28. 29, 30. 31. 32 33. 34, 35, 36. 37. 38. Spirometry COPD Spirometry restrictive pattern... Lung cancer (Med) 264-Post viral runny nose/cough (Med) Pleural effusion (Med) .... Occupational lung disease/Mesothelioma/Lung cancer (Med). Pneumonia (Med) 119-Haemopneumothorax CT. Pneumothorax IPT counselling...» Condition 097 Abnormal GTT. 357-HPV 16 positive (Gen) 359-Urine obstruction, uterine fibroids (Gen) 360-Vaginal discharges. Table (Gen). Endometrial thickening. Mid cycle ovulation (mittelschmer2)..... osteopenia 22.HIV during pregnancy. Thalassemia Minor... 59-Parapneumonic effusion (Ped) Error! Bookmark not defined. .. Error! Bookmark not defined. Error! Bookmark not defined. Error! Bookmark not defined. ... Error! Bookmark not defined. Error! Bookmark not defined. Error! Bookmark not defined. Error! Bookmark not defined. Error! Bookmark not defined. Error! Bookmark not d Error! Bookmark not Error! Bookmark not d .. Error! Bookmark not defined. Error! Bookmark not d ed. .. Error! Bookmark not defined. .. Error! Bookmark not defined. Error! Bookmark not defined. .. Error! Bookmark not defined. Error! Bookmark not defined. Error! Bookmark not defined.8 cases of counselling 1. SIDS counselling You are a GP. A mother of 6 weeks old new born here for consultation with you. Her neighbour had lost their 4 months baby due to SIDS and she was concerned about it. TASKS Take History for 4 minutes 2.Counsel about her counsel Positive points in history: * She and husband both smoker. * Usually smokes outside sometimes in hall. * Baby sleeps in their room in separate cot * Immunize happy to do. * And is breastfeeding BHistory: BSorry to hear about your neighbour's baby. al know you are concerned about it. But before explaining about it, will it be alright if | ask you few questions? @Pregnancy questions BHow did the pregnancy go? Any complications? @Did you have any DM, hypertension, infections during pregnancy? Delivery questions @How was the delivery? At what term? Mode of delivery? Did the child cry after birth? Did the child had prolong hospitalization after birth? Jaundice? Prematurity? @lmmunisation: have you started the child immunization? @Nutrition: Breast feeding? Or bottle feeding? How is the feeding going on? Is the child feeding well? any issues with nappies? Bowels? Gaining weight?General health: Any fever? Rash? @Development and Social History @How coping? Happy family? @smoking and alcohol history of her and partner? BSleeping position of child? Sharing of cot? Do you all sleep together on the same bed? BHow does the baby sleep, over the back or over the tummy? Do you have separate bed for the child? In the baby’s bed have you kept anything around like toys? @SADMA BDo you use alcohol, elicit drug? Smoking? @How is your mood? @Do you have enough support? PCOUNSELING: al will be explaining to you the condition, SIDS is also called as cot death and it is one the major cause of death of a child under age of 1 yr. most of the time, the cause of the condition is not known, but there are some risk factors that can be modified to prevent the occurrence. ®Please continue breastfeeding. It is good that you have opinion about immunization and help to prevent life threatening infection Smoking is one of the risk factor. passive smoking is one of the risk factors 1 will arrange another appointment to talk about quitting smoking. Please think about it a for the betterment of your child. 2Avoid pillows or toys around the cot. Place the child in separate bed. BThere are few things that you need to take care of when the child is sleeping, Do not sleep together. Wrap the child properly but head is exposed. Ensure the baby not overly covered, since hyperthermia is a risk factor. Place the baby in supine position (on his back) with no pillow. Whenever the child is active, put the child in prone position under supervision. (tummy time) BARWhat can | do to help reduce the risk SIDS ? -Sleep baby on their back -Keep head and face uncovered -Keep baby smoke free before and after birth -Provide a safe sleep environment night and day -Sleep baby ina safe cot in parents' room, -Breastfeed baby 2. 102-HSIL test result (Obg) Cervical Changes Cervical Normal <—— isi, ——— HSI > “acer 32 years old woman comes to your GP for the result of cervical screening. HPV is positive, and pap showed HSIL (High-grade Squamous Intraepithelial Lesion). Tasks: - Take history- Explain result and treatment History 1-Approach can see that you are here for the results of your cervical screening is that right? Before that, can | just ask you a few questions in order to assess your current health and correlate the history with the results? 2-5Ps questions Periods When was your LMP? Are they regular? How many days of bleeding and how many days apart? Any pain or heavy bleeding during menstruation? Any bleeding in between menstruation? Partner/Sexual Are you sexually active? (Yes) Are you in a stable relationship? (Yes) How long have you been in relationship? (3 years) What type of sexual activity do you prefer? Do you practise safe sex? Do you use condoms? Have you or any of your partner ever been tested for STI? Any pain during intercourse or bleeding after intercourse? Pregnancy Have you ever been pregnant before? Are you planning for pregnancy? Any previous miscarriage? Pill have you had Gardasil vaccine 3-Symptoms questions Any tummy pain, vaginal bleeding or discharge? Any Loss of weight, loss of appetite, lumps or bumps? 4-General -Medications and allergies -PMH, PSH-SADMA -Occupation -Family history of any cancer? Why you ask me this question? We need to ask such questions as a routine to assess the general and reproductive health. Explain results Here are the results with me, let me explain it and | am going to draw a diagram to be clearer. If you have any question or confusion feel free to interrupt me. First, these tests are part of, |. The aim for this screening is to identify any early changes in the cervical cells before becoming nasty or cancer. So, itis This is the womb, and this is the neck of the womb or the cervix. In cervical screening we S¢rape ‘lsamplelof tise to detect the presenie6 OFTHPV which is a type of virus that can cause abnormal growth and changes in the cervix. The result shown to be HPV +ve which mean that you have this virus This virus usually transmitted by ditéct'skin to|skin contact usually from/sex and any sexually This sample of tissue also been examined for the presehes of BbHOMBICEIE as there are levels of cervical cells abnormality. The test showed that you have a high grade squamous intra epitheliallesion which is a moderate to severe abnormal cells of the cervi Is it cancer doctor? The presence of HSIL 68s Rot mean that you have cancer; * some cells are growing and dividing abnormally, and * itis good that we picked it up * because, if not treated these can turn into cancer. * So, we can prevent this with early treatment.Management As you have abnormal cells so further tests need to be done for you: PTS WUE GUEprRnANE), Fa, es, UCE, LT Would like to Fefer you tola specialist for colposcopy which is a procedure when the doctor use light and magnification to see the vaginal and cervical tissues more clearly. (Critical error) in some cases they ili aKS Ssripl66t WoUFESHVCSI SURE n a procedure called biopsy Treatment will be decided by the specialist. Options could be + suspected segment ESREBIOB) the upper segment cannot be seen which is taking a What if | become pregnant? It can couse [RESTSESIANSSDRAAREE or having labour prior tothe exact date called preterm labour. But all of these will be managed and prevented accordingly by frequent check-ups. Types of cervical biopsies include: 0 endocervical curettage: cels SRESEESESEMERRENGNE ofthe cervical canal 1 Punch biopsy: 2 RSIS of cervical tissue is removed Cone biopsy (or conization|: a Eoi@sshaped Sample of cervical tissue is removed Some women have bleeding and/or discharge after a biopsy. Others have pain that feels like menstrual cramps. Common treatment methods include:Cold knife conization (also called cold knife cone biopsy) is a procedure in which a cone-shaped piece of abnormal tissue is removed from the cervix using a scalpel or laser knife. Some of the tissue is then checked under a microscope for signs of disease, such as cervical cancer. This procedure is done at the hospital and requires general anaesthesia Cryotherapy a procedure in which an extremely cold liquid or an instrument called a cryoprobe is used to freeze and destroy abnormal tissue. A cryoprobe is cooled with substances such as liquid nitrogen, liquid nitrous oxide, or compressed argon gas. Also called cryoablation and cryosurgery. This procedure is done in your doctor's office. It takes only a few minutes and usually does not require anaesthesia. Laser therapy is a procedure that uses a laser (narrow beam of intense light) to destroy abnormal tissue. This procedure is done at the hospital and general anaesthesia is used. LEEP (loop electrosurgical excision procedure) is a procedure in which a thin wire loop, through which an electrical current is passed, to remove abnormal tissue. Local anaesthesia is used to numb the area. Your doctor usually performs this procedure in the office. It takes only a few minutes, and you will be awake during the procedure.Pap test results and possible next steps 3 a ae SS ge See pri Sammon) (Sha acer ers be orien Celis Of Undetermined —iritation, some infections, such as a yeast infection, growths such as polyps Significance ‘or cyst that are benign (not cancer), and changes in hormones that occur pes a ee ree arene Seren temeset SS eras eas, ae ae AGC ‘AGE moans that some glandular cls were found that do net look norma ‘typical Glandular Cells "2% testing s usualy recommended Dacela next cape: Cripneopy and Np Cae the a9 Tsing earn nose to Jeam about these procedures, LSIL {StL ic comotimae called ld ayepiea ft may alo be calla CIN eer eet areata low-rade Squamous Saori sist Aap be ees oy ean oro intraepithelial Lesions yrtner testing is usually done to find out whether there are more severe eee pect wa ee eee eri eee een tra ee area ASC-H ‘ASC-M mers thet some abnormal squamous cls were found that may ‘Atypical Squamous __°2Mt-arade squamous itraeptheal ein (HSI, athough isnot san MOUS certain More testing i recommended ca Possible next steps: Colposcopy and biopsy See the Flown Test | ‘Secon 08 pace 0 ta eam about these procedures HSIL SIL sometimes called moderate or severe dysplesia. It may io be tain/cna chas ech Snes tte woos Nigh Grad Sauamous se ea ete Ketone Ladons pth SL env Th cancr cet tPV Fen nt pcan ai nt oe ei ees Als "AIS moans that an advanced lesion (area of abnormal arowth) was found inthe glandular tissu of the cervix. AS lesions may become cancer ‘Adenocarcinoma in Situ eorjes aenocsreinoms) Hn estes. Possible next steps: Colposcopy and biopsy. See the Foi Teng ‘secon on pane 0 t lear about these procedures, artical Sometimes cervical cancer cls (squamous el carcinoma or adenocarcinoma) ‘are found. However. for women who are screened at regular intel. itis Cancer Cells ‘ery rare for cancer cells to be found on a Pap test. For more information about cervical cancer, al -800-4-CANCER (1-800-422-6237) or vist concer goueeris, Possible next steps: Colposcopy and biopsy See the ono Tena Sesion on aust 0 fo leam about these procedures. 