-Rokh'S emaker i Paces By ECL @ Veh dtAl-Rokh’s Pacemaker of Paces BESTT Uy airtel tanh be) om (01.9 th Communication — History — Brief consultation First Edition By/ Dr. Sadek Al-Rokh MBBS Mansoura University MRCP United kingdom International Medical Center (Jeddah) eM Buugill Gull Cis MIDDLE EAST LIBRARIES 104440450022 -01001485817 -012215701S4Pacemaker of Paces A simplified approach - for MRCP Paces Edited by Dr. Sadek Al-Rokh MRGP (UK) International Medical Center (Jeddah) Copyright © 2017 ISBN 978-977-6551-04-6 glant Ay : 2016 / 20959 All rights reserved No part of this publication may be reproduced, printed or transmitted in any form or by any means leetronie or mechanical, including photocopying, recording or any information storage or retrieval system without permission in writing from the Publisher Adi gas Gisiall ee 8d Maayan ule ABD ale eee sh Oats hia 3} ist Ieee SANS A ce as als Ce YS. he Bas Wasa AED Te alps Qa US hn hay US Publisher: Middle East Libraries 01110150022 - 01065351200 - 01001485817 - 01221570154 E-mail: Me_book2010@yahoo.com Bug ill pill Cubtisg MIDDLE EAST LIBRARIES (01110150022 - 01001485017 - 01221570154And of knowledge, you (mankind) have been given only a little. DEDICATION This book is dedicated to my great mother who always taught me to love giving and helping others. And to my wonderful wife for her patience and encouragement. And to my dear colleagues , wishing that this book could help and ease their approach in the exam and real medical practice.Contents Station 4 Communication...1 About Communication (Station 4).....2 Communication Scheme.....5 Counseling for chronic disease (Pheochromocytoma).....7 Counseling for chronic disease (Multiple Sclerosis).....10 Counseling for chronic disease (Adult polycystic kidney disease).....13 Counseling for chronic disease (Addison disease). 6 Counseling for chronic illness (Celiac Disease).....19 Counseling for chronic illness (Epilepsy).....22 Active TB Asking for discharge.....25 Breaking bad news (Advanced cancer for palliative care).....29 A Nurse with a needle stick injury from a patient with HIV.....32(Medical error) Angry son - Father developed Allergy for codeine.....35 Complication Of a procedure Angry son — Father died after a procedure (PCI).....38 Counseling for DNR decision... 41 “ounseling for Steroid therapy Side effects.....44 ounseling for Warfarin side effects. ....47 Counseling for Genetic test.....50 Counseling for a procedure (SLE for Renal biopsy).....53 Breaking bad news Counseling for hickman line (Hodgkin Lymphoma for hickman line).....56 Drug incompliance.....59 Patient with Suicidal Attempt Asking For Discharge. ....62 Somatization Somatoform Disorders.....66 Station 2 History...73 About station 2 (History taking).....74 History Approach.....75CeO) Microcytic Anemia in Young Female.....78 Chronic Diarrhea.....83 Jaundice.....88 Chronic Cough and Wheezy chest.....94 Chronic cough and hyponatremia.....100 Both Lower limb weakness.....105 Periodic paralys Abnormal ¢©. referral to specialized doctor or to MDT team to give him the proper care and management plan, > Main points of management without details.Social histo © Whatde you go for ti ‘ ipaateallier or his job anc: sual daily « veri his social life is affected , and i artipihis work is affected. © With whom the patient is living) Who ae Financial support? © Smoking and alcohol history ? ~ Emphasize again for these bad news today , | ki you , but be sure that we will do our best to give management. CONCEFNS: Do you have any concern? if didn’t ask about the concern you may lose this station and may be the exam. Summary: Summarize your meeting with the surrogate in brief: ’'m going to summarize the important points in our discussion today. Check understanding: by asking may I know please how much did you get from our discussion today? Help : I'm sorry again for hard news today, I will give you some leaflets, brochures, websites to know more about the disease. Twill give you my contact number as well to call me if you have any worries or queries any time .. Anyone to drive you home? = Nice to meet you — Shake hands.Introduction - Shake hands. = Introduce yourself. - Confirm the patient ide -Confirm Agenda of mee, ~ Ask if the patient need any si + ~ Ask how much hr know about ~ Ask about his expectation. to attend the discussion (for support). ‘ondition, Breaking the news gradually ; ~ The results of blood tests and imaging have been released, and they are not as. we hope .. Stop for a while .. they reveal that you have a disease called (Pheaochromcytoma)... Stop for a while (let the patient to express his feelings and thoughts) .. Have you ever heard about this disease before ? .. Do you want me to explain for you more about it ? Explain the disease simply without jargon -It's a disease due to increased secretion of a special protein in the body called Adrenaline and Noradrenalin hormone due to overgrowth of the gland located above your kidneys . -10% of this overgrowth may be malignant, 10% could be familial, 10% are located on both glands over your kidneys , 10% could be located in other sites. - Symptoms and complications of the disease: Increased level of this hormone leads to some manifestations like loss of weight, flushing , anxiety and mood disturbance, racing of heart beats, sweating , shaking of the hands and high blood pressure which may be difficult to control with increased risk of heart attacks and strokes. - Treatment plan: What we are going to do is to refer you to MDT from Gland physician , surgeon , psychotherapist , social worker to give you the full care and the proper plan of management . -The main treatment is surgical resection of the overgrowth, You are going to receive oral medications for high blood pressure 10 — 14 days before the operation to control your BP and ovoid sever 7hypertension dari mn Will be sliscuss . i \ agreement to d Empathy and symj reall ton today , I highly appreciate your feel for you , But be sure that we are going to do and management. Social histor © What are you doing for living? .. How much your iliy ss tn job and usual daily activity? .. Refer the patient to an occupations: caith worker if his job is affected , Refer to a social worker if social life is affected . © With whom you are living? are they doing well ? Who is supporting you at home ? © Are you financially supported? © Do you smoke at all , do you drink aleohol ? ... you didn't thing about giving up smoking ? .. We can help you by referring you to smoking cessation clinic if you don't mind. Concerns : Do you have any concem ? + Is it curable condition Dr ? Mostly yes , if the operation done successfully , your hormone will return to normal range and all your symptoms will be subsided and your blood pressure will be controlled and even you will be free from medications .. Any other concems ? Is it cancer Dr ? ; 10% of this overgrowth is cancerous, so when we are going to do the operation , wwe are going to have a snip from the overgrowth do to be analyzed and make sure of its nature , and we will you to screening counselling team for this reason. . My children may have the disease Dr ? 10% of the disease is familial, so we can refer you and your children to a gentic counseling team to discuss this issue in details and for possible screening. 8Make sump including refers Check unde meeting today? Help: tm going to about the disease i will give you my con any womes of queries + Shake hands. PACEMAKER OF PAC UpOrtant points of the disease and was. “ment May Lknow: ho dyou our »: res , weds: ores. morev NOlivis te . BR tis eos Introduction ~ Shake hands, - Introduce yourself. ~ Confirm the patient identity. -Confirm Agenda of meeting. ~ Ask if the patient need anyone else to attend the discussion (for support). - How much do you know about your condition? - Ask about his expectation, Breaking the news gradually - The results of blood investigation and imaging have been released, and it's not as we hope .. Stop for a while ... they reveal that you have a disease called (Multiple Sclerosis) .. stop for a while (let the patient to express his feelings and thoughts) .. Do you have any information about this discase ? ~ Show your empathy here if the patient know the disease or has bad family experience about the disease. Explain the disease simply without jargon: Do you want me to explain to you more about this disease? «It's a disease due to disturbance in your defensive system which suppose to attack the bugs , in your condition it attacks your brain and main nerve cable in your body disturbing the electrical impulses in your nerve cables. © It's coming in attacks on and off with different forms and times, Symptoms and complications: © Itcan come in attacks in different forms like visual disturbance, abnormal speech , shaking of the hands , unsteady gait , muscle weakness or sensory disturbance some symptoms together or separated. +The majority of patients with Ms (85%) are left without major disability and can live near normal life only minority(15%) are left with major disability and need walking aid . 10"ACEMAKER OF PACES | Management p! * Sowes © you to MDT team from nerve destor physiothe Mogist, eye doctor (if visual disturb. nce } to give you the | ! management plan ¢ Inthe sudden vill be given treatment through a necdle called steroids « » course of the attack. ¢ Some treatment the chance of the recurrence of the attacks but it nee: o be und to be diseussed and decided by the ne: a Pregnancy: May I ask do you have a partner , if you are planning for pregnancy. you have to inform your Obs and Nerve doctor to make MDT to give you the full care during your pregnaney. Empathy and sympathy : I'm really sorry for these bad information today , I highly Appreciate your feelings , I know how much these news are hard for you , But be sure that we are going to give you the full care and support as much as we can. . Social history: © What are you doing for living? .. How much your illness impact your job and usual daily activity? .. Refer the patient to an occupational health worker if job is affected , Refer to a social worker if his or her social life is affected . ‘With whom you are living? are they doing well ? Who is supporting you at home ? * Are you financially supported? * Do you smoke at all, drink alcohol ? Concerns :Do you have any concerns ? [Ist carable condit a | I'm sorry to tell you that it is not curable, but we are going to do our best to control it and give you the full care, support and regular follow up to live near normal life and... Any other concern? 