Al-Rokh’s MLAs nel ase of Paces A TAsimphied Approach For MRCP Peas, History-Communication-Brief Consultation a Sadek Al-RokhAl-Rokh's Pacemaker of Paces A simplified approach for MRGP Paces Second Edition — By Dr. Sadek Al-Rokh ME == MRCP Paces instructor © augill Gill iso — MRCP (UK-London) MIDDLEEASTLIRARES | MA@ACWUA SCE Acute medicine (UK) EET aster strtcn SCE Endocrinology and diabetes (UK) European board of Endocrinology and diabetes Copyright © 2020 middie East & E! Marwa for Publishing & Distribution. All rights reserved. ISBN: 978-977- 6551-58-9 14576 / 2019 :¢!2¥! Ab All rights reserved No part of this publication may be reproduced, printed or transmitted in any form or by any means, electronic ot mechanical, including photocopying, recording ar any information storage or retrieval system without permission in writing from the Publisher. ee abyss Ggsll ue espa Asay Gl FSi J Ay Sl aay col ia go aja lS eed J ane oI ec zee DpH ge AS as bad Gs VI OS gol in end Veal AD 1 a a an Usha jh LS. ‘The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this farm has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify materials mentioned in this book. ‘This book does nat indicate whether a particular treatment is appropriate or ‘suitable for a particular individual. Ultimately it is the sale responsibility of the medical professional to make his or her own professional judgements, so.as to advise and treat patients appropriately. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or darhage to persons or property as a matter of products liability, negligence, or otherwise or from any use or ‘operation of any methods, products, instructions, or ideas contained in the material herein. Publishar: Middle East & El Marwa for Publishing & Distribution Cairo, Egypt Tel, 00201110150022 - 00201200381 085 - 0201211361734 E-mail: me_book2010@ yahoo.com Publishing Services Manager & Design: Abd E| Hamid Abd El Ghafar Printing Services Manager: Abd Ei Aleem Adel El Syed Printed in EgyptABOUT THE BOOK ‘Alrokh’s Pacemaker of Paces is a simplified approach for clinical Exam of MRCP UK, MRCPI Irish, Egyptian board, Saudi board, Sudanese board and ‘Arab board, The first edition of the book achieved more than 5 thousand sales allover Egypt, Gulf area, Sudan, Pakistan, India, Bangladesh, Malaysia and UK with very amazing feedback from hundreds of candidates who passed paces all over the world. The second edition of the book includes 120 clinical exam cases which appeared in the exam in the recent few years. ‘The book is aiming to-a simple and a straightforward approach of clinical exam cases without redundancy or suffocation. The book is still valuable for the modified MRCP Paces exam in 2020. I wish the book would help all my dear colleagues in their clinical practice and ‘exams to offer the proper care for their patients and best performance in their exams. [At the end, { wish you all a great sucess in your exam and career. Kindly, don't forget to pray for me. Sadek Al-Rokh MRCP (UK-London) SCE Acute medicine (UK) SCE Endocrinology and diabetes (UK) European board of Endocrinology and diabetesDEDICATION * Tomy Lovely mother who taught me that the best people are those who are most beneficial to others. And every one is created for a reason, and the topmost reason is to be helpful for others. Thanks a lot. | appreciate your precious guidance, e Tomy beloved wife who has endured a lot of time and effort for years. I appreciate your efforts and tolerance. « This book is ongoing charity to the soul of Dr.Basem Elazony, who passed away recently ina painful car accident. Dr. Elazony was one of the most decent and diligent Mrepicians. Kindly, pray for him. May Allah bless his soul.Station 4 Communication. ~ About Communication (Station 4). = Ethical and legal issues in communication skills . = Communication Scheme ~ = Counseling for chronic disease (Pheachromeytoma’ = Counseling for chronic disease (Multiple Sclerosis) «= Counseling for chronic disease (Adult polyeystic kidney disease)... = Counseling for chronic liness (Celiac Disease) = Counseling for chronic disease (Addison disease)... = Counseling for chroniciliness (Epilepsy) ~ Breaking bad news (Advanced cancer for palliative care)... = Breaking bad news (Meningitis) ... = Counseling for chronic disease (Uleerative colitis) ~ Counseling for chronic iliness (Hereditary Obstructive Cardiomyopathy) = Breaking bad news (Advanced ILD for palliative care) = Breaking bad news (Mesothelioma with metastasis) (Disablement compensation) = Breaking bad news (Hodgkin Lymphoma for Hickman line). XxSe ~ Active TB Asking for discharge . = Breaking bad news (Guillain Barre syndrome). = Counseling for DNR decision = Counseling for Brain stem death and organ donation .. = Breaking bad news (Advanced COPD — Not to ventilate)... = Counseling for a procedure (SLE for Renal biopsy) ..... ~ Counseling for a procedure (Gastrostomy tube) = Medical negligence(Angry son - Father developed Allergy for codeine! = Medical error (Complication of a procedure) Patient died after aprocedure (PCI) ~ Angry son (Side effect of a medication) = Counseling for side effects of Warfarin.. ~ Counseling for side effects of Steroid therapy. = Counseling for a medication (Bisoprolol for heart failure in BA patient) . = Drug nencompliance (Diabetic patient on Insulin)... = Drug Non-compliance (Anti TB medications) - Pulmonary embolism asking for discharge... = Patient with Suicidal Attempt Asking For Discharge... ~ Breaking bad news (Subarachnoid hemorrhage asking for discharge) ..... = Breaking bad news Possible medical negligence.- ANurse with a needle stick injury from a patient with HIV . = Breaking bad news (Angry patient for delayed diagnosis) = Deteriorated ischemic stroke Angry daughter for Aspirin = Counseling for Genetic test (Huntington disease)... - Somatoform Disorder. - Post Ml Counseling.. = Patient with pneumonia (Daughter refusing discharge) ... - Refusal of treatment .. Station 2 History taking. 141 143 = About station 2 (History taking) . ~ Microcyti¢ Anemia in Young Female. 147 = Chronic Diarrhea .... 152 - Jaundice 163 = Chronic Cough and Wheezy chest... ~ Chronic cough and hyponatremi: 169 = Both Lower limb weakness. 173 ~ Periodic paralysis...... 178 = Abnormal sensation in both Lower limbs... 183 - Ataxia 189 Xl~ = Monoarthritis.. ~ Osteoporosis ~ Hematurea in young Female = Recurrent chest pain in young male... = Recurrent Sweating and Glycosurea .... = Skin rash and SOB... = Chronic Recurrent Headache .. = Polyurea ... jabetes type 1 with dizziness... = Palpitation.. = Recurrent hypoglycemia ~ Weight gain and fatigue after delivery. ~ Post-partum amenorrhea and failure of lactation ... - Angioedema - Transient Hemiparesi - Delirium Transient global amnesia. = Chronic epigastric pain... xi eee 209 214 219 225 236 242 247 251 256 260 265 269 1874 10.279= Joint pain and fatigue = Low Back pain Ankylosing spondylitis = Chronic Cough and Wheezy chest EAA (Bird fancier disease). = Chronic Diarrhea with recurrent Hypoglycemi: ~ Shortness of breath in Rheumatoid Arthritis = Chronic liver disease (Hemochromatosis). = Recurrent vomiting in type 2 diabetes (Gastroparesis).. ~ Hyponatremia .... ~ Hypertension in Young patient... ~~ Dysphagia ~ Syncope. ~ Uncontrolled seizures in patient with epilepsy... Station 5 Brief Consultation sessenemnanenns ~ About station 5 (Brief consultation). = Vitiligo ~ Psoraisis = Hereditary Hemorrhagic Telangectesia (HHT). - Pemphigus... = Neurofibromatosis ...= Chronic Mouth Ulcer. = Tuberous Sclerosis. - Acromegaly, ~ Addison Disease (Hyperpigmentation).... = Cushing Syndrome (Weight gain) . + Neck lump {Graves' disease) . = Obstructive sleep Apnea{ Hypothyroidism) ... ~ Ankylosing Spondilitis = Psoraitic Arthropathy ~ Rheumtoid Arthritis. = Systemic Lupus Erythematosus ~ Systemic sclerosis. = Monoarthritis ~ Retinitis Pigmentos: ~ Papilloedema. - Optic Atrophy. ~ Diabetic & Hypertensive Retinopathy... = Limb weakness in young female ~ Sudden Painless Lass of Vision 370 373 377 383 387 39 396 399 A285 433 ABT 442~ Both lower limb swelling = Chest pain (Pulmonary embolism) . ~ Hematemsis and Melena 0... = Lymphadenopathy ...... = Tall Stature (Marfan Syndrome). = Pruritus. ~ Pyoderma Gangrenosum. * Carpal Tunnel Syndrome... ~ Unilateral lower limb swelling... = Obstructive sleep Apnea + Raynaud's phenomenon. ~ Headache with pregnancy. = Miscellaneous NotesStation 4© Communications is 20 minutes, 14 minutes with the surrogate, 1 minute to review your ideas and 5 minutes with the examiner. ‘= Youare given $ minutes before the station, in which you have to read he scenario and prepare yourself. Focus on every word in the scenario to know the patent name, your task and your position. ‘© These 5 minutes prior the station are very precious to prepare yourself, organize your ideas structure your case and write scheme of the headlines of the case to cover all the important points in the scenario Golden points in communication 1. Makes good scheme in your mind and write it on your white paper in headlines to cover al ‘the important points in the station, 2. You have to organize your tasks and decide what is the counseling for. 3. Puta good structure and be organized in your thoughts and information during your discussion with the surrogate. 4, Avoid jargons absolutely. Try to be fluent in your discussion 5. You have to be a good actor, with empathic body language and eye contact, 6. Don’t push a lot of detailed suffocated information to the patient. 1. Don't interrupt the patient when he is talking and let him to express bis thoughts, feelings or queries, 8. Beinteractive with the surrogate, Don't talk a lot without checking his understanding and absomption saving: “(Are you with me Mr (x) ? .. Does it makes any sense for you?). 9, IPthe Surrogate showed any variant emotions like anger, denial or crying, don't interrupt him and try to understand and appreciate his feeting, 10. Show empathy and sympathy froma time to the other in breaking bad news and counseling for chronic illness in empathic body language and eye contact. 11. Avoid confrontation and argument with the patient or aay one of the relatives KIues: ‘These ethical issues are fixed for all the eases of communication: + Autonomy: > ‘The patient has the right to know everything about his condition and share in the ‘management plan. Beneficence: To do good for the patient, yee Non maleficence: ¥ Notto harm the patient. «Justice: > The patient has the right of management regardless his race, religion ot color. Honesty, Be honest when explaining the disease, but follow it with reassurance, (ie In cancer with metastasis : The patient will ask you : There is no hope doctor? (A Tricky question). ‘Always don’t give false hope, but also reassure and don’t make hitn t lose hope. Incase of cancer with metastasis: ¥ Be honest (I'm somy to tell you your condition is so advanced). ¥ Reassure (But, be sure that we are going to give you all the social, psychological, medical support and t0 keep you comfortable and pain free all the time). vve vw Other Ethical issues according to the case: Confidentiality: Respecting the privacy of the patient. The patient is the only one to know the results of his investigations. Results are not released by mail or telephone and to be delivered tothe patient himself (ie In cases of HIV and Genetic testing) Breaking confidentiality: if the patient is harmful for the others, and insist not to tell his partner about his HIV status for example (Avoid confrontation and try to convince in a diplomatic way). views os + Avoidance of confrontation, % Avoid argument and confrontation with an angry patient or relative.