Outpatient/Follow-up ConsultationWha

1. WIPE (wash hands, introduce self, check patient details, explain the purpose of the consultation)
2. 5 C’s
   1. Check
      1. Check how the patient is doing; their background understanding of the condition/treatment and why they need a consultation (NB this may involve taking a focused history from the patient, particularly if you have never met them before)
   2. Current Complaints/Problems
      1. Ask if the patient has any new/worsening/unresolved symptoms that are bothering them.  What is the biggest impact on daily life? etc
      2. NB it may be that some of these are nothing to do with the original condition (in which case, it may be an option to explore further or note them but focus only on the condition)
   3. Control
      1. What is the patient taking/doing for treatment?
      2. Check/explain any test results
      3. Explore then summarise how well condition is controlled
   4. Compliance
      1. Ask (non-judgmentally) whether the patient thinks they are fully compliant with management (particularly if these are lifestyle changes; it also could be reasonably to take a detailed social history to explore the reasons behind poor compliance)
   5. Complications/Events
      1. Ask specifically about potential complications the patient may not have noticed and should be wary of
      2. Remind them of the risk of complications in context with previous points (e.g. poor compliance)
3. Summarise the current situation
4. 4 A’s
   1. Advise
      1. Make a plan together with the patient as to what should happen next
   2. Agree
      1. NB it is a good idea to summarise the consultation at this point too
   3. Assist
      1. Offer any help where appropriate, including input from other members of the team e.g. specialist nurses/services, INFORMATION sheets etc
   4. Arrange follow up

Explaining results/diagnoses

1. WIPE (Wash hands, Introduce self, check Patient details and Explain)
   1. NB Explain usually involves asking the patient what has been going on, leading up to this point- then you may explain that you are here to discuss x, y, z…
      1. Important to try and build some rapport at this point early on
      2. Assess their prior knowledge and ideas/concerns/expectations
      3. Also ask if there is anything else they are wanting to know/discuss today- it may be that their agenda is different from yours
2. Explanation
   1. Explaining a Disease
      1. If possible, explain the normal anatomy/physiology (use of a diagram may be very helpful)
      2. Go on to explain what the disease process is and what the patient has
         1. After this, IMPORTANT to check the patient has understood and answer any questions
      3.  If you haven’t already, try and explain the causes of the disease and the problems caused by the disease
      4. Explain what can be done to manage the disease
         1. NB This may mean going on to explain procedures/treatments (see below)
      5. IMPORTANT- it may be appropriate to use the SPIKES method of explaining diagnoses which may come as bad news to a patient
      6. IMPORTANT- it is also useful to give out an INFORMATION LEAFLET or similar
   2. Explaining a procedure
      1. Good idea to explore the patients prior understanding of the condition/indication and the procedure first
         1. NB Whether or not the patient has a good knowledge of the procedure should not prevent you from explaining it all in detail (for consent purposes)
      2. Explain what the procedure is/how it is done
      3. Explain the reasons for it
      4. Explain what the patient needs to do before/during/after the procedure
      5. Explain any risks/benefits/alternatives
      6. NB IMPORTANT (as with disease) to chunk and check details/understanding and summarise at the end to make sure the patient understands the main points; answer any questions the patient may have
      7. It may be that you are also required to Gain consent from the patient
      8. IMPORTANT- try and give out an information leaflet too
   3. Explaining results
      1. Again, if possible, check the patient understanding as to the condition, reason for testing, what they think the result could be etc
      2. Explain what the test set out to do and how it works
      3. Explain normal results
      4. Explain the patient results in context (particularly if the patient has had previous test results i.e. better or worse)
         1. Good idea to check that they have understood this
      5. Explain what are the options for further tests/management
   4. Explaining a treatment
      1. Important to first check for any contraindications to treatment
         1. Ask about allergies; liver disease; kidney disease; (good idea to do a focal systemic enquiry/PMHx)
      2. Check to see how much the patient understands their condition and treatment
      3. Explain what the treatment is and how it works (a diagram may be helpful)
         1. Ask if this makes sense to the patient now before going on to the practical aspects
      4. Explain the treatment course and administration
         1. NB this may involve a detailed explanation of techniques e.g. inhalers/spacers; measuring BMs/calorie counting/dose adjusting; having blood tests regularly; when to stop/continue etc
      5. Explain the side effects- and what to do if they occur
      6. The mnemonic ATHLETICS may help (Action; Timeline; How to take; Length of treatment; Effects (good and bad); Tests; Important SE; Complications; Supplementary advice)

