CONTENTS LIST
Cardio lo gy - Self-Assessment 117
SELF -A S S E S S ME N T
CO M MU NIC AT I ON/ETH ICS
Topic: Discussion with patient with heart failure around lifestyle
modifications following a presentation of acute decompensated
heart failure.
KEY POINTS:
• Initiate the session


Greet patient, obtain patient’s name, introduce self
Demonstrates respect and interest, and attends to patient’s
physical needs
•
Providing the correct amount and type of information
 Chunks & checks
 ‘Mr Jones can you tell me about your condition and
the problems that you have been having?’
 ‘Did you know a large part of preventing future episodes
of heart failure are down to lifestyle modifications?’
 ‘These changes can be small but can make a big difference to your health’
 They can be difficult to follow all of the time but they are
important your future well being.’
 Address any concerns or knowledge gaps the patient has
 Give explanation at appropriate times
•
Aiding Accurate Recall and Understanding
 Organises Explanation (discrete sections with logical sequence)
 ‘The changes we would like you to make revolve around
reducing the amount of fluids you have in a day, reducing
salt intake reducing alcohol intake and keeping track of
your weight’.
 'Most of the symptoms that made you feel unwell are to
do with the amount of fluid in your body'.
 'If you reduce your Fluid intake to 1 to 1.5 L a day it will
significantly help your heart to keep working efficiently'.
 'Salt is important in regulating how much fluid is in your
body it. The more salt we take in the more likely we are
to retain fluid'.
CARDIOLOGY
CONTENTS LIST
RCSI
11 8 Ca rd i o l o g y - S e l f - A s s e ssme n t
CONTENTS LIST
 '1 teaspoon of salt equals 2.2 g of sodium'.
 'We recommend you should not to exceed 1 teaspoon of
salt a day'.
 'You should limit your alcohol intake limited to 2 drinks a
day or as low as you can get it down'.
 'Monitoring your weight is a really proactive way that
you can stay on top of your heart failure if you notice
more than 0.9 kg (>2 pounds) weight gain in 24 hours,
2 days in a row, or develop symptoms of shortness of
breath, chest pain, palpitations, increased tiredness,
dizziness. or lightheadedness, or increasing swelling of
the legs or abdomen, then you should come back to us
here in the hospital'.
 Check patient’s understanding periodically
 ‘Do you have any questions so far, Mr Jones ?’
•
Achieving a Shared Understanding: Incorporating the patient’s perspective

How do you feel about making these changes?
 ‘Do you need any further clarification?’

Elicit patient’s beliefs, understanding and reactions

Pick up and respond to patient’s verbal and non-verbal cues
•
Planning: Shared Decision Making

Relate explanations to patient’s perspective

Provide opportunity to encourage patient to contribute
 ‘These changes will help to contribute to you staying well
and keeping your heart healthy.’

Involve patient & explore management options

Negotiate a mutually acceptable plan
 ‘I can provide you with some literature and link you in
with our specialist nurse who has some more information
about how to proactically apply these strategies.’

Checks with patient if they accept the plan and concerns
have been addressed
•
Closing the session

Summarise session

Safety net
 ‘Should you have any other questions or queries then please come back to me and ask me and I can get
you the information.