(ie. counseling fora ‘medical error or a side effect of a medication)Legal issues: + Consent: A signed consent of a procedure after detsited explanation about benefits and ‘complications. > Patient has the right to withdraw any time after his signature. Advanced directive and living will: Tethe patient i competent, he has the ight to make a signed informed decision for his future treatment plan. whe Lasting power of attorney: 5 Enables the patient to give another person the right to make decisions about his care and welfare, in case if he last his mental capacity DNR: “The treating team has the right o make DNR decision in the bes interest ofthe patient condition regardless the decision ofthe family members (Try fo convince them aveiding confrontation). ‘The patient has the right to ask for DNR when he is competent ‘The patient or any te relatives doesn’t have the right to refuse DNR deeision. Explain the complications and bad outcome- Avoid confrontation) ve vy ‘© Treating life threatening condition: > The treating team has the right to teat the patent in the best interest of his condition to save his ft even without consent, incase ofthe patient doesn’t has advanced directive or ‘ving will. + Discharge against medical advice (DAMA): tne patent is competent, ie has the right to sign a form of eischarge against medical advice after discussion of the risks of discharge. > Hehas the right to be given home treatment and outpatient cline appointments. He has the right to come back to the hospital any time. + Admission under the common low: If the patient has ective infectious disease and may infect the others and doesn’t have suitable circumstances for isolation at home , 50 that this patient is nat allowed to be ‘Escharged until his disease is controlled and not infections any more (avoid confrontation). (ie Active TB) Trereumstances at home are suitable for isolation, then isolation gan be done at home, y v Admission under the mental health act: > Hthe patient is not competent or has psychological instability, o that he oe admited agains bie or her wishes of discharge unl to be assessed by a pryciorist ora newologtt {Gecording 0 the case) o evaluate his or her eonition (Avoid confrontation). (ie Suicidal attempt )Disablement compensation: ‘The patient has the right to claim for disablement compensation if he developed any disease related to his job.{i.e. Mesothelioma in shipyard workers} Refusal of treatment: If she patient is competent, he has the right to refuse treatment alter counseling for hazards of refusal of treatment. If the patient is not competent and lost his mental capacity, you have to follow his advanced, directive, living will or power of atomey. I the patient is not competent, and doesn't have advanced directive, living will or power of attorney, then the management plan has to be decided by the treating team in the best interest of the patient condition. If the patient is not competent , and doesn’t has advanced directive, living will or power of attorney, then the management plan has to be decided by the teating team inthe best interest ‘of the patient condition, And any of the family members doesn't have the right to refuse the ‘treatment plan. Refusal of discharge: Ir'the patient or any of the family members refused discharge, explore reasons of refusal and try to solve them. And try to explain complications of say in the hospital without need. Solving all social dilemmas is crucial ( May be the patient is living alone or doesn’t have ‘enough care at home). You can involve social worker and home health team ifthe patient lacks medical care at home,Introduction: «Shake hands. ‘Introduce yourself, ‘Confirm the patient identity ‘Confirm agenda of meeting and take permission to start discussion. + ask ithe want anyone else 0 attend the discussion freaking bad pews o ‘coonseling for chronic iliness ).. (Absolutely don't in cases ‘of confidentiality like Counseling for HIV). ‘Ask open question how much he knows about his condition. A tum about his expectation (freaking bad news or counseling for chronic illness ) Gradual breaking of the news: _ Start breaking the news gradually with some tragedy: aarp reali of the blood test or imaging have been released and i's not as we hope Stop fora while. «They revealed that you have a condition eae (.) or (Cancer) « StOP fora while and let the patient to his feelings. Showing empathy and sympathy: (itis eancer, or the patignt knows information about the disease: ‘eTimrcally sorry for these bed news today. + Thighly appreciate your feclings. 4s Tknow how much these news are hard for you. © Be sure that we are here to give you the full care and care ‘© Give the surrogate tissue if start crying, Eexplanation of the disease: ‘Do you want me to explain to you more about your condition? o Sant explain the disease simply avoiding jargons(eedical teams) & Avoid pushing a lot of suffocated information, © Explain all symptoms and complications ofthe disease, ¢ Explain the management plant > Referral toa specialized doctor ot to a MDT team to give him the proper care and ‘management plan > Main poinis of management without detailsSocial history ‘May L ask some social questions if you don’t mind? «What do you do for living? - How much your symptoms affect yout job and usual daily activities? (Refer the patient to a social worker if his soviel life is affected and to an occupational health care worker if his work is affected. With whom you are living? Who is supporting him or her at home? Are you financial supported? ‘© Smoking and alcohol history? = Emphasize again for these bad news today, Tknow how much i's hard for you , but be sure that we wall da our best to give you the full care and management, Concerns: Do you have any concem? (If you didn’t ask about the concems, you may lose this station) Summary: Summarize your meeting with the surrogate in brief: I'm going 10 summatize the important points in our discussion today. Check understanding: By asking: May | know please how much did you get from cur discussion today? Help: I'm sorry again for hard news today, «+ Loui pive you some leaflets, brochures and websifes to know more about the disease + L-will give you the contact number of the department to call us any time if you still ‘have any worries or queries, + Anyone to drive you home? -Nice to meet you~ Shake bands.Scenario : Mr.Ahmed is 27 years old, He has been complaining of bouts of headache and palpitations for the last 6 weeks. Blood investigations including urinary and plasma metaneprins and CT abdomen confirmed a diagnosis of pheochromocytoma. You ate SHO of the outpatient clinic today. You have been asked to discuss the results with Mr.Ahmed. Introduction: * Shake hands. © Introduce yourself (I’m Dr.Rokh SHO in the outpatient clinic today). © Confirm the patient identity.(May i confirm that you are Mr. Ahmed 27 years old?) * Confirm Agenda of meeting. .( We are together today to discuss the results of blood investigations and imaging done for. Id ot alright with you?) «Ask if the patient need anyone else to attend the discussion (for support). © Ask how much he knows about his condition. * Ask about his expectation. Breaking the news gradually: © The results of blood tests and imaging have been released. And, I"m sorry to tell you they are not as we hope... Stop for a while. + They fevealed that you have a disease called (Pheaochromeytoma).. Stop fora while (let the-patient to express his impression) .. 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: «Ts 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 . = Mostly 90% of the growth is benign, 10% of this overgrowth may be cancer, 10% could be familial which runs in families , 10% are located on both glands over your kidneys , 10% could be located in other sites.Symptoms and complications of the disea: ‘Increased level of this hormone leads to some manifestations like loss of ‘weight, flushing, anxiety, 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: «Referral to a MOT: Refer youto MDT from Gland physician , surgeon . psychotherapist, social worker to give you the full care and the proper plan of management - «Surgical resection: The main treatment is surgical resection of the overgrowth. + Blood pressure control: You are going to receive oral medications for high blood pressure 10 —14 days before the operation to control your blood pressure and to ovoid complications of the procedure. The details of this procedure will be discussed by the surgeon in details involving your consent for agreement to do the operation. Showing empathy and sympathy: ‘© I'm really sorry for these bad news today. «highly appreciate your feelings. «© Lknow how hard these news for you © Be sure that we are going to do our best to give you the full care and proper management plan. ‘Sogial history: Can 1 ask some social questions if you don’t mind? What are you doing for living?... How much your symptoms affect your job and usial daily activities? .. Refer the patient #@ 4h 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 at all? Do you drink alcohol? ... Didn't you think to about giving up smoking? - We can help you by referring you to the smoking cessation clinic if you don't mind.‘Concerns : Do you have any concer ? © Mostly yes. * If the procedure 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 off any medications .. Any other concems? "10% of this overgrowth is cancerous. Therefore, during resection of the growth, we are going to have a snip from the overgrowth do to be analyzed to be sure about the nature of the growth, |, which means it runs in families, * Therefore we will refer you and your children to a genetic counseling team to discuss this issue in details and for possible screening, Make summary: About the important points of the disease and management including referral to MDT. Check understanding: May I know how much did you get from our meeting today? Help: I'm going to give you some leaflets, brochures and websites to read more about the disease. 