Toxoplasmosis

Background/Epidemiology

• Caused by Toxoplasma gondii (protozoa)
  • Incubation period: 7-14 days
  • Transmitted via Ingestion (oral); blood contact.  Most commonly transmitted via cats, in whom the full life cycle of toxoplasma can occur
• One of the TORCH infections
  • High risk of transmission to foetus from mother, particularly during the third trimester (up to 60%)
  • Can cause foetal abnormalities (see below) if caught in the first/early second trimester
  • Important to treat any mothers
• High seroprevalence (16-40%)
  • NB this does not necessarily reflect true prevalence as IgG levels may be raised with old infections.  In any case, the prevalence is still high.

Presentation

• Adults- immunocompetent
  • Most (90%) are asymptomatic and the remainder usually present with vague symptoms e.g. lethargy/mild fever, lymphadenopathy
• Newborns (congenitally acquired)
  • Depends on the duration (i.e. the gestational age at which infection started)
    • If early- can cause abnormalities such as microcephaly; foetalis hydrops; hydrocephalus; even stillbirth
    • If later, can rarely cause retinochoroidosis; developmental delay/epilepsy; prematurity/IUGR; hydrocephalus
      • Usually, neonatal infection is asymptomatic
• Can cause life-threatening infections in immunocompromised hosts (usually a pneumonitis with multi-organ involvement/failure)

Investigations

• Serology
  • IgG
    • NB this persists for life.  A patient (e.g. mother) with no toxoplasma IgG indicates risk of new acquired infection
    • Can indicate current or previous infection- IgG avidity can help to distinguish between the two
• PCR can be used to detect active infection
• Imaging (foetal/neonatal brain USS) can be helpful but is rarely specific for toxoplasmosis.  Changes include hydrocephalus/ventriculomegaly; CNS calcifications

Management

• For immunocompetent patients (non-pregnant)- no treatment is usually required
• For immunocompromised patients
  • Pyrimethamine/sulfadiazine and folinic acid is standard (other combination regimes are available) for 4-6 weeks
• For newly acquired maternal infection
  • avoid pyrimethamine in the 1st trimester- otherwise use the above regime if the foetus is known to be infected
  • use spiramycin ASAP if the foetus is not infected (or status unknown)

NB The UK does not routinely screen pregnant women for toxoplasmosis (unless immunocompromised).  

Infection risk can be reduces by good hand hygiene and other infection control measures.

Paracetamol Overdose

Background/Pathophysiology

• Paracetamol overdose is the most common method of intentional self-harm/suicide in the UK.
• Paracetamol is usually very safe at therapeutic doses
  • <150mg/kg is unlikely to be toxic; >250mg/kg is likely to be toxic and >12g in total (i.e. 24 500mg tablets) is potentially fatal.
  • Toxicity occurs due to the normal metabolism of paracetamol (conjugation) to become saturated and instead being metabolised to the toxic NAPQI metabolite.  Normally, small levels can be inactivated by glutathione.  However, once glutathione stores are depleted, NAPQI begins to cause necrosis of hepatocytes and renal tubules.
    • NB Alcohol induces the metabolism of paracetamol (as can other drugs e.g. carbamazepine and rifampicin) and can increase the toxicity

Presentation/Assessment

• Most patients are asymptomatic and present seeking medical attention for known paracetamol OD
  • It can take more than 24 hours for hepatic necrosis to occur and up to 72 hours for the kidneys to be affected.
  • Occasionally there are signs of liver/kidney damage e.g. upper quadrant pain/jaundice, abnormal blood tests etc in patients with a delayed presentation
• It is important to ascertain
  • How many tablets?
  • Any other tablets/drugs (including alcohol)?
  • WHEN were they taken?
  • It is also important to assess the patient’s mood/intentions and carry out a full self-harm/suicide risk assessment

Investigations

• Paracetamol level
  • Take at 4 hours post ingestion and ideally before 15 hours (after this the level is unreliable)
    • If the patient has taken a staggered dose, measure level ASAP.
• Other tests e.g. U&Es (kidney function); LFTs (ALT may be raised- often markedly- but can be initially normal)
• An ABG may show acidosis early on and can be a poor prognostic indicator

