January 22, 2009

Patient Management in General Practice

Today we discussed the principles of patient management, which can be summarised into these 3 points:

1. Reaching a shared understanding of the problem with the patient
2. Negotiate the management plan
3. Give the patient the responsibility for the problem

These points should be worked through in order, and to achieve this we should use the RAPRIOP acronym: Reassurance & explanation, Advice, Prescription, Referral, Investigations, Observation, Prevention.

REACHING A SHARED UNDERSTANDING OF THE PROBLEM WITH THE PATIENT

There are two points here. The doctor must understand the problem from the patient’s perspective, and the patient must understand their problem from the doctor’s perspective.

In order for the doctor to manage the patient, they must fully understand the patient and how their problem affects them. To do this the doctor must elicit the patient’s ideas, concerns, and expectations, and make the ‘triple diagnosis’ (i.e. how does the problem affect the patient from a biological, social, and psychological perspective). This is done as a part of competent history taking.

Now the patient must also understand the doctor’s view of their illness, this is basically the medical side of things. Here the doctor must use reassurance and explanation to give the patient an understanding of their illness in their own terms. The doctor may discuss anatomy, pathophysiology, epidemiology etc etc, or none of this if the patient does not want to know!

NEGOTIATE THE MANAGEMENT PLAN & GIVE THE PATIENT RESPONSIBILITY FOR THE PROBLEM

I have chosen to discuss these points together as I feel that they are closely interlinked.

I think the key word here is negotiate. The management plan should be decided upon in a two-way process between the doctor and the patient. The doctor must tell the patient about their options for treatment, so this would usually involve either prescription or referral, or both. The doctor should tell the patient objectively what each prescribed treatment would involve, i.e. risks, side-effects. They must also endeavour to find what the patient wants from their treatment. The patient must be empowered and encouraged to decide upon a management plan which suits them best.

In this way the patient can be given responsibility for their problem, or at least offered the opportunity. Indeed, some patients would must prefer that the doctor makes all the decisions unilaterally, though I think this situation should be avoided and the doctor should make the utmost attempts to fully involve the patient in their own care.

Other aspects of the management plan which I have not yet discussed include: referral, investigations, observations, and prevention.

REFERRAL

This can mean referral to a specialist doctor, a senior colleague, or the consulter may refer to an information source to refresh their knowledge about the diagnosis in question. Referral is something which all doctors should be proficient in doing as it is a necessity when a medical problem demands skills or knowledge beyond the bounds of their own competence.

INVESTIGATIONS

These can be used not only to differentiate between working diagnoses, but to monitor a patient’s progress, and also to reassure an anxious patient. An investigation should not be performed however if it does not impact on the patient’s management plan or welfare.

OBSERVATION

In the general practise setting observation can mean to give a follow up plan, this can be an open follow up or a closed follow up.

Open follow up is where the consultation ends with the patient being informed on the prognosis of their condition and then advised about the conditions under which they should seek another consultation. Safety netting is an important tactic used here.

Closed follow-up is where another consultation is agreed in advance, i.e. “come back in 6 weeks and we can check your blood pressure to see if the medication is working”.

PREVENTION

Disease screening and address modifiable risk factors.


March 27, 2007

Offering Reassurance

In today’s clinical skills session I saw a re-emergence of a problem that presented a few weeks ago whilst on another clinical skills session, the issue of offering reassurance to a distressed patient. Owing to our lack of knowledge and qualifications, I think some medical students feel powerless to address this situation.

A few weeks ago as a part of a cardiovascular examination I was measuring a patient’s pulse rate, a process which usually requires 15 seconds of concentration, and consequently, silence. Once I had measured their pulse, the patient asked if everything was OK, to which I replied ‘yes’. As a colleague later highlighted, this was the wrong thing to say because despite finding a pulse of 70 beats per minute there was no way of telling if this was healthy. Therefore I didn’t have the right to tell the patient that they were OK, simply because I’m not a doctor and have none of the skills required to diagnose or treat patients.

Sometimes when patients are concerned or distressed about their health it is important to be very cautious when offering them reassurance because, especially as a medical student, this may come at the cost of instilling false hope. What I should have said to the patient is that as a medical student I have no place to say whether or not they are healthy.

