Station4:Consent

Casts:

Patient:Mr G Andrew,77
Carer: Mrs J Fawkes,eldest daughter of the patient
Supporting Roles:Your consultant,gatroenterologist,registrar,speech therapist

Setting:Station 4

Plot:
Dementia
Right Basal Pneumonia
Poor swallowing coordination
Poor nutrition
Failed NGT,Drips

Plan to insert PEG tube for feeding

TASKS:
1.Why PEG tube is being considered
2.Obtain consent from pt's daughter

Ryder & Freeman,vol 2,p 165

Investigating suspected anaemia

The patient

A 70 year old retired barber presented to his general practitioner with breathlessness on walking. A history of gradual onset of fatigue, lethargy, and exertional dyspnoea was elicited.

The patient was a non-smoker who had previously been well, took no medications or supplements, and shared a bottle of wine with his wife at weekends. He was not a vegetarian and took a good mixed diet.

Physical examination showed pallor of the conjunctiva and nail beds and mild oedema of the ankles. There was no hepatosplenomegaly nor were there any signs of iron deficiency (such as glossitis, angular cheilosis, or koilonychia). Anaemia was suspected.

An initial full blood count confirmed this suspicion:

Hb concentration was 76 g/l (normal range 133-167 g/l),

MCV was 110 fl (82-98 fl),

white cell count was 4.7x10⁹/l (3.7-9.5x10⁹/l),

neutrophil count was 1.4x10⁹/l (1.7-6.1x10⁹/l), and

platelet count was 182x10⁹/l (145-350x10⁹/l).

Serum creatinine was 98 µmol/l (60-125 µmol/l) and

serum ferritin was 875 ng/ml (20-200 ng/ml).

What is the next investigation?

The clinical history has already excluded relevant drugs and excessive alcohol intake. The following investigations should be performed:

• A repeat full blood count to confirm the initial count and to establish if the abnormalities are stable or progressive.
  
• A peripheral blood film.Many laboratories will automatically review a blood film when the blood count is as abnormal as in this patient, but it cannot be assumed that the blood film will have been reviewed.
  
• Vitamin B-12 and folic acid assays.
  
• Reticulocyte count—will be raised in haemolysis or bleeding.
  
• Liver and thyroid biochemistry.

Identification of hypothyroidism, liver disease, or deficiency of vitamin B-12 or folic acid in general practice avoids the need to refer a patient to a haematologist. On the other hand, referral is indicated if initial tests suggest haemolytic anaemia or a myelodysplastic syndrome.

Coeliac Disease

Recognition and assessment of coeliac disease in children and adults: summary of NICE guidance

Who should be offered serological testing for coeliac disease?

Offer testing to children and adults with any of the following signs and symptoms:

-Chronic or intermittent diarrhoea

-Failure to thrive or faltering growth (in children)

-Persistent and unexplained gastrointestinal symptoms including nausea or vomiting

-Prolonged fatigue

-Recurrent abdominal pain, cramping, or distension

-Sudden or unexpected weight loss

-Unexplained iron deficiency anaemia or other unspecified anaemia.

Advice to patients

• Inform people that testing for coeliac disease is accurate only if the person is eating a diet that contains gluten at the time of testing.
  
• Inform people that when following a normal gluten containing diet they should eat some gluten (for example, bread, chapattis, pasta, biscuits, or cakes) in more than one meal every day for a minimum of six weeks before testing.
  
• If a person is reluctant or unable to reintroduce gluten into their diet before testing refer them to a gastrointestinal specialist and inform them that it may be difficult to confirm a diagnosis of coeliac disease on intestinal biopsy.
  
• Inform people and their parents or carers that a delayed diagnosis of coeliac disease, or undiagnosed coeliac disease, can result in:
  

  -Continuing ill health
  

  -Long term complications, including osteoporosis and increased risk of fracture, unfavourable pregnancy outcomes, and a modest increased risk of intestinal malignancy
  

  -In children, growth failure, delayed puberty, and dental problems

  Serological tests
  

• All tests should be undertaken in laboratories with clinical pathology accreditation.
  
• Do not use IgG or IgA antigliadin antibody (AGA) tests in the diagnosis of coeliac disease.
  
