – 1
    yes, on more than one occasion – 2
    A FAST score of three or more would usually suggest that you're drinking at a hazardous level.
  46. Neha Gupta

    Neha Gupta Active Member

    1. Opiate dependency, Hx and Cx, although he completed the history format, P3 maftosa and talked on CAGE plus relevant Hx about the drug, sexual Hx and past Hx besides leaflet web etc. Pt satisfied and prepared to be admitted and referred after due care.

    2. Hypoglycaemic seizure in 2 yr old child (Sugar 1.5 Bolus of Glucose given), talk to Mother Immediate and delayed Mnangemnet. He said all the concerns of mother were addressed plus advise on how to prevent hypoglycaemic attacks in future he talked in detail. He took the social Hx as well.

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