In today’s session I saw a stroke patient who was concerned about a persistent pain in her chest and right arm. She was very distressed and quite emotional, probably due to the symptoms of the stroke she had a few weeks earlier, and she was in tears when mentioning this pain in her chest. She asked if it could be a heart attack, to which I replied ‘there’s no way of knowing’. In hindsight this was probably the wrong thing to say as it may have worsened her anxiety by making her feel very uncertain about her symptoms. Again I think this was a case of blurting out the first thing that comes into your head in a rash attempt to allay the fears of the distressed patient in front of you.

In these situations I think it is safest to firstly take time to think and never rush to close silent moments, then mention that as a medical student you can’t offer medical advice. To ease the patient’s distress you can reiterate that there is a team of doctors and nurses caring for them. It may also be a good idea to call a doctor or nurse to chat with the patient.


March 24, 2007

Think, then speak!

After examining Mr R I moved on and attempted to interview and examine the next patient, Mrs B, with two of my colleagues. Here I learned absolutely nothing scientific or clinical, but I feel that what I did learn may be equally as important as all the clinical stuff.

I don’t remember much from the consultation because it started off as the worst consultation I’ve ever experienced, though I haven’t experienced many, I therefore just sat there reeling, half of me in slight disbelief at what I’d just said to the patient and the other half wishing I could crawl under a rock somewhere and lick my wounds!

Basically I started the consultation with the usual introduction and consent, everything was going swimmingly at this point, then I asked the patient how long she had been in hospital, to which she replied “a week”.

I can only speculate as to why I said this, but my reply to her was “oh, just a week”, and she didn’t react too well, she said something which I can’t remember, but something I haven’t forgotten is the fact that she pretended to have a gun in her hand and gestured to shoot me with it!! She even made the bang noise!!

She was pretty cheesed off and I was quite gutted at what had just happened, and as a result I didn’t pay much attention to what was said from there on in, I just sat there wondering why the hell I said what I said, and also wishing that the gun she had mimed at me with was real.

The three of us continued with the next agonising 20 minutes of the consultation (it was probably more amusing than agonising for my colleagues!) and at the end Jayne asked the patient if there was anything more she would like us to know, which was quite a good thing to say in hindsight. The patient then went on to say that she wished doctors (and medical students I assume) would consider that patients have lives outside hospital and are not just ‘asthmatics with names’, their life pretty much goes on hold when they’re in hospital and it would be nice for us medical people to think about what’s going on in their life and give them the opportunity to discuss their problems or offer them support i.e. liaise with social care workers etc.

During the consultation it turned out that the patient had a young child at home who was going away soon and needed help packing etc, on top of that she had ‘brittle asthma’ which is basically a very unstable form of asthma – this is the reason why one week prior to the consultation she was unconscious in the ITU and being considered for ventilation. And on top of all that she undoubtedly has all the same bills to pay as the rest of us, and while she’s in hospital the funds are going out but nothing’s coming in. And she’s been in hospital for “just a week”.

My only attempt at an explanation (not an excuse!) for what I said was that I had just interviewed a patient who had been in hospital for 4 weeks, so comparatively a week seemed like a very short time. And when you’re asking the patient questions for the sake of going through the motions of how to do a history, the answers to which don’t always mean anything to you, sometimes there are awkward silences which I for one am usually too eager to close (a problem I had with my DISC consultations). In this instance I chose to close the silence by blurting out a completely unprocessed and insensitive thought.

We will never know just from looking at a patient what kind of life they have and what stresses they are under so it’s best to start afresh with each patient and consider each person as an individual with unique circumstances. Obviously it was presumptuous to deduce that because one patient was seemingly coping OK with a 4 week hospital stay, another patient should be absolutely fine with a ‘mere’ 1 week stay.

This was another case of me being far too eager to close an awkward silence, and cramming my foot in my mouth as a result. As long as I can learn from this mistake hopefully it won’t happen too frequently in the future. Though I do expect mistakes like this to happen again because all us medical students have a phenomenal amount of learning to do over the next 40 odd years, and mistakes are usually quite good opportunities for learning, as long as you’re not learning about drug dosages etc.


March 23, 2007

Bronchial and vesicular breath sounds

Mr R

Today I had my respiratory clinical skills session at the Walsgrave hospital, and I learned a couple of valuable things.