Final check - patient agrees and is comfortable with the plan
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CARDIOLOGY
CONTENTS LIST
CONTENTS LIST
Cardio lo gy - Self-Assessment 119
Other topics to consider :
•
Explaining limitations in terms of physical exercise to someone
who has had a STEMI
•
Explaining a valvular replacement procedure to someone with
critical AS
•
Explaining the need for prophylactic antibiotics following IE
•
Discussing lifelong anticoagulation medication in refractory A fib.
CARDIOLOGY
CONTENTS LIST
PRACTICE
YOURSELF
Practice yourself using
the Calgary Cambridge
method
RCSI
CONTENTS LIST
Re spirato ry - Self-Assessment 223
SELF -A S S E S S ME N T
CO M MU NIC AT I ONS / ETH ICS SCENA R I O S
Communication should be a collaborative process with the patient.
The Calgary-Cambridge model acts as a framework for developing
your communication skills. One worked example (smoking cessation)
is seen below and an additional of topics to practice and discuss with
colleagues.
Topic: Obtaining Consent for a Bronchoscopy
KEY POINTS:
• A bronchoscopy is a day procedure usually performed in an
endoscopy unit or in the ICU. The bronchoscope is a flexible tube
used to visualise the vocal chords and airways, and to obtain
tissue samples. The patient receives sedation but not general
anaesthesia so can be aware or alert during the procedure
•
Indications: Bronchoscopy is used for the investigation of
symptoms such as haemoptysis, and persistent cough, or it may
be used to investigate and evaluate the airways in infection.
•
Potential Complications: Desaturation (>5%), Pneumothorax
(<0.5%), Infection (<5%), Cardiac arrythmias (1-5%), bleeding from
biopsy (1-5%), Asthma like reaction (1-5%), Laryngospasm (<1%),
fever (<1%), death (rare), as well as complications from the
sedation.
•
Types of tissue samples: Endo-bronchial biopsy, bronchial
brushings, bronchial washings, transbronchial biopsy,
trans-bronchial needle aspiration (EBUS), broncho-alveolar
lavage.
RESPIRATORY
CONTENTS LIST
COMMON
PITFALL
Bronchoscopy is
not the same as
EBUS. EBUS is
an endobronchial
technique using an
US to visualise +/guide a biopsy of
surrounding structures
e.g. mediastinal lymph
nodes.
RCSI
22 4 Re s p i r a t o r y - S e l f - A s se ssme n t
CONTENTS LIST
Topic: A Brief Health Intervention for Smoking Cessation
KEY POINTS:
• Unassisted quit rate is 2-3%. A brief health intervention increased
that rate by 1-3% (which only takes 5-10minutes)
•
Smoking/ tobacco use is one of the largest causes of preventable
death
•
Brief advise on the dangers of smoking should be given at every
opportunity
•
A brief intervention is a range of effective health behaviour
change interventions that are patient-centred, short and can be
provided in a variety of healthcare settings
•
The 5 A’s Model can be used as a framework when raising the
issue of smoking and support them in their attempt to quit.
1. A – Ask

Identify and document tobacco use for every patient at every
visit

“Do you smoke? How much do you smoke per day? How
many years have you been smoking for?”
2.


A – Advise
In a clear, strong and personalised manner urge every tobacco user to quit
“Smoking is detrimental for your health. Your breathing
difficulties from COPD, have been caused by your smoking
habit. It is extremely important for you to stop smoking, to
prevent your COPD getting worse, reduce your lung cancer
risk and improve your overall quality of life”
3.


A – Assess
Is the tobacco user currently willing to quit?
“Have you considered quitting yourself? Are you ready to
give up smoking?”
4.


A – Assist
For the patients willing to quit, support them with counselling and pharmacotherapy to assist them in their
attempt to quit
“I can help you in your efforts to quit smoking. There is a
hospital Tobaccos Cessation Support programme that I can
refer you to. I can also prescribe nicotine replacement
patches to help with cravings when you stop smoking”
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RESPIRATORY
CONTENTS LIST
CONTENTS LIST
5.


Re spirato ry - Self-Assessment 225
A – Arrange
Schedule a follow-up contact in person or by telephone,
preferably within the first week of the quit date
“What date do you want to set for yourself to quit?”