1 will give you the contact number of our department to contact us any time if you have any worries or queries . - Shake hands, Notes for the case: + Ethical issues here Autonomy ~ Beneficence ~ Non maleficence- Justice — Honesty. + Legalissues here : Consent if planned for surgical resection.Introduction: © Shake hands Introduce yourself. Confirm the patient identity. Confirm Agenda of meeting. Ask if the patient needs anyone else to attend the discussion (for support) ‘Ask how much do you know about your condition? Do you have any expectations? Breaking the news gradually: * The result of the imaging has been released, and I’m sorry to tell you that it is not as we hope .. Stop for a while. + They revealed that you have a condition called (Multiple Sclerosis) .. Stop for a while (let the patient to express his feelings and thoughts). + Have you ever heard about this condition before? ‘* Show your empathy here if the patient knows the disease or has bad family experience about the disease, Showing empathy and sympathy : f the patient knows about the disease or has bad experience with it with one of the family members , show you empathy directly. « I'm really sorry for these bad news today. © highly appreciate your feelings, * [know how much these news are hard for you. © Bute sure that we are going to give you the full care and support as much as we can. Explain the disease simply without jargons: Do you want me to explain to you more abaut this disease? * Its disease due to disturbance in your defensive system which supposed to attack the bugs; in your condition it attacks your brain and main nerve cable disturbing the electrical impulses in your nerve cables. * It's coming in attacks on and off with different forms and times. a4Symptoms and complications: © Itcan come in attacks in different forms like visual disturbance, abnormal speech, shaking of the hands, unsteady gait, muscle weakness or altered sensation. Some symptoms can come together or separated. © The majority of patients with multiple sclerosis (Approximately85%) are left without major disability and.can live near normal life. Only minority (Approximately 15%) are left with major disability and might need walking aid. Management plan: «Referral to MDT ; So we are going to refer you to a MDT team from a nerve doctor , eye doctor ( if visual disturbance ) , a physiotherapist , a psychiatrist , a social worker and an occupational health care worker to give you the full care and management plan «Acute attacks: During the sudden attacks you will be given treatment through a needle called steroids for 3 to S days to shorten the course of the attack. * Prophylaxis: Some medications can be given to reduce the chance of the recurrence of the attacks. But it needs certain criteria to be given. It will be discussed and decided by the nerve doctor Pregnancy: © May i ask if you have a partner? © Are you are planning for pregnancy soon? ® You have to inform your women doctor and nerve doctor to make a MDT. to give you the proper advice and full eare during your pregnancy and to review your medications before pregnancy. Some medications might need to be changed during pregnancy. Showing empathy and sympathy again: «I'm really sorry again for these bad news. « Tunderstand how you are feeling now. + But be sure that we are gaing to give you the full care and supportSocial history: May I ask some social questions if you don’t mind? .. How much your condition impacts your job worker if her job is affected, Refer to a social worker if her social life is, affected. © With whom are you 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? « Finsorry to tell you that i if not curable; but we-are-guilg 1S db out eel to control it and give you the full care and support and regular follow up to live near normal life ... Any other concern? * Disease is presented differently from one patient to the other © But] want to reassure you that the majority of patients with MS (Approximately 85%) are left without major disability and can live near normal fife. Only minority (15%) are left with major disability and need walking aid. © You ean become pregnant without complications. © Ifyou are planning for pregnaney, you have to inform your women doctor and nerve doctor to make a MDT, to review your medications before pregnancy and give you the full care during your pregnancy Make summary: About the important points of the disease and management plan. Check understanding: Can i ask how much did you get from our discussion today’ Help: Emphasize again. «I'm going to give you some leaflets, brochures and websites to tad more about the disease. + will give you the contact number of our department to contact us any time if you have any worries.* Iwill give you also the number of MS society who meet regularly to share information and experience about the disease. Shake hands. Notes on the case: * During counseling for any chronic illness with female patient in child bearing period, you have to rise up the issue of pregnancy. You have to advise her if she is planning for pregnancy, she has to inform her specialized doctor and women doctor to make a MDT to give her the best advice and care. * Patients with MS need showing enough empathy and sympathy. + Explain the discase very simply. Don’t push a lot of suffocated information to the patient.Scenario: Mrs, Noha is 25 years old, She has been complaining of recurrent flank pain and bloody urine, Kidney fimetion done for her and was normal, US abdomen done for her and a diagnosis of (Adult polycystic kidney disease) is conformed. ‘You are SHO of the outpatient nephrology clinie today. You have been asked to discuss the results with her. Introduction: © Shake hands. © Introduce yourself = Confirm the patient identity Confirm Agenda of meeting Ask if the patient want anyone else to attend the discussion (for support. How much do you know about your condition’? ‘© Ask about her expectation. Breaking the new gradually: ‘The resulls of blood investigation and imaging have been released, and I'm sorry to tell you that the ishaging result is not.as we hope.. Stop for a while, © The image reveals that you have a disease called (Adult polyeystic fora while (let the patient to express hier feelings and thoughts) . © Have you ever heard about this disease before? rey disease} .. Stop Explain the disease simply without jargons: -Do you want me to explain to you more about the disease? © I's familial disease which runs in families, im which there is enlargement of both kidneys due to multiple sacs fifled with fluid invading both kidneys. It may be associated with sacs in other body organs like the liver spleen and balloon formation of any of blood supplies in the brain. Symptoms and complications: «The disease has some symptoms and complications like recurrent tummy pain, recurrent rupture of the sacs causing bloody water work, recurrent infection af your kidneys and stone formation, @ It may be associated with gradual deterioration of kidney function and kidney failure on the long nun. In certain stage kidney replacement therapy may be needed. ‘© 50% of patient with APCKD may need kidney replacement therapy at the age of 60. © Hypertension is one of the complications of the disease 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 contplications ah)Management plan: + Referral to MDT : So we ate going to refer you to MDT team from kidney doctor, brain doctor, physiotherapist, occupational health worker fo give you the full care and management plan, * Regular follow up : The management plan will be in the form of regular follow up of your kidney function aspiration of the sacs if causing pressure symptoms, and tresting any recurrent infection, * Blood pressure control : Your blood pressure necds to be strictly controlled on ‘one drug for hypertension. We will do imaging to the brain to confirm any presence of balloon dilatation of blood conduits, Special advices : New medications: if you are going to receive any new medication especially pain killer, you have to inform your kidney doctor. As many medications can worsen your kidney function. Vigorous sports: You have to avoid vigorous sports like ‘rugby and football to avoid rupture of the sags, Pregnancy: [f you are planning for pregnancy, you have (o inform your kidney physician and women doctor to make a MDT, to give you the full eare during your pregnancy to avoid any complications at all. we % v Showing empathy and sympathy; + How do you Feel now Mrs. Sara? © I'm really sorry for these bad news today. + highly appreciate your feelings. + [know how much these news are hard for you. + Bessure that we are going to do our best to control your condition and give you regular follow Cy Social history: May Task some social questions if you don’t mind? + What are you doing for living? .. How much your symptoms affect your job and usual daily activity? .. Refer the patient to an occupational health worker ither job is affected , Refer to the social worker if hor socal lite is affected, + With whom are you living? Are they doing well ? Who is supporting you at home? * Do you have children, brothers or sisters? Are they doing well? Any family history of sudden death? + Screening: As itis a familial condition, we can refer all your family members tothe genetic counseling tcam to discuss the methods af screening for early detection ofthe disease and regular follow up.© Are you financially supported? ‘© Do you smoke, drink alcohol? ‘Concerns: Do you have any concerns? -[sit curable condition Dr ? + Tim sorty to tell you that itis not curable , but we are going to do our best to control it and give you the fui care and regular follow up to avoid any complications. . Any other concern = ihhave kidney transplant now doctor? ‘You kidney function is within the normal range in the time being, No need to think about kidney transplant now. + [would ike to reassure you that only 50% of patient with this condition develop kidney failure atthe age of 60 © Weare going to give you regular follow up to check your kidney function from time to the other I'm pregnant doctor any action can be taken to prevent the disease For my baby? «The chance of your baby to have the disease is $0%_ And Fm sorry to tell you that the disease cant be prevented , we will refer you to the genetic counseling team to discuss all the details about sereening methods. Any method to prevent the disease in my future pregnancy? '* Some techniques can be used for ova seleetion. But unfortunately itis not available in ‘most ofthe centers. ‘What about screening for my children now doctor? + Genetic testing is not of a big value as it may has false positive and false negative results , and it will not alter the outcome af the disease = The golden standard of screening is at the age of 20 by imaging for early detection and early 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. © Tm going to give you some leaflets, brochures and websites to reacl more about the disease. ‘+ Ewill give you the contact number of our department to contact us any time if you have any worries or queries. = Shake hands, al)Notes on the case: + During counseling of chronic disease with female patient in the child bearing period, you hhave to rise up the issue of pregnancy. This is important to refer her to a MDT from a spevialized doctor and women doctor to give her advice and care. ‘© During counseling of chronic familial condition, you have to ask about other family members ‘and to offer referral to the genetic counseling team to discuss methods of screening. Legal issues : Screening for children bofore the age of 18 + ¥ Ifcarly diagnosis wouldn't be ofa big value and will not alter the outcome ofthe disease , it is better to wait until they reach 18 year old and to decide themselves. (ie APKD) > Ifearly diagnosis is of a big value and will alter the outcome of the disease, early screening ‘according to the parent wishes is considered. (ie HOCM)Scenario : Mrs, Hala is 27 years old. She has been complaining of recurrent tummy pain , loose motions and loss of weight for the last three months. Upper endoscopy done for her and a diagnosis of ccliae disease has been confirmed. ‘You are SHO of the gastroenterology on duty today. You have been asked to discuss the result with her Introduction: Shake hands. © Introduce yourself ‘+ Confirm the patient identity. * Confirm Agenda of meeting and take permission to start the discussion (We are together toxay to discuss the results of your blood tests and camera test dane for you, Is it aright with you?) ‘© Ask ifthe patient want anyone else to attend the discussion (for support), + Ask how much the patient knows about his condition. ‘+ Ask about his expectation. Breaking the news gradually: ‘+ The results of blood tests and camera test have been releasod., And I'm sonry to tell you that the result of camera testis not as we hope.. Stop for a while. ‘© trevealed that you have a disease called (Celiac disease) .. Stop for a while (Let the patient to express his feelings and thoughts) . Have you ever heard about this disease before? Explain the disease simply without jargons : Do you want me to explain for you more about this discase ? + Iisa disease due to bow! allergy to any type of food containing gluten. + This type of allergy results in disturbance of the defensive system which supposed to attack the bugs and germs. in your condition it attacks