3. Asthma action plan counsellingAsthma Action Plan + if you are well which means you have occasional day time symptoms, no night-time symptoms = youcan continue taking ©. the blue puffer (reliever) as required ©. the Symbicort puffer (preventer) twice daily + If you not well, that means you have frequent day time symptoms, night-time or morning symptoms © increase the biue puffer as needed © make an urgent appointment with your GP within 48 hours © will start you on a short course of oral steroids + In case, you are getting more severe symptoms that means you need to repeat the puffer in less than every 3 hours = it means you are having severe asthma attack. © You need to follow the 4*4*4 rule + 1 puff-4 breaths-1 puff-4 breaths ~ 1 puff-4 breaths -1 puff 4 breaths (vou have to take the 4 puffs from blue puffer and 4 breaths in between) "Wait for 4 minutes, if improves do your follow up in 24 hours with GP if No improvement repeats 4x4x4 rule again + if still symptoms persist, call for ambulance and continue with the cycles. = Please don’t worry, everything will be written for you in a paper so that you can go through it in your own time. Father John comes to your GP with his 3 yr old boy David diagnosed as Asthma 3 days before. Recently d/c from hospital now stable. Task: LTake short Hx, 2.explain to father how to use puffer with spacer 3.long term management plan. - Attack h/o - Pattern of asthma - Triggers: - BINDS - Past medical hx - eczema or allergy? - Family hx — of asthma, eczema,allergy,hay fever? Cl MANAGEMENT: U Key points to cover:Oi It usually get worse with certain triggers like cold weather, smoking, dust, pollen, pets etc. So its very important to avoid these triggers to prevent further attacks. Also its very important to take the medicine regularly with appropriate technique. Now, | am going to show you how to use the puffer. = Remove the protective cap from the puffer. = Shake the puffer well ~ Insert the puffer firmly into the end of the spacer. = Place the mask over your child’s face, making sure that it covers the mouth and nose. Try to get a good seal on the skin so that no air can get in. OR: + If your child is able to use a spacer without a mask, they should place the mouthpiece of the spacer in their mouth and put it between their teeth, then close their lips around the spacer mouthpiece. Make sure their lips cover the entire mouthpiece so there are no gaps. = Ask your child to sit upright and breathe out gently. = Press the puffer once to release a dose of the medicine into the spacer. Do not remove the puffer. * Allow your child to breathe in and out four times. ASTHMA ACTION PLAN : WHEN WELL: THIS MEANS: * your child have no night-time wheezing, coughing or chest tightness * only occasionally have wheezing, coughing or chest tightness during the day * you can do your usual activities without getting asthma symptomsAction: Continue the blue inhaler 2 puff as needed. WHEN NOT WELL: ‘THIS MEANS ANY ONE OF THESE: * you have night-time symptoms * you have morning asthma symptoms when you wake up * your asthma is interfering with your usual activities THIS IS AN ASTHMA FLARE-UP * Continue the blue inhaler 2 puff as needed-but you need to take it more frequently than usual * Contact GP in 48 hours- for short term oral steroid and for possible preventer medication addition IF SYMPTOMS GET WORSE THIS MEANS: you have increasing wheezing (whistling sound during breathing), cough, chest tightness or shortness of breath you are waking often at night with asthma symptoms you need to use your reliever again within 3 hours + THIS IS A SEVERE ASTHMA ATTACK (SEVERE FLARE-UP) Follow the 4*4*4 rule (11 puff - 4 breaths-1 puff- 4 breaths ~ 1 puff -4 breaths -1 puff 4 breaths) © Wait for 4 minutes Ifimproves=call GP in 24 hours No improvement=call for ambulance and continue with the cycles DANGER SIGNS : THIS MEANS: = your symptoms get worse very quickly = you have severe shortness of breath, can’t speak comfortably or lips look blue = you get little or no relief from your reliever inhaler = CALL AN AMBULANCE IMMEDIATELY: DIAL 000* SAY THIS Is AN KSTHIMIA/EMERGENCY + Start 4*4*4 until ambulance arrives or follow the instructions on the phone, * Check for understanding and give written handout. Also refer to the specialist for medication review = Refer to asthma educator = Regular follow up = Red flag * Lots of reassurance You are a GP and 7 year old girl is BIB her Mother. She had cold and developed breathing problem and thus was required to be taken to hospital. She was diagnosed Asthma and was prescribed salbutamol puffer via facemask and spacer. Amber has no signs of asthma today. Task Further Hx Review prescription and administration technique counsel for Asthma action plan = History: "Hello | am Dr X, How may | address you? | can understand Amber recently needed to be hospitalize can you explain me what happened exactly? = So what did the hospital advised you? = How is she doing after discharge and whether she had recurrence of symptoms post discharge? = SIQORAA: * Intensity determine the severity of Asthma: = How many episodes of asthma attack that is cough in a week usually? = How many times she has to wake up in night with cough and difficulty breathing in 1 week? * Quality of life “Is she actively participating in physical activities? = Any concerns regarding her growth and development? = Onset since when you have noticed she is having the symptoms? * Course: is it progressing over the time? * Duration: for how long symptoms stay and how are they relieved? = Frequency not relevant since she is diagnosed now? * Aggravating and relieving factors you have noticed? = Associated symptoms: dust, pet, carpet and fluffy toy exposure? = How many times does she need reliver?= BINDSMA Well controlled Asthma: * Ifless than 3 times/week required reliever(Salbutamol) * If no attack/week in night or no night awakening with symptoms of asthma Ifthe above criteria is not fulfilled advise preventer(ICs) to the child = Can you show me how you help Samantha take the medicine? + htto://www.rch.org.au/genmed/clinical_resources/Asthma - using a puffer_with spacer_and_mask/ + If they ask how to use spacer: explain to patient SPACERS INHALERS Moderate asthma * Normal consciousness + Effort breathing present/recessions present = Tachycardia/HR>100 = Some limited ability to talk = Mild asthma not responding to Bronchodilator = Oxygen if 02 saturation is < 92%. Need for Oxygen should be reassessed += Salbutamol by MDI/spacer - 1 dose every 20 minutes for 1 hour = Review 10-20 min after 3rd dose to decide on timing of next dose. - Oral prednisolone - 2 mg/kg (max 60 mg) initially, only continuing with 1 mg/kg daily for further 1-2 days if there is ongoing need for regular salbutamol = Consider consultation with local paediatric team when = Assessed as moderate or severe asthma = Poor response to inhaled salbutamol = Oxygen requirement Severe Asthma * Agitated and distressed child * Moderate to marked effort breathing and recessions"Tachycardia = Marked limitation of speaking Involve registrar to b safe RCH says in Critical involve senior. = Oxygen if SPO@<92% + Salbutamol by MDI/spacer - 1 dose every 20 minutes for 1 hour; = Review ongoing requirements 10-20 min after 3rd dose. *Ifimproving, reduce frequency. If no change, continue 20 minutely. If deteriorating at any stage, treat as critical = Ipratropium by MDI/spacer - 1 dose (dose below) very 20 minutes for 1 hour only. 4 puffless than 6 years & 8 puff more than 4 = Aminophylline If deteriorating or child is very sick. + Oral prednisolone (2 mg/kg); if vomiting give i.v. methylprednisolone (1 mg/kg) Consider transfer when * Severe or critical asthma requiring intravenous therapy or respiratory support * Children with escalating 02 requirement = Children poorly salbutamol responsive or unable to wean salbutamol requirement * Children requiring care above the level of comfort of the local hospital. Discharge requirements = Each child should have a written action plan. This can be generated using the online Asthma action plan. * Observe inhaler technique before discharge. + Advise parents to seek further medical attention (preferably from their GP) should the patient's condition deteriorate or if there is no significant improvement within 48 hours. * At discharge, all patients should have an outpatient appointment or appropriate follow-up arranged with a GP and/or paediatrician. = Consider Community Asthma Program referral for those eligible = Parents should be informed of other sources of information about asthma such as the Asthma Foundation, and the RCH Child Health Information Centre Action plan for children 6 year and above *6X6X6X6=6 breath in and out = 6 times *6 puffs * Wait for 6 minutes = Meanwhile call 000 wait for the ambulance * Give inhaler with the face mask = Keep checking child breathing status4. 77. Septicaemic shock Ur HMO at hospital, nurse wants you to see a middle aged male pt with fever and recently diagnosed with BPH. He was catheterixed for 24 hour and remove after starting tomsulosin, On exam GA- unwell, restless VS- T = 40 C, BP = 85/60, HR - 110/min, SPO2- 91% RR 36/min Task * Explain the condition to nurse * Discuss immediate mx with reasons * Discuss inv with reasons Dx septicemia (ARDS as SPO2 reduced) Explain Septicaemic shock Possible Causes - BPH ~ stasis and inf - Catheterize — infection = Pneumonia = Covid - Infection (head to toe) Immediate resuscitate = Callfor help - WVline and bid sample = Fluid 0.9% normal saline bolus 500 ml over 15 min, 2 bolus dose = Oxygen 94-98% will be maintained if there is no COPD - IF COPD + 82-88% will be maintained ~ Bld sample for inv © Septic screen (SPU ISESESTEVET) © Bid clultre © CP, ESR + Uring culture - ABG ~ Clotting profile - Lumber puncture if indicated - Imagaging o ECG © OxR © Echo = Monitoring for vital sign = Broad spectrum antibiotic (Ampi + genta) - Vital not stable after 2 bolus of fluid infusion© Inform to ICU 5. 66. Bee sting You are an HMO, a 5 year old girl, Jenny has come to ED with his father. The child was stung by a bee and developed shortness of breathing and swollen lips. On examination the child has tachycardia and his BP is 60/40mmbhg. Tasks 1)Manage the condition/ Give nurse directions regarding management 2)Counsel the mother about the condition and further management plan ~ Basically, it contains = an EpiPen (an injection of adrenaline) that needs to be given in the muscle in case of anaphylaxis, Italso contains a Ventolin puffer, a tablet of antihistamine, and steroids, * During another attack, you need to observe her for certain signs such as wheeze, hoarseness of voice, loss of consciousness, vomiting/diarrhea, and swollen blue lips with or without swelling all over the body. Incase she develops these symptoms, you will use this injection and giveit on the thigh over the clothes. You can fIREEAEREASSORTMIREE. Make her ie flat on the ground, elevate the leg, cal family for help, but most importanty, call 000 for an ambulance. Please provide these injections to the school along with written instructions as well Management: = Proceed with DRSABC and Adrenaline simultaneously. Remove allergen or any danger like bee sting. = Examine for any other sting anywhere in the body, Treat the patient in supine position, left lateral position if vomiting; let the * patient sit at 45 degree if breathing difficulty. = Adrenaline I/M 0.01mi/kg of 1/1000 into lateral thigh which should be repeated after 5 minutes if patient is not improving * Call for help = Resuscitate with fluid; if signs of shock give 20ml/kg of 0.9 % NaCl If upper airway obstruction nebulised salbutamol can be given as well, High flow 02 can give symptomatic relief. * Antihistamines can be given to treat symptoms like itching All children with anaphylaxis should be admitted and observed for at least 4hrsRef: RCH guidelines and ASCIA guidelines Australia Instructions to the nurse: -Can you please check patient's level of consciousness? GCS -If you see a bee sting please take it out with a forceps -How is her airway? Any secretions? Can you auscultate the lungs for air entry? Now put her on -Can you please give her adrenaline in a concentration of -Check her blood pressure, if it’s still low, repeat the same concentration -If the response is still not good, put in 2 IV cannula, start her on normal saline -If there is wheeze or shortness of breath- give nebulized salbutamol, if necessary -Other antihistamines if available. Counselling: Let me assure you that your child is stable at the moment. It's quite understandable that you are concerned about what happened to her. Basically Jenny had an anaphylactic reaction due to the bee sting. Itis the severe form of, allergic reaction that occurs in response to insect bite, food etc. It can be life threatening if not treated immediately and | really appreciate that you have done the right thing to bring him to ‘the ED. Now his condition is stabilized but we have to keep him in the hospital for 12-24 hours to monitor recurrence of symptoms, as there is a chance of rebound reaction within the Ast 6-12 hours -He will be assessed by paediatric registrar. -A further allergic testing needs to be done - skin prick or blood tests for allergen specific IgE (formerly known as RAST) at ASCIA( Australian society of clinical immunology and allergy) -Referral to clinical immunology/ allergy specialist for detailed assessment 2 -Before discharge he will be given anaphylactic action plan. It is a written plan which helps you to identify mild or serious allergic reaction and it’s management. You will be given a anaphylactic kit which consist of inj. EpiPen and other medications. 