Management

• N-Acetylcysteine
  • Treatment dependent on plasma paracetamol level (see nomogram)
  • 
  • 
• Patients with the following may require specialist care e.g. in an intensive setting
  • Encephalopathy/raised ICP
  • INR >2 at or before 48 hours or >3.5 at or before 72 hours
  • AKI (creatinine >200umol/l)
    • Haemodialysis may be required if creatinine rises above 400umol/l
  • Metabolic acidosis (pH <7.3 and/or bicarbonate <18mmol/l)
  • Hypotension (SBP <80mmHg despite fluid resuscitation)

King’s College Hospital criteria for liver transplantation in paracetamol-induced acute liver failure

• List for transplantation if
  • arterial pH <7.3 or arterial lactate >3.0 mmol/L after adequate fluid resuscitation, OR
  • if all three of the following occur in a 24-hour period:
    • Creatinine >300 μmol/L.
    • PT >100 seconds (INR >6.5).
    • Grade III/IV encephalopathy.
• Strongly consider transplantation if:
  • Arterial lactate >3.5 mmol/L after early fluid resuscitation.

ECG Interpretation

Below is a systematic approach to the interpretation of the ECG.

1. Check Patient Details
   1. Name, DOB (and age), patient number
2. Rate
   1. Calculate either by
      1. 300 divided by the number of large squares between each QRS complex (if the rhythm is regular)
      2. or by multiplying the total number of QRS complexes in a rhythm strip (usually 10 seconds) by 6
3. Rhythm
   1. Is the rhythm regular or irregular?
      1. Regularly irregular (heart block)
      2. Irregularly irregular (Atrial fibrillation)
4. Axis
   1. The most accurate way of determining the axis is by REMEMBERING THIS DIAGRAM
      1. I.e. lead I (0°); lead II (60°); lead III (120°); aVF (90°); aVR (-150°) and aVL (-30°).  Also -30-90° is normal; >90° is RAD; <-30° is LAD
      2. You then can calculate the axis by finding the iso-electric lead and +/- 90°.  Depending on the positive leads, you can determine the axis.
         1. e.g. if the isoelectric lead (biphasic lead with similarly sized positive and negative deflections) is lead aVL (-30°), the axis will either be 60° or -120°.  If leads I (0°), II (60°) and aVF (90°) are all positive, we know it must lie within this range, so it has to be 60° (normal axis).
      3. In short the axis is always in the direction of positive leads, away from negative leads and 90° to isoelectric leads.
   2. Alternatively, 
   3. RAD suggests right ventricular hypertrophy e.g. Pulmonary hypertension; mitral stenosis; PE (note there can also be the classic prominent S wave in lead I and prominent Q wave in lead III and inverted T wave in lead III (S1Q3T3)); cor pulmonale; right ventricular cardiomyopathy.
   4. LAD can be due to left ventricular hypertrophy but is more commonly seen in LBBB, inferior MIs and other conduction defects e.g. WPWS
5. Go through the waveform systematically
   1. P-waves: Present/Absent (Atrial fibrillation/flutter)
   2. PR interval (0.12-0.2 secs/3-5 small boxes): Normal/prolonged (see heart block)
   3. QRS complex (<0.12 secs): Narrow (normal) or broad (Ventricular arrhythmias; bundle branch block)
   4. ST-segment: elevated/normal/depressed (ischaemic changes (see ACS))
   5. T waves: normal/inverted/tall (old ischaemic changes or acute MI/hyperkalaemia)

Assessment and Management of Massive blood loss

• Massive blood loss is defined as the loss of more than one blood volume in a 24 hour period
  • NB This is an arbitrary definition.  In patients where blood loss is causing haemodynamic compromise, management will be fairly similar
  • One blood volume is ~7% of ideal body weight (e.g. ~5l in a 70kg individual)
  • Other definitions include >50% loss in 3 hours or >150ml/min.