the Lining of the bowls eausing long standing soreness and mal absorption to main nutrients , minerals and vitamins. Gluten present in Oates , wheels, ryes , and barley involved in some types of food like Dread , 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 nun ifthe condition is not controlled, it may lead to certain type of cancer in the gut called lymphoma atthe 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 ghaten, 20Management plan: + Avoidance of gluten: The comer stone of the treatment is to avoid any type of food contsining gluten completely. If you avoid any food coataining gluten completely, then you ‘an avoid all the complications of the disease and live near your life. + Referral to MDT: We will refer you to a MDT team involving a bowel physician to provide you with csscntial nutrients, minerals and vitamins, a dietitian to give you the list of {ypes of food which has to be avoided completely and a social worker to support you socially. + Restaurant: There are some restaurants have special partitions for food free gluten, + Travelling: If you are travelling on ainplanes inform the crew about your condition to give you food free gluten. + Pregnancy: May Lask if you have a partner? Are you planning for pregnancy son? If you plan for pregnancy anytime, you have to inform your women doctor and bowel doctor to make a MDT to give you the proper care during your pregnancy. Showing empathy and sympathy: + How do you feel now Mrs. Amira? ‘Mm really sory for these bad news today. + highly appreciate your feelings. * I know bow much these information are hard for you. ‘+ But be sure that we are going to do our best to give you the fall social and medical eare as much as we can to live near normal life. Social history: + What are you doing for living? .. How much your illness affect your job and usual daily activity? . Refer the patient éo an occupational health worker if her job is affected. Refer toa social worker if her socal life is affected. + (ifshe is working as a crew, you have to refer to occupational health care worker to exchange it with an office job). ‘+ 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 drinks alcohol, advise him to ‘contact the dietitian as most types of alcohol contain gluten and mat trigger his condition. Concerns: Do you have any concems? Isit 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 concem? May Ihave cancer in the future dr? «If you avoided any food containing gluten , your condition will be controlled and the chance to have cancer will be extremely low ,What about small piece of pizza dr , like it so much? «Even small piece af pizza may trigger your symptoms, Therefore, itis better to avoid any type of food conntaining gluten even with a small piece. Make a summary: About the important points of the disease and management plan. ‘Check understanding: Check how much the patient got from the distussion? Help: + Fm going to give you some leaflets, brochures and websites to read more about the disease. + Ewill give you the contact number of our department to contact us any time if you have any worries or queries. ‘+ Anyone to drive you home if not admitted). ~ Shake hands Pr)Scenario : Mr.s Hers is 25 years old. She has been complaining of loss of weight and dizziness for the last six weeks, Blood investigations including short synactin test done for him and a diagnosis of Addison disease has been confirmed. ‘You are SHO of thr medical department oncall today . You have been asked te discuss the resulls with Mr-Hera Introduction: Shake hands. Introduce yourself. Confirm the patient identity. Confirm Agenda of meeting. [Ask the patient if he needs anyone else to attend the discussion (for support). Ask about his expeetation. Breaking the news gradually: © The results of blood investigations have been released, and I’m sorry to tell you that the results are not as we hope. Stop fora while. ‘© They reveal that you have a disease called (Addison disease) . Stop for a while (let the patient to express his (eelings and thoughts). + Have you ever heard about this condition before? ‘= [sit serious condition doctor? ‘© Itcanbe serious if untreated, but we are going to do our best fo control your conition. Explain the disease simply without jargon: Do you want to explain to you more about the disease? + Wsadisease due to diminished secretion ofa special protein in the body called cortisone , 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 atacks your glands. Symptoms and complications of the disease: + Cortisone is an important hormone in the body. ‘+ Deficiency of this homione leads to some symptoms and complications like loss of weight, decreased blood pressure, dizziness, cecreased glucose Jevel, electrolyte disturbance, tummy ppain, feeling and getting sick and tanned skin + Ifthe homnone severely diminished , it may result in severe dehydration , sever hypotension, comand even can be life threatening. yy‘Treatment plan: Referral to MDT: What we are going to do is to refer you to a MDT including a gland physician, a psychiatrist and a social worker to give you the fall care and appropriate plan of ‘management. Replacement therapy: The main treatment is replacement therapy of this hormone by oral tablets; You have to be strictly adherent to your medications to avoid complications of the disease to live near normal life. We will provide you with regular fellow up in the outpatient clinic to be sure of Your hormone level and offer you the full care. Rules of sick days: In special situations like fever, recurrent vomiting, recurrent loose ‘motions you have to duplicate your cortisone dose. If you felt any time that you are sick and unwell you have to seck medical emergency al once , as your condition may be unstable at that time and you may need urgent medical care Medic Alert Bracelet: You have to wear Medic Alert Bracelet to make the others to know about your condition and to carry one ampoule of cortisone to be given to you if needed in emergency situation. Pregnancy: May i ask if you have a partner?, Ifyou are planning for pregnancy, you have to inform your women and gland doctor to make a MDT to give you the full care and to avoid any complications during your pregnancy. Showing empathy and sympathy: «Pm really sorry for these bad news today, + [highly appreciate your feelings. + Tlatow how much these news are hard for you. ‘+ But sure that we are going to do our best to give you the full care and proper treatment. Social history: Mat ask what do you do for living? How much your illness impact your job and usual daily activities? .. 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 at all? Do you drink alcohol? Diein't you thing about giving up smoking ? We can help you by referring you to a smoking cessation clinic if you don't mind Concerns : Do you have any concems ? = Isit curable condition Dr? ‘© Pm sony to tell you that t's not curable but it can be controlled on medication. | you will be completely compliant on your medications and on regular fellow up , you can live near normal life. Any other concem ?“What about complications of steroid therapy Dr’? ‘© Steroids will be given to you as replacement therapy, to reach the normal level, So that, mostly you will not suffer frem complications of the long term use of sterois. * May be some soreness of the stomach which can be managed by simple medigation. ‘Make summary: About important points ofthe disease and management plan. ‘Check understanding: Check how much the patient got from the discussion? Help: Emphasize again. ‘+ Tim going to give you some leaflets, brochures and websites to be more aware about the disease. Iwill give you the contact umber of our department to contact us any time if you have any worries or queries = Shake hands‘Scenario: Mrs. Hend is 24 years old. She had becn complaining of 2 episodes of seizures, ‘during the last six weeks. Ct brain done for her, and it was nortsal. A diagnosis of epilepsy is ‘confirmed by the neurology consultant. ‘You are SHO of the neurology department on call today . You have been asked to discuss the diagnosis with her. Introduction: Shake hands Introduce yourself Confirm the patient identity. Confirm Agenda of meeting. ‘Ask if the patient need anyone else to attend the diseussion (or support). Ask how much the patient knows about your condition? ‘Ask about his expectation. Breaking the news gradually: ‘The results of blood tests and imaging of your brain have been released. And fortunately they are normal ‘© Bur the nerve doctor made a diagnosis of your, a condition called (Epilepsy)... Stop for a ‘while (Let the patient to express his feelings and thoughts) .. Have you ever heard about this discase before? Explain the disease simply without jargons: Do you want me to explain to you more about this disease? + Epilepsy is an active focus in the brain , sending abnormal clectrical impulses to the body , ‘causing uapredietable shaking ofthe body . # Itcan be precipitated by strong flashes, voices, stress and sleep deprivation, ‘+ The underlying cause ofthe disease is unknown for the most cases cand sometimes could be ‘familial. Symptoms and complications: ‘* Ttcan 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 fee! now Mrs. Amira? + Vmreally sorry for these bad information today. + highly Appreciate your feelings, Iknow how much these news are hard for you , But be sure that we are going to do our best to give you the fll eare to control your condition to live near normal life Treatment plan: + Referral to MDT : So what we are going to dois to refer you toa MDT from a nerve doetor social worker , occupational health care worker to give you the proper care and ‘management plan to control your condition + Medications: Treatment of this condition is by oral medications. You have to be completely compliant on these medications to control your condition and to dacrease the chance for any further attacks, Modification of life style: You have to follow some life style modifications: [Avoid percipients: Like strong flashes and voices, avoid stress and sleep deprivation. ‘Avoid life risky situations: If you are going to swim, you should be under supervision. ‘Avoid presence in high atiudes , beside fire and sharp objects. Don't lock inthe door of the bathroom, If you developed any seizures attacks in these situations, your life may be threatened. vy + Oral contraceptive pills : May i ask if you are receiving any oral contraceptive pills? You have to inform your women doctor and nerve doctor because anti-epileptic medications can change the efficacy of OCP and you may get pregnant ant time. * Pregnancy: May [ask if you have a partner? Are you planning for pregnancy? You have to inform your women doctor and nerve doctor to make a MDT to give you the full care during pregnancy as seizures attacks be harmafal forthe baby. 'Also anti-epileptic medications may be harmful to your fetus. Therefore, they will provide you ‘with anti-epileptic medications with the least harm for your baby. You may be given folie acid to decrease the harm, © 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 | year until you will be completely frec fom attacks. Your condition is risky on yourself and for the others ifyou developed any scizures attacks during driving,— Social history: Can [ ask some social questions? What are you doing for tiving? How much yout illness may affect your job and usual dally activities? .. I’m going to refer you | the toa social worker and An ‘occupational health. worker to manage any social or ocrupational troubles. {ifthe patient job is risky. Like, itrequires presence in high atitudes or sharp machines, YOU have ta contact the occupational health care worker to exchange it with an office job- «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? (Moderation of alcohol intake is crucial as it may tigger seizures attack) ‘Concerns: Do you have any concems ? -lsiteurable condition Dr ? ‘Tm sorry to tell you that it isnot curable. But itcan be controlled by avoiding triggers, ‘complete compliance on yout medications and regular follow up, Any problem if get pregnant Dr? «if you are planning for pregnancy, you have to inform your wotten doetor and nerve doctor to make a MDT to give you the full care during your pregnancy. 