11Mostly ne Janda | patd you betes (85°) are lett rnnajor disabilit only minoritys. ace lett with major di ae aid. > Any problem with pregnancy Dr? P You ean become pregnant without complication: a! z for Pregnancy, you have to inform your Obs and nerve « give you the full care during your pregnancy. v NOILYLS Make summary :About the important points of the diva management . Check understanding :Check how much the patient got from the discussion ? Help: Emphasize again. * I'm going to give you some leaflets, brochures, websites to read more about the disease. * Iwill give you my contact number as well to contact me any time if you have any worries or queries. © [will give you also the number of MS society to share information and experience about the disease. Shake hands. 12PACEMAKER OF PAC Introduction: - Shake hands, = Introduce yourself, ~ Confirm the patient ides: -Confirm Agenda of mee Ask if the patient want anyone else io attend the discussion (for support) ~ How much do you know about your condition ? ~ Ask about his expectation . Breaking the new gradually: ~The results of blood investigation and imaging have been released , and unfortunately they are not as we hope .. Stop for a while .. They reveals that you have a disease called (Adult polycystic kidney disease) .. stop for a while (et the patient to express his feelings and thoughts) .. Have you ever heard about this disease before? Explain the disease simply without jargon : -Do you want me to explain for you more about it? © It’s a familial disease which runs in families , in which there is enlargement of both kidneys due to multiple sacs filled with fluid invading both kidneys , May be associated with sacs in other body organs like the liver , spleen and balloon formation of any of blood conduit in the brain. Symptoms and complications: +” The disease has some symptoms and complications like recurrent tummy pain, recurrent rupture of the sacs causing bloody urine , recurrent infection of your kidneys , stone formation * On the long run-deterioration of kidney function and kidney failure and you may need kidney replacement therapy in certain stage.. 50% of patient with APCKD may need kidney replacement therapy at the age of 60. ‘* Hypertension is one of the complications of the discase which need strict follow up and control. © If there is any balloon formation of the blood conduits of the brain may rupture at any time causing serious complications 13Mani a d brain doctor, physiotherapiss, coop i th 1 and manageme\ p) © Thema: pian will be in the kidney fimetion . aspiration of the sacs if eausi treating any recurrent infection. © Your blood pressure needs to be strictly controlled on one « hypertension, our ns, and v NOILYLS We will do imaging to the brain to confirm any presence v balioun dilatation of blood conduit. Special advice : * New medications : if you are going to receive any new medication, you have to inform your kidney doctor as many medication can affect the kidneys and may worsen your kidney function, * Vigorous exercise :You have to avoid vigorous exercise like rugby and football to avoid rupture of the sacs. © Pregnancy: If you are planning for pregnancy, you have to inform your kidney physician and Obs doctor to make MDT, to give you the fall care during your pregnancy to avoid any complications at all. Empathy and sympathy : © How do you feel now ? © T'mreally sorry for these bad information today , I highly Appreciate your feelings , i know how much these news are hard for you ,And be sure that we are going to do our best to control your condition , and give you the regular follow up . Social history: © What are you doing for living? .. How much your illness impact your job and usual daily activity? .. Refer the patient to occupational health worker if job is affected , Refer to social worker if social life is affected. © With whom you are living? are they doing well ? Who is supporting you at home? Do you have brothers and sisters? Re they doing well? Any family history of sudden death? 14"ACEMAKER OF PAC © Screening: \ they have the ¢ of early detect so that we can 1 veening for your family members (> cos os itis a familial di: to have the ‘atment to avoid compli * genetic counseling team. ud vant tions of the disease © Are you financia! © Do you smoke, «i v NOILVLS — Concerns :Do you ha: oncems ? Is it curable condition Dy ? T'm sorry to tell you that it is not curable , but we are going to do our best to control it and give you the full care and regular follow up to avoid complications as much as we can. .. Any other concern? I'm pregnant doctor any action can be taken to prevent thé disease for my baby ? * The chance of your baby to have the disease is 50% , and I'm sorry to tell you that the disease can't be prevented , we will refer you to genetic counseling team to discuss all the details about your baby © Genetic testing is not of a big value as it may has false positive and flase negative results , and it will not alter the outcome of the disease * The disease is not prevented , the golden standard of screening is at the age of 20 by imaging for early detection and carly follow up to avoid complications . Summary :About important points of the disease and management plan. Check understanding: How much did you get from our meeting today? Help : Emphasize again , I'm going to give you some leaflets , brochures , websites to read more about the disease , i will give you my contact number as well to contact me any time if you have any worries or querics . ~ Shake hands. 155 Introduction: ~ Shake hands. ~ Introduce yourseli. - Confirm the patient identity. -Confirm Agenda of meeting. - Ask if the patient necds anyone else to attend the discussion (for suppor). ~ Ask about his expectation. v NOILVLis Breaking the news gradually : - The results of blood investigations and imaging have been released, and they are not as we hope .. Stop for a while .. They reveal that you have a disease called( Addison disease) .. Stop for a while (let the patient to express his feelings and thoughts) .. Do you have any information about this disease ? Is it serious condition Dr ? It can be scrious if untreated , but we are going to do our best to control your condition. Explain the disease simply without jargon : Do you want to explain to you more about the disease ? It's a disease due to diminished secretion of a special protein in the body called cortisone hormone secreted from the glands located above your kidneys, Mostly is due to disturbance of your defensive system which supposed to attack the bugs and viruses, in your condition it attacks your glands. ‘Symptoms and complications of the disease: It is an important hormone in the body, deficiency of this hormone leads to some complications like loss of weight, decreased blood pressure, dizziness, decreased glucose level, tanned skin, tummy pain, feeling and getting sick, electrolyte disturbance and if the hormone severely diminished may result in severed hydration and coma and can be life threatening at that time. Treatment plan: What we are going to do is to refer you to MDT from Gland physician,, psychiatrist , social worker to give you the full care and appropriate plan of management, 16A\CEMAKER OF fF | -The main treatmeni ment therapy of this hormone you have to be sitic! h {10 your medications to avoid ¢ ' the disease and to | °| fife and we will provide you fellow up in the oui > be sure of your hormone level the full care. . -If you felt any time emergency care at on you may need urgent 1 Special circumstances; | L recurrent loose motions 3 to seek medical care to adj Medic Alert Bracelet: you hay Bracelet make the others to know about your condition i") one ampoule of cortisone to be given to you if needed in emergency siti If female patient: if you are planning ‘or p< gnaney , you have to inform your Obs and gland doctor to make MD, to give you the full care and to avoid any complications during your pregnancy, {and unwell you have to « ition oy be unstable at cha leri Showing empathy and sympathy: I'm really sorry for these bad information today, | highly Appreciate your feelings , i know how much hard these news for you, But be sure that we are going to do our best to give you the full care and proper treatment. Social history: © What are you doing for living? .. How much your illness impact your job and usual daily activity? .. Refer the patient to an occupational health worker if his job is affected, Refer to a social worker if his social life is affected. * With whom you are living? are they doing well ? Who is supporting you at home ? * Are you financially supported? * Do you smoke, drink alcohol ? ..didn't you thing about giving up smoking ? We can help you by referring you to a smoking cessation clinic if you don't mind. 17ER OF PACES roiled on medications and -Wha wr Steroids will be given to you as replacement So that you will not sufler from complications of May be some soreness of the stomach which can be =" medication. herap: ic normal level, use of steroids, imple Make summary : About important points of the disease and management Check understanding : Check how much the patient got from the discussion? Help : Emphasize again, I'm going to give you some leaflets, brochures, websites to read more about the disease, I will give you my contact number as well to contact me any time if you have any worries or queries. ~ Shake hands 18PACEMAKER OF PACES mg for chronic illness peliac Discase) Introduc - Shake hands. ~ Introduce yoursel! - Confirm the patient identity. -Confirm Agenda of mecting and take permission to start the discussion (We are together today to discuss the results of your blood tests and camera test done for you , Is it alright with you ?) ~ Ask if the patient want anyone else to attend the discussion (for support). - Ask how much the patient knoe about his condition. - Ask about his expectation . Breaking the news gradually : - The results of blood tests and camera test have been released , and they are not as we hope .. Stop for a while .. they revealed that you have disease called (Celiac disease) .. Stop for a while (Let the patient to express his feelings and thoughts) .. Do you have any idea about this disease ? Explain the disease simply without jargon : Do you want me to explain for you more about this disease ? * It is a disease due to bow! allergy to any type of food containing gluten . causing disturbance of the defensive system which supposed to attack the bugs and germs , in your condition it attacks the lining of the bowls causing mal absorption to main nutrients , minerals and vitamins, * Gluten present in Oates , wheels , ryes , and barley involved in some types. of food like bread , pasta , pizza and biscuit . Symptoms and complications: * Ithas some symptoms and complications in the form of recurrent tummy pain , loose motions , loss of weight , anemia , fatigue , fragile bone , easy bleeding due to mal absorption of certain vitamins . ; * And on the long run if the condition is not controlled may lead to certain type of cancer in the gut called lymphoma at the late stages of the disease .. * BUT... all of these complications can be avoided and chance of cancer can be significantly reduced if you completely avoided any type of food containing gluten. 19 4 Ke C) z ESPACEMAKER OF PACES rentplan: re of the trea Javnletely., if you avoid any fy avoid all the complications ¢ you toa MDT team involving vith ths essential nutrients , minerals and vi‘@r the list of types of food to avoid comp aument is to avoid any LyPe of food containing y food coniainins gluten completely , orice diese and enjoy your life, a ysician to provide your Jietitian to give you sworker to support Netely 2 you s cially. © There are some restaurants have special partition: gluten . Tf you are travelling on airplanes inform the airplar »bout your condition to give you food free gluten. Empathy and sympathy : How do you feel now ? I y sorry for these d ur feelings .| »w how much bad information today , I highly Appreciate yo! these information are hard for you, But be sure thi to give you the full social and medical care as mu normal life. at we are going to do our best ch as we can to live near Social history : © What are you doing for living? .. How much your illness impact your, job and usual daily activity? .. Refer the patient to occupational health worker if job is affected , Refer to social worker if social life is affected . © With whom you are living? are they doing well ? Who is supporting you at home? © Are you financially supported? Do you smoke at all, do you drink alcohol ? (If the patient drink alcohol advise him to contact the dietitian as most types of alcohol contain, gluten and mat trigger his condition. Concerns : Do you have any concerns? ig it'curable condition Dr? Unfortunately i's not curable , but it can be controlled , and if you avoided any type of food containing gluten , your condition will be completely controlled and you can live near normal life. -Any other concern ? May have cancer in the future dr? If you avoided any food containing gluten Sion wa 20PACEMAKER OF PACES \bout the important points of the disease andr n Chee Check how much the patient got from the discu: Help: you some leaflets , brochures , websites to read more abor wil give you my contact number as well to \ have any worties or queries .. Anyone to drive ed), contact me any you home 2 ~ Shake hands 21+ Shake = Introdu Ts ~ Confirm the pation identity, -Confirm Agende of meeting. - Ask if the patient need anyone else to attend the discussio. 17 © ipport). ~ Ask how much the patient knows about your condition ? ~ Ask about his expectation . Breaking the news gradually : - The results of blood tests and imaging done for your brain have been released They are all normal .. But the nerve doctor made a diagnosis of your condition @ disease called (Epilepsy) .. stop for a while ( let the patient to express his feelings and thoughts) .. Do you have any information about this disease ? Explain the disease simply without jargon : Do you want me to explain to you more about this disease ? Epilepsy is An active focus in the brain , sending abnormal electrical impulses to the Body , causing unpredictable shaking of the body . It can be precipitated by strong flashes and voices , stress and sleep deprivation, «The underlying cause of the disease is unknown for the most cases or sometimes mat be familial. Symptoms and complications : It can come in the form of unpredictable shaking of the body with loss of consciousness , tongue biting , frothing from the mouth and may be uncontrolled water work. Empathy and sympathy: How do feel now Mrs.(x) ? I'm really sorry for these bad information today, I highly Appreciate your feelings , | know how much these news are hard for you , But be sure that we are going to do our best to give you the full care to control your condition to live near normal life .PACEMAKER OF PACES Treatment + Sowh © 1» lo refer you toa MDT froma nerve doctor social “health care worker to give you the proper and mar nirol your , © Treat: oral medications will be prescribed by the Nerve cous ‘ve to be completely compliant on these medication dition and to decrease the chance for any further attack, Modification of li You have to follow some ¢ modifications : * Avoid percipients : like Strong flashes and voices , avoid stress and sleep deprivation and to be compliant on medications and regular fellow up. * Avoid life risk situations : presence in high attitudes , beside fire and sharp objects , don't lock in the door of the bathroom as if you developed any attacks in these situations as your life may be threaten in such situations , and if you are going to swim your should be under supervision, OCP : May I ask if you are receiving any oral contraceptive pills , you have to inform your Obs and nerve doctor because Anti epileptic medication can change the efficacy of OCP and you may get pregnant despite contraception. pregnancy : © May Lask if you have a parer, are you planning for pregnancy? * You have to inform your obstetrician and nerve doctor to make a MDT to give you the full care during pregnancy as seizures and be harmful for the baby . # Also anti epileptic Medications may be harmful to your fetus , so they may provide you with the least anti epileptic medications that may affect your baby and some medications that will decrease the effect of anti epileptic medications on your fetus like folic acid. Driving : May I ask if you drive ?You have to inform DVLA about your condition , I’m sorry to tell you that you will be banned from driving for at least 1 year until you will be completely free from attacks , as your condition is risky ‘on yourself and for the others during driving . Social history : © What are you doing for living? .. How much your illness may affect your job and usual daily activity? .. I'm going to refer you the to a social worker and 23 HH 4 (2) z iPACES ‘cupational troubles any sect fing 8 pporting, you at ° you ly supped © Do you smoi ik aleaho!? Coneeras : Do you have any concems ? 2 Is it curable condition Dr? ; nt I'm sorry to tell you that it is not curable , but it by avoiding ar follow up, triggers and complete compliance on your medicati Any problem if I get pregnant Dr? . Ifyou are planning for pregnancy , you have to inform your obstetrician and nerve doctor to make a MDT to give you the full care during pregnancy as seizures may be harmful for your baby . anti epileptic Medications may be harmful to your fetus as well, so they may provide you with the least anti epileptic medications that may affect your baby and some medications that will decrease the effect of anti epileptic medications on your fetus like folic acid. Make summary: About the important points of the disease and management plan. Check understanding :Check how much the patient got from the discussion ? Help: Emphasize again , 'm going to give you some leaflets , brochures , websites to read more about the disease , i will give you my contact number as ‘well to contact me any time if you have any worries or queries .. © Anyone to drive you home ? (If not admitted) -Shake hands 24Introduct - Shake hans - Introduce you - Confirm the pat -Confirm Ageniis of see ~ Ask if the patient want « - Ask how much do you know ~ Ask about his expectation . La fe) Ad a Se to attend the discussion (for support). about your condition, Gradual breaking of the news ~ The results of blood tests and imaging have been released, and unfortunately they are not as we hope .. Stop for a while .. they revealed that you have infection with a big bug in your lungs called (TB lung).. Stop for a while (let the patient to express his feclings and thoughts) .. Have you ever heard about this disease before? ~ Patient may ask Is it scrious condition Dr ? It can be serious if untreated, but we are going to do our best to the full care and management Explain the disease simply without jargon: Do you want me to explain for you more about your condition ? Unfortunately Investigations done for you revealed that you have lung infection with a serious bug called TB, Which may be transmitted by droplet infection from another patient or decrement of or unhealthy environment . Symptoms and complications of the disease: There are some symptoms and complications of this disease in the form of fever, night sweating, Cough, coughing up blood, loss of weight , shortness of breath, and my be lung failure and even death if untreated. ; t may spread to other organs as well like brain, kidneys and the bones, if not treated properly. ‘Treatment plan: 7 . * The good news is that it is a curable condition , and most-of the patients are completely cured after their full course of anti TB medications : * So what we are going to do is to notify the preventive medicine department 25| Pe “ER OF PACES i} nm fons a tung physician infectious dise ational health cate worker tO Bive you the the form of a full of anti TB drugs lar f 1 the outpatient imp saur condition ; z fa your dicate the ° Y ¥ les in the © These medicatios ymes , But we hands and feet . i nage a will follow up your condition to detect any sid fi once. © Outweighing the risk versus the benefits of the drugs . uv >enefits are extremely more Empathy and sympathy: how do feel now Mr.