1 -You need to look out for signs such as hoarseness of voice, swollen lips or face, shortness of breath, noisy breathing or wheeze, if she turns pale or blue 2 -In case she develops these symptoms you have to give inj EpiPen as itis instructed and call 000. An educator will teach you how to use the kit. One copy of the action plan will be given to his school as well. 2 -Referral to the allergy specialist will be arranged to check whether Jenny is allergic to anything else by doing further tests. U1 -Avoid places where bee sting can occur, avoid wearing colourful clothes or perfumes in places like gardens. Follow up by the GP after discharge.age Anaphylaxis §} Meee + Swongf ps, fee jes 1 Hes or wets Tatra mouth Admiral pan vomiting treme sr of apf res li) Eee fern + Forinect lg ok out sing visble, Donat ove teks + Sto th person ar cal fr help + Give other mediators f prescribes) + Phone famiy/emergency contact. ta | uid to moderate allergic reactions may ‘not always occur before anaphylaxis ‘Watch for ANY ONE of the following signs of rene UNE oe + Dieuk/noiybrething et + Swating fone + Snonng/ognress im toat + Dieu ang and/or hoarse vloe + Wheeze or persistent cough + Pattee ctzaness oF colepse + Pale an loopy young eden) 4 Lay person flat Do not alow them to stad or walk. ‘breathing is eeu allow them to st. 2 Give EniPen® or EpPon® Jr adrenaline atonjector '3 Phone ambulance: 000 (AU) or 443 (NZ). 4 Phone family /emergoney contact. 5 Further adrenaline doses may be Even If no response after ‘Sminutes, another adrenaline autoinjector is avaible. How to give Epipen® alpen fall] == Cad | SSS Another case: Child stung by bees today, sting taken out, uncomfortable and crying kid, had been bitten by bee before... At time.. Just local reactions.. Pefe given in stem, vitals - normal, CVS resp - normal - ‘Tasks -History current and future mxHistory: 1-Hemodynamic stability -(already given in the stem and stable Bp=90/60, RR=25, PR=90) -let me assure you that your child is stable and his vitals are fine. 2-chief complaint questions -can you tell me more? -how has he stung by the bee? What was he doing? -Local reaction (they said it was swelling on arm) so ask -since when? Is it getting bigger? -anywhere else? -is it itchy? Is it painful? Does it affect his sleep? -Ican see that you have taken the sting out. Have you done anything else? -has this happened before? (2nd time) 3-Associated symptoms -redness fever -SOB, noisy breathing - antibiotics * You may also be advised to take “medicines that control diarrhoea, relieve pain % supplement your diet (to boost your iron levels, vitamin D and calcium, for example). Surgery * Ifthe colitis is severe and does not respond to medication, he surgeon may recommend surgery to FGM GIESISA] * Another option is to ergate’a|temporaty or permanent stomal ‘ This is an artificial opening in the stomach ‘© diverts faeces (or urine, in some cases) into a bag, ‘ The surgery eliminates the symptoms of UC * so medications are often no longer required. ‘+ But those are the options less likely to consider in young patients * To keep healthy, consider: * keeping a food diary to check if there are any foods that make your symptoms worse during a flare-up . to lift your mood and help relieve stress . to help manage stress © Complications — + Cases of marked inflammation caused by UC can also lead to: > nutritional defi ciesweight loss heavy bleeding due to deep ulcers perforation (rupture) of the bowel problems with the bile ducts, affecting the liver fulminant colitis and foxie megacolon, conditions that cause the bowel to stop working vvVVY small number of people with colitis can develop inflammation in other parts of the such as the (thinning of the bones) can develop as a > Inthe long-term, UCis associated with SiS elo B= VBISI ni BSWETESREEE me risk can be decreased by maintaining SiRalEIGI= resis sheeVeTaIneTSIEGHE] le effect of long-term + Regular monitoring by a gastroenterologist, a5 Well'aS/COIOROSCOpIES, may help prevent complications from developing * But medications, including steroids and drugs designed to prevent inflammation “occasionally surgery — may be needed. * For information and support, Iwill give you the number. + Reading materials 3. Lithium Travel Advice (2020) 36 years old lady came to your GP clinic known case of bipolar disorder for 10 years, on lithium planning for trip to mountains in In All her vaccination is up to date. Her last attack of mania was 5 years ago. you have taken history about her mental status which is fine. Tasks: * take history about her medication. + Give advice regarding travel.History Since when you have been diagnosed with bipolar? Lithium dose? Change in dosage? Are you taking it regularly? Any other medication? Last visit to specialist? Last blood check for lithium levels and baseline tests? Side effects — nausea, vomiting, shakiness, muscle weakness, urinary frequency? weather preference? + Howis your mood now? With whom are you travelling? Which activities are you going to do? When? How long? Immunization? Past medical, past surgical, SADMA Advice — > Dos- * travel with someone who can take care of you. If going with tour, let the tour leader know your condition. If possible, stay near to the healthcare facilities. Take the numbers of local GPs and emergency services. + Take enough amount of medicines and some extra. Put it in two separate luggage, better put medicines both in carryon baggage and the check-in one. Take the prescription with you. Don'ts — * Avoid street foods and unsafe water. Don’t take sleeping pills and other OTCs without consulting a doctor. Avoid alcohol + Iwill need to check your blood Li levels, TFTs, LFT, RFT, full blood examination. You will need specialist review before travel as well. go to the ED ASAP.* Iwill see you again with the blood test results, 8 cases 9. VBAC (Vaginal birth after CS) Your next pt at your GP is Jenny, 28 yr old lady she’s 8 weeks pregnant now, and wants to discuss about pregnancy and delivery. Task = Relevant h/o - Relevant inquiries you want to know from examiner - Counsel mom accordingly Positive findings - Current preg—no eventful - Previous preg — fine, emergency CS in previous preg, obstruction of labor, Baby 4.2 kg - No DM/HT - Pt want normal vg delivery Previous CS scar at lower abd History =| read from my notes that you are 8 weeks pregnant, is this a planned pregnancy for you? Congratulation! = 5Ps questions = Periods: When did you have your LMP? 8 weeks ago * Are your periods regular? Partner: do you have enough support for this pregnancy = Pregnancy: How did you confirm your pregnancy? (Home pregnancy test) ok, will do a confirmatory office PT as well = Do you have any breast tenderness? Morning sickness? Yes * Do you have any tummy pain, or bleeding, or discharge from down below? Pill= How long have you been off your contraception? = Pap or HPV = previous pregnancies questions: (key point) =I have read that you had a previous C section done. When was it done? 2 years ago? Was it an elective or emergency C section? Emergency C-section was done = Why was it done? Sort of obstruction during the labor = Do you know the weight of your baby at birth? 4.2kg. = What type of C-section was done on you? [draw a photo if necessary] = Did you have any complications during your previous pregnancy? Like high blood pressure or diabetes that you had? = Did you have any complications after the surgery like any excessive bleeding? Infections? Or any complications? Clotting in your veins? = Past surgical history = Did you have any other surgeries done on your womb apart from the c section? = Past medical history + Family history+ SADMA+ diet and exercise O To Examiner = What is the reason for the c section (obstructed second stage of labor) = What is the cause of the obstructed labor? Was there any cephalopelvic disproportion (the baby was big, but the pelvis was adequate) = What is the type of C-section done? (low uterine segment) = Any complications during or after surgery? None = How long until the patient was discharged from the hospital (normally should be 3 days) = Any previous uterine/pelvic surgeries done to her? None = How was the condition of the baby after birth? counselling: Vaginal birth after a c section is an option for all women who had a previous c section provided that the indication of the previous c section does not recur and in many women, successful vaginal birth could be achieved safely for both mom and the baby. The success rate of vaginal birth after c section is 55-85%. Oin your case the previous c section was done as the baby was a little big and your labor was not progressing smoothly. But this is not a recurring condition and your baby might not be that big this time. And from the notes, your pelvis is not narrowed but quite roomy as well. At present, you do not have any contraindications for the vaginal birth, and other points in favor for itis the type of C-section, which is a lower segment C section, and also you don't have any previous uterine surgeries. You are in the early weeks of pregnancy now, and as the pregnancy progresses, if any complications develop in you like uncontrollable high blood pressure, diabetes, or bleeding during pregnancy,placenta previa, then a C-section needs to be considered again. Also certain complications in the baby like the big weight of the baby, or any abnormal presentation or lie of the baby in the womb can also lead to a C-section. Chere are certain advantages of the vaginal birth over the Csection. it avoids the risk of C- section like complications of anaesthesia, excessive bleeding, infection of the womb, and also injury to other organs. The pain during the delivery will be short, and also you will have a shorter duration of stay in the hospital. Cif you have one successful vaginal birth after a C-section, you can go in for any number of vaginal births afterwards. (key point) CIVBAC carries risks as well. These include failure of the vaginal birth which will necessitate an emergency C-section, and there is a risk of scar rupture (1:200), and a chance to develop endometritis or infection of the womb. Repeated C-sections can lead to placenta accreta, a condition where the placenta grows deep into the C-section scar of your womb. If you have one more C-section, the next deliveries should always be by C-section and it advisable not to have more than 3 C-sections. Cl Management: *Do all antenatal blood checks * Start on folic acid = Advice regarding down syndrome screening * Needs to go for a shared antenatal care with ultrasound done at 18 and 32 weeks, sweet drink test at 26-28 weeks. During each visit you will be monitored for any complications. And if any complications happen, you will be managed at the high risk pregnancy clinic. =| need to arrange for a specialist consultation at 26 weeks for discus: about the possible mode of delivery, and another at 36 weeks for a definite decision.(key point) * During delivery, you and the baby will be continuously monitored and the delivery should be done in a tertiary hospital, under specialist guidance. You can also have excellent pain relief options. Chere are reading materials regarding VBAC to give you more insight about this. Please observe to eat a healthy diet, and engage in regular exercise. Please avoid smoking, alcohol, or recreational drug use. Cl will arrange a review with you once your blood tests are out You are a HMO at the hospital. Your next patient is Lily, 67 years old lady, who was diagnosed with bowel cancer and waiting for an operation in 3wks time. She had aortic valve replacement 10yrs back and has hypertension. She is onwarfarin for her atrial fibrillation, atenolol and Atorvastatin, metformin, All investigations were normal with INR 2-3. Task: History regarding medications and risks Discuss with the examiner about pre op preparation and medication plan. 10. Heroin addiction You are a GP38years old female, Fiona, presented in GP with heroin addiction for 5 years. She wants to quit it because she is afraid her husband might leave her if she continued with it. Never doing needle sharing. Tasks: sHistory sinv Mx «Start with general history (5A approach) *ASK How are you doing? *What happened ? *Confidentiality(key point) *Are you happy to discuss the details of your heroin usage *Assess Acknowledge her problem and appreciate her effort to come to you-Takes lot of courage to. come and discuss this. *Ask since how did she start *When, how much, how often, what sort of drugs *Route, Ask her about needle sharing (key point) *Have you ever tried to quit-withdrawal signs(key point) *Any side effects of the drug *any Violence associated with the kids while she was on drugs *Advice sbenefits of quitting —life will be better definitely, reduce cost and also can have more time with family and friends sits not impossible to get off the drug * Effects of heroin on body —in long term, dependence, loss of appetite, Chronic constipation, heart, chest and respiratory problems, menstrual problems and