4 Seanutes may be harmful for your aby. Anti-epilepic medications may be harmful as well © But outweighing the risk versus the benefits , the risk of seizures attack is extremely more ‘Make summary: About the important points ofthe disease and management plan, Check understandings Check how much the patient got from the discussion? Help: Emphasize again «= Tmgoing o give you some leaflets, brochures and websites (read more about the disease, ‘2 [will give you the contact number of our department to contact us any ‘time if you have any Worries or queries. Anyone to drive you home? (If not admitted) 28Scenario; Mr, Kamal is 65 years old. He has been complaining of recurrent loose motions and loss of weight for the last 2 months. Blood investigations and CT abdomen, chest and pelvis confirmed a diagnosis of advanced cancer colon with metastasis to the liver and bones. The oncologist made decision that Mr. 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 son of Mr. Kamal. Introduction: Shake hands. Introduce your self Confirm the son’s 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 I'm sorry to tell you that they are not as we hope .. Stop for a while. «They revealed that your father has advanced cancer in his bowels... Stop for a while (let the son to express his feelings and thoughts). Empathy and sympathy: (Use body language, eye contact and voice tone impressive of sorrow) « I'mreally sorry for this bad news today. Thighly appreciate your feelings. * [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. + Give atissue if started crying.Explain the disease simply without jargons: May i explain to you more about your father's condition? © Unfortunately the blood tests and images done to for your father revealed that he has advanced cancer in his gut . It seemed to spread out to other organs like liver and bones. Symptoms and complications of the disease: I'm sorry to tell you that cancer has a lot of complications in the form of fever, loss of weight , fatigue , decreased appetite , easy infection , lumps and bumps and may be failure of the affected organs on the long run. ¢ P'msorry to tell you that your fatherss cancer seems to be in advanced stage. T'm sorry again for these bad information today. ‘Treatment plan: © So what we are going to do is to refer your father toa MDT from a Tumor physician, Macmillan nurse, a psychiatrist, a social worker, and pain management doctor to give your father the full care and proper plan of management, © The cancer physician assessed your father. And he believes that the cancer in your father’s condition is very advanced. And unfortunately, he is not fit for chemotherapy or radiation, and only for supportive care. ‘+ This decision was taken in the best interest of your father's condition, as he is not going to have any benefit at all form such therapies. On the contrary, he may suffer from the side effects of this treatment and even may shorten his life, The son: Why notchemotherapy doctor? Please do everything to keep my father alive. Thighly appreciate your feeling. This decision was taken by the aancer doctor in the best interest of your father's condition. ‘Chemotherapy has a lot of side effects and your father is going to suffer from tions of chemotherapy with no chance to improve. Palliative cares: We are going to give your father the full supportive care in the form of : Potent pain killers to keep him pain free all the time. Providing him with the appropriate nutrients and fluids that he needs. Correction of any electrolyte imbalance. ‘Treating any infection Referring him to the home health care team for regular follow up and management at home. wvvvySocial history: ‘+ What is your father doing for living? .. How much bis illness affect his life? And daily activities? . I'm sorry for that we will involve a social worker and occupational health care ‘worker to solve any sacial trouble he has. + With whom your father is Tiving? Are they doing well? Who is supporting him at home? + Is your father financially supported? + Does your father has any advanced direction or living well or power of attorney? (This question is for all eases of cancer). ‘Coneerns: Do you have any concems? + Tmsorry to tell you that the condition of your father seems to be very advanced. ( Honesty) + But, we are going to do our best and give your father the full medical, social, psychologica ‘medical care and to keep him pain free all the ime, (Reassurance) arcs ‘* Tmsorry to tell you that may be not for long time as his condition is very advanced. + Butbe sure that we are going to do our best and give him the full medical, psychological, and sacial care and to keep you pain free all the time. © May ask why you don’t want your father to know?(Explore reasons) * Lappreciate your feeling. But as your father has the full mental capacity, so that he has the {ull right to know everything about his condition and to share in the management plan. © Weill give him the information in pieces according to his worries. * We will involve a psychiatrist to manage any mood disturbance. Make summary: About the important points of mecting and management plan. ‘Check understanding: Check how much the som got from the discussion? Help: Emphasize again I'm going to give you some leaflets about advanced cancer bowel and palliative care to ‘be more aware about it, Im going to going to give you the contact number of our department to contact us any. time if toy have any queries Notes on the case: Ethical issues :Autonomy : > Aslongas the patient is competent and has the full mental capacity, he has the ight to know everything about his condition and to share the management plan with him. > The son or any of the relative doesn’t have the right to ask far hiding information from the patisat, > Ifthe patient asked about any worries or queries, he has the right to be informed. Provide the patient with information avcording to his queris, Beneficence - Non maleficence ~ Honesty - Justice Legal issues : > Discussion of DNR in cases of advanced disease is a matter of debate. It is different from one ‘examiner to the other. ® Lassume, it is better to be adherent to your task in the scenario & IFDNR decision is not mentioned in the scenario , no need to mention it as DNR is a decision of the consultant.Scenario: Mr. Jack is 65 years old. He has been complaining of fever and altered conscious level for the last two days. Ct brain and lumber puncture done for him. CSF analysis revealed meningococcal meningitis. ‘You are SHO of the neurology department oneall today. You have been asked to discuss the results with Mrs sara his daughter. Intreduction: © Shake hands. Introduce yourself. Confirm the daughter identity. Confirm agenda of meeting. ‘Ask if she want anyone else from the family to attend the discussion (for support). ‘How much do you know about your father’s condi * Ask about his expectation . zt Breaking the new gradually: * The result of the blood tests done to your mother have been released, and unfortunately I’m sorry to tell you that it is not as we hope .. Stop for a while. © The results revealed that your mother has a serious bug infection of the covering layers lining his brain, A condition called meningitis. Stop for a while (let the daughter to express her feelings and thoughts) .. Have you ever heard about this condition before Explain the disease simply without jargons : + Do you want to explain to you more about this condition Mrs. Sare? fection of the lining of the brain and main nerve cable by germs . * These germs are normal habitants on our bodies , but can be harmful and serious with diminished defensive system. * I'm sorry to say that it is a serious condition and even could be a life threatening condition if not treated o oSymptoms and complications = «The condition may be presented in simple symptoms or serious symptoms. © There are symptoms variation like fever , skin rash, headache , visual disturbance . feeling sick , vomiting shaking of the body , altered conscious level and may be coma. «The outcome of the disease ismostly good, and most patients make a good recovery if treated carly enough and received the full course of antibiotics. Management plan : © Sothat , we are going to refer your father urgently to MDT from a nerve doctor and infectious disease doctor to give him the proper care and management plan. © The treatment plan will be by receiving a course of antibiotics through a needle, » As I mentioned before, the outcome of the disease could be good and most of the patients are completely cured after receiving the full course of antibiotics. Isolation : © Don’the bothered if your father is isolated with droplet precaution. We are ‘going to wear a special mask during handling your father to prevent infection of the care givers. © During visits, you have to wear this mask as well, Screening and immunization for close contacts: © Can I ask if'your father had close contacts recently? © Allclose contacts of a patient with such infection have a risk of catching, the infection . However, the risk is still low, Close contacts usually means houschold members, or intimate kissing contacts. Thus, itis crucial to give us the list of the close contaets within the previous seven days. These people are offered a short course of antibiotics to prevent possible infection Notification : Meningitis is one of the noticeable diseases. Hence, we are going to notify the public health . Empathy and sympathy © How do you feel now? «I'm really sorry for these bad information today. + Thighly appreciate your feelings. Kz.+ [know how much these news are hard for you. © Besure that we are going to do our best to give your father the best care. Social history: = Can Task some social questions if' you don’t mind? What is your father doing for living? .. How much his illness impact his job ‘and usual daily activity? .. Refer the patient to an occupational health worker if his job is affected. Refer to social worker if his social life is, affected. With whom your father is living? Are they doing well ? Who is supporting ‘him at home? = [s your father financially supported? Concerns : Do you have any concerns ? | We can’t guarantee the outcome of the disease . But in general , the outcome of the disease could be good , and most of the patients are completely cured after they receive the full course of antibiotics. Summary: Summarize the important points of the disease and management plan. Check understanding: May I know how much did you get from our meeting today? Help: «Emphasize again , 'm going to give you some leaflets , brochures and websites to read more about the disease. # [will give you the contact number of ou department to contact us any time if you have any worries or queries . = Shake hands. 