The first patient, Mr R, was a 69 year old male, currently retired, who worked for 35 years as a coal miner. Mr R had been in hospital for 4 weeks with shortness of breath which began 3 weeks prior to his admission to hospital. He also reported a dry (not ‘painful’ but ‘dry’) cough which produced an eggcup of green sputum per day, in the recent 24 hours the sputum production had doubled.

Mr R suffers from rheumatoid arthritis of the lower back, which had progressed from osteoarthritis some years earlier, probably due to him having worked as a coal miner. There was a fairly strong family history of heart disease, and Mr R himself suffers from left heart failure though this is likely to be secondary to his concurrent diagnosis of pernicious anaemia – the increased cardiac output induced by anaemia put extra strain on his left heart.

It was particularly interesting to talk with Mr R as he presented a bit of a challenge in that due to his dyspnoea he was on oxygen and could not talk for very long. This meant that some parts of my history had to be phrased such that he could answer with a ‘yes’ or ‘no’, though he did make an excellent effort to talk with me and even got carried away in parts.

Upon inspection Mr R had peripheral and central cyanosis and finger clubbing, all things I had only previously seen in textbooks! I couldn’t feel his pulse (nor did I make the mistake of telling him this), but I established that his respiratory rate was 40 breaths per minute – very high. Pallor was evident on his palms and ocular mucous membranes, this is consistent with his anaemia.

When I percussed Mr R’s chest, anteriorly I found dull areas over the left and right upper lobes approximately at the 4th intercostal spaces, this dullness was particularly pronounced on the left side.

Auscultation was particularly interesting with this patient. For the first time yet I heard crepitations over the patient’s lungs, and funnily enough the crepitations were more pronounced in the areas which were dull on percussion, and particularly on the 4th intercostal space on the left side. I would describe these crepitations as the sound of a grainy old vinyl record player with the crackling being a background noise which was present between the patient’s breaths. The crackling did however become louder and more chaotic during inspiration and expiration.

During the rest of my auscultation I think I heard what all the textbooks and doctors refer to as ‘bronchial breathing’, and it is fascinating to consider this in the light of the pathophysiology of Mr R’s current diagnoses. When auscultating over Mr R’s lower lung lobes (posterior chest) I identified that his breath sounds were in separate distinct inspiratory and expiratory ‘packets’, with a gap in between them – a sound which can be imitated by breathing through ones open mouth with your tongue pressed against the roof of your mouth. This is the sound of bronchial breathing.

Bronchial and Vesicular breath sounds

By comparison, vesicular breathing (the sound you should hear over the lungs) has a rustling quality which builds up from the onset of inspiration to expiration, where it tails off such that it is not heard in the latter half of expiration. The important difference is that with vesicular breath sounds there is no gap between inspiration and expiration, I’ve attempted to explain this below.

I think the concepts of bronchial and vesicular breathing are quite difficult to grasp, but I found it so much easier when I considered this alongside Mr R’s diagnoses, so I will begin with these.

Mr R has suffered from pulmonary oedema (secondary to his left heart failure, which is secondary to his pernicious anaemia) in the past, and I suspect that he was suffering from it when I examined him. The cyanosis I observed, and crepitations I heard on auscultation are consistent with this.

Furthermore, Mr R has been diagnosed with pulmonary fibrosis (working as a coal miner and smoking 26 pack years are both risk factors for this) which is a condition resulting in fibrosis of the lungs, this essentially means that his bronchioles and alveoli have a significantly reduced compliance.

This is the pathology which underlies his presentation with bronchial breathing, and I’ll have a go at explaining it now…

Bronchial breathing is the sound which can be heard when one auscultates over the trachea, as aforementioned bronchial breathing consists of discrete inspiratory and expiratory breath ‘packets’ separated by a silent gap.

This silent gap can be equated to the split second moment of inertia when you throw a ball up in the air, the moment between the upwards journey (i.e. inspiration) and the downwards journey (i.e. expiration). It is also useful to consider this in analogy with the heartbeat, and imagine the heart is pumping into a rigid tube with little compliance (like the trachea!). If the heart beats into a rigid tube, then the blood flow is in discrete packets, which coincide with systole, and between the beats there would be absolutely no blood flow (the diastole, or ‘silence’). In principle this is how bronchial breathing works, with each systole representing the airflow heard in inspiration/expiration, and the diastole representing the moment of silence where breath direction is reversed between inspiration and expiration.

