Diagnostics and therapeutic decision making. Linda Nazarko. London Northwest Healthcare NHS Trust

Transcription

1 Diagnostics and therapeutic decision making Linda Nazarko London Northwest Healthcare NHS Trust

2 Aims and objectives To be aware of: The value of consultation models The importance of history taking How physical examination can validate or lead to questions How to nail the diagnosis Determining treatment options When to treat and when to refer How to work with others to enhance care

3 The value of models Provide structure Holistic Enable development therapeutic relationship Enable practitioner to understand the patient, the patient s understanding of the problem(s), beliefs, motivation Enable practitioner to engage with the unique human being who is being treated

4 Calgary- Cambridge Model

5 History taking the theory Provides subjective data In vulnerable, older, cognitive or language difficulties obtain collateral history Obtaining collateral history in relation to falls. Over 80 percent of diagnoses are made solely on the basis of history.

6 History and reality Mrs Al Badawi fit and well and in good health tripped while making tea. Never fallen before, hasn t been to hospital in years. however on further questioning reports: Pain in lower back had it all my life Dizzy for the last few years. Tired and unsteady for the last few years. Tries to get lots of sleep but can t seem to get enough sleep to stop the tiredness.

7 What the history tells us Mrs Al Badawi has type two diabetes, long standing back pain, hypertension and OA of the knees. She s been dizzy, tired and unsteady for years Is there anything else we need to know?

8 Why? One word makes a difference. The word is Why Why is Mrs Al Badawi, dizzy, tired and unsteady? Lets look at medication

9 Prescribed Prescribed Amlodipine 10mg OM, Paracetamol 500mg two tablets QDS Zopiclone 3.75mg two tablets nocte. OTC Movelat gel to knees Nytol two 25mg tablets every night

10 Any thoughts? Do you know why Mrs Al Badawi is tired, dizzy and falling?

11 Social history Provides a view of the whole person Level of social support Relationships Housing Level of mobility Level of ability Any difficulties

12 Mrs Al Badawi London, New York, Montreal and York In London three bed house, living alone Independent ADLs and support with shopping and housework

13 Physical examination Objective data that complements the history. Most diagnoses are made solely on the history. But physical examination can allow you to revisit the history and gain valuable clinical information.

14 Mrs Al Badawi- clinical findings Arcus senilis Bilateral carotid thrill and bruits Laminectomy scar around L4-L5

15 Formulating the diagnosis History taking Any outstanding results Physical examination Diagnosis Any further information required Identify red flags Any further investigations?

16 Therapeutic decision making Ability to determine the patient s expectations Ability to determine when onward referral required Ability to determine who else can help in patient management Ability to work as a team to provide the best possible care and treatment

17 1.Arcus senilis Clinical findings 2.Bilateral carotid thrill and bruits and reported history of 60 percent carotid artery stenosis 3. Tenderness on percussion 11 th intercostal space posterior chest right side no bruising or abrasions noted. 4. Concurrent use of prescribed & over the counter night sedation.

18 Arcus senilus Arcus senilis is caused by the deposition of lipids in the cornea. is associated with elevated cholesterol and triglyceride levels and increased cardiovascular risk factors No statin, receiving healthcare three countries and four GPs. Check diabetic control and lipid levels

19 Carotid stenosis? Bilateral carotid thrill and bruits and reported history of 60 percent carotid artery stenosis Asymptomatic no history of stoke or TIA Obtain details regarding previous investigations to guide treatment

20 Intercostal tenderness Possible intercostal sprain Review x-ray Consult physiotherapist Treat symptomatically

21 Polypharmacy and falls Dizziness Drowsiness Increased risk falls Increased risk dementia NB: Patient dizzy, tired and falling

22 Hypnotics and older people Only to be prescribed following investigation & treatment of any underlying problems contributing to difficulties sleeping. Should not be prescribed to those who have unrealistic expectations in relation to sleep Recommended dose for older people is 3.75mg and 7.5mg should only be prescribed in exceptional cases It should not be prescribed for longer than 2-3 weeks not suitable for chronic insomnia Benzodiazepines and Z-drugs such as zopiclone can increase the risk of falls, are potentially inappropriate in older people and should be prescribed with great care

23 Nytol Diphenhydramine hydrochloride, a sedative antihistamine - anti-cholinergic Use with caution in older people, can cause tiredness, dizziness, drowsiness and impair balance. Interacts with hypnotics and enhances their effect Prolonged use of anti-cholinergics increase dementia risk

24 When to treat and when to refer I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. Dr Lasanga

25 The art and science Art trusting relationships. We meet people in their darkest hours and they share their hopes, fears and aspirations Science working out what can be done to aid recovery or come to terms with changes Art is in working with the person through these times The art and science combine to provide kind, compassionate humane care.

26 Teamwork Older people & those with complex conditions require skills of a team rather than one person. Team members include physiotherapy, pharmacy and occupational therapy. Strong teams = best outcomes.

27 Last words The key to excellent treatment is to ensure that you have the right diagnosis Its important to work with the patient to ensure treatment meets the person s needs and aspirations No one profession can meet all needs, teamwork is vital

28 Thank you for listening Any questions?