“I will call you on the following Thursday to see how you’re
getting on, and if there is anything more I can do support
you”
Topic: Breaking Bad News: New Diagnosis of Lung Cancer
KEY POINTS:
• Prepare adequately for the consultation, ensuring you’ve read all
of the patient’s background medical history and have all of their
test results and anticipated some of the questions they may have
after hearing the news.
•
SPIKES Framework is a helpful model for structuring the consultation. Also use the Calgary-Cambridge Model for giving
Information in conjunction.
S - Setting

Choose a comfortable, private and quiet room

This may not always be possible, but avoid standing in a
corridor

Have tissues available and ensure you are uninterrupted

Check with patient if they would like a family member or
friend in with them
P - Perception

Establish the patient’s starting point and what they already
know or what they might be expecting

Discuss the events leading up to the diagnosis: symptoms,
investigations, scans, biopsies
I - Invitation

Check if the patient is ready to receive their results today.
Some patients may recognise it is not the news they hoped
for and may want to put off the results
K - Knowledge

Deliver the information in sizeable chunks (warning shots),
avoiding medical jargon

Leave pauses to allow the patient to digest what you’re
telling them

Provide the diagnosis in clear and unambiguous language
RESPIRATORY
CONTENTS LIST
RCSI
22 6 Re s p i r a t o r y - S e l f - A s se ssme n t
CONTENTS LIST
E - Emotions and Empathy

Ensure you tone is respectful, slow and clear

Recognise and respond to emotions

If you do not know information or answer to their question,
tell them that you do not know and make an effort to find
accurate information as soon as is possible or after
discussion with their specialist
S - Strategy and Summary

Make a plan together and inform the patient what the next
steps are

Written material can be helpful

Ensure the patient’s questions and concerns have been
addressed

Highlight where the patient can go for more questions or
concerns

Offer to inform family members or NOK for them if they wish
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RESPIRATORY
CONTENTS LIST
Ga st roente ro lo gy - Acute Ga stroenteritis 243
CONTENTS LIST
•
GI acute complications (less likely in viral gastroenteritis)
 Bowel perforation
 Fulminant colitis
 Toxic megacolon
 Intestinal obstruction
•
GI chronic complications
 Post-infectious Irritable Bowel Syndrome: may improve with
trial of oral probiotics or Rifaximin.
 Recurrent or refractory Clostridium difficile infection
•
Other:
 Haemolytic Uraemic Syndrome (Associated with EHEC
O157:H7). HUS is a triad of microangiopathic anaemia, renal
failure, and thrombocytopenia
P R O GNOS IS
•
Most acute gastroenteritis episodes are self-limiting
CO M MU NIC AT I ON AND ETH ICS
Topic: Open Disclosure in the case of healthcare-associated
diarrhoea (C. diff). Explain to a patient about their diagnosis and
cause of same.
KEY POINTS:
• Initiate the session
 Greet patient, obtain patient’s name, introduce self
 Demonstrates respect and interest, and attends to patient’s
physical needs
•
Providing the correct amount and type of information
 Chunks & checks



“Mr. Smith, can you tell me about your feelings/ knowledge about what has happened so far?”
Address any concerns or knowledge gaps the patient has
Give explanation at appropriate times
•
Aiding Accurate Recall and Understanding
 Organises Explanation (discrete sections with logical sequence)

“When you first came in Mr. Smith, you were suffering
from symptoms of pneumonia”
GASTROE NTEROLOGY
CONTENTS LIST
RCSI
24 4 G as t ro e n t e ro l o g y - Ac u t e Gast ro e n t e r it is
CONTENTS LIST
 “You were treated with an antibiotic called co-amoxiclav,
to help treat your pneumonia”
 “This helped clear up the lung infection but unfortunately has resulted in a second infection of the
bowel”
 “This is why you are having frequent diarrhoea”
 “This infection is called C.diff and it relates directly to the
antibiotics that we prescribed you”
 “I am sincerely sorry this has happened to you”

Check patient’s understanding periodically
 “Do you have any questions so far, Mr. Smith?”
•
Achieving a Shared Understanding: Incorporating the patient’s perspective
 Relate explanations to patient’s concerns, expectations and
ideas
 Provide opportunity and encourage patient to contribute
 “Do you need any further clarification?”
 Elicit patient’s beliefs, understanding and reactions

•
Pick up and respond to patient’s verbal and non-verbal cues
Planning: Shared Decision Making
 Relate explanations to patient’s perspective