35Scenario: Mrs . Heba is 25 years old. She has been complaining of recurrent abdominal pain and bloody loose motions for the last 3 months. Blood investigations and colonoscopy were done for her. A diagnosis of wleerative colitis has been confirmed You are SHO of gastroenterology on call taday. You have been asked to discuss the new diagnosis with her. Introduction: + Shake hands, + Introduce yourself © Confirm the patient identity. © Confirm Agenda of meeting and take permission to start the diseussion (We are together taday to discuss the results of your blood tests and camera test Is it alight vvith you? © Ask if the patient want anyone else to attend the discussion {for support). # Ask how much the patient knows about hes condition. ‘+ Ask about his expectation, Breaking the news gradually: # The results of blood tests and camera test have been released. Im sorry to tell you that they are not as we hope... Stop for a while. © The results revealed that you have disease called (Ulcerative disease) .. Stop for a ‘while (Let the patient to express his feelings and thoughts) © Have you ever heard about this disease before? Explanation the disease simply without jargons: May I explain to you more about this disease? # Ilis a disease due to disturbance of the defensive system causing fong standing soreness of the bowels. Symptoms and complications: The disease has some symptoms and complications in the form of recurrent flaring up ‘with recurrent tummy pain , loose motions , bloody stool , mal absorption of many nuteients and vitamins causing significant loss of weight , anemia, fatigue, fragile bone and casy bleeding ++ F'm sorry to tell you that in some cases in the long run the condition could be complicated by bowel eancer if ot controlled and treated properly.‘« BUT.. All ofthese complications can be controlled and chance of eancer can be significantly reduced if you received a proper treatment and kept on regular follow up. (Hard news has tobe followed by reassurance) Management plan: + Referral to MDT: Our management plan mainly will be by referring you to a MDT team involving a bowel physician, a dietician, a social worker and an occupational health care worker to give you the appropriate care and regular follow up. «Treatment of the acute attacks: During flaring up of the condition, you may receive steroids through a needle to shorten the flaring. period. + Long term treatment: You will reccive some medications in the long run to ‘modify your defensive system fo control your condition and reduce flaring up of your illness «Diet control: The dictician will give you some adviees regarding your diet and will provide you with essential nutrients and vitamins. + Pregnaney: may I ask if you have a partner’? If you are going to plan for pregnancy any time, you have to inform your women and bowel doctor to make a MDT to stop ‘some medication which may harm the fetus , and give you the full care to avoid any ‘complications at al. Showing empathy and sympathy: * How do you feel now? «Tm really sorry for these bad news today. ‘© Lhighly Appreciate your feelings « Tknow how much these news are hard for you. + Be sure that we are going to do our best to give you the full care and regular follow as much as we can to live near normal life. Social history: May [ask some social questions if you don't mind ? © What do you do for living? .. How much your iliness affect your job and usual daily activity? . Refer the patient to an occupational health worker if her job is affected. Refer to social worker if her social life is affected . For example, if she is working as air hostess then you have to refer to an occupational health care worker to waite a ‘nedical report @ change her job to an office work . ‘© 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 drinks alcohol , advise her to contact the dietitian as aleohol may trigger her disease. Concerns: Do you have any concems?Isit curable condition Dr? “Unfortunately its not curable , but it can be controlled on. strict compliance on medications , diet control and regular follow up ~Any other concem ? May [have cancer in the future Dr? I'm sorry to tell you that the chance of bowel cancer on the long run is higher than normal people. But the chance will be extremely decreased with good control of your condition and regular follow un, What about complications of steroids Dr? # Steroid will be given to you ina short term in the acute attacks. Therefore, mostly ‘you are not going to suffer from the long term complications, We are going to give you regular follow up in the outpatient clinic to manage any side effects of this medication. 4 Outweighing the risk versus the benefits of steroids, the benefits are extremely more Make summary: About the important points of the discase and manageinent pla. Check understanding: Check how much the patient got from the discussion? Help: «Tm going to give you some leaflets, brochures and websites to read more about suleerative colitis. ‘© Till give you the contact number of our department {o contact me any time if you have any worries or queries - - Shake hands. ‘+ You task here is counseling for a chronic discase. + If mentioned in the scenario thatthe patient asked to discuss about side effects of steroids, then your approach will be different. It will be counseling for side effects of ‘medication, That is why, we didn't focus on complications of steroids here , andl we replied her concern of steroids in short focused way( Counseling for sie effects of steroids is discussed in another scenario), + Inccounscling for chronic illness in female patient, you have to raise up the issue of pregnancy to refer the patient for a MDT.Scenario: Mr, Robert is 25 years old, He had been complaining of syncopal attack which rnning in the track today, Echocardiography done for him and a diagnosis of hereditary obstructive cardiomyopathy bas been confirmed ‘You até SHO of the cardiology department on call today. You have been asked to discus the result with Mr. Robert. Introduction: # Shake hands. + Introduce yourself. © Confirm the patient identity. © Confirm Agenda of meeting. + Askif the patient needs anyone else to attend the discussion (for suppor) + Ask how much he knows about your condition? © Ask about his expectation, Breaking the news gradually: ‘© The result of the imaging done for you has been released. And I'm sorry to tell you that itis not as we hope ., Stop for a-while. + Itreveals that you have a heart condition call (Hereditary obstructive cardiomyopathy), Have you ever heard about this concition before? + sit serious condition doctor? + Pm going t tell you all the details about that condition if you don't ming. Explain the disease simply without jargons: «Hereditary obstructive cardiomyopathy isa familial condition which runs in families. © In this condition, the muscles of the heart is thickened and become weak to the extent that it can’t supply adequate blood flow to the brain and other body organs . + The thickened mascles of the heart also result in obstruction to the outflow of the blood through the cardiac outlets, ‘© Iisassociated with disturbance of the electricity of the heart(Represent by a simple drew to the Surrogate if possible) Symptoms and complications: + The symptoms of the disease vary from one patient to the other according to severity of the disease, ‘+ Symptoms are different and variable, in the form of chest pain , racing of heart beats, shortness of breath with exertion , dizziness , syncope . swelling due to retention of the water and salts ‘in the body and im sorry to tell you may be heart failure in the long run Kh)+ T'm sorry to tell you it can be serious and even can result in sudden heart arrest and death in severe cases., but be sure that we are going to give you the care and proper management, Empathy and sympathy; + How do feel now Mrs.(Sameer) ? « Pmreally sorry for these bad news today. + Lhighly appreciate your feelings, + T know how much these news are hard for you « Besure that we are going to do our best to give you the full eare to control your condition Treatment plan: Let us talk about management plan in your condition + Modification of life style: Modification of life style is crucial in your condition .You are advised strongly to avoid vigorous exercise , smoking and alcohol intake + Referral to MDT : So what we are going to do is to refer you to a MDT from a heart physician ,a heart surgeon , social worker , occupational health worker to give you the proper care and management plan . * Oral medications: Treatment of this condition can be in the form of oral. medications to decrease the blood load on the heart and control the heart rate and shythen, * ICD: Some Implantable devices can be used in case of heart beats irregularity to control the heart electricity and therefore control the heart rate. © Surgical intervention: Surgical intervention ean be an option in some severe cases , which don’t respond to oral medications., The whole management plan will ‘be discussed with the heart consultant in details. © Avoidance of vigorous sports: You are advised to avoid vigorous exercise and sports to avoid putting the hearl under pressure and complications, Driving: May Task if you drive. # You have to inform DVLA about your condition. + I'mssorry to tell you that you will be banned from driving until you will be completely free from attacks . as your condition is risky on yourself and for the others during driving . Pregnancy + (iffeenal patient) ; You have to rise up the issue of pregnancy in any female patient with newly diagnosed chronic ilness. + Ifyou are planning for pregnancy, you have to inform your women doctor and heart doctor to make MDT approach to give the proper advice and carc. 40Social history: ‘© What are you doing for living? . If the patient is working as a pilot or bus driver: 'm sorry driving an airplane is very dangerous for your life and for the passengers + 88 you may develop syncope anytime during driving, * So we will refer you to an occupational health worker to. exchange your job with anolber office job. * For any hereditary condition . you have to ask about other family members for referral to genetic counseling team. + Do you have children, brothers or sisters? Are they doing well? We can refer you all tothe genetic counseling team to discuss methods of screening for early detection of the disease and to start early management plan if exists, With whom you are living? Are they doing well? Who is supporting you at home? ‘Are you financially supported”? * Do you smoke, drink alcohol? If. ‘smoking: Smoking may worsen your heart condition. Therefore we can refer you to the smoking cessation clinic to help you to give up smoking. If drinking alcohol : Drinking aleohol can worsen the heart condition as well So, you are advised strongly to give up drinking alcohol, Concerns : Do you have any concerts ? ~Is it curable condition Dr? © I'm somry to tell you that itis not curable, but it can be controlled with strict compliance on medications and regular follow up. What about my childern doctor? + Tm sorry to tell you that every one of your children has chance of 50% to have the Aisease. + We-will refer them to genetic counseling team to discuss methods of screening either by genetic test of imaging of the heart. Make summary: About the important poins of the disease and management plan, ‘Check understanding: Check how mueh the patient got from the discussion ? Help: ‘+ Emphasize again. 