(x) ? .. I'm really sorry for these bad information today . I highly Appreciate your feelings , i know how hard these news for you . But be sure that we are going to give you the full care and the proper management to live near normal life until your condition will be cured completely . Social history: What are you doing for living? .. How much your illness impact your job and usual daily activity? .. Refer the patient to occupational health worker and if he is working in risky infectious job tell him that the occupational health worker will provide him with another job away from the public in the first few weeks until his sputum is free from the bugs , Refer to social worker if social life is affected . * With whom you are living? are they doing well ? Who is supporting you at home ? Screening : We will do screening for the persons in direct contact with you, to be sure they are free from the infection and to receive prophylactic medications if there is history of exposure. © Are you financially supported? Do you smoke at all , do you drink alcohol ? ..Didn't you thing about giving up smoking ? .. We can help you by referring you to smoking cessation : clinic if you don't mind as smoking may worsen your condition , Advice 10 stop alcohol intake also. , 26PACEMAKER OF PACE Concerns : >: y concerns?) sIsit curable risa curable oy the cases after the full course of Anti TB medic ceks your condition will improve and you can enjoy your Li's regular follow up is very important to guarantee the full c: neers ? - IT want to go home » ventions at home dr ? EB: May i ask way do you k AU (0 go home ? Try to solve any dilemma for the patient . nt : Some of the nurse stuff have bad attitude here doctor . I'm sorry for that , | am going to talk to the nurse in charge and i promise to improve their attitude . Patient: They forbidden me to drink alcohol Dr? Hl: Didn't you think to give up drinking alcohol at all? .. Alcohol intake may worsen your condition as it worsen your defensive system , we can help you in this issue by referring you to a specialized team to help you to give up alcohol intake , Patient: they forbidden to smoke doctor . WBE: Didn't you think about giving up smoking before , smoking may Worsen you condition , so we can help you to give up smoking by referring you to smoking cessation if you don’t min Explain for the patient the risk of discharge: You have to be admitted under our observation for at least 2 weeks until your sputum is free from the bugs , to be discharged now is risky on yourself. as your condition may worsen and even may be life threatening , and may be risky for the public as you still infectious for the others. . If the patient still persist to be discharged . : I'm going to involve my consultant soon to solve any other worries or queries you may have . Make summary: About the important points of discussion and management plan, 27:MAKER OF PACES derstanding :Check how much the pats om the Eniphasize again , 'm going to give you some |: srochures , to read more about the disease , I will give you act number as well to contact me any time if you have any worries oF que + Shake hands. N.B: The main issue here is that patient is not allowed to be cischarged , but avoid confrontation with the patient , Try to convinee him kindly to stay in the hospital until his sputum will be free from the germs , showing the hazards of being discharged in_ the time being on himself and for the others , involve your consultant at the end if the patient still insisting. -This patient has to be admitted under the common low and not allowed to be discharged against medical advice. (Discussion with the exmanier) 28PACEMAKER OF PACES onic br for palliative care) ld has been complaining of recurrent loose st 2 months, motions and loss Blood investig: omen . chest and pelvis confirmed a diagnosis of advanced cancer cole ‘astasis to the liver and spleen. The oncologist made decision tir, Kamal is not fit for chemotherapy or radiation and only for palliative treatment, You are SHO of the medical department on call today , you are asked to discuss the condition to Mr . Ahmed the son of Mr. Kamal. Introduction: - Shake hands. = Introduce your self = Confirm the son identity. - Ask if he is next of kin of Mr. Kamal. ~ Confirm Agenda of meeting - Ask if he has permission from Mr. Kamal to discuss his condition. ~ Ask if the he need anyone else from the family to attend the discussion (for support). - Ask about his expectation . Breaking the news gradually : “The results of blood tests and imaging have been released, and they are not as we hope .. Stop for a while .. They revealed that your father has advanced cancer in his gut .. Stop for a while (let the son to express his feelings and thoughts). Empathy and sympathy : How do you feel now Mr. Ahmed? I'm really sorry for these bad information today , I highly Appreciate your feelings , i know how much these news are hard for you , But be sure that we are going to give your father the full care and support. Explain the disease simply without jargons: Do you want me to explain to you more about your father’s condition ? 29PAC vther revealed that : sther organs like Untoy inmiges done 10 he has ae his gut , whieh has bece liver and s Complications of the disease: @ Tm sorry Wo tel! you that eaneer has a lot of 0 et, Joss of weight , fatigue . decreased appetts and bumps and may be failure of the affected orga: © And Fm sorry to tell you that your father cancer sens be in advanced stage , I'm sorry again for these bad information today v NOILVis Treatment plan: © So what we are going to do is to refer your father to. a MDT from a Tumor physician , Maemillin nurse , psychiatrist , social worker . and pain management doctor to give your father the full care and proper plan of management . ¢ Unfortunately the cancer physician saw that the condition of your father is very advanced and he is fit for chemotherapy nor radiation , as there is no chanee to improve his condition , and only will be for palliative care. ‘The Son : Why doctor , please do anything to keep my father alive , why you are not going to give my father chemotherapy doctor. + Thighly appreciate your feeling , This decision was taken by the cancer doctor in the best interest of your fathers condition . «Chemotherapy has a lot of side effects and your father is going to suffer from all the side effects of chemotherapy with no chance his condition to be improved. © But we are going to give your father the full palliative care in the form of patent pain killers to keep him pain free all the time . providing him with the appropriate nutrients and fluids that your father needs , correction of any electrolyte imbalance and treatment of any infection . Social history: What is your father doing for living? .. How much illness of your father impact his life? .. I'm sorry for that we will involve a social worker to solve any social trouble he has. With whom your father is living? are they doing well ? is anyone in the family needs any social care? © Is your father financially supported? 30*EMAKER OF PACES © Do your ‘lvanced direction or living well ? (this question | ‘ cancer), Concerns: Do you \: acerns ? There is no hope I'm sorry to tell you that 1 ion of your father seems to be very advanced , But we are going to do our besi and give your father the full care and to keep him pain free all the time. Any other concern ? For how long my father is going to live doctor ? I'm sorry to tell you that may be not for long time as your father condition is very advanced , but be sure that we are going to do our best and give you the full care and to keep you pain free for the rest of your life and support you socially, psychologically I don’t want my father to know about his condition doctor! May ask why you don’t want your father to know? © Lappreciate your feeling , But as your father has the full mental capacity so that he has the full right to know everything about his condition and to share in the management plan. © We will give him the information in pieces according to his worries and queries , and will involve a psychiatrist to manage any mood disturbance. Make summary : About the important points of meeting. Check understanding : Check how much the son got from the discussion ? Help: Emphasize again , I'm going to give you my contact number to contact me any time if you have any worries or queries .. - Shake hands 341vin: I sympathy and Reas sgain for what happened to yous # HIV i ‘low after a 9 reassure you Im really again that the needle stick injury. ance of catching infection of Social History: My Lask some social questions if you don’t mind’ «With whom you are living Pare they doing well ? whe home? Are you financially supported? © Do you smoke? Drink alcohol ? «ipporting your at Concerns: Do you have any concerns ? Make summary: About important the points in the meeting. Check understanding : May I know how much did you get from our discussion today? Help: Twill give you some leaflets and websites about needle stick injury, I'm going to give you my contact number, if you have any worries or queries, please don't hesitate to contactme Anyone to drive you home ? - Shake hands. 