infertility in women and impotence in men + Effect on social life -can lead to emotional problems and affect relationships with family and friends. When people are under the influence of drugs, changes can occur intheirbehaviourdepending on how they feel (for example, sleepy, euphoric or sick). Friends may not be able to rely on the person as the user's moods can change depending whether they are using or not. Long-term use can lead to serious health and financial problems, which can also affect relationships. *Needles problems and raised chances of contracting an infection but | really appreciate you not to share needle(key point) sits illegal !! sAssist— *Before a person starts a treatment program for drug dependence, it is important that they understand what is involved. A doctor experienced in drug treatment, or a drug counselor, can explain the process. *Go cold turkey (key point) *Avoid spending time with people who use the drugs sExercise *There may be some withdrawal symptoms - Some common heroin withdrawal symptoms include runny eyes and nose, sneezing, yawning, sweating, feeling agitated and irritable, goosebumps, hot and cold flushes, strong urges to use heroin, stomach cramps, diarrhoea, poor appetite, nausea, vorniting, back pain, pain in legs or arms, headache, poor sleep and poor concentration. Withdrawal symptoms usually peak between the two and four days following last use *Arrange + Inv: | will arrange several investigations .Urine and blood drug screen, Hepatitis B, CD HIV screening (key point) along with FBC, LFT, KFT, TFT. started on a medicine to reduce the withdrawal effects of heroin.To help you in quitting | would like to refer you to Specialist Clinic who will give Methadone, Buprenorphine +/-naloxone for stabilization of dependence(key point) *CBT and Motivational enhancement therapy by psychologist *Family meeting to discuss with your husband with your consent «Helpline numbers—call them 24 hrs service. Deciding on the best treatment pathway or combination of pathways is best done in consultation with a drug and alcohol counsellor. *Support for family once she is rehab! *Stay away from such company. +4 R's 11. HaemochromatosisYou are a General practitioner. Your next patient is 25 years old Ashley, coming to see you because her brother was recently diagnosed with haemochromatosis. Your tasks: ‘+ -Explain her about the condition * Tell her about the management Greetings Build rapport Explain the condition Condition Haemochromatosisis a condition where your BR S6ESrESRSE RiUEHIIFGR TFOMIENEITSE you eat. Normally, the body limits the amount of iron absorption from the foods you eat. So no matter how much iron rich foods you eat, there is a maximum limit of the absorption by the body Excess ron i toed in your organs, especialy the Iver, her, joints and pancreas Commonality It is one of the most common hereditary diseases that means it funs in the families. Around ‘one in 200 Caucasian Australian people have a genetic predisposition to this disease — meaning that they may get it. Both Sexes are equally atirisk, but Women tend to/develop the | since menstrual periods and pregnancy deplete the body of Causes and risk factors © Gene - Hereditary hemochromatosis is caused by a futation in a Bene that controls the amount of iron your body absorbs from the food you eat. These mutations are passed from parents to children. «So if you have a first-degree relative — a parent or sibling — with hemochromatosis, you're more likely to develop the disease. ‘© Ethnicity - People of Northern Europeal descent are more prone to hereditary hemochromatosis than are people of other ethnic backgrounds. © Gender - MER|SFE/MOFENIREIVIENEAIWORIER to develop signs and symptoms of hemochromatosis atan earlier age.Clinical features The first symptoms include «feeling Weakiand tired fatigue)))painlin the joints and pain in the fUmimy © BFOAzIng of the skin (looking like a permanent tan) Loss of Sex drive + Loss of body hair «an inability to get or maintain an erection in men (erectile dysfunction) + lff@gilar periods or absent{petiods in women Confirmations (inves ations) ‘We can confirm the condition by genetic testing which detects the fault in a gene called HFE gene. Wllother tests we do are checking the ifOAIeVEls and EAHSFEHIA (proteins which transport iron) in the blood « Liversean because liver is the main organ affected in this condition, © Liver biopsy in few cases where there is potential serious complications and echocardiogram which is the imaging of the heart. ‘© We will also do) ba86 line bI60d tests as well to know your bleed) eounts) liver and kidney funetions and also blood sugar|lévél to detect the diabetes which also is a complication. Course of the disease «There's SUPA NOIRUPSTGERSEMGENPSMBWEEE, but there are treatments that can * People can have a normal life expectancy if the condition is detected early with lesser complications. Complications Complications are mainly based on the excess of iron deposits in various organs. They include: + INBEBFBBIEREE— including scarring ofthe liver (cirhosis) or ler cancer where the level of sugar in the blood becomes too high + arthritis — pain and swelling in the joints+ fieart failure - where the heart is unable to pump blood around the body properly But we can reduce those by giving treatment at early stage. Common Management There's Gurently no eure for haemochromatosis Since the patient will always have the faulty gene, but there are treatments that can reduce|the/amount ofiron|in the body, This can help relieve some of the symptoms and reduce the risk of damage to organs such as the heart, liver and pancreas. He will be under the care of a specialist - usually a Raematologist, who will monitor his blood levels, and advise on treatment. If there is very high levels of iron, or any evidence of liver damage, he would also be referred to a liver specialist (a hepatologist)) Phlebotomy ‘The most commonly used treatment for haemochromatosis is a BFSEHUF=ITOIFEnIGVE SORE SF THEIBIGOd, known as a phlebotomy or Ven@section! The procedure is similar to giving blood. The patient lies back in a chair and a needle is used to Grain/a/Siiall amount 6Fbloed, Usually about SOOM, from a vein in his arm The removed blood includes red blood cells that contain iron, and the body will use up more iron to replace them, helping to reduce the amount of iron in the body. There are 2 main stages to treatment: induction ~ blood is removed on a frequent basis (usually WeeKIY)iuntil your iron levels are formal; this can sometimes take up to a year or more faintenance — blood is removed less often (USUBIMAROMMMESEIVEAE) to keep the iron levels under control; this is usually needed for the rest of the life (Simin ORSIOBEnI) Regular blood removal will not cure some of the complications of haemochromatosis such as HIZBELEEOFIIVERTECSHIREGHHGE). Therefore, early diagnosis and treatment are very important.Liver transplant may occasionally be needed if the liver is very badly affected, Chelation therapy ‘A treatment called chelation therapy may be used in a small number of cases where regular phlebotomies are not possible because it's difficult to remove blood regularly - for example, ifonehas very tin ofa veins. This involves faking medicine that femiovesiiron from the blood and feleasesiitinto the urine Acommonly used medicine is HeferasirOx. It comes as a tablet that's usually taken 6heeaday. Diet and alcohol He does not need to make any big changes to his diet, such as avoiding all foods containing iron. But there are usually some advi to: * have a generally healthy, balanced diet avoid * avoid taking ~ these may be harmful for people with high iron levels as they increases iron absorption © be careful hot to eat Faw oysters and clams — these may contain a type of bacteria that can cause serious infections in people with high iron levels © avoid drinking @xcessive amounts of alcohol — this can increase the level of iron in your body and put extra strain on the liver i you may find having tea, coffee or a milky drink with meals helps a little with iron levels. Screening Since it is inherited, when you have a parent or sibling with haemochromatosis, BVEHIIFVOU do ot ave Symptons Yourself = tests canbe done tol cheek if you're at risk of developing problems. These include irom levels\and iron binding protein ferritin IeVElg and will proceed to Bene testing if these levels are high. Review, Recheck, Reading materials,12. COVID 19 Vaccination Counselling 80 year old Gorge in aged care fa Pfizer at your facility Task: Take hx if you need to, Counsel regarding the Covid vaccine (Pt wasn’t interested in getting covid vaccine had concerns due to media hype etc. His past medical h/o COPD, CCF and atrial fibrillation on apixaban. ry not vaccinated against covid, you have AstraZeneca and Introduction = Ask about Pt concern "Hx: Ask Covid S/S : Any fever, Sore throat, loss of smell, cough, SOB, chest tightness, wheeze = Any h/o anaphylaxis = Any h/o previous vaccine side effect? = Any Heart problem: Chest pain, Chest tightness, murmur, abnormal heart beat, palpitation, dizziness, fatigue, fast breathing, SOB on lying down , leg swelling (R/O Myocarditis/ pericarditis) = Any h/o clotting problem = Family h/o clotting problem = Past medical history details : COPD = Medication h/o for AF taking apixaban : ask about DISCO = Any h/o DVT/ PE /any immusuppresive condition O Pfizer Vaccine: = Comirnaty (Pfizer) is a vaccine that can prevent people from becoming ill from COVID-19. O Mechanism of action: = The Pfizer COVID-19 vaccine does not contain any live virus, and it cannot give you COVID-19. It contains the genetic code for an important part of the SARS-CoV-2 virus called the spike protein. After getting the vaccine, your body makes copies of the spike protein. Your immune system will then learn to recognise and fight against the SARS-CoV-2 virus, which causes COVID- 19. The body breaks down the genetic code quickly. O Doses: = Two doses are required initially (called the primary course). These 2 doses are usually given 3-6 weeks apart. In special circumstances the interval may be longer. The Pfizer vaccine can also be used for a booster dose in people aged 16 years and older. The booster dose is given 3 months or more after the primary course. 2 Cost: Vaccination is voluntary and free.Ol Benefits of the vaccine * Pfizer is effective in preventing COVID-19 in people aged 12 years and older. People who had two doses of Pfizer were about 95 per cent less likely to get symptomatic COVID-19 than people who did not get the vaccine. + It was equally effective in people over the age of 65 years, as well as people with some stable pre-existing medical conditions. = Protection against COVID-19 starts from about 2-3 weeks after the first dose. While one dose may give some protection, it may only last for the short-term. = Two doses will give improved protection. = No vaccine is 100 per cent effective, so itis possible that you can still get sick from COVID-19 after vaccination. = SARS-CoV-2 could potentially still infect a vaccinated person. Even if they have no symptoms or only mild symptoms, they could still pass it on to others = However, the COVID-19 vaccines currently used in Australia are effective in reducing the likelihood of a vaccinated person transmitting the virus to close contacts if the person is infected. O This is why after vaccination it is important to continue other preventative measures like: * physical distancing hand washing = wearing a face mask + If you have been vaccinated with Pfizer, you should still get a COVID-19 test if you have symptoms that meet testing criteria according to your local health authority (e.g. fever, cough, sore throat). U Safety of the vaccine + Pfizer has been safely given to hundreds of millions of people around the world. Spikevax (Moderna) and Pfizer COVID-19 vaccines both have a very rare risk of heart inflammation (myocarditis or pericarditis). * This is more commonly seen in males aged under 30 years after the second dose. In some countries, myocarditis and pericarditis have been reported more commonly after Moderna than after Pfizer. Most people who have had these conditions after their vaccine have recovered fully. ‘The benefits of vaccination outweigh this very rare risk and vaccination is still recommended for all eligible age groups Who can receive this vaccine = People aged 5 years and older can receive the Pfizer COVID-19 vaccine for their primary course. = People aged 16 years and older can receive Pfizer vaccine for their booster dose. 2 Booster doses = A booster dose refers to an additional vaccine dose after the primary vaccine course. It is intended