1'm going to give you some leaflets , brochures , websites to read. ‘more about the disease * Iwill give you the contact number of our department to contact us as well to coniact us any time if you have any worries or queries. © Anyone will drive you home ? (If not admitted) “Shake hands cy — Lert eee eee StScenario: Mr. Hady is $5 year old known case of cryptogenic interstitial lung disease for the last 7 years. He was admitted 2 days back because of exacerbation of his ILD . ‘He was assessed by a pulmonology consultant who made a decision to put him on palliative care on discharge. You are SHO of pulmonology department on call today. You have been asked to discuss this issue with Mr. Samir , his son . Introduction: © Shake hands. * Introduce yourself. * Confirm the son’s identity. * Confirm he is the next of kin of Mr.Hady + Confirm if he has permission from his father to discuss his condition. + Ask iffthe patient need anyone else to attend the discussion (for support), + Confirm Agenda of meeting (We are together today to discuss the condition of your father and further plan of management, Is it alright with you?) Can i know how much do you know about your father’s condition? Ask about his expectation. Explanation of the condition of the patient: ‘+ Your father has been complaining of long standing scarring of his lung tissue, a condition called interstitial lung disease. * He was admitted few days ago because of exacerbation of his condition, which resulted in breathing distress and higher requirements of oxygen and supportive breathing, + He was assessed by lung consultant, who see that he reached an advanced stage of lung scarring. I'm really sorry for that. * Therefore, he made a decision in the best interest of your father to keep him on palliative care, which is the supportive care, * Have you any idea about this kind of care?Explanation of the palliative care: Palliative care includes: No need for any active treatment for lung searring, as it has no role in the time being. To support your father with long term oxygen therapy. To provide him with sedative medications to relieve his stress. To involve a psychiatrist to manage any mood disturbance. To include home health team for regular visits for assessment and care at home. Showing empathy and sympathy : I'm really sorry for these bad information today Thighly appreciate your feelings. I know how much these news are hard for you. But be sure that we are going to give you father the full care and support as muchas we can. Social history: May Lask some social questions if'you don’t mind ? What is your father doing for living? .. How much his illness impact his 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 your father is living? Are they doing well ? Who is supporting him at home? Does he has any advanced directive , living will or power of attorney? Ishe financially supported? Does he smoke at all, drink alcohol? Concerns: Do you have any concerns ? = There is no hope doctor? I'm sorry to tell you that he reached an advanced stage of his condition. But we are going to give him all the social, psychological and medical support and to keep him out of stress all the time. Avoid giving no hope ot false hope. (Don’t reply: There is hope or there is hope)Make summary: About the important points of the disease and management - Check understanding: Check how much the son got from the discussion? Help: Emphasize again. + I'm going to give you some leaflets, brochures, websites to read more about Advanced lung scarring and supportive care, | will give you the contact number of our department to contact us any time if you have any worries or queries. -Shake hands. N.B : You have two tasks here : > Breaking bad news of the advanced stage of ILD. ; > Explanation of the palliative care. “Any patient with advanced condition like cancer with metastasis , Advanced ILD or COPD , you have to ask about advanced directive . living will and power of attomey. 4 Discussion about DNR here is controversial if not mentioned in the scenario. 4 |tis better to be adherent to your task in the scenario, and not to mention DNR if it is not mentioned in the scenario. DNR is a decision of the consultant. 44Scenario: Mr. Jack is 45 years old, He has been working in shipyards for the last 10 years, He has been complaining of cough and loss of weight for the last ‘wo months CT chest, abdomen and pelvis done for him and a diagnosis of diffuse mesothelioma with metastasis to the live has been confirmed - ‘You are SHO in the medical department . You have been asked to discuss the results with Mr. Jack, Introduction: + Shake hands. Introduce yourself. Confirm the patient identity. Confirm Agenda of meeting. ‘Ask if the patient want anyone else to attend the discussion (for support) ‘Ask how much do you know about your condition? + Ask about his expectation. Breaking the new gradually: + The result of the imaging done for you has been released .. and I'm sorry to tell you that unfortunately it is not as we hope .. Stop for a while « Itrevealed that you have cancer in the ining of your lungs .. Stop for a while (Let the surrogate to express his feelings and thoughts). Showing empathy and sympathy: + Tm really sorry for these bad news today Mr. Jack. Ihighly appreciate your feelings. know how much these news are hard for you . Be sure that we are going to give you the full and best care . ( Show your empathy by eye contact , voice tone and body language . Give the surrogate a tissue ifstarted crying). 45Explain the disease simply without jargons: «Do you want to explain to you more about your condit on? | Unfortunately the results of the images done to you revealed cancer inthe lining of your lungs, a condition called (Mesothelioma) - = The eancer seems to be advanced and spread to other organs inthe body . This type of cancer is most probably related to your job due to long term exposure to industrial materials at your Work. Symptoms and complications: ayers cancer may has variable symptoms like fever , sweating , loss of weight , cough , shortness of breath and gradual deterioration of the general condition . Management plan: = Furthermanagement plan will be by referring you te a MDT team including einer doctor , Macmillan nurse , psychiatrist, social worker, social ‘worker and occupational health worker to give you the proper care and management plan. «The cancer doctor will discuss with you the details of the management plan like cycles of chemotherapy or radiation. Disablement compensation: s Lwould like to inform you that you have the right to claim for compensation as your cancer is related to your job: You have to fill and post a special claim form. © Then you will be assessed by a medical advisor to assess your degree of disability to decide the amount of benefit you deserve. ¢ And if you are not satisfied with that compensation, you can contact & Iawyer to claim for more compensation benefit. Empathy and sympathy again: eHow do you feel now Mr. Jack? © (understand how much you feel right now. “eRe sure that we are going to give you the full social, psychological financial support and keep you comfortable and pain free all the time 46Social history: Can | ask some social questions if you don’t mind? © With whom you are living? Are they doing well? Who is supporting you at home? © Do you need any social o financial support? © Do you have advanced directive, living will or power of attomey? Concerns: Do you have any concerns? There is no hope doctor? = I'm sorry to tell you that your condition seems to be advanced,.Honesty © However, we are going to give you the full social , psychological , medical support and to keep you comfortable and pain free all the time. Reassurance For how long I'm going {6 live doctor? © It varies from one patient to other according to the progression of the cancer, response for treatment and general condition of the patient, Summary: For the important points of the disease, management plan and disablement compensation. Check understanding: Can I know how much you did get from our meeting today? Hel «Emphasize again. I'm going to give you some leaflets, brochures , websites tread more about the disease. ‘© Iwill give you the contact number of our department to contact us any time if you have any worries oF queries . - Shake hands. NB: ‘Your task here is : © Breaking bad news of methoselioma = ‘The right for claim for disablement compensation. -In a case of cancer with metastasis , ask about advanced directive, living will and power of attorney‘Scenario: Mr. Adam is 27 years old, He hus been complaining of fever, loss of weight and Iymphadenopathy for te last eight weeks, Blood investigation , open biopsy and Pan CT done for him. ‘A diagnosis of Hodgkin lymphoma (Grade 2b) is confirmed, The oncologist decided to insert Hickman line to regimen of chemotherapy. ‘You are SHO of the oncology department on call today. You have been asked to discuss the results and Hickman line with Mr. Adam. Introduction: © Shake hands Introduce yourself. ‘* Confirm the patient identity. + Confirm Agenda of meeting and take permission to start the discussion (We are together today to discuss the results of your blood tests and imaging. Is i alright with you ?) ‘Ask if the patient want anyone else {o attend the diseussion (for support) Ask about his expectation. Breaking the news gradually: “The results of blood tests, snip test and imaging have been releascd, Lm sorry to tell you that the results are not as we hope .. Stop for a while. They revealed thal you have a type of eancee of the lymph gland called (Hodgkin lymphoma) .. Stop for a while (Let the patient to express his feelings and thoughts) Showing empathy and sympathy: «Thm really sorry for these bad news today. + Thighly appreciate your feetings. © T know how much these news are hard for you. ‘© But be sute that we are going to do our best and give you the full care. ‘# The good news is that it could be curable condition. A lot of cases are completely cured afer full course of chemotherapy. Explain the disease simply without jargons: May Iexplais to you more about the disease if you don’t mind? ‘© Hodgkin lymphoma is cancer ofthe lymph glands, which exist in different sites all over the body. + Ithas some symptoms in the form of loss of weight, fatigue , fever, night sweat, anextia and easy infection due to disturbance of the defensive system + BUT... Treatment is available for this discase and a lot of cases were completely eured from the disease after treatment. (Reassurance after bad news).Treatment plan: + Referral to MDT: > What we are going o do is to refer you to MDT from blood physician, Macmillan nurse, psycho therapist, social worker 19 give you the appropriate care and plan of management. + Chemotherapy : ‘The main treatment plan isa course of chemotherapy (explain advantage and disadvantage of chemotherapy ) chemotherapy can destroy the nasty growth and may cure the cancer completely .. Itfhas some complications in the form of feeling or getting sick that can be treated by some medications, falling of hair which will grow again, you can use a wig during that time, your defensive system may be disturbed and you might get easy infection and we will give you a card and follow your condition and give you antibiotics if had infection any time. Ourweighing the risk versus the benefits of chemotherapy, the benefit are significantly more. ie o " Hickman line explanation: Chemotherapy has to be given though a wide bore needle called hickman line, © Explanation of Hickman line: It is wide bore needle which will be inserted in a large blood conduit under local anesthesia xo numb the area of insertion and under aseptic condition, done by expert doctor who did such procesture hundreds of times before. + Advantage: This line has advantage of providing easy avcess forthe cycles of chemotherapy. * Complications: It has 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, © Consent: If you agree io 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 any time, you hhave the sight. Social history: * Can Tknow what are you doing for living? How much your illness impact your job and usual daily activities? - 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? Who is supporting you at home? + Are you financially supported? © Do