34m | , was admitted 2 days ago because of pneumonia . His cond! oving. Yesterday n pain , codeine was give Unfortunately he develo he was given anti allergic nevi eine Bata) scenario: Mr. Sany ht he developed back he best interest of his condition , 10 codeine with skin rash and hypotension. on and his condition was stabilized and was put under close observation You are SHO of the medical department on call today , you have been asked to discuss this issue with his son Mr. Anw who is very angry for what happened to his father. Introduction Shake hands, -Introduce yourself, -Confirm the patient identity(May | confirm that you are Mr, Amr son of Mr.Sami? Are you next of kin of Mr. Sami? -Confirm agenda of meeting and take permission to start (We are together today to discuss what happened to your father , 1 it ok?) -Ask the son ; How much do you know about your father condition ? let the son to express his feeling and anger without interruption. Apologize for what happen to the fath P'm really sorry for what happened to your father .. may [explain for you more about what happened exactly ? - Explain the incident: Your father was admitted 2 days ago because of lung infection , and he was given the proper treatment and his condition was improving , yesterday he developed back , and he was given codeine in the best interest of his condition. Unfortunately he developed allergy for codeine with some skin rash , and low blood pressure , codeine was stopped and he was given Anti allergic treatment at once and his condition was stabilized and he is under our close monitoring now. & 35Mi : ° z x ‘PACES ible ce ing the possid : 1 know how m Poy eatly sorry .gsnin For what happened to your Ft i uch your f s highly ap) father is precious for you , your feeling is highly ont May be there was breaking of communication or going to investigate what happened seriously. vrmation and we are Explain what actions will be done: So what we are going to do is: 7 © To check your father file to know what happened * write incident report for what happened. Inform our consultant and nurse in charge. ‘© Write in clear obvious notes in your father file that hes not to be given to him in the future. | ‘* Discuss this issue in the next morbidity and mortality me: to happen in the future © Refer this issue to the risk management team to investigate what happen, Is it OK with you? rgic to codeine ag to avoid this ~ The son might be still angry - Apologize again and clarify for him that we are here to help your father as much as we can , and any harm for your father was not intended at all. Social History: May [ ask some social questions if you don’t mind © What is your father doing for living ? do his illness impact his job and usual daily activity ? I’m sorry for that I’m going to refer him to a social worker to solve any social troubles he has. ¢ With whom your father is living ?Are they doing well 2 Who is supporting your father at home « Ishe financially supported? * Does he smoke? Drink alcohol ? Concerns: Do you have any concerns ? Iwant to make a complain doctor - This is definitely your right. We will hel . ; . a al fou by nt advice lnison office and we will follow up dhe reese on the P the result of your complain and be sure thatthe plan of management of your father will hot Hp attected m ail 36PACEMAKER OF PACES Any other concer {Want'the name - I'm not defendin team members are re ho prescribed this medication please? ‘twe are working here as one team, all of ar father"s condition . Make summary: Ac “tant points in the meeting. Apologize and emphasize again. Help: I'm going to give you vi) contuct number, if you have any worries or queries, please don't hesitate to contact me any time. + Shake hands. 37coday morning teral MI, sold. He secked med and reveal Scenario: Mr.Gamal is 65 yea after complaining of chest pain , EC don i ition aller} snsent PCI done for him in the best interest of hi ondition i ca Unfortunately his condition was deteriorated after Pcl Ar eas to the ICU, and had cardiac arrest , resus ation done for him unfortunately he d away. y i + been asked to today , you hs You are SHO of cardiology department on call < Ran st came asking for his father discuss this issue with Mr, Rami his son who ju condition . Introduction : -Shake hands. -Introduce yourself. -Confirm the son identity and ask if he is the next of kin. -Confirm agenda of meeting and take permission to start, ~ Ask if he want any one of the family members o attend the meeting . Ask the son : How much do you know about your father condition ? Explain to the son the condition of the father since he seeked medical care in ER and break the news gradually : © Actually our father seeked medical care in our emergency department today morning complaining of chest pain, Blood tests and heart tracing done for him and unfortunately it revealed that he had severe heart attack with extensive blockage of the blood supplies of his heart. « Anurgent life saving procedure done for him in the best interest of his condition which is called (Percutaneous Coronary Intervention) . It is a procedure done to widen the narrowed and blocked blood conduit and remove any blood clot of the heart, + A.consent was signed by your father after explaining the Advantage and complications of the procedure and he agreed to do the procedute. Unfortunately your father condition was deteriorated after this procedure, and was transferred to Intensive care unit to be given the best care , then he had heart arrest , Maximum efforts were done to restore his heart beats but unfortunately... he passed away®, Stop for awhile and let the son to express his feclings 38MAKE (Here the son may | sc may be anger that you have to mani Showing empati hy for the son: I'm really sorry for you, L appreciate your fe be sure that we did our b w much theses news are hard for you, and our father's life . 3 [e) r4 mS The son may have some queries and anger: Did you kill my father doctor? .. How dear you to do such procedure without informing us ? - Ireally appreciate your fecling again , be sure that we did our best effort to save your father’s life , this procedure was done for him in the best interest of his condition .. without this procedure , your father would have cardiac arrest and would die at once. - Your father was completely competent and had full mental capacity to made decision .. All the procedure information including the advantage and complications were explained to him and he agreed .. So the procedure was done urgently to save his heart and his life .. And like any other procedure it has its own complications that he developed unfortunately. Does this make any sense for you ? Show empathy and sympathy again: I'm sorry again Mr. Rami. All the medical team members are feeling sorry for your loss , and be sure that we did our best to save your father's condition. Social History: © What was your father doing for living ? © With whom your father was living ?re they doing well ? any one of them need special care , social or financial support? Concerns: I want the name of the doctor who did the procedure to my father ? ~ Your concer is highly appreciated , I’m not defending my colleague but we are working here as one team , and all of team members are responsible for your father's condition . 39PACE 2] want to male 2 complain doctor? Definitely this is your right , We wall help you by reter >the patient advice liaison office , and we will follow up the result & nplain, Any other concem? + T want the death certificate of my father now “9 ~ L appreciate your concern , the dk te will be tele by the coroner . We will contact him soon to release it to avoid any delay of + funeral ceremony . ~ Help: I'm going to give you my contact number , if you have any worries or queries , please don't hesitate to contact me + Shake hands. 40CEMAKER OF PACE Scenario: Mr. Sale ys ‘old Know case of advanced multiple myeloma, DM, HT N, fi “| last week because of altered conscious. level, His condition w. sd: «J and was put on mechanical ventilation and transferred to intensive » The treating team made .le of his condition. You are SHO of the medical department, you are asked to discuss this issue with his son Mr. Ahmed. | hot to resuscitate the patient in the best interest Introduction : - Shake hands. = Introduce yourself. - Confirm the son identity, ~ Ask if he is the next of kin. ~ Ask if he need any onc of the family members to attend this meeting - Confirm agenda of meeting and take permission to start. ~ Ask the son: how much do you know about your father's condition? Initial question : May i ask if your father has Advanced directive or living will or power of Attorney? Explain the condition of the father to the son: ‘Your father is known to have advanced multiple myeloma which is a cancer of the blood, DM, HTN, IHD admitted last week because of altered conscious level, Unfortunately His condition was deteriorated and was transferred to intensive care unit and was put on assessed ventilation. Showing empathy and sympathy: How do you feel now Mr. Ahmed? I’m really sorry for that, I highly appreciate your feeling, and be sure that we are here to do the best for your father and to offer him the full care. Explain the decision of DNR: So according to the advanced deteriorated condition of your father, the treating team made decision in the best interest of your father's condition not to be resuscitated if he had heart arrest. 