to strengthen and prolong protectionagainst COVID-19. * If you are 16 years or older, you can receive an additional dose of Pfizer as a booster if it has been 3 months or more after your primary course. O Who should not receive this vaccine * anaphylaxis (a type of severe allergic reaction) to a previous dose of an mRNA COVID19 vaccine (i.e. Pfizer or Spikevax (Moderna)) * anaphylaxis after exposure to any component of the vaccine, including polyethylene glycol (PEG) * any other serious adverse event that, following review by an experienced immunisation provider or medical specialist, was attributed to a previous dose of an mRNA COVID-19 vaccine (i.e. Pfizer or Moderna) and without another cause identified = Precautions for vaccination = People with certain conditions may need additional precautions such as staying for 30 minutes of observation after having their vaccine or consulting an allergy specialist. * Tell your immunisation provider if you have had * an allergic reaction to a previous dose or to an ingredient of an mRNA COVID-19 vaccine (i.e. Pfizer or Moderna) anaphylaxis to other vaccines or to other medicines. Your provider can check to ensure there are no common ingredients with the COVID-19 vaccine you are receiving confirmed mastocytosis with recurrent anaphylaxis that requires treatment. Ifyou have a bleeding disorder or you are taking a blood-thinning ‘medication (anticoagulant), tell your immunisation provider. Your munisation provider can help determine whether it is safe for you to have an intramuscular injection and help decide the best timing for injection. O Special circumstances to discuss before vaccination = People with a history of any of the following conditions can receive Pfizer but advice should be sought from a GP, immunisation specialist or cardiologist about the best timing of vaccination and whether any additional precautions are recommended: * Recent (i.e. within the past 3 months) myocarditis or pericarditis * Acute rheumatic fever (i.e. with active myocardial inflammation) or acute rheumatic heart disease * Acute decompensated heart failure. Tell your doctor if you had myocarditis or pericarditis diagnosed after a previous dose of Pfizer or Moderna.= People with weakened immune systems (immunocompromise) = People with immunocompromise includes medical condition/ taking medications that suppress their immune system. Pfizer is not a live vaccine. It is safe in people with immunocompromise. = People with severe immunocompromise are recommended to have a 3rd dose of Pfizer for their primary course. Severely immunocompromised people aged 16 years and over who received a 3rd primary dose are recommended to receive a booster dose (i.e, 4th dose) at 3 months, in line with the timing for the general population. People with immunocompromise, including those living with HIV, have a higher risk of severe illness from COVID-19, including a higher risk of death. Ol Women who are pregnant or breastfeeding = who are pregnant should be routinely offered Pfizer or Moderna at any stage of pregnancy. If you are trying to become pregnant you do not need to delay vaccination or avoid becoming pregnant after vaccination. = Pregnant women with COVID-19 have an increased risk of severe illness and adverse pregnancy outcomes. Real-world evidence has shown that Pfizer is safe for pregnant women and breastfeeding women. * If you are breastfeeding, you can have Pfizer. You do not need to stop breastfeeding after vaccination = Pregnant women their primary COVID-19 vaccination course 3 or more months ago are recommended to have a booster dose. = People with a history of COVID-19 = COVID-19 vaccination can be given after recovery from the infection, or can be deferred for up to 4 months after the acute illness O (Astrazeneca) vaccin = Vaxzevria (AstraZeneca) can prevent people from becoming ill from COVID-19. = M/A: This vaccine does not contain any live SARS-CoV-2 virus, and cannot give you COVID-19. It contains the genetic code for an important part of the SARS-CoV-2 virus called the spike protein. This code is inserted into a harmless common cold virus (an adenovirus), which brings it into your cells. Your body then makes copies of the spike protein, and your immune system learns to recognise and fight the SARS-CoV-2 virus. The adenovirus has been modified so that it cannot replicate once itis inside cells. This means it cannot spread to other cells and cause infection. = Doses: Two doses are required as part of the primary course. These 2 doses are usually given 4-12 weeks apart. The AstraZeneca vaccine canalso be used as an additional booster dose, 3 months or more after the primary course, although Comirnaty (Pfizer) or Spikevax (Moderna) are preferred for this booster. * Vaccination is voluntary and free. ~ Benefits of vaccination = AstraZeneca protects people from becoming ill from COVID-19. + It particularly prevents severe illness, hospitalisation and death. * COVID-19 is a very serious disease which can cause serious illness in people of all ages. It has caused millions of deaths and hundreds of millions of infections worldwide. * Vaccination helps protect both individual people and benefits all people in the community by reducing the spread of COVID-19. = Who can receive this vaccine = People aged 18 years and older can receive AstraZeneca + Pfizer, Moderna or Novavax are preferred over AstraZeneca in people aged under 60 years. = However, AstraZeneca can be used in adults aged under 60 years if Pfizer, Moderna or Novavax are not available and if the person has made an informed decision based on an understanding of the risks and benefits Ci Risks of vaccination = Common side effects after AstraZeneca include injection site pai tenderness, tiredness, headache, muscle pain, and fever and chills. = Most side effects are mild and temporary, going away within 1-2 days. As with any medicine or vaccine, there may be rare and/or unknown side effects, = Thrombosis with thrombocytopenia syndrome (TTS) very rare side effect, = TTS involves blood clots (thrombosis) and low levels of blood platelets (thrombocytopenia), and occurs around 4 to 42 days after vaccination. The blood clots can occur in different parts of the body, such as the brain (called cerebral venous sinus thrombosis or CVST) or in the abdomen {idiopathic splanchnic thrombosis). * TTS is rare, but it can make people very unwell and can lead to long term disability or death. + Is the AstraZeneca vaccine safe in people who have had blood clots in the past? + If you have had other types of blood clots in the past, such as deep vein thrombosis (DVT) or pulmonary embolism (PE), or if you have risk factors for blood clots, you can still have the AstraZeneca vaccine, = There is no evidence that people who have had a past history of othertypes of blood clots have an increased more ill from it if it occurs. of developing TTS or becoming = What if I have had my first dose of AstraZeneca vaccine? = People of any age without contraindications who have had their first dose of AstraZeneca without any serious adverse events should receive a second dose of the same vaccine. The risk of TTS is much lower after the second dose Who should not receive this vaccine * anaphylaxis (a type of severe allergic reaction) to a previous dose of the vaccine * anaphylaxis after exposure to any component of the vaccine, including polysorbate 80 * a history of capillary leak syndrome * TTS occurring after a previous dose of the vaccine * any other serious adverse event, that following review by an experienced immunisation provider/medical specialist, was attributed to a previous dose of the vaccine (and without another cause identified) Precautions People with certain conditions may need additional precautions such as staying for 30 minutes of observation after having their vaccine or consulting an allergy specialist. O Special circumstances to discuss before vaccination Pfizer or Moderna are recommended in people who have had one of the following rare causes of blood clots: * cerebral venous sinus thrombosis * heparin-induced thrombocytopenia * idiopathic splanchnic thrombosis * antiphospholipid syndrome with thrombosis. O People with weakened immune systems (immunocompromise) Itis safe in people with immunocompromise. People with severe immunocompromise are recommended to have a third dose of Pfizer or Moderna for their primary course. Novavax can also be used for this third dose. Cl Women who are pregnant or breastfeeding: Pfizer and Moderna are the preferred vaccine.13. DVT You are a HMO in ED. Your next patient, 45 years old Venessa came with ultrasound report showing deep vein thrombosis in lower leg. (popliteal vein) Tasks : * Take quick relevant hx. * Explain result of ultrasound and dx to patient. * Mx and counselling, = Approach: Pain questions * SOB? Stable? = Fever? Trauma? Insect bite? += Risk factors- COST VMPF (key point) = C—contraception, O — obesity. BMI? S ~ recent surgery? TTravel history? = \V— problems with Veins? M — malignancy ~ LOW, LOA. Lumps and bumps, P- pregnancy, F- family history of clotting problems * Social - occupation = SADMA = Make sure she is stable * = Explain the ultrasound result: = Blockage of the vein that’s why blood pooled in legs and then pain in calf muscles. Blocked by blood clot, result from prolonged immobilisation of the legs during flight. © = Risk (key point) * If not treated - dislodged and travel down the blood stream, block the main vessel in. lungs, life-treatening = Reassure ~ safe hands now * = Mx: (key point) * Admit, call senior = Inv: blood tests including FBC, LFT, KFT, TFT, ESR/CRP, coagulation profile and D-dimer, imaging CTPA if SOB, thrombophilia screening. * blood-thinning medications will be given through injections and observation * Discharge with adjusted dose of medications, needs to take a few more months = Stop OCP and use other form of contraception += Stop smoking + Follow-up, for blood thinning medications = Any bleeding, from anywhere or black stools, go to see the doctor = Tell the doctor about your medication whenever you consult the doctor = Review and admit14. Rheumatoid arthritis 45-year-old Jenny, who is in an orchestra player is complaining of pain, swelling and stiffness of both hands. Her mother was diagnosed with rheumatoid arthritis and she has been on steroids for a while. You started Jenny on ibuprofen tablets and organized some blood tests, FBE, U&E, LFT, ESR/CRP, ANA, RF. The results came back confirming an early stage of rheumatoid arthritis. She has come to GP clinic to discuss with you the results. She is complaining that the pain is getting worse extending to the wrist. TASK: * Counsel the patient Answer her questions Notes: Criteria for diagnosis of RA ‘© symptom duration Early morning stiffness Arthritis in of joints involved RA~ management + Education and reassurance + Regular exercise + Smoking cessation Pharmacological to reduce pain ~ start early to induce remissions and prevent complications —to be used in acute flare ups vyve (GEEUBEHIGHEI in case the occupation is contributingMethotrexate First line Sulphasalazine Hydroxichloroquine Azathioprine Gold salts D=penicillamine vVvVVY Biological agents Infliximab anti TNF alpha Anakinra ~ anti interlukin 1 vve Counselling * Assess knowledge and build rapport * Do you know anything about rheumatoid arthritis? Do you have any particular concerns? Talk about what RA is + RAis an autoimmune disease where your immune system starts attacking the body itself which in your case, is the joints. Most likely affected are the small joints of hands and feet and rarely, the large joints. This usually presents as stiffness which is more in the morning. The cause of this condition is unknown, but it is more commonly found in people with a family history. What investigations you will do ‘© The diagnosis is based on a lot of investigations, so | would like to refer you to the rheumatologist and he will organize further laboratory investigation. Mainly look out for a test called Anti-CCP. Talk about the disease prognosis + I'm sorry to say that this is a chronic progressive condition. It is not curable, but controllable. However, the course of RA varies from person to person. + The good news is that with early diagnosis and treatment, most of the people will be able to live a normal active life. ‘+ I shall be referring you to the rheumatologist who will be able to talk to you more about this. Talk about management+ Symptomatically - for your pain and stiffness, we will give you painkillers. You could also use a hot water bottle or pads on affected joints as soon as you get up from the bed to reduce stiffness. * Long term - The rheumatologist will also consider starting you on DMARDs which is a group of drugs which slows the progression of the disease and recommended to start at an early stage * Ishould also tell you some people experience attacks on top of chronicity when the joints become more inflamed, painful and stiffer. This is called as an acute flare up. For these times we will be using steroids to treat such an episode. Talk about occupational management ‘+ In acute flare-up, the use of the joint may leave an impact on the joint causing further destruction. With the right scheme of medications and rest, it reduces the impact of the disease on the joint. | understand that itis important for you to use your hands, but | would recommend you not to play in the orchestra during acute flare-ups. We can have a talk with your team if they can find you a much more suitable position at the orchestra.