Vesicular breathing on the other hand is the ‘attenuated’ form of bronchial breathing, heard at the lung surface. It has been attenuated by passing through the moist and compliant bronchioles and alveoli, which dampen down its ‘pulsatility’ – exactly the same as how the elasticity of the aorta and arteries help to dampen down the pulsatility of blood flow. In the circulatory system, the result of this dampening of ‘pulsatility’ is that blood flow persists between heartbeats, albeit at a lower rate. In the respiratory system exactly the same principle applies – the end result is that the breath sounds (vesicular breath sounds) persist between inspiration and expiration, and then tail off until the next inspiration. I think the reason that the vesicular breath sounds tail off in the latter half of expiration is because the alveoli collapse in the latter half of expiration, and thus no air can be heard travelling through them.

SO, the reason Mr R had bronchial breath sounds at his lung surfaces is because the lung fibrosis reduced the compliance of his bronchioles and alveoli – this locks them in a half open state wherein, due to their lack of movement, they conduct the bronchial breath sounds from their origin (the trachea) to the lung surfaces unattenuated. The reason we can hear the full expiratory sound is because the alveoli are ‘locked open’ due to the fibrosis, and they therefore conduct the sound of the air leaving the lungs throughout expiration.


November 07, 2006

First GP Practice Visit, 24/10/06

Overall, today was a successful and enjoyable visit. I saw two patients throughout the visit, a young boy aged 10-12 years and a middle-aged woman.

The woman was my first patient, and she was presenting with a wheeze and a cough with sputum production following an episode of a sore throat a few days before, she was diagnosed as having a chest infection and was prescribed anitbiotics and steroids. I felt comfortable with the patient and ensured that I had kind and attentive body language i.e. smiling, gesturing that I was listening to her (acknowledgement), not sitting too close or ‘aiming at her’ – angle slightly deflected such that the patient does not have to look away to avoid eye contact. The purpose of the consultation was not to elicit the required information, but just to get a hang of the communication skills required to acquire this information.

The doctor was very efficient in his analysis and inquiry, he repeated important issues to clarify them, and also put a strong emphasis on the family/social history, which I usually forget! The patient started to cry towards the end of the consultation, and the doctor comforted her with a soft voice and reassured her that these illnesses can sometimes get on top of people i.e. her being emotional wasn’t that much out of the ordinary!

My second patient was a tad more difficult, as he was quite young. Every question I asked was replied with a one word answer, the lad wasn’t generally that chatty – I’m sure I wasn’t at that age. So the main issue here was that there were silences quite often, and I was struggling to close them – it was obvious here that the lad wasn’t going to use these silent opportunities to speak his mind – his mum was there as well, and he was only presenting with an itchy skin rash! So there probably wasn’t much more than met the eye here (but yes, you never know for sure), unlike the first patient, whose sudden breakdown was quite unexpected.

One very important thing is to be confident – even when you don’t have the foggiest idea what is wrong with your patient/what to do etc, just explain the situation and get on with it, but be confident. Your patients will lose trust fast in a doctor who is shaky-voiced and unsure, I would.


October 31, 2006

Second DISC Consultation, 05/10/06

I did not interview today but observed my colleagues as they conducted mock interviews.

General good points were that the students did not close silences too early, thus allowing the patient to speak freely. Also, they demonstrated good introductions: consent, confidentiality, assertion of status. Interviews were generally commenced with open questions, and closed questions used later on.

One negative point is that a student let the patient ‘run away’ with the conversation for a short while. The patient was a very friendly and talkative gentleman, thus meaning it was easier to strike up an effective rapport. This rapport is of crucial importance in eliciting information regarding a patient’s history, however, the rapport may become too friendly – at the cost of professionalism and time management – the doctor only has a short time to elicit all relevant information, and a patient may lose confidence in a doctor who appears very chatty and almost blazE. Therefore a balance must be struck between an efficient and professional inquiry and the friendly trust-building chit-chat.

The take-home message here is that the doctor should, whilst also allowing the patient to speak their mind, direct the patient towards relevant information and away from idle chit-chat.


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