Provide opportunity to encourage patient to contribute
 “In order to treat this infection, we need to give you
another antibiotic. This is a different antibiotic that you
have NOT had before”
 Involve patient & explore management options


•
Negotiate a mutually acceptable plan
 “We can start the antibiotic today, if you are agreeable?”
Checks with patient if they accept the plan and concerns
have been addressed
Closing the session
 Summarise session

Safety net

Final check patient agrees and is comfortable with the plan
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GASTROENTEROLOGY
CONTENTS LIST
26 8 G as t ro e n t e ro l o g y - I n flammat o r y Bo we l Dise ase
TOP
TIP
Other topics may
include:
1. Providing
dietary advice and
management of flares.
2. Counselling around
conception and
pre-natal health as
well as drugs such
as methotrexate,
and biologics during
conception and
pregnancy. (IBD
patients have increased
risk of voluntary
childlessness)
CONTENTS LIST
C OMM UNICATION/ETH ICS
Topic: Education regarding need for colonoscopy surveillance
Purpose of Consultation: To explain and provide information on the
need for colonoscopy surveillance to a patient with IBD. A patient
with IBD has an increased risk of colorectal cancer especially after
about 8-10 years after initial flare.
KEY POINTS:
• Initiating the session
 Greet patient & introduce yourself and your role
 Demonstrate respect and interest
•
Providing the correct amount and type of information
 Chunks & Checks
 Assess the patient’s starting point
 “Mr. Reid, what is your understanding of why you have
been getting regular colonoscopies?”
 “Do you know what your last colonoscopy showed?”
 “How do you tolerate the colonoscopy procedure?”
 Use patient responses to guide how to proceed
•
Aiding Accurate Recall and Understanding
 Organise your explanation (can use categorisation to
help)
 “Colonoscopy surveillance is done regularly in order
for us to be able to detect any abnormalities early and
treat it”
 “People with your condition have an increased risk of
developing abnormal cells, called dysplasia, and if left
untreated they could result in bowel cancer”
 Use repetition and summary to reinforce
 Avoid medical jargon
 Use visual methods if needed to convey information
 Check patient’s understanding:
 “Could you tell me what you have understood from our
conversation so far?”
•
Achieving a shared understanding- incorporation the patient’s perspective
 Discover the patient’s thoughts and feelings about the
information and encourage interaction rather than a one-way
transmission
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CONTENTS LIST
CONTENTS LIST
Ga st roent erol ogy - Infla mma tory Bowel Disea se 269
Provide opportunity and encourage the patient to contribute
Respond to verbal and non-verbal cues
 “Do you have any questions or concerns about anything?”


•
Planning: Shared Decision Making
 Allow patient to understand decision-making process
 “The timing of your next surveillance colonoscopy
depends on the duration of your disease, and the findings on the last colonoscopy”
 “Depending on these factors, according to official
guidelines, a colonoscopy may be booked for you every
1, 3 or 5 years”
 Involve patient in decision making and explore management
options, and negotiate a mutually acceptable plan
 Check with patient if they accept plan and if concerns have
been addressed
 “Are you happy for me to proceed and book your next
surveillance colonoscopy?”
 “Have I addressed all your questions and concerns”
•
Closing the Session
 Forward plan and safety net, and ensure appropriate point of
closure
FU RTHE R RE A DING
•
ECCO guidelines for management of IBD
 Management of UC
available here
 Management of CD
available here
GASTROE NTEROLOGY
CONTENTS LIST
ONLINE
RESOURCE
RCSI
28 8 G as t ro e n t e ro l o g y - Malab so r p t io n
CONTENTS LIST
C OMMUNICATIO N/ETH I CS
Topic: Medical Ethics and Nutrition
KEY POINTS:
• Malabsorption is a spectrum of disorders leading to a specific
adverse outcome for patients. Management requires an MDT
approach and development of specific communication skillset
by the clinician to identify condition, investigate cause and
support treatment plan and therapeutic trials, facilitated by allied
health professionals. This requires a lot of patient communication
and often psychological supports
•
Irish Medical Council Guide to Professional Conduct 2016 also
comments on Nutrition and Hydration:

ONLINE
RESOURCE
“45.2 If a patient is unable to take sufficient food or drink
orally, you should consider giving nutrition and/or hydration
by subcutaneous, intravenous or enteral feeding routes.
You should assess whether doing this will be of overall benefit to the patient, taking into account the patient’s views,
if known, and balancing the benefits, burdens and risks of
each form of treatment. You should be sensitive to the
emotional impact on the patient and their family of not
providing nutrition and/or hydration. If you decide that
providing artificial nutrition or hydration through medical
intervention will not be of overall benefit to the patient,
you must make sure the patient is kept as comfortable as
possible and their symptoms addressed. Where possible, you
should tell the patient and/or those close to them of your
decision and the reasons for it”
F U RTH ER READ ING
ESPEN is a good source for information on nutrition assessment,
malabsorption and intestinal failure
available here
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GASTROENTEROLOGY
CONTENTS LIST
CONTENTS LIST
G a s t roent erol ogy - Eme rg e n c y: No n -Va ricea l Upper GI H a emorrha ge 301
CO M P L IC ATION S
•
Shock
•
Acute kidney injury
•
Perforated peptic ulcer disease
•
Rebleeding (40% mortality in patients with a rebleed)
•
Death
P R O GNOS IS
•
In patients aged > 80, with multiple comorbidities, disseminated
cancer and renal or liver failure, mortality is up to 75%.
•
Use of prognostic scoring identifies patients with poor prognosis
for early endoscopic intervention (Rockall score= risk stratification
to identify patients with likely adverse outcomes after OGD)
CO M MU NIC AT I ON/ETH ICS
Topic: Obtaining consent for an OGD
KEY POINTS:
• For full Calgary-Cambridge Model example see PSC Chapter
Communication/Ethics section
•
Consent for OGD in upper GI haemorrhage is important, especially since the aetiology is unknown until the investigation
performed. Therefore, consent should cover the diagnostic
test, risk of bleeding and risk of sedation, along with the risks
associated with endoscopic injection, clipping, gold probe and
APC interventions.
FU RTHE R RE A DING
Expert Review: Management of acute upper gastrointestinal bleeding. BMJ 2019; 364:l536
GASTROE NTEROLOGY
CONTENTS LIST
FURTHER
READING
RCSI
CONTENTS LIST
Hepatology - Liver Failure (Acute & Chronic) 329
P R O GNOS IS
•
Child-Pugh and Maddrey Grading Scales can guide prognosis
•
Median Survival:
• Compensated Cirrhosis = 12 years
• Decompensated Cirrhosis = 1.6 years
CO M MU NIC AT I ON/ ETH ICS
Topic: Obtaining consent to perform a Large Volume Paracentesis
KEY POINTS:
• Initiating the Session & Establishing rapport
 Greets patient, confirms their name and introduces self
 Demonstrates respect and interest
•
Identifies the reason for consultation
 “What is your understanding about what is happening
so far?”
 Answer any questions/ concerns the patient may have.
 “I’m here today to discuss a procedure, we would
recommend, to help with the swelling/ fluid in your
abdomen.”
•
Providing the correct amount and type of information
 Chunks and Checks
 Give information about procedure in manageable chunks
and check patient’s understanding.
 “The procedure involves the insertion of a needle, using
local anaesthetic, to drain the fluid from your abdomen”
•
Aiding accurate recall and Understanding
 Organises explanation and plans related to the patient’s
perspective
Uses clear & concise language
 “The procedure is performed at the bed side.”
 “Local anaesthetic is used to numb the area, in order
that you don’t feel any pain.”
 “The needle is used to insert a tube into the abdomen,
and then the needle is removed while the tube stays
in place.”
 “The tube will then remain in place for 6-8 hours to drain
the fluid from the abdomen, before being removed. The
removal is not painful.”
 “Do you have any questions so far?”