4& PAGES he son: Do you! Lohan resuscitation? Whemaiv cart saps beating, we start to dh citation to stimulate the heart to i tepeated compression on th nsertion ofa tube Throwals thy air pine and giving some medication Ie {le to stimulate the heart to work again, Expiaiv ications of Resuscitation: red: bteenigs “Resta. ation has its own complications like ehest Por es, bleeding in the lungs. deformity of the chest and injury 10 the ar “The chance of your father to revive again is extremely love -and even ithe bad fife quali'y sci’s condition .. ations are revived he will suffer a lot and will has a very : decision not to resuscitated was taken in the best of your fi COutweighing the complications versus the benefits, the com! extremely more for resuscitation. - Showing empathy and sympathy again: How do you feel now Mr. ‘Ahmed ? __ [really appreciate your fecling. you, and be sure this decision was tal condition. T know how much there news are hard for ken in the best interest of your father ~ Managing the dilemma of rejection of the son to DNR: The son may be unsatisfied with DNR decision and may tell you: please doctor do anything to keep my father alive. -Treally appreciate your feeling, I know how much your father is precious for you and be sure that he is precious for us as well .. As your father do not has Advanced directive, living will or power of attorney so that the medical team has the right to make medical decision in the best interest of the patient condition. _But as long. as your father heart is beating, he will be offered all the medical care and management. -If the son still not aecepting DNR decision., Then tell him we ean arrange another meeting involving anyone else of your family members whom you cat trust, we can involve our consultant as well to reply any worries or queries you still have . ° 42ACEMAKER OF PACES Social Ii.to -May Task some ‘you don’t mind With whom sour are they doing well ? Any one of them need any social of nied « support? -Are they financial Concerns: Do you neems 2 Make summ Sbout (he wnportant points in the meeting. Cheek unders sion today? anding May U know how much did you get from our = Help: t'm going to give you my conti worries or queries, please don't h ct number, if you have any ¢ to contact me + Shake hands. 43 Fl 4 ic} z SScenario: Mrs, Mona is 23 years old was admitted 3 ¢ cafter history of recurrent loose motions for 2 months. colonoscopy dor and a diagnosis, of ulcerative colitis was confirmed, she was prescribed S by the gastroenterology consultant . She read about steroids side effects on t this medication, You are SHO of the Gastroenterology clinic, you are with Mrs. Mona he internet, She is very worried about asked to discuss this issue Introduction: - Shake hands. = Introduce yourself. - Confirm the patient identity. = Confirm agenda of meeting and take permission to start. ~ Ask the patient: How much do you know about your condition. 2 ~ Ask what information you read about Steroi Explain the condition of the patient simply without jargons: May i explain to you more about your condition? Ulcerative colitis is long standing soreness of the bowls duc to disturbance of your defensive system. It is a long standing disease causing recurrent loose motions, tummy pain, anemia, fatigue, electrolyte imbalance and loss of weight. Advantage of Steroids: Steroids are prescribed to you in the best interest of your condition to adjust your defensive system and control your condition. © Steroid is very important drug in your condition that you have to be completely compliant and adherent to control your condition to avoid complications of the disease. «You will receive steroids for a time will be decided by the bowl physician until your condition is controlled, Disadvantage of Steroid: Like any other drug steroid has its own complications , like weight gain , thin shin and linear rash, easy bleeding, abnormal hai growth, stornach soreness high glucose level, high blood pressure, fragile bones, diminished defensive system, But .. 44CEMAKER OF PAC Explain ho se compli © But. we are of the drug t © We will checi for any distur For fragile bone # And we will follow tions: regular follow up to check for any side effet vel and blood pressure , Electrolytes regularly 2u calcium to keep your bone density i ction to be treated properly. © Outweighing the risk vers. ‘ie benefits of steroids , the benefits are extremely more. -Without Steroid, your condition will be deteriorated, and you may have a lot of complications of the disease. -With steroids your condition will be controlled, and the chance for any complication will be low, and you can live near normal life. Is it ok with you? Pregnancy: May I ask if you have a partner? Are you planning for pregnancy? - If you are planning for pregnancy any time, you have to inform your Obstetrician and gut doctor to make MDT to give you the full care and proper management during your pregnancy. Social History: May i ask some social questions if you don’t mind ? © What are you doing for living? .. How much your illness may affect your work and social life? (Refer the patient to occupational health care worker if) work will be affected , and to social worker if social life will be affected) © With whom you are living? are they doing well ? do they support you? © Are you financially supported? © Do you smoke at all ? Do you drink alcohol ? -Concerns: Do you have any concems ? Any other alternative doctor? — , [appreciate your concern, steroid was prescribed in the best interest of your condition by the gut consultant who is expert in such cases. It varies from one patient to th according to the disease acti and control. 45KER OF PAC Ahout the important points | oe ich get from our standing ; May know how? meeting today? ‘ Help : mm Thope t could cover your worries about sterord tI li . 1m going to give you some leaflets and websites a! roids to read more about it, Hill give my contact number, H yey 7 any Womnes or queries , please don't hesitate fo conttcl me ~ Shake hands. 46PACEMAKER OF PACES Ke Scenario: Mis. A, xs old wad admitted 3 days ago as a case of pulmonary embolis ~ologist prescribed warfarin for her in the best interest of her conc She read about warti about this drug You are SHO of the medical department, you are asked to discuss this i with Mrs. Amira, » eel SOE ae jo oileets on the internet, and she is very worried Introduction ~ Shake hands. - Introduce yourself, - Confirm the patient identity. - Confirm agenda of meeting and take permission to start. - Ask the patient: How much do you know about your condition? ~ Ask How much information you got about warfarin? Explain the condition of the patient simply without jargons: May i explain to you more about your condition? You have admitted 3 days ago because of a blood clot in the blood conduit of your lungs, which is a life threading condition. Advantages of warfarin: That is why the blood doctor prescribed to you warfarin as a blood thinner in the best interest of your condition to thin your blood to prevent further extension of the clot and prevent another blood clot in the future. Warfarin is very important drug in your condition and you have to be completely compliant and adherent to it to control your condition. Without warfarin your condition may deteriorate ans you may have another blood clots in the future. Disadvantages of warfarin: As any other drug warfarin has its own complications , like increased blood thinning and may be bleeding from anybody orifice or even bleeding in the brain . But... 47PACE: omplicatic complications by refe ) a special nic) with « special ¢ your warfarin alue for regular Follow ar checking of your blood thinning value to keep it within target is (23), © If we kept the range of blood thinning within (2-3)! o of bleeding will be extremely low. © Outweighing the risk versus benefits of warfarin, the ben more. ire extremely Without warfarin you will be at high tisk of developing further blood clots in the future, and your life may be in danger, Sorry to tell you that. -On warfarin your condition will be well controlled, and the chance of blood clots will be extremely rare, and you can live near normal life. - New medications: If you are going to receive any new medication, you have to inform you blood physician as many medications may interact with warfarin and may alter its efficacy. ~ Diet: Some types of food may alter warfarin effect as well , so we will refer you to a dietician to write the list of types of food you have to avoid. - Pregnani © May [ask if you have a partner ? Are you planning for pregnancy? - If you are planning for pregnancy any time, you have to inform your Obstetrician and blood doctor to make MDT to give you the full care during your pregnancy. «Warfarin can be harmful to the baby, so during pregnaney it will be exchanged with another thinner given under the skin which is safe during pregnancy. - Social History: May i ask some social questions if you don’t mind ? ‘© What are you doing for living ? © How much your illness may affect your work and social life? (Refer the patiant to occupational health care worker if work fected, and to social worker if social life will be affected) will boasted With whom you are living ? are they doing well ? do they support you? 48“ACEMAKER OF PACES Are you fil od? ! drink alcohol ? ( Alcohol may alter warfarin cussed with the dietician in details). is? Tappreciate your conce “in Was prescribed in the best interest of your condition by the blood phy 1a who is expert in such cases, any other alternative to be discussed wit! blood doctor himself. For how long I’m going to receive this medication doctor? It varies from one patient to the other, may be for few months or may be forever according to the underlying cause, this will be decided by the blood doctor. Make summary: About the important points in the meeting. Check understanding: May i know how much did you get from our discussion today? Help: I’m going to give you some leaflets and websites about warfarin therapy, i will give my contact number, if you have any worries or queries, please don't hesitate to contact me any time. - Shake hands. 