Assessment

• NB Most patients with massive haemorrhage will
  • be acutely unwell -> assess using ABCDE approach
  • most will also have an obvious cause of bleeding e.g. trauma, postoperative, obstetrics, obvious GI bleed
    • Note that these may require further specific management

Management

• Resuscitation
  • Ensure at least one (ideally two) wide bore peripheral cannula(e) and/or central cannula are inserted
    • Give crystalloid or colloid and avoid hypotension/low urine output
      • Ideally pre-warmed
  • Also keep the patient euthermic (i.e. warmed)
• Blood investigations
  • Ensure Routine bloods (FBC, U&Es, Glucose) plus LFTs, coag screen, crossmatch and group and save
    • Also remember to repeat investigations regularly (certainly after first unit of blood)-
• Inform senior (usually surgeon involved or on-call staff +/- anaesthetist/ICU) and BTS/Haemorrhage team
  • If the patient is in hypovolaemic shock secondary to blood loss, a shock pack (4 units type specific RBCs, 4 units FFP and 1 unit platelets) can be requested
  • Indications for RBC replacement include:
    • Haemoglobin <60g/l or between 60-100g/l with haemodynamic compromise e.g. tachycardia, hypotension refractory to volume expansion, signs of end-organ ischaemia (e.g. reduced GCS; reduced urine output)
  • Give O- blood if you cannot wait for crossmatching.
  • For each unit of blood given, a unit of FFP should be requested
  • Platelets should be given just to keep platelet count >100×10^9/l

see Blood transfusion

• Where possible, arrest the bleeding
  • Urgent referral to surgery/theatre in the case of post-operative bleeding; urgent obstetric intervention for obstetric bleeding; urgent endoscopy for upper GI bleeding

A good flow diagram can be found here– NB always refer to local guidance

Diabetes and Surgery/Acute Illness

General Advice

• Ideally patients with diabetes should be placed first on the theatre list (so to avoid prolonged fasting)
• Ideally patients should have good control of their blood glucose and their HbA1c should be within normal range
  • I.e. pre-prandial: 4-6mmol/l; <12mmol/l post-prandial; HbA1c <8.5%/69mmol/mol
  • If not, it may be necessary to admit a patient early to control blood glucose prior to operating
• Try to avoid glucose containing infusions

Patients managed with diet alone

• Monitor capillary blood glucose (CBG) every 2 hours from admission pre-, intra- and post-operatively
  • If <4mmol/l- manage as hypoglycaemia and inform surgical/anaesthetic team
  • If >12 (or 15 depending on area) mmol/l- consider the need for IV insulin and fluids and inform anaesthetic/surgical team
• Recommend diet/fluids post-operatively ASAP

Patients managed with oral hypoglycaemics

• If the patient is on the morning list (i.e. missing one meal)
  • Usual medications the day before surgery
  • Omit breakfast and all hypoglycaemics on the morning of the procedure and allow water up to 2hrs pre-operatively.
  • Check BM on admission and 2 hourly
    • If between 4 and 12 mmol/l, no further actions
    • If >12mmol/l, consider variable rate insulin infusion or a one off dose of short acting insulin and monitor BM hourly
  • Restart oral hypoglycaemics with first meal post-operatively
• If on the afternoon list (i.e. missing >1 meal)
  • Light breakfast may be allowed but still omit oral hypoglycaemics (then as morning list)
  • Alternatively, start VRII and fluids
• A note about metformin-
  • If the patient is receiving any IV dye/contrast, metformin should ideally be omitted before this.  Similarly, before restarting metformin, ensure the patient has no evidence of hypoxia, volume depletion, cardiac failure or renal impairment (creatinine <150umol/l)- to avoid lactic acidosis.

Patients on insulin

• Day before- take normal insulin and oral hypoglycaemics
• If the patient is on the morning list-
  • Omit breakfast short acting or pre-mixed insulins and tablets the morning of surgery
  • If the patient takes a long acting insulin in the morning- half the usual dose may be given in the morning
  • Monitor BMs on admission and every 1-2 hours
    • If between 4 and 12 mmol/l, and the procedure is a minor one (with short duration/quick recovery) then there may not be a need for VRII
    • If >12mmol/l, IVII is recommended
  • If the procedure is a major one- i.e. missing more than one meal- VRII should ideally be started the morning before surgery alongside their longacting insulins
  • Restart short acting insulin with next meal or, if taking premixed insulins, give half the normal dose at lunch

NB For any patients started on IVII, serum potassium should be monitored and potassium included in fluids