HEPATOLOGY
CONTENTS LIST
RCSI
33 0 Hepatology - Liver Failure (Acute & Chronic)
CONTENTS LIST
•
Achieving a shared understanding
 Relates explanation to patient’s perspective
 Ask the patient what information is helpful.
 Benefits of procedure
 “When the ascites/fluid is drained, your abdomen
will be a lot softer and less uncomfortable. You’ll
also be able to breathe more easily. During the procedure a sample can be taken to help diagnose
the problem”
 Risks of the procedure
 “The risks of the procedure include but are
not limited to; pain & discomfort around the insertion
site, bleeding at the site, internal bleeding, injury
to a blood vessel, organ puncture, infection, adverse
reaction to the local anaesthetic (lidocaine)”
These are the risks but not always appropriate to give long list like this.
 Risk of not doing the procedure
 “The fluid accumulation could become worse, impairing your diaphragm from working properly, and
making it difficult to breathe for yourself.”
 Provides opportunity and encourages patient to contribute
 Elicits patient’s beliefs and reactions
 “Do you have any questions or concerns on anything
we have discussed so far?”
•
Planning: Shared decision making
 Involves the patient and encourages them to contribute
their own ideas and explores management options with
patient
 Negotiates a mutually acceptable plan & checks with patient if they accept the plan and if all of their concerns
have been addressed
 “Do you have any further questions before we
proceed, or has anything been unclear that you would
like further information on? Is it acceptable to you to
proceed with the large volume paracentesis procedure?”
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HEPATOLOGY
CONTENTS LIST
34 0 Hepatology - Non-Alcoholic Fatty Liver Disease
KEY
POINT
TIPS procedures can
precipitate hepatic
encephalopathy
CONTENTS LIST
 Statins
 Important to use in NAFLD due to increased cardiovascular risks particularly in NASH
 Careful to monitor rise in transaminases
 Use with caution in Cirrhosis as increased risk of
Rhabdomyolysis
•
Procedural management
 TIPSS: treatment of Portal hypertension in interventional
radiology in end stage decompensated liver disease
•
Surgical Management
 Bariatric Surgery: the most effective therapy for NAFLD; not
only does it cure diabetes, but it leads to the resolution of
NASH in >90% cases at one year.
 Liver transplant for advanced decompensated liver disease or
HCC
C OMPLICATIONS
•
End-stage liver disease and its sequelae
P RO GNOSIS
•
1/3 of patients will die from CLD or progress to liver transplantation
•
NAFLD: MELD scoring system may be used; the higher the score
the higher the mortality.
•
NASH: approx. 1/3 remain stable (fibrosis stage), 1/3 progress
and 1/3 regress
•
Increased overall mortality risk with NASH, and higher rates of
CVD related deaths
C OMMUNICATIO N/ETH I CS
Topic: Counselling the patient on weight loss and importance of
same
KEY POINTS:
• Initiate the session
 Greet patient, confirm name and introduce self and your role.

Demonstrate respect and interest
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CONTENTS LIST
CONTENTS LIST
Hepatology - Non-Alcoholic Fatty Liver Disease 341
•
Providing the correct amount and type of information
 Chunk & check
 Give information in chunks and check patient’s understanding
 5As framework
 Ask
 Elicit if patient is open to discussing their weight
 Assess patient’s starting point
 “What is your understanding about your condition?”
 “Is this a good time to discuss your weight?”
KEY
POINT
The 5As framework is
integrated through the
Calgary-Cambridge
model.
5As Framework for
behaviour change
- Ask
- Advise
- Assess
- Assist
- Arrange
 If the patient is not ready to undertake behaviour
change, the consultation won’t progress.
 Advise
 Benefits of losing weight
 “I think if we could make lifestyle changes, we could
prevent your liver disease from progressing”
 “10% weight loss can result in >90% of the fat being
shifted from the liver.”
 Assesses
 Elicit the patient’s health status, psychosocial factors and
barriers to weight loss.