49«as Huntington is 25 years old, her father was « : ilial di weeks ago, She read on the internet that it hrs | predisposition. She is very anxious since that time; she 15 10 do Genetic test for Huntington. ; You are SHO of the Neurology clinic, you are asked to discus this issue with Mrs. Heba, Introduction : - Shake hands. = Introduce yourself, ~ Confirm the patient identity. - Confirm agenda of meeting and take permission to start, ~ Ask if she want her husband to attend this meeting. ~ Ask the patient: How much do you know about Huntington disease? ~ How much she know about the test? -Ask if anyone pressurized you to do the test? Explain Huntington disease simply without jargons: May j explain to you more about Huntington disease? @ It isa progressive condition causing Cognitive function impairment and abnormal jerky movements all over the body. © It isa familial condition, unfortunately the chance of every one of the offspring to have the disease is 50% © Unfortunately The discase in the next gencration is coming in earlier age, and with more severe symptoms (Anticipation and Expansion) «We cannot guarantee when the symptoms will appear exactly, it varies from ‘one to the other. Explain the test: -Genetic test is a blood test, the result will be released within 24 or 48 h. You will be the only one to receive the result, it is not released by email oF telephone (Confidentiality). -This test may has false positive or false negative results.MAKER OF PAC If the test is pe & Positive ‘ne disadvantages: You may have a bad mood and snxic our future insurance, but prior insurance will be pre > Advantages * you early to MDT to give you regular follow up and mana Ifthe test is negative: > Disadvantages: it may be false negative the result. > Advantages; You will be relaxed , and continue your life without stress and may be repeated to confirm Consent: © If you agree to do this test, you have to sign a consent in which all the information of the test are mentioned, if you want to withdraw any time you have completely the right for that . * you can have some time to think about it , And you can bring your husband next time to share the information and decision with you, postponing the test will not alter the outcome of the disease. Social History: May [ask some social questions if you don't mind? © What are you doing for living ? © With whom you are living? Are they doing well ? Are you supported at home? © Do you have any sisters or brothers? Are they doing well? Are you financially supported ? * Do you smoke at all? Do you drink alcohol ? Concerns: Do you have any concerns ? If i have the disease doctor, when will the symptoms appears? Lappreciate your concern, We cannot guarantee when the symptoms will appear exactly, it varies from one to the other. What about my children doctor, they may have the disease? If you are confirmed to have the disease, I’m sorry to tell you that every one of your children have chance of 50% to have the disease 51“MAKER OF PACE Sood to be pregnant doctor? 1 test sitive, and you have a plan fOr pre Mi vi time we will rele you to MDT involving genetic counseling 16408 | make the best of your inte Make summary: About the important points in the Cheek understanding May [know how much did you -<< from our discussion today? Help: I'm going to give you some leaflets and websites about Genetic test of Huntington, Lill give my contact number too, if you have any worries or queries, please don’t hes : ~ Shake hands. 52PACEMAKER OF PACES Scenario : Mrs Hala: » old has been diagnosed as a case of Systemic Iupus 3 years ago . Recently she has been complaining of morning eyes puffiness and frothy urine , 24h urine protein done for here and a diagnosis of nephrotic syndrome has been confirmed. The nephrology consultant decided to do renal biopsy to know the staging of her kidney involvement to start the proper treatment, You are SHO in nephrology department oncall today , You are asked to discuss this issue with here, Introduction -Shake hands, -Introduce yourself. -Confirm the patient identity -Confirm Agenda of meeting and take permission to start. ~ Ask if the patient needs anyone else to attend the meeting ~ Ask open question: May I know how much do you know about your condition? Explain the disease briefly and the decision of renal biopsy: May I explain to you more about your condition ? + Systemic lupus is a multi system disease due to disturbance of your defensive system which supposed to attack the germs and viruses, in your condition it attacks your own body, like the joints, lining of the heart and lungs, the skin and kidneys . * Blood and urine tests done for you unfortunately revealed that you have Protein in urine , which means your kidney are involved . the kidney consultant decided that a kidney snip is seriously needed to assess your kidney condition , * Do you have any idea about this procedure of kidney snip ?z PACE ty) without fa his procedure st doctor wht yg. a special need! mdr aseptic com anesth. ¢ ares of needle insertion x ken and ent to a pathologist for nay stay in the hospital for 24 hours after |! Trom any complications - ask if the palien bind and that you will do some blood test prior to | sure about any bleeding tendency. Explain Advantage: Explain disadvantages : internal organ and inappropriate snip. versus the benefits, the benefits are extremely more. withdraw any time if you changed you mind . ¢ This procedure is very important as it will give us idea " your kidneys are affected and what is the stage of your kidney disease, and according to that you will receive the proper treatment. © Without this procedure we can’t find out the stage of your kidney disease so that we can’t give you the proper treatment, and your kidney function will be deteriorated and I’m sorry to tell you that even you may have kidney failure and need renal replacement therapy in the future. h procedures back while you guided, and local pain, the snip will ure to be sure you drug thin her rocedure to make about how much ‘© This procedure has some complications like bleeding, infection, injury to ‘But such all complications are extremely rare and outweighing the tisk Consent: If you accept to do the procedure , you have to sign a consent for agreement containing all the information of the procedure, and you can §NIBIE The patient task here is to refuse the procedure for a reason , and your | task is to convince her to do the procedure exploring the reasons of patient refusal trying to solve them .. like needle phobia : We are going to give you local anesthesia to numb the area of insertion so that you will feel so little pain If the patient is still hesitated or refusing the procedure: I will give you some time to think about it and may be to share opinion with some one of your family members , i will involve my consultant as well in another meeting to convince you more about the procedure, 54PACEMAKER OF PACES ‘ons if you don’t mind? © What are 9» ng? do your illness impact your job and usual daily actis “0! 0 occupational health worker if job is affected, reie cocial worker if his social life is affected. # With whom y« ‘are they doing well ? who is supporting you at home? # Are you financially supported? @ Do you smoke? Prin! ohol ? Concerns : Do you have any concerns? Is there any alternative doctor? I'm sorry to tell you this is the only way to know staging of your kidney disease to start the proper treatment , This procedure is prescribed to you by the kidney consultant who is an expert of such cases. Make summary: About the important points of the meeting. Check understanding: May I know how much did you get from our discussion today? Help: I will give you some leaflets, brochures and websites about this procedure, I will give you my contact number also, if you have any worries please contact me. -Shake hands. 55PACEMAKER OF PACES feature (Hodgkin Lymphoma Introduction : - Shake hands. - Introduce yourself. - Confirm the patient identity. -Confirm Agenda of meeting and take permission to sts:: the discussion (We are together today to discuss the results of your blood tests and imaging, Ist alright with you? Ask if the patient want anyone else to attend the discussion (for support ~ Ask about his expectation . Breaking the news gradually : -The results of blood tests, imaging , and snip of the gland have been released and unfortunately they are not as we hope .. Stop for a while .. they revealed that you have a type of cancer of the lymph gland called (Hodgkin lympho) _. Stop for a while ( let the patient to express his feelings and thoughts) Empathy and sympathy: = How do you feel now Mr. (x)? ~T'm really sorry for these bad information today. I highly Appreciate your feelings. | know how much these news are hard for you, But be sure that we = going to do our best and give you the full care, Explain the disease simply without jargons: - May I explain to you more about the disease and management plan if you! mind? Hodgkin lymphoma is cancer of the lymph glands which exist in diffe sites all over the body. + Ithas some symptoms in the form of loss of weight, fever, night sweat, anemia and easy infection due to disturbance of the defensive syst@™ ~ BUT .. treatment is available for this disease and a lot of cases Were completely cured from the disease after treatment.PACEMAKER OF PACES Treatment » CU What we ‘« refer you to MDT from blood physician, = Maemil “manist, social worker to give you the LA appropria sonagement, a The main: course of chemotherapy (explain advantage (>) and disadva apy ) chemotherapy can destroy the nasty z growth and 1 completely .. © Ithas some co. form of fecling or getting sick that canbe | b= treated by some me Uing of hair which will grow again, you can use a wig at that timc “ensive system may be disturbed and you may get easy infection anc) we will give you a card and follow your condition and give you antibiotics if any infection developed... * Quoweighing the risk versus the benefits of chemotherapy, the benefits are significantly more. Hickman line explanation: Chemotherapy has to be given though a wide bore needle called hickman line , ¢ It is wide bore needle will be inserted in a large blood conduit under local anesthesia to numb the area of insertion and under aseptic condition, done by expert doctor who did such this procedure hundreds of times before. This line has advantage in the form of providing easy access for the cycles of chemotherapy. * Ithas some complications in the form of bleeding, infection, injury to the adjacent