you smoke at all? Drink alcohol? Concerns: Do you have any o a Iknow that chemotherapy can cause infertility doctor? + Infertility is one of the complications of chemotherspy, which can be irreversible some times, + Bat, we can overcame this problem by saving some of your sperms in sperm bank to be used in the future. You ean bring your wife next time to discuss this issue with both of you. 49Ist cone d a A lot of cases were completely cured after the full course of chemotherapy Make a summary: About the important points of the disease and management plan. Check understanding: may i ssk if you got all the information in our diseussion today? (Ifyou have time) Help: # Fimgoing to give you some lafets and websites to read more about the disease and Hickman Tine. 4 Trill give you the contact aumber of our department io contact ws if you have any worries ‘or queries = Shake hands. Notes on the casi You have two tasks here : + Breaking bas news of Hodgkin lyrmphoma + Counseling for Micknaan line Ethical + Autonomy - Beneficence - Non Maleficence ~ Justice ~ Honesty Legal issues : + Consent 50Scenario : MrJack is 35 years old. He has been complaining of fever , productive cough and loss of weight for the last 6 weeks . Chest x ray, Acid fast bacilli and TB PCR revealed a diagnosis of active TB. You are SHO of the medical department on call today. You have been asked to discuss the results with Mr. Jack Introduction: * Shake hands. * Introduce yourself. + Confirm the patient identity. * Confirm Agenda of meeting, Ask if the patient want anyone else to attend the discussion (for support). Ask how much do you know about your condition. * Ask about his expectation. Gradual breaking of the news: * The results of blood tests and imaging have been released, and im sorry to tell you unfortunately they are not as we hope .. Stop for a while. + They revealed that you have a superbug infection in your lungs called (Lung Tuberculosis)... Stop for a while (Let the patient to express his feelings and thoughts) .. Have you ever heard about this type of infection before’? + Is itserious condition Dr ? It can be serious if untreated, but we are going to give you full eare and proper management plan. Explain the disease simply without jargons: Do you want me te explain to you more about your condition? © Unfortunately investigations revealed that you have lung infection with a serious bug called tuberculosis. ‘© Tuberculosis can be transmitted by droplet infection from another patient or 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 on the long run. 51I'm sorry to tell you that it even may threaten your life if not treated properly. Ie may spread to other organs like brain, kidneys and the bones if not treated perfectly. Treatment plan: Reassurance: The good news is that it is a curable condition, and most of the patients are completely cured after receiving their full course of anti TB medications . Notification: So what we are going to do is to notify the preventive medicine department Referral to MOT : We will refer you toa MDT from a lung physician , infectious disease doctor , social worker , and occupational health care worker to give you the proper plan of management. Isolation: This condition needs isolation for at least two weeks until you phlegm is completely free from the bugs , and you are not infectious any more. Can i ask if the circumstances at you home are suitable for isolation? May i confirm if you are going to be adherent to isolation at home? Anti T8 medications : The management plan will be in the form of a full course of anti TB drugs which will continue for 6 months with regular follow up in the outpatient clinie to confirm that your condition is improving - You have to be compietely adherent to your medications to eradicate the ‘bugs and to guarantee the full cure Side effects of Anti TB medications: These medications have some side effects like pins and needles in the hands and feet , change of urine color , elevation of liver enzymes. But we will follow up your condition to detect any side effects to manage at onee. Outweighing the risk versus the benefits of the drugs , the benefits are extremely more Screening: We will do sereening 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. $2Empathy and sympathy: * How do feel now Mr.Jack ? © [’mreally sorry for these bad news today. © Thighly appreciate your feelings. ‘* Tknow how much these news are hard for you. = 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. (Use empathic eye contact, body language and voice tone) Social history * What are you doing for living?.. How much your illness could affect your job and usual daily activities? © [fhe is working ina risky infectious job tell him that you will refer him to ‘the oecupational health worker who 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 a social worker if his social life is affected, © With whom you are living at home? Are they doing well? Who is supporting you at home? © 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. Smoking may worsen your condition and delay your recovery. Advice to stop alcohol intake too. Concerns : Do you have any concems ? -Isif curable condition? * tis acurable condition in most of the cases after receiving the full course of anti TB medications. © Your condition will improve within few weeks, and you can enjoy your life. © Compliance and regular follow up is crucial to guarantee the full cure .. Any other concerns? ~ I want to go home and take medications at home please ‘ * Can ask if the circumstances at you home are suitable for isolation? * May iconfirm if you are going to be adherent to isolation at home for two weeks at least?@if the circumstances at you home are not suitable for isolation or the patientis not going to be adherent to isolation athome: Itt is better to stay in the hospital for isolation in 2 special room until your a tition is stabilized, and you arent infectious any more for the others. @lfthe patient refused isolation at the hospital, clarify complications of discharge without isolation: otf you are discharged now without isolation for two weeks atleast» YOR may infect your close contacts. In addition, your condition could deteriorate without close observation. if the patient still argues and refusing isolation: = Never mind, I’m going to involve my consultant for another meeting to convince you more and reply any worries you have. (Avoid confrontation) Make summary: About the important points of discussion and management plan. Check understanding: Check how much the patient got from the discussion? Help: Emphasize again. «I'm going to give you some leaflets , brochures and websites about tuberculosis and importance of isolation jn the first two weeks © Will give you the contact number of our department to comtact us any time Ifyou have any worries or queries - Shake hands Notes on the case: You have 2 tasks here: Breaking bad news of lung tuberculosis. © Managing the dilemma of refusal of isolation. >} The patient can be isolated at home if he accepted adherence to isolation, and the circumstances at home are suitable for isolation 54If the patient refused adherence to isolation, and the circumstances at home are not suitable for isolation, therefore he is not allowed to be discharged. Try to convince him kindly to stay in the hospital until his sputum would be free from the germs, showing the hazards of being discharged in the time being on himself and for the others. Avoid confrontation with the patient. Involve your consultant at the end if the patient still insisting for discharge and refusing isolation... ‘This patient has to be admitted under the common low and not allowe d to be discharged against medical advice ifrefusing isolation at home or at the hospital. ( Legal issue) (Admission under the common low). a aScenario: Mr.Jack is 32 years old has been diagnosed to have Guillain Barre Syndrome 2 weeks ago. He was admitted three days ago with respiratory failure and was intubated ‘Now, he is extubated and breathing spontaneously . He was evaluated be neurology consultant who assumed that his lower limbs is severely disabled and mostly will be bound to bed. ‘The wife was informed 2 weeks ago that his condition has good prognosis. You are SHO Neurology on call. today. You have been asked to discuss this issue with Mrs Jack his wife. Introduction: ¢ Shake hands. + Introduce yourself, * Confirm the patient identity. Ask if she is the next of kin of the patient. Ask if she has permission from her husband to discuss his condition, Confirm Agenda of meeting. Ask if the patient want anyone else to attend the discussion (for support). How much do you knew about yours husband’s condition? Wife : My husband was diagnosed to have (Guillain barre syndrome) two weeks ago. One neurology doctor told me that he going to walk again and the disease has a good outcome Now doctor, my husband was severely deteriorated, and he was put on assessed mechanical machine and had severe lower limbs weakness . Empathy and sympathy: T'm really sorry for what happened to your husband. Thighly appreciate your feelings. T know how much this event is hard for you. Be sure that we are going to give him the best care . Show your empathy by eye contact, voice tone and body language. Give the surrogate a tissue if started crying)Explanation of the condition of the patient: * Can tell you more about your husband’s condition if you don’t mind? + Your husband has been diagnosed to have a condition called (Guillain Barre Syndrome). = Accondition due to disturbance of'his defensive system which supposed to attack the bugs. In this condition, it attacks the nerve cables of the limbs causing limb ‘weakness, and sometimes nerves cables ofthe chest muscles causing shortness of breath and may be failure of breathing * The disease acts differently from one patient to the other. It can be presented with mild Timb weakness to severe limb and chest muscle weakness causing significant limb weakness and failure of breathing. which could require assessed mechanical machine to support his breathing, + The disease could present in recurrent unpredictable attacks from time to the other + Treatment of this disease during the flaring up is by giving a medication through a needle called (Lmmunoglobulia), which sometimes doesn’t give a desired results. Outcome of her husband's condition: + I'm sorry to tell you that the nerve consultant see that yous husband presented this time with severe form of the disease, and his lower limbs was severely’ disabled. Mosily probably be is going to be bound to bed. ‘Wife Sadly: But I was informed 2 weeks ago that he is going to walk again doctor??? justification of the neurologist opinion two weeks ago: + May be your husband presented 2 weeks ago with a mild form of the disease with a good response for the treatment at that time. That is why, he informed you that he is going to walk again with a good outcome. However we ate going to contact hin 0 now what was the situation at that time. ‘+ Butas Itold you, this discase is unpredictable with recurrent attacks. Unfortunately he presented lnree days back with a severe form of the disease , with sever Lower limbs and chest muscle weakness which resulted in failure of breathing and required assessed ventilation . Now he is off mechanical machine and is breathing spontaneously. Management plan : May I tell you about the future management plan?” © Weare going to refer him to a MDT team including a nerve doctor, psychiatrist to rmanage any low mood or depression , a physiotherapist to give his the prober care and a social worker to manage any social troubles. Empathy and sympathy agaii © How do you fecl now Mrs. Jack ?