Variable Rate IV Insulin Infusion

• Usually prescribed on an insulin prescribing sheet but MUST ALSO be written in the kardex
• Usually composed of 50 units of Human soluble insulin e.g. Actrapid or Humalog, in 49.5mls 0.9% saline (i.e. 1 unit per ml)
• Patients should also be given fluids (0.45% saline + 5% glucose +/- 0.15% or 0.3% KCl at a rate of 100ml/hour)
  • Depending on U&Es patients can be given more or less KCl or more concentrated saline (e.g. 0.9% if hyponatraemic)
  • Give through the same cannula as the insulin infusion (Y-connector)
  • The patient may require extra/less fluids depending on clinical state e.g. patients with cardiac failure could instead get 10% glucose mixture at 50ml/hour i.e. keeping glucose intake the same.
• The infusion should not be stopped until after the patient has restarted insulin/oral hypoglycaemics
• 

Assessment/Certification of Death

Definition

• There is not a clear medico-legal definition of death.  However, the AMRC suggests ‘the simultaneous and irreversible onset of apnoea and unconsciousness in the absence of the circulation’
  • this is providing that a full attempt at the reversal of any contributing factors to cardiorespiratory arrest has been made and one of:
    • the patient is not to receive CPR or CPR attempts have failed or
    • treatment aimed at sustaining life has been withdrawn
• A practical definition
  • An unresponsive patient, with a body temperature of >35°C, who has not been taking drugs/alcohol, if
    • there are no spontaneous movements
    • there is no respiratory effort (examine for 1 minute)
    • There are no heart sounds/palpable pulse (examine for 1 minute)
    • There is an absence of reflexes
    • The pupils are fixed and dilated

Confirming death

• The assessment must not be shorter than 5 minutes to make sure that the arrest is irreversible
  • Absent central pulse on palpation and absent heart sounds on auscultation; combined with no respiratory effort
    • Plus asystole on ECG or other absent activity on other vital monitoring
    • NB it is good to palpate all the major pulses
• After 5 minutes of absent cardiac/respiratory activity- assess corneal and pupillary reflexes and any motor response to supra-orbital pressure
• Time of death is recorded as when these criteria have been fulfilled

Completing the medical death certificate (NB Scotland)

• In Scotland, in hospitals, an MDDC must be completed
• 5 sections
  1. Details of Deceased
  2. Details of Certifying Doctor
  3. Cause of death
  4. Hazards (e.g. public health, pacemaker in situ etc)
  5. Additional Information
• For a sample- see here

Warfarin Prescribing and Counselling

NB- Make sure to follow local guidance on warfarin prescribing (there are often slight differences- not all guidance is the same)

Indications

• Venous thromboembolism (DVT/PE)
• Atrial Fibrillation (and pre/post-cardioversion)
• Valvular heart disease and valve replacements
• Mitral stenosis/regurgitation (with AF or history of systemic embolism/left atrial thrombus/enlarged left atrium)
• Dilated cardiomyopathy

Contraindications

• Haemorrhagic stroke
• Bleeding disorders (including liver failure/renal failure)
• Potential bleeding lesions e.g. peptic ulcer, varices, aneurysm, proliferative retinopathy, recent trauma
• Uncontrolled severe hypertension (SBP>200mmHg; DBP>120mmHg)
• Pregnancy