tissues, or may be blockage of the line, but such complications are rare to happen. © Ifyou agree to do this procedure you have to sign a consent involving all the information about the procedure, and if you want to withdraw from the consent, you have the right any time. Social history : © How much your illness impact your job and usual daily activity? ..Refer the patient to occupational health worker if job is affected, Refer to social worker if social life is affected. * With whom you are living? Who is supporting you at home? * Are you financially supported? * Do you smoke at all, drink alcohol? Concerns: Do you have any concerns ?conons ofhemotherapy which ean be irreversiy this proble? sving some of your sperm, ature , You € our wife next time ty he of chemotherapy, symary ¢ About the important poinis 0° « Jisease and management plan, Check understanding: may | ask how much did you get from our discussion today ? (If you have time) Help: I'm going to give you some leaflets, brochures, websites to read more about the disease, I will give you my contact number as well to contact me any time if you have any worries or queries. ~ Shake hands, 58\CEMAKER OF PACES : Q Tp 3 ey Scenario: ) * Ic Known ease of DM on insulin, her co} HBAIC in the last: “Mt ‘iabetic nurse see that uncontrolled DM is 2 most probably duce compliant on her medications. You are SHO of the di » YoU are asked to discuss this issue with her. | bam Introduction : ~ Shake hands. = Introduce yourself, - Confirm the patient identity. - Confirm agenda of meeting and take permission to start, ~ Ask the patient: How much do you know about your condition? Inform the patient about the result (Avoid confrontation): * The blood result of HBAIC, Which measures DM control in the last 3 months unfortunately is high. It means that your DM is not controlled, And mostly this is due to incompliance on your medications. What do think about that Mrs. Hend? * Mrs. Hend be sure we are here not to judge you , we are here to offer you the full care and help. Ask about reasons of incompliance: | Can I ask if you have any troubles with your medications like forgetfulness, needle phobia or bad experience? Offer solutions to the patient: | | * If forgetfulness : We can help you by giving you reminder aid device to remind you every time for your injection. ; + Ifneedle phobia: I appreciate you feeling, the diabetic nurse can teach you or one of your family members how to inject you in perfect way. * Other important options to help adherence : > Nowadays there are a lot of different advanced devices and equipment for treatment of DM , one of them is insulin pump to avoid repeated injection + I will refer you to the diabetic nurse to explain to you the different devices and you can choose the most suitable one for you . Is it OK with you Mrs. Hend? 59*ACEMAKER OF PACES i avoid complications: of compliance (0 ayoid comple ' ant (0 control Your DM ang is very import Compliance on your medication om 1s of high glucose level . sos Short term oo aplications of uncontrolled pyy od water work frequene, irsty and it ‘ous and you may have of uncontrolled D\y © eyes , deterioration ends and feet due to ii > wounds , easy <)> cosure to heart attacks fications: javbanee due fo impact 0» of the retion i , pins and 1 Impact on the nerve eables , impaired bs infection due to impaired defensive syster in the future. © But. If you are completely compliant on your medications and your alucose level is well controlled, you are going to avoid all of these complications and you can live near normal life. Life style modification: Beside Drug compliance, you have to make some life style modification to help your diabetes control: * Daily Exercise is very important for DM control, we can refer you to exercise training program for more education. © Diet control is very important as well, and we will refer you to a dietician for more education about diet adjustment. Social History: © What are you doing for living? How much your illness impacts your job and usual daily activity? Refer the patient to an occupational health worker if her job is affected, Refer to a social worker if her social life is affected, With whom you are living? Are they doing well? Who is supporting you at home? Are you financially supported? Do you smoke, drink alcohol? Concerns: Do you have any concerns? Make summary : About the important points in the meeting, 60Cheek discussion © = Nice to meet you PACEMAKER OF PACES Can [know how much did you get from our "rome leaflets , websites about DM and new ment, ‘act number, if you have any worries or queries me any time, 61pario: Mrs, Liala is 23 years 0! 2 days ago with suicidal attempt atier intake of 20 table! test are normal , she is asking for disc! You are SHO of the medical department ono" called you to talk with Mr. Laila. nol , with TOFMAl blog The nurse in charge Introduction -Shake hands. -Introduce yourself. -Confirm the patient identity. . -Confirm agenda of meeting and take permission to start. - How do you feel now Mr. Laila? Ask about circumstances of the suicidal attempt : To assess the patient liability for further suicidal attempts in the future May I know whatt happened exactly ? © What happened before? Do you have History of similar attempt in the pat 2 Did you write any suicidal notes? What happened during ? How many tablets did you take , did you take any other tablets or alcohol? Did you lock the door form inside? ¢ What happened after ? did you call for help? do you still have any suicidal thoughts ? Is life still precious for you? Ask why the patient want to go home and try to solve ht" troubles : MGM: May Task why do you want to go home ? Try to solve any troubles the patient has.. 62PACEMAKER OF PACES For example. Patient: ‘titude dr, Tm sorry ‘o talk to the nurse in charge and I promise they wi ade, Patient: They ba» ny doctor? Didn't you think abou up smoking before, we can help you by cession elinie to help you giving up if you don’t Patient: The food quality is so bad here doctor? Tm sorry for that, I'm going to talk to the chief in charge, and i promise ‘oimprove the food quality and provide you with the of food you like, Is it ok for you? The patient still insists to go home, Explain the complications of Paracetamol overdose : May i explain to you more about your condition? Paracetamol over dose may beasymptomatic with nomal blood tests in the first 2 or 3 days, But it may carry high risk later on in the form of: © Deterioration of liver function, and may be liver failure in the late stages, and may procead to coma , and in advanced condition liver transplant may be needed. Deterioration of kidney function, and may be kidney failure in late stages. Increased thinning of the blood due to decrease level of clotting factors, and increase chance for bleeding. Increase blood acidity, and deterioration of the functions of the body organs . Patient: Thank you doctor + [feel ok now , 1 just want to go home ?MAKER OF PACES of discharge: tantied under our ob mn fi least 5 Days to 1 condition is stable ane completely free from any bncationed befor i any complications, ane ol 1eecive the proper vi. yous life will be in serious dan: sorry to tell that you } may ever The task is to insist to be discharge! I you i can sign any form to be discharged on my own responsibility » you more, 'm going to involve my consultant soon to r and Psychiatrist. to assess your condition before dischiw» . 18 Ok with you? Social history: © What are you doing for living ? Does your mood affect your job and your social life ? — Refer the patient to occupational health care worker if her job is affected, and to a social worker if her social life is affected, © With whom you are living ?are they doing well ? who is supporting you at home ? © Are you financially supported? * Do you smoke? Drink alcohol ? Concerns: Do you have any concerns ? Make summary : About the important points in the meeting. Check understanding : Help: © I’m going to give you some procures about paracetamol over dose to know more about it. ¢ I’m going to give you my contact number , if you have any worries of queries , please dont hesitate to contact me . ~ Shake hands, 64PACEMAKER OF PACES N.B: -The sur insist for discharge, = Your ty surrogate kindly to stay for further investigations, and obser © retsons for asking for discharge, trying (6 so! Jor him , clarifying the risk of carly discharge. = This lady is ‘ ' vo home before assessment by a psychiatrist , Not allowed even tu »sanst medical advice, and if insist for discharge has to be kept under the mental act. ~ Avoid confiontation with the patient,and try to conveinse hir kindly without judgment, 65 e 4 (c) z isj vie 40 years old has Bes ing of recurrent for (12 ! ibdominat | ne tor here we | joys dee needed for her v1 the medical Outpatient elinic aanmal ont made decision ng -d to discuss this Introduction : + Shake hands. = Introduce yourself. = Confirm the paticnt identity. - Confirm agenda of meeting and take permission to start. = Ask the patient: How much do you know about your condition? = Do you ¥y expectations for results of the blood test done for you? Inform the patient about the result: Mi amia | have good news for you, that the results of the blood test done for you all are normal .. What do you think about that ? ‘The surrogate will express anger: At that point you will find the surrogate so angry. Patient : What do mean doctor, you mean I’m medically free, do you mean I'm malingering, do you want me (o go back to my husband telling him all blood test are normal and [’'m such a big liar). -Let the surrogate to express her anger without interruption and keep calm until she end her anger , and then start to explain her condition . Managing anger of the surrogate and admit her suffering : You : Ereally appreciate your feeling , i didn’t say you lie or you are malingering at all , i admit you are suffering , and you have something we have to manage and we are here to give you the full help and care , is that ok with you ? 66