• When clinicians request serology, laboratories should:
  

  -Use IgA tissue transglutaminase antibody (tTGA) testing as the first choice of test
  

  -Use IgA endomysial antibody (EMA) testing if the result of the IgA tissue transglutaminase antibody test is equivocal
  

  -Check for IgA deficiency if serology is negative (if the laboratory detects a low optical density on the IgA tTGA test, very low IgA tTGA results, or low background on the IgA EMA test)
  

  -Use IgG tissue transglutaminase antibody or IgG endomysial antibody tests (or both) for people with confirmed IgA deficiency
  

  Communicate clearly the results in terms of values, interpretation, and recommended action.

Chronic Cough

Case scenario

A 42 year old non-smoking woman presents with a three month history of cough after a coryzal illness. The cough is worse in the morning and rarely produces sputum.

She is not short of breath, and she has been taking an angiotensin converting enzyme (ACE) inhibitor for two years for hypertension.

common:

asthma,

chronic obstructive pulmonary disease,

postnasal drip,

gastro-oesophageal reflux disease (GORD),

drug (ACE inhibitor) induced

and

rare but more serious causes.

"Red flag" symptoms
In both smokers and non-smokers, certain features require early investigation:

• Copious production of sputum (indicating bronchiectasis)
  
• Fever, sweats, weight loss, haemoptysis (indicating tuberculosis, lymphoma, bronchial carcinoma)
  
• Considerable breathlessness with the cough (indicating heart failure, obstructive airways disease, fibrotic lung disease).

Clinical features to be elicited:

• Duration and frequency of cough
  
• Pattern of cough: productive or dry, nocturnal, postural, or associated with food
  
• Haemoptysis or chest pain
  
• Smoking history and exposure to dust
  
• Use of ACE inhibitors
  
• Red flags—for example, breathlessness, sweats, weight loss
  
• Absence of focal chest signs (including normal heart sounds)
  
• Results of spirometry or serial peak expiratory flow rate if asthma or chronic obstructive pulmonary disease is likely or if a first test of treatment fails
  
• Chest x ray if patient smokes or red flag is present; consider also if first test of treatment fails

Ref:Education > BMJ 2009;338:b1218, doi: 10.1136/bmj.b1218 (Published 24 April 2009)

Liver Transplant

How long do patients wait for a transplant?

In the UK, nearly a fifth of all listed patients die or are considered too sick before a graft is available.

Waiting times vary by country and reflect

donor numbers,

clinical caseloads,

recipient weight and

blood group

the organ listing or allocation strategies.

The sickest patients benefit most from transplantation.

Adults in the UK on average wait 95 days (www.uktransplant.org.uk/ukt/newsroom/fact_sheets).

Clinical management of patients on the waiting list aims to minimise new complications:

diuretic-precipitated renal failure, prompt treatment of infection.

Surveillance for varices and hepatocellular carcinoma

Thyroid Swelling

A 48 year old post-menopausal woman with

a diffuse thyroid swelling more than 10 years:

1.Issues to be covered:

• pregnancy,puberty
• where she lives
• any medications:antithyroid,Lithium,Amiodarone
• women in reproductive years or >65
• hard & fixed suggest malignancy
• tenderness in thyroiditis
• Ask hyper/hypo symptoms
• Ask 3Ds:dysphagia,dysphonia,dyspnoea
• When does she first notice the swelling?
• Any past history of irradiation
• Any family history of thyroid cancer,FAP
  

2.Examination

• Inspect the fully extended neck
• Ask to swallow
• Elicit Pemberton’s sign
• Palpate including cervical glands
  
• Auscultation
  

3.Management

• Immediate referral in case of suspected malignancy

• Perform TFTs and follow up to inform about the results

• Hyper:nearly always benign

• Nodule with normal TFT:Ultrasound scan and possible FNAC

REF:

Practice

10-Minute Consultation

Thyroid swellings

BMJ 2009;339:b2563
Published 13 July 2009, doi:10.1136/bmj.b2563

Requesting Assisted Suicide

A journalist in her 30s has been diagnosed as primary

progressive multiple sclerosis 2 years back.

Now she says :
In agony ,Like legs are on fire,take every last grasp of energy to get out of bed ,even swallowing is starting to get difficult ,very soon to lose sight,use of hand,power of speech and all likely scenario:choke to death.

she is accompanied by her partner who is willing to support her final decision:Assisted Suicide

She ask Who could help her to enjoy life with dignity and peace by means of assisted suicide?

Counsel her.

Hypogonadism

A man in his 40s
with a feminine voice
Sparse axillary and pubic hair
Small phallus and testes

What are the possibilities?
What cardiac conditions are associated?