Counselling patients about warfarin

• WIPE (Wash hands, Introduce self, Check Patient details, Explain why you are there)
  • It is good to check understanding of warfarin, patient’s condition, risks and benefits, any contraindications (double check consent)
  • Explain
    • Side effects e.g. Bleeding/bruising, rash, alopecia, nausea/diarrhoea
      • Explain when to contact doctor/medical attention e.g. blood in urine, in vomit, in sputum/cough, excessive nose bleeds, excessive PV bleeding, prolonged wound bleeding (generally >5 mins for small cuts)
    • Drug interactions
    • Monitoring
• Explain how to take/compliance
  • Try to take at same time every day (e.g. 6pm in the evening)
    • Take missed dose ASAP (within 6 hours of missed dose)- do not double up doses
  • Explain the different warfarin doses/tablets (colours) and how to make up the dose
  • Explain the yellow book (or equivalent) and alert card
  • Explain the importance of not running out of tablets.
  • Explain duration of therapy
    • For single VTE (with explanation)- 3 months; (without explanation)- 6 months
    • For recurrent VTE – usually long term
    • For AF – as long as the condition persists
    • Valve replacements- lifelong
    • Cardioversion – 4 weeks before and after
  • Explain monitoring- measure INR initially every few days/every week; if the INR is stable on a good maintenance dose, the frequency can be reduced
• Explain lifestyle changes
  • Advise against contact sports
  • Advise re certain foods e.g. broccoli, sprouts, cabbage, liver, pork, cranberry juice, grapefruit juice- try to limit/avoid
  • If a heavy drinker, recommend cutting down (make sure to check LFTs/clotting prior to initiation).  Ideally, minimal alcohol intake.
  • Discuss appropriate contraception- in general try to avoid oestrogen containing preparations.  Reinforce importance of contraception and warfarin in pregnancy.
  • Advise about falling ill/going to hospital- letting staff know about the prescription.  Also re: drug interactions (don’t take aspirin, seek advice before starting herbal/alternative preparations, inform doctor before starting any new drugs/change of dose- may require more frequent INR monitoring)
    • Also important to inform your dentist
• Explain initiation
  • 2 kinds- fast/rapid (for acute VTE/valve replacement) and slow (for AF/valve disease)
  • Fast initiation
    • Usually used in combination with LMWH (for 4 days minimum and until INR>2)
    • ‘Loading dose’ of warfarin is usually 5mg (can be 10mg if there are no risk factors: age>60; body weight <50kg; liver disease; cardiac failure; low albumin; known bleeding risk; taking drugs that affect warfarin; previously anticoagulated at maintenance dose <2mg)
    • Subsequent doses are as follows (refer to local guidelines)
    • 
  • Slow Initiation
    • Once initial checks (e.g. contraindications/bloodwork) has been carried out, start on a low dose of warfarin (e.g. 2mg/day; 1mg if patient is unwell/potential for drug interactions) for a week.
    • Check INR after this and adjust dose as required:
    • 
    • In general, if the patient is taking an antiplatelet, this can be continued until the INR is in therapeutic range and then stop.  NB patients who have had an ACS in the past 12 months or have got a stent may require dual anticoagulant/antiplatelet therapy
•  Explain monitoring/dose adjustments (once INR therapeutic and maintenance dose reached)
  • If INR is abnormally high or low (i.e. sub- or supra-therapeutic)- consider a change in dose (see below) and recall in 7-14 days
  • In general, if the INR is within therapeutic range, the patient can be monitored by increasing weekly intervals (i.e. 1 normal measurement- 1 week; 2 normal measurements- 2 weeks etc).
    • More than 5 therapeutic INRs suggest stable therapy and patients can be seen every 8-12 weeks following this
  • If the patient becomes unwell or there is any other reason to increase the frequency of monitoring- ensure the patient understands the importance of notifying the doctor/clinic.
  • Dose adjustments
    • For target INR 2-3 (2.5)
      • If low-
        • increase dose by 10% of total weekly dose (e.g. if the patient takes 21mg/week- increase the dose by 2mg/week) if the INR is consistently slightly low (1.8-1.9) or if the INR is low (1.6-1.8) at any time
          • This may mean alternating daily doses.
          • Also review INR in ~2 weeks
        • consider a loading dose (150% of maintenance dose) and increasing dose if the INR is lower than 1.6 (e.g. if the patient normally takes 6mg/day- consider a one-off dose of 9mg and increasing the dose by 4-5mg/week)
          • review INR in several days/one week
      • If high
        • decrease dose if the INR is consistently slightly high (3-3.2) or if the INR is ever high (3.4-3.9)
          • Review INR in ~2 weeks depending on severity
        • if the INR is significantly high (4-5), consider omitting one dose and reducing overall dose.  If >5, it may be appropriate to omit >1 dose.
          • Review INR in a few days
        • If the INR >6, stop warfarin until INR <5 and consider vitamin K reversal
          • Review INR next day if the patient is stable and not bleeding (oral vit K (1mg) is suitable)
          • If the patient is bleeding, admit for IV vitamin K (usually 1mg if not compromised; 5mg if in haemodynamic compromise +/- clotting factors/prothrombin (or FFP if not available))