| shall also write you certificates during an acute flare ups and Centrelink should be able to help Talk about healthy lifestyle * It would do you best to stop smoking. | could arrange another session for that. + The physio will also tell you exercises to keep your joints less stiff. + Ahealthy diet and exercise should go a long way in keeping you fit Follow up + It is a chronic illness so you will need regular follow up but do no worry, you will be managed by a MDT with the rheumatologist, physiotherapist, occupational therapist and me as your GP. + There are support groups as well, the contact details of which I can provide. 15. Counselling for chronic alcoholic (Phyo) GP, you are about to see a 45 year old who is concerned about his drinking habit, he stopped alcohol drinking 6 months ago. On PE, 150/90 mmHg, liver- 1 finger breath enlarged, Inv- AST raised*, ALT raised, 1 Task: history, counsel the patient Feedback + uSG‘+ BP counselling © Refer to specialist 16. PAPILLARY THYROID CANCER QUES: 27 year old man with hx of neck swelling, USG shows solid mass at left lower lobe, no LN enlargement, FNAC shows nuclear atypia with Papillary thyroid carcinoma, TASK: 1. Explain inv to pt 2. Counsel about the mx plan 3. Explain the risk of possible treatment u suggested EXPLAIN: 2 Hijohn, this is Dr. Arshan. Thank u so much for coming today. How are you doing these days? Any pain at the biopsy site? Okay john, the result of your test is in my hand now. Do u have any expectation about the result? 2 Ok now! am going to explain the result, Jhon as u have a swelling in your neck, we did the examination and USG , found out that itis originated from thyroid gland. Then we took a sample from the gland in your neck which turned out to be a cancer in the thyroid gland. GIVE PAUSE. Wait for the expression 1 Offer tissue and water if crying 1 Thenstart-> Jhon, Ican see you are really stressed . | do understand this came as a shock to you; | cant even imagine how you are feeling at the moment but | want u to know that still there are lots of things we can do . U don’t have to go through this alone, if this is in the early stage and we can start tx as early as possible you will have a very high chance to be cured. UW Do uwant me to continue or if u want we can arrange another session as well. If u want me to call anyone to be with u now, I can also arrange that. Alright let me explain it in detail. in our neck there is butterfly shaped gland , we called thyroid gland that produces thyroid hormones which is very important for the metabolism of each and every cell in our body Now the cancer is in the thyroid gland , ( explain with pic ) the type of cancer is papillary thyroid cancer which is most common type of cancer in thyroid . good thing is, itis a slow growing tumor . and it spreads usually through the lymphatic channel , but i cannot see any gland or lymph node enlargement in your neck , thats the good point , most likely your cancer is in the early stage2 wewill help you with MOT, i will first refer you to ENT specialist and cancer specialist Who will do further assessment for staging, like CT scan to your body to make sure it, has not spread to other body parts. the main part of treatment is surgery , before the surgery , we will need to do some basic blood test to make sure you are fit for surgery , checking thyroid hormone level in your blood as baseline . the surgeon may need to remove the whole thyroid gland to treat for it . so after the surgery , there will no longer thyroid hormone in your body $0 you may need to take hormone replacement throughout your life the surgeon may consider giving you radioiodine therapy which is medicine that has radio- iodine that you can take by mouth to make sure the possible remaining cancer cells are killed . but the specialist will decide all of it for further mx O after treatment we will follow u up with frequent blood test. 2 JHON, every treatment is not without the complication , i want to tell you about them but dont be scared , we can do many things to prevent it. The possible complication from the surgery could be infection , injury to surrounding, structure , bleeding , anesthesia side effect , injury to nerve that supply the voice box leading to HOV , low thyroid hormone level , sometimes injury to nearby gland what we called parathyroid gland that maintains the normal calcium level in body can lead to low calcium level but the surgeon is well experienced so we will do everything to make sure these complication do not occur. 1 JHON, we are here to help you . you are not alone . do you have any family member? you can bring them in next appointment , so that they can understand your condition and can give enough support . when you go home if you have any concern , you can contact me anytime . if you feel stressed about this condition , i can refer you to psychologist as well . 2 there are lots of support group available for you as well. 1 Finish with 4R 8 cases 17.SCC 50 year old female, Nancy, came to your clinic for Biopsy result for a lesion on her temporal region. it shows SCC. On examination, there is no cervical lymphadenopathy. Your tasks + Tell the diagnosis + Management plan to herGreetings Nancy, we have done a biopsy of a lesion on your temporal region and now we've got the results. Jam very sorry. The result is not as good as we expected before. Show — nasty condition of skin — we call it SCC. I can see the it might be distressing for you. You want me to discuss the treatment now or should | make an another appointment? Can you tell me what is going through your mind? | am here to help you. Let me explain what is SCC. There are the nasty condition arise from |. First of all, | want to say that it is We can get and it has a | can assure that this is the early stage because the nodes around the neck can’t be felt. When the nodes in the neck become enlarged, it implies that the cancer has spread. In biopsy specimen, it shows that there are some cells around the margin of excised tissue. This happens because it is difficult to know the real margin of the lesion with naked eye. ‘So you will need further excision with adequate margin of clearance. So | will refer you to the surgeon who will do a wide local excision until the safety margin is reached. The benefits - curable. Drawbacks- scar, plastic Sx may be needed in some cases, The biopsy will be sent again and make sure the margin is clear. At this stage, | don’t find any neck lumps so it means no metastsis so probably no further treatment will be required after surgery. To make sure there is no cancer spread, imaging called CT scan will be done around head and neck region. But this test will likely to be normal.Prevention — sun smart ~ sunglasses, broad brim hat, Sun cream t least SPF 30 and apply 2 hourly, avoid going out between 10 am to 3 pm, long sleeves pants and shirts Red flags — consult with doctor because these may change to nasty condition. 1. NIPT counselling Case 1 You are at GP cli NIPT result. Task Take history NIPT result will appear (Ifthe result are available) Explain the result and counsel accordingly Erin a 11 weeks worried pregnant lady came to your clinic to discuss about Positive findings ‘© (LMP 11 weeks ago, regular) (No pain) stable relationship? (yes) partner supportive? (yes) diagnosed with STI? (No) © first pregnancy? (yes) previous miscarriages? (No) (OCP) HPV up to date? (yes) '* (does not smoke or drink)* (HPT, DM, SLE, Epilepsy, heart) (No) PEFE card (everything normal) History “Hi Erin | am Dr X, one of the GP working in this clinic. How can | help? Any specific concerns = 5Ps questions: periods = when was your LMP? were they regular? * any pain or heavy bleeding during periods? = Partner * are you in a stable relationship? (yes) + is your partner supportive? (yes) = have you or your partner ever been diagnosed with STI? (No) = Pregnancy ‘is this your first pregnancy? (yes) have you had any previous miscarriages? (No) ~ Any excessive Nausea, vomiting, any tummy pain, vaginal bleeding or discharge? Pills = what contraceptive method were you in? (OCP) = pap or HPV is your pap or HPV up to date? (yes) * General questions = do you take any medications? = do you start taking folic acid? = Past medical history (HPT, DM, SLE, Epilepsy, heart) (No) = SAD (does not smoke or drink) * family history of birth defects? + diet and vaccination? ~ blood group? = PEFE card (everything normal) 2 Counselling 2 The non-invasive prenatal test, or NIPT, is a new, highly sensitive test that screens for Down syndrome and certain other abnormalities in a baby that is done in the first trimester of, pregnancy. 2 What is the non-invasive prenatal test (NIPT)? Oi During pregnancy, some of the baby’s DNA passes into the mother’s bloodstream. The non- invasive prenatal test (NIPT) analyses the genetic information contained in this DNA to screen for a number of abnormalities. The test is particularly sensitive to Down syndromeO NIPTs have been referred by different names including Harmony, Generation and Percept depending on company. The NIPT involves a simple blood test and can be done from 10 weeks into the pregnancy. What does it test for? O The NIPTis a safe and highly effective way of screening for conditions that include: = Down syndrome (also called trisomy 21) = Edwards syndrome (trisomy 18) = Patau syndrome (trisomy 13) "Turner syndrome = Some laboratories also test the gender of the baby and look for problems with the sex chromosomes. O The test detects many chromosomal abnormalities, but not as many asa diagnostic test such as amniocentesis. tt cannot screen for genetic disorders such as cystic fibrosis, thalassaemia or sickle cell anaemia. Cl Why have an NIPT? O The NIPTis highly sensitive and picks up more than 99% of cases of Down syndrome. But it is still a screening test rather than a diagnostic test. This means it can only tell you whether there is an increased risk of having a baby with an abnormality, rather than give you a definitive answer, Oi The only way of knowing for sure whether your baby has Down syndrome is to have a diagnostic test such as chorionic villus sampling (CVS) or amniocentesis. Most women in Australia are offered the combined first trimester screening to screen for Down syndrome. This combines results from a blood test, the mother’s age and an ultrasound scan (which measures the thickness of fluid behind the baby’s neck, called the nuchal translucency) to show whether the baby is at increased risk of Down syndrome. The advantage of this type of screening is that the ultrasound can pick up other problems with the pregnancy and estimate the age of the fetus. Cl You might choose to have an NIPT test if: = your combined first trimester screening test shows you are at increased risk of having a baby with Down syndrome = you did not have the combined first trimester screening test because it was too late or the test wasn't available in your area = you want to be sure you are at increased risk before you opt for diagnostic tests such as amniocentesis or CVS, which carry a small risk of miscarriage = you are at increased risk (for example, if you are older or you have had a baby previously with Down syndrome or another chromosomal condition) = NIPT is a good option if you are willing to pay for it — the test is expensive and not covered by Medicare (see ‘How much does the NIPT cost’ below). You should also consider genetic counselling before you have an NIPT. Ol What to expect from your NIPT resultsCit can take up to 2 weeks to get the result of your NIPT. If the result is ‘negative’, ‘normal’ or ‘low risk’, your baby is unlikely to have any of the chromosomal disorders tested. if the result is, ‘positive’, ‘abnormal’ or ‘high risk’, this means your baby is likely to be affected. O Ifyou have an abnormal NIPT result, a diagnostic