Doctor s Instructions Patient: Mr Abdul Shareef Age: 40. Last Consultation Dr Mitchell 2 weeks ago

Transcription

1 Doctor s Instructions Patient: Mr Abdul Shareef Age: 40 Last Consultation Dr Mitchell 2 weeks ago Telephone Triage: Patient just wants a routine blood test as FH of diabetes. Plan: Fasting blood test, to come in after to discuss results. PMH 1 month ago: Obesity. BMI 32 Drug History NKDA Nil prescribed Social History Non-smoker Alcohol nil Blood Results (1 week ago) FBC RBC 4.9 ( ) WBC 3.9 (3.8 10) Plts 350 ( ) Hb 14.9 ( ) MCV 90 (80 94) MCHC 32 (28 36) U&Es Na 140 ( ) K 3.7 ( ) Cr 72 (70 110) EGRF > 60 LFTs Bilirubin 3 (3 21) ALP 67 (40 130) ALT 20 (0 55) Cholesterol Profile Total Cholesterol 5.6 (< 5.1) LDL 3.0 HDL 1.4 Total Cholesterol / HDL ratio 4.0 Triglycerides 1.5 (< 1.7) HbA1c 36 mmol / mol Fasting Glucose 5.0

2 Actor s Script *The most important things to remember have been underlined* Background (this information is for you please follow the script to determine when to disclose this information) You are Abdul Shareef a 40 year old overweight / obese gentleman. You have a family history of diabetes in your aunt on your mother s side (she got it in her 60s). You own a shop, where you work. You called the doctor last week to ask for a blood test to ensure you do not have diabetes, as you got a bit worried about that when you heard about your Aunt. The doctor will tell you your cholesterol is high, you know that cholesterol is due to eating fatty foods. **Your main aim is to find out if you have diabetes, and you will also hint about your weight problem to try and encourage the doctor to give you advice on weight loss** Opening Statement As you can I am a bit overweight, so I asked for a general blood test to make sure everything was ok, and I have just come in for the results Next Statement If you are asked an open question next (e.g. tell me more why did you have the blood test? ) or any open question after this say: I just wanted a check up Questions about your blood results: Is there any diabetes? What is my cholesterol? How do you treat cholesterol? You are happy to follow the doctor s advice. If the trainee asks any more open questions, ask them what they would like to know, and only given the information in the rest of this script if the trainee specifically enquires about it. History of Presenting Complaint If the doctor does not discuss your weight try to bring in your weight a couple of times. E.g. I know I am overweight I am worried about my health due to my weight Obesity Symptoms: You have been trying to loose weight for 6 months You want to loose weight, because your children are still young, and you don t want anything to happen to you like a heart attack (one of your distant friends died of a heart attack in their 50s 6-7 months ago; you were not close to them, but it made you realise you need to look after yourself). You have always been on the bigger side of normal Your weight was 90kg 6 months ago. Over the last 6 months you have lost 3kg, but you have stopped loosing weight despite continuing with a good diet You want to loose at least 10-15kg. You have tried weight watches, but that did not work for you Your diet involves: 3 meals a day

3 Breakfast a cup of tea, no sugar, and two pieces of toast with the cholesterol lowering margarine flora proactive Lunch home made salad sandwich and fruit Dinner chapatti (no ghee / butter), and a curry with rice and yoghurt You snack occasionally between meals on fruit You avoid fried foods, cakes, crisps and chocolates. You do not binge eat You do not make yourself vomit You do not take any medication to help you loose weight You have no time for exercise, you are at the shop 12 hours a day You run the shop by yourself with staff You have no other symptoms Past Medical History You have no medical problems Drug / Medication History You take no medications You have no drug allergies Family History Your parents are still alive and fit and well You have an older brother, who is fit and well Your aunt on your mother s side has diabetes (she got it in her 60s), but otherwise no medical problems in the family You have no family history of any other medical problems Psychological History Your mood is fine You are not anxious Occupational History You work in a grocery shop You own the shop The business is doing well The job involves sitting around a lot. The staff do the cash and carry, and the filling up You basically work in the check out region Social History: You do not smoke You do not drink alcohol. You have no time for exercise You live with your wife, and your two young children aged 8 and 10. Financially you are ok

4 Ideas I have just come for my blood results Concerns I just want to make sure I do not have diabetes Expectations I just want my blood results. Examination If the doctor says he would like to examine you, agree to this. Management Follow the doctor s plan You want to know how to treat your cholesterol. You are happy to take tablets if these are offered Agree to the doctor s plan otherwise

5 Examination Card BP 130/78 Weight 87kg Height 166cm BMI 31.5 QRISK SCORE: 12%

6 Mark Scheme Obestity and Raised Cholesterol Data Gathering and Clinical Practical Skills Obesity: Why do they want to loose weight? Why now? Any triggers for this? Have they made any attempt to loose weight? Dietary habits breakfast, lunch, dinner, snacks in between. Weight watchers / slimming world / dietician / gym / exercise. Previous attempts at weight loss. Red flags binge eating / self induced vomiting / any medication to loose weight / symptoms of hypothyroidism Cholesterol Hx - NOT required as you already have blood results; if you didn t have blood results you could have asked: Previous hx of raised cholesterol, yellow spots on skin or around the eyes (xanthalesma / arcus senilis), symptoms of HTN (headache, visual problems), chest pain, symptoms of DM (polydipsia / polyuria) PMH MI / HTN / DM FH Obesity / IHD / DM / Cholesterol Occupational History Sedentary job Social: Smoking, alcohol, exercise. ICE Examination: BP, BMI, QRISK Score Clinical Management Shared management plan Lifestyle: smoking, alcohol, diet, exercise, weight loss. Work with patient re: exercise and try to develop a plan Conservative: Dietician, weight watches, slimming world Appropriate Investigations: bloods (consider TFT) Medications: As per guidelines. QRISK > 10%, so eligible for statin (NICE guidelines) BMI > 30 (or > 28 if additional risk factors) so eligible for olistat. Appropriate Safety Netting / Follow Up (needs LFTs in 3/12 if initiated on statin) Interpersonal Skills Develops rapport Active listening do not repeat questions Does not use inappropriate terms Non patronising Empathy Appropriate ICE Patient centred consultation Communication skills When the patient asks for the results, do not rigidly stick to drs agenda I have got the results, I can either give you the results now and then go through your history or I can go through your history and give you the results in context, what would you like to do? Brings in obesity sensitively A number of things can cause a raised cholesterol including, diet / lack of exercise and weight. You mentioned you were overweight earlier, have you had any thoughts about what you would like to do about your weight? Positivity when the patient states they are trying to loose weight ( That s great ) / they have lost weight ( That s great That is really difficult to do, you have done really well ). Context confrontational lifestyle questions (e.g lack of exercise). I think you have done brilliantly to loose weight, and I know you don t have much time because of your shop, but exercise can significantly help, and exercise does not necessarily mean going to the gym, there are a number of ways in which you can exercise. Total Score: / 9 Suggestions