What have they tried in the past?
 Assist
 Help the patient to develop a weight loss goal and a
plan of action.
 Arrange
 Identify a way to execute the plan successfully
•
Aid accurate recall and understanding
 Use clear and concise language
 Use signposting and categorisation
 “First thing is to look at your diet…”
 “Second thing is to look at your level of physical activity”
•
Achieving a shared understanding
 Provides opportunity and encourages patient to contribute

Elicits patient’s beliefs, reactions and feelings
HEPATOLOGY
CONTENTS LIST
RCSI
34 2 Hepatology - Non-Alcoholic Fatty Liver Disease
CONTENTS LIST
•
Planning: Shared decision-making
 Aim to involve the patient in the decision-making process
and aim to increase patient’s commitment to plans made

Negotiate a mutually acceptable plan

Check with patient if plan is acceptable
F U RTH ER R EAD ING
ONLINE
RESOURCE
•
EASL Guideline on the Management of Non-Alcoholic Fatty
Liver Disease: available here
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HEPATOLOGY
CONTENTS LIST
CONTENTS LIST
Hepatology - Viral Hepatitis 353
CO M MU NIC AT I ON/ETH ICS
Topic: HBV: Counselling the need for family screening and for
compliance with long-term antiviral therapy
KEY POINTS:
• Rationale of consultation is to:
 Educate the patient around transmission with a view to
halting further infections.
 Counsel them regarding long term antiviral drug compliance
 Counsel them regarding need for family screening
•
KEY
POINT
This guide follows the
Calgary-Cambridge
Communication
Framework
Initiate the session
 Greet patient, obtain name and introduce self
 Assess patient’s starting point
 “What do you know about hepatitis B and how it affects you?”
 “How do they feel about testing and screening?”
 “Do they have concerns about long-term therapy/
screening?”
 Chunk and Checks
 Gives information in manageable chunks, checks for understanding, uses patient’s response as a guide to how to
proceed
 “Are you aware of how you might have contracted the
virus?”
 “Do you know how to stop further transmission of the
infection?”
 “HBV is a blood born virus, which can be transmitted
through bodily fluids or ‘vertically’ if the person is pregnant”
•
Aiding accurate recall and understanding
 Organises explanation and plans related to the patient’s
perspective
 Uses repetition and summarisation to reinforce information
 Uses concise and easy to understand language
 “HBV is a blood born that may spread through the use
of contaminated needles, contaminated blood products,
or through sexual contact.”
 “HBV can survive outside the body at least 7 days and be
capable of causing infection.”
HEPATOLOGY
CONTENTS LIST
RCSI
35 4 Hepatology - Viral Hepatitis
CONTENTS LIST
 “HBV is highly contagious, and transmission occurs
between sexual partners and household contacts with
infected blood or other fluids as well as contact with skin
lesions.”
 “Highest rates of infection occur between sexual partners.”
 “Screening and vaccination are recommended for
household contacts, including children of those newly
diagnosed with HBV.”
 “People should not share toothbrushes or razors. All
open wounds cuts and scratches should be covered, and
any blood spillages should be cleaned with bleach
solution.”
 “To avoid transmission of the virus to other people,
compliance with lifestyle factors and anti-viral
medications is important”

Check patient’s understanding periodically.
•
Achieve a shared understanding: Incorporating the patient’s
perspective
 Provides opportunity and encourages patient to contribute
 Picks up and responds to verbal and non-verbal cues
 Elicits patient’s beliefs, reactions and feelings.
 “Do you have any questions and concerns on what we
have discussed so far?”
•
Planning and shared decision making.
 Explores management options
 Negotiates a mutually acceptable management plan
 “We will arrange for your family to be screened and
vaccinated against Hepatitis B.”
 “You will continue to take your anti-viral medications
regularly”
•
Closing the session:
 Forward plan and summarise session
 Final check patient comfortable with plan


“Are you happy with the plan?”
“Do you have any further questions or concerns that I
have not yet