test such as CVS or am: confirm the result. You should discuss your options with your doctor, midwife or genetic. counsellor, Cl How much does the NIPT cost? jiocentesis can O The NIPT is not currently available for rebate under Medicare or private health insurance in Australia. The costs depend on the type of test and where it is analysed. If the test is sent overseas, it can cost more. You may also need to pay for an appointment with your doctor to get a referral, as well as an ultrasound. O you can expect to pay about $400 to $500 for an NIPT. 2 Counselling: = NIPT stands for non invasive prenatal testing . = This test has revolutionised how we screen for possible chromosomal abnormalities in your baby . The detection rate is about 99.9 % in accuracy and has a very low percentage of false positive results meaning have a positive result probably means there is an increased chance that a chromosomal disorder is present + Originally it was used to screen for trisomy 21 Down syndrome but now it screens for other added chromosomal abnormalities like trisomy 13, 18 and can also detect sex chromosomal abnormalities = Chromosomes store our genetic material we call DNA and it’s present in every cell in our body In healthy individuals we have 46 chromosome that are arranged in 23 pairs. We get 23 from our mother and 23 from our father = Sometimes however we can inherited to many or to missing chromosome or fragments of DNA . This can happen in any pregnancy but as a woman's maternal age advances so does her eggs and added or missing chromosomes are more likely . Other risk factors include history of genetic defects in the family = As the name suggest the test is non invasive , collect a small blood sample from you . and can be down as early as 10 weeks = When your pregnant. Your blood also contains a percentage of baby’s blood and placental blood . So we are able to analyse cell fragments containing babies DNA * Your results will be ready in 4 days after blood test * This test is only a screening test and the result tells us the risk that a chromosomal abnormality is present . It is not diagnostic . If your test results show that there is a high likelihood of chromosomal abnormalities there are to diagnostic test we can do. *= These test are invasive involving USS guided needle carefully inserted into the uterus taking a Sample of the placental cells or the fluid surrounding baby called the amniotic fluid . In every pregnancy there is small risk of miscarriage and these test are associated with a slight increase in risk of miscarriage = CVS - 1% first trimester 1: 100+ Amniocentesis-<0.5. 1: 200 + It does not screen for all genetic defects . * Combined test - blood test and us in the first trimester . Look for three hormones in the blood associated with chromosomal abnormalities us (11-13) specifically called a nuchal translucent scan where the back of baby’s neck is evaluated for increased fluid . * Ultimately choice is up to you . This is your journey and Decision . NIPT can determine the sex of your baby so please inform the genetic counsellor or health care professional if you do not wish to know the sex. 18. Domestic Violence You are a HMO in suburban hospital. This is your patient, Jenny, came to see you about having a black eye. X ray and CT have been done and they are totally normal. There is no fracture or complications from the black eye. Your tasks: © -Talk to her *-Tell her about your management plan Positive findings ‘© Fell from bed and got injury © Fight a lot with partnerBe warm, nice and professional How are you? Ask about the vision or any pain, vomiting, headache Explain the X ray and CT - no abnormal findings Ask what happened? Kids, how are they? How is everything at home? Partner? Get along with you ? Get along with kids? You look stressed, are you alright coping everything? Any stressor? Financial burden, job, drinking, smoking, drug (HEADDSS questions) Home, Education, Work, Alcohol, Drug, Depression, Smoking, Suicide Ensure about privacy, | am your doctor here to help you, tell me everything frankly. Everything we discussed here is confidential unless you harm yourself or others. Ask happy family? Sometimes, itis usual that the two persons in a relationship argue. What about you? Sometimes, some people in argument Byany chance partner did that to you? First time? How often? How about kids? Is he father of the kids? Explanation (based on a passed feedback with good score) lunderstand what you are going through. It is called domestic violence and a lot of women are facing the same situation as you are. You are not alone. You are telling me that he only does it when he is drunk or angry. But even he is drunk, it’s not acceptable. Don’t worry we are here to help you every step of the way if you allow us. Let me tell you what can | do for you. Your black eye will go away on its own after a few days since there is no serious condition, You can try {e8 packing if there is any pain. can arrange to help you and your children. as he may also harm the kids, There are if you feel unsafe at home we can arrange for you and your kids to stay there. You can about your partner but that decision lies with you. Ican arrange some so you can talk to them Also I can arrange with your consent if possible. can also Contact Centre link to arrange some required -Don’t worry our priority is your safety and your child's safety. You are a strong confident woman and we will be there to support you every step of the way.19. Hypertension counselling You are a GP. Your next patient is a 32 years old lady, Julia, who had high BP on 3 occasions, 24 hr monitoring done ~ and also high BP. Your tasks: History PEFE explain causes of increased blood pressure initial management How can | help you? | understand that you had high blood pressure on 3 occasion. How high? Symptoms of hypertension — Headache, palpitation, fatigue? Cardiovascular — SOB? Racing of heartbeat? Chest pain? Causes : Any weather preference? (thyroid), recent weight gain, purple striae in tummy, acne, excessive hair growth (Cushing's) any kidney disease?Any headache? Excessive sweating? Increased thirst? Increased frequency of passing urine? (Pheochromocytoma, Conn’s) Cx any visual disturbance? Any changes in urine? Tingling and numbness? Are you on any regular medications? 5P — sexually active? Pregnancy? Pills? Periods? (thyroid) Family history of hypertension? SADMA + social (exercise, stress) PEFE — General appearance, Vitals, BP all 4 limbs(coartation), BMI General inspection Cushing's syndrome ~ moon face, acne, hirsutism Acromegaly Hands Evidence of hypothyroidism/thyrotoxicosis (cold hands/warm moist palms) Face Fundoscopy : hypertensive changes enlargement/IVP Chest Heart : LVH/4"" heart sound Abdomen Palpation : renal/adrenal mass/AAA Auscultate : renal bruit* Nervous system examination Carotid artery bruits ‘+ Urine dipstick, blood sugar, ECG Se Investigations - USG, RFT, LFT, Thyroid functions, blood cholesterol, ECG, blood glucose, * Life style modification (exercise, walking 30 mins a day, reduce stress, avoid salty foods), Follow-up after 2 weeks. If still high, will start medications. + GCpills - stop. Other contraceptive methods can be used like condoms. (0. 111-Breast cancer breaking bad news (Med)What are the facts about breast cancer in women? About Lin 100 15 women (1 in 10 in Astra) develops ‘east cancer Breast cancer is uncommon under the age of 30 but itthen steady increases toa maxinuum a the age of out 60 yeas, being most common over 80 years Most cases start the milk dues and a fist rma localised vo the bresst, hte if refered to a eaneee i st the samen grows to about 25 nm, cells can bes ‘fF and spread metastasse) vin the Bloodstream and the Iymphate system w paso the boy sich as de iver, ng Most breast cancers are found when they arenas’ Ne: ery rarely breast cance can develop in men What are the symptoms? ‘The majority of people with breast cancer present with a ‘breast amp, most commonly inthe upper cuter part towards thearmpst Other symprom ae: Jump tats usally painless (16% are paul + bird and regular hip + change in brea shape * puckering or dimpling of cvetying skin * nipple changes: averted (tuned in) or discharge. his utssal forthe hump wo bes noticeable bulge Diagnosis is confirmed by 2 biopsy and imaging (ultrasound and mammography) What are the risk factors? + Incresng age (ove 40 yar) © Heredity a strong filly history © Preven Mtoe of bres cancer © Hemone mpliceneat therapy, excaly Tanger thin + Using the orl contacepive pill * Incresed akobol intake hei cing ey treme right gon Early age at ist period Late age at menopause (55 yeas or olde) + Childlesiness or having children after 30 * Tonising nadation exposure What ara the horaditary factors? ‘About | tn 20 brea cancers are caused by specific genes (GueBRCA 1 sud 2 gone) hut can be tered Thos ‘irony fay br ca bested So he gees i =a What is the treatment? ‘The treatment depends on several fictors including the size type and nature of the cancer and the 2p, heath and personal preference ofthe patent The options inlage angry, chemotherapy radiotherapy and hormane zeament, sual 3 ‘combination of to or mere of these. The first-line eatment {s usualy an operation to remove the cance, surrounding. Tress sue and possibly adjacent mph glands. The main surgeal options are + Breastonservig satyry— lumpectomy’ or partial mastectomy—vhere a smaller operation or a Sinaler tumor removes the cancer and some ofthe sirtounding reat sue + Mestony—removal of the emtize breast wit Impl lands frm the armpit Ths the singery of choice for 2 large tumour Since the canoer cells fist spre 10 the nearby Iynph glands i the armpit, its usual to remove these o a as, Inve radiotherapy to this area, eis leo standaed to follow sung for owe ance wh chemo raditerpy ‘orantihormne therapy (eg. tamexifen) depending on the Pathology report and advice ofthe specialist. Breast implants and reconstruction _Avalabeopalons Sor commati reasons cde bres ors ‘or prostheves to wear dnd the be, brat capa such os lee Elie doris well rent ercoeniemtin ea lage of ttn sed gece Hewett med flowing What is the outlook? ‘The results of weatment continue to improve. The 5-year sureval rates now ust over 80%. Breast cancer screening hisrecommended that women bite screening mammogrophy Key points Brest cancer fle in 10 Australian wore, “The chances of eure ae good. Breast cancer suppor groups re hel Tresiment options include sigery (alo partial mastectom), radiotherapy, chemotherapy and hormone therapy. Breast tasvehttps://youtu.be/_uOS7hfKkVI You are at your GP and is about to see 58-year-old Susan who had a lump in her left breast. She was seen by another GP who had ordered a core biopsy and the biopsy result has shown invasive ductal cancer with progestogen and estrogen receptor positive. The lump was 1cm in size and she has come to collect the result of the cone biopsy. Tasks: Take further history -Discuss the results with her -Discuss your further management with the patient History Lump questions (Lump, nipples, LN, secondary sites-liver lung brain bone) -How long has the lump been there? -Is it a single or multiple lump? -Where is the site of the lump? Is it towards the inner or the outer side? -Is it increasing in size? -Is the lump fixed or is it moving freely? -Is it soft lump or a hard lump? -Any pain in the site of the lump? -Any skin changes that you have noticed over the lump like dimpling or puckering? -Any ulcers or any discharge? -Any ulceration or distortion of the nipples? Any blood-stained discharge? -Any lumps or bumps in your armpits or the neck? -Have you noticed any weight loss? -Any back pain? (spinal metasta Any shortness of breath? (lung metastasis) “Any yellowing of the skin? (liver metastasis) -Any headaches? (brain metastasis) Risk factors questions -Period: when was your first and last period (early menarche and late menopause) -Pills: have you used HRT and for how long? (HRT> 5 years) -Sexual history: are you sexually active? Have you been sexually active before? (nulliparity)SAD (alcohol) personal history of any cancers -PMH/ PSH/ medications and allergies -Family history of breast or ovarian cancers 1-Knoweldege about the test -I have got the results of biopsy with me. Do you know why the biopsy has been done for you? 2-knowledge about the disease -have you been told about your medical situation so far? 3-How much information they want -How much do you want to know about the results? 4-breaking bad news -the news that I've got for you is a little bit concerning. Unfortunately, the sample of tissue that we have taken from the lump in your breast has shown that it is a nasty growth or cancer. Scsilence, tissue and water -the patient will start crying so offer box of tissues and glass of water if available, wait for her to settle down. 6-after few seconds break your silence -would you like me to continue the consultation today? ‘offer a call for someone -would you like me to call anyone for you? &-showing empathy -I know that this is not what you wanted to hear, and | also wish the news were better. | can see that this is an upsetting news for you and also very difficult situation to face. 9- showing support to reassure she is not alone-but we will be working as a team with you, supporting and monitoring you along with your family to take you through this difficult situation and the survival rate has significantly increased overtime due to the better diagnostic tests and scans and improvement in the treatment methods. 10-ask if she is ready -Are you ready to discuss a treatment plan now, or should | arrange another appointment with you? L-MDT and Refer to the specialist for Ix to check for spread -from now on the treatment is by a multidisciplinary team, in this case mostly no need. -| will make an immediate referral to the cancer specialist. Further investigations needed to be done to check if it has spread to other parts of your body, which we are not suspecting at the moment but need to look for. -They might need to do: * FBC and blood group, * UEC * UTs © Bone scan * Ifnecessary, CT head 2-Treatment according to the disease (usually talking about surgery, radio and chemo and LN) reatment will be decided by the specialist -if itis stage 1 usually itis breast conserving surgery. ‘The surgery will either be: a lumpectomy where the cancerous lump is removed with a border of normal breast tissue, or Partial removing of the breast. -the surgery is usually followed by radiotherapy. -Meanwhile the LN which are adjacent to the breast also will be checked to see if there is any cancer and would be removed.-other treatment will depend on receptor positivity, in you it showed Bstrogen receptor positive 0 you will most likely put on adjuvent hormonal therapy with 3-Follow up (usually blood tests and imaging) is important (till 70 years old) BRSBFEETEIGHIVE need to be screened SVSaHIVaHErSOVERES with mammogram -can talk about plastic surgeon and reconstructive surgery Note/ itis diagnosed [@SHHaH SOE old so screen 1" degree relatives fBmnIaS (40?) ears finally till 49 years then 2 yearly till 70 years 21. Chlamydia 22 y old uni student, Joshua, went abroad on sports tour. come after STI screening He recently Visited overseas where he had casual sex partners. He didn’t take any blood transfusion, no hx of tattoo and piercing. His general heath is good. Investigation report- gonorrhoea, HBV, HCV, HIV negative but chlamydia positive. Tasks: + explain investigations * Counsel accordingly (no history) understand that you are here for the results of STI -do you know why it has been done for you? -Tell about the negative results one by one. -1am concerned that it appears to be + for chlamydia -pause --do you want to call anyone for you? -do you want to discuss the Mx now? ‘+ -Chlamydia is an infection of genital tract with a bug bacterial one called chlamydia trachomatis. ‘+ itis usually transmitted by unprotected sexual intercourse -in most of the case it is asymptomatic. However, it can be presented with discharge or painful urination-If left untreated, it can spread to body organs. The good thing is we picked it up early so we can treat it and prevent any Cx. Management + Lwill prescribe you (if asymptomatic) (if symptomatic)SE of azithromycin (nausea/ vomiting, stomach upset) and sone of the tests HIV needs to be repeated after 3 months | * Also EonitaGt tracing to partners 6 month back is important. -Yourneed to inform contact if you are comfortable directly or you can use a website called ~The pathologist will notify the department of health Service to break the chain of spread as there is high possibility to spread by others. But let me assure you that your sit is important to avoid sexual activity during this time of infection and before the retest, otherwise use safe sex for which you need to use condoms. ‘© Red flags - any rash, discharge, lumps to come see again Review, reading materials22. Retinoids (2019) ‘Acne in face, using retinoid, pt is wearing cap and hoodie telling don't go school that much as acne, Picture was there. © Take Hx * tell about the impact and S/E of retinoid Dx- (acne vulgaris) History © Site, duration, any evolution? worsened? Better? Anything make it better or worse? Food or cosmetics? Pain? © Retinoid — how long? How often ? What form? Sunscreen? Did you use it at night or day? © SE of retinoids — © topical ~ SFV/dermatitis) ash pal (Oral topical side effects + adhe laiarhiaea)iivemiting) labdomninallipain]+ How's it affecting routine life? + Past medical, past surgical * Social - depression, stress? How's everything at school? * Show sympathy + SADMA + Menstrual history if female! + Other features of PCOS - voice changes, male pattern hair changes, obesity * Side effects skin dryness, redness, itching, pain, infection, headache, nausea, vomiting, diarrhoea, tummy pain, 23. 3NOAC counselling You are a HMO at a hospital. You are going to see Nickol, 57 years old patient, diagnosed with diverticulitis, now it was infected and resulted in diverticular abscess. He is currently on antibiotics and IV and under watchful waiting. If not improved in 2-3 days, surgery will be carried out. He is a case of AF but it is controlled and he is on Apixaban (NOAC) and Atenolol and Atorvastatin. *Address his concerns *and counsel the pt Introduction *Ask about his concerns. Ask about any history of stoke or VTE previously? If present, when? First concern: 1am concerned for the operation. | am going to die. Is it necessary? *Counselling —First of all, let me explain you why we need this surgery. As you have already known, there is collection of pus in the outpouching of your large bowel. Currently, you are onantibiotics through veins. Sometimes, the collection of pus can be drained a needle but depending on the patient’s condition, a major surgery is needed to remove part of the large bowel which is already dead. *Second concern: 1am on blood thinners due to a stent placed in my heart. They will stop my medication for this surgery. If you stop this medication, | am going to have a stroke and if you don’t stop this medication then | am going to bleed to death. I die both ways *1 understand that you are afraid of having a stroke when your medications have been stopped Let me explain you about this. *The surgery we planned is a major surgery which has relatively higher risk of bleeding. So we need to stop the Apixaban which is a blood thinning medication you have been taking. If we don’t suspend this medication, the chance of major bleeding is so much higher than the chance of stroke. But the good thing is these drugs like Apixaban are the new agents that have quicker actions and live shorter in the blood. So they allow a short-term cessation and early re-initiation after surgery. And we can The actions can be seen within 2 hours we recommence it. During this time, if needed, the specialist might consider other blood thinners. Also you don’t have any history of stroke or VTE previously and your AF is well controlled, so stroke is less likely to occur within this short period of cessation During surgery, we will keep blood and blood products ready if any bleeding occur. *Before surgery, you'll be reviewed by MDT including Haematologist, cardiologist, Anaesthetist and surgeon to make sure you are safe for Sx *During the surgery, the surgeon will cut into the large bowel, remove the damaged pockets or pouches, then reattach the remaining segments of the bowel. Third concern Colostomy is dreadful! | am going to have a colostomy bag (stoma bag) forth rest of my life *Sometimes, when the reattachment is impossible, the surgeon may create a colostomy which is a small hole that allows stool to exit through the stomach and requires the person to use a colostomy bag. Usually, itis temporary too. *Colostomy —living with colostomy is much easier these days. The patient will just have to follow the instructions about the diet, medications and proper care. They are odor proof and no one will notice if they are not told. Fourth concern:Doctors are saying its elective and safe, but my mother died during elective operation as well! ‘They were operating on her for cancer. ‘Everyone case is different and this procedure will be done by trained specialist and very well equipped hospital where all the facilities is there “For: ‘*We may need to run The bowels before surgery. {antibiotics already be able to do normal activities within 1-2 weeks. ‘After surgery, the patient AR You are a HMO at a hospital. You are going to see Noel, 55 years old patient, diagnosed with diverticulitis, now it was infected and resulted in diverticular abscess. He is currently on antibiotics and IV and under watchful waiting. If not improved in 2-3 days, surgery will be carried ‘out. 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PERIOPERATIVE MANAGEMENT AND OTHER CONSIDERATIONS ‘ranean ft roy rng ton et Pt eg hat econ erasure eso ate os rey" Atte ea sheds ol Pate ‘a rr ae carom Ea For wne 1h eg rab ect gry ely ry Et bw NS Fertig "Borat 0 nama ange Coke tenn) Poem 5 Com eno wre mt ta ata ig Car a ety Iter 2 Bett NOME seu peor comin ns‘Table 27: Recommencng NOAC postoperatily® Satorenme2t has ater sugey Hani itk —Ooretreune trees dng ul (siRT), > (which will destroy the tumor cells with electric current) > Trans-arterial chemo embolization (which is a therapy that involves vessel occlusion, delivering high doses of chemotherapy to the target lesion. These techniques have proven dramatic increase in survival rates. Aim — to improve the quality of life to the most, make sure the patient is comfortable ~ no depression, no pain, no worries Support groups for bowel cancers 8 cases 25. HRT Counselling Perimenopause ... < 12 mth of amenorrhoea sequential HRT = continuous oestrogen + progesterone in last 14 days = withdrawal bleeding (SE — Nausea, bloating, headache, breast tenderness, breakthrough bleeding) Menopause ... >12 mth of amenorthoea continuous HRT © with uterus = continuous oestrogen + progesterone © without uterus = continuous oestrogenTypes of HRT Regimens ss | 1 ePTRegimen Estrogen Progesterone ree Day225 Last 10.4 days of Teyle ‘eyele-combined —Day25— Day 25 Continaows-eveic ally 10:4 days every month Continuouslongcyele Daly 14 days every 3-6months Continuous -combined Daly Daly You are at your GP when 53-year-old Tracy presents to you. She has come to you to discuss about HRT. TASKS * 1. Focused history * 2. Counsel regarding HRT History © Why are you considering for HRT? © Symptoms of menopause: > Vasomotor symptoms: Are you experiencing hot flushes, heavy sweating? Psychological: Are you having mood changes, sleep disturbances, depression? Atrophic vaginitis: Any vaginal dryness, itchiness, discharge? Atrophic urethritis: Any burning or stinging while passing urine? Somatic symptoms: any muscle aches and pains? Any bone pain? Any history of fractures? vvvvyY o Is it interfering with your lifestyle? ‘when did you get menopause? © Any bleeding after menopause? © Contraindications for HRT: - Any increased clotting in your veins? (DVT) - Any undiagnosed vaginal bleed? - Any active liver disease? (HRT is processed in the liver) - Any uncontrolled high blood pressure? - Any history of stroke? - Any recent heart problems like angina or heart attacks?- Any history of ovarian or endometrial cancer? Any suspected current or past history —_— Any medical or surgical conditions in the past? Counselling After menopause, the ovaries shut down completely so that very low levels of estrogen and no progesterone is found in the body. = The lack of estrogen, contributes to menopausal symptoms that you are having. HRT has both estrogen and progesterone in it and this replaces these hormones in your body. - progesterone is added to prevent the thickening of the endometrium or the inner lining of your womb which happens due to estrogenic influence. The benefits of HRT is that it can relieve your symptoms It can increase the risk of thromboembolic disease DvT increased clotting tendency in your veins stroke breast cancer (especially if you use it for more than 5 years), endometrial and ovarian cancer, gallbladder disease. > > > > > Before starting HRT, you need to do certain blood tests like > FBE, UEC, LFT, BSL, lipid profile > No need to estimate the hormones if already menopause - will refer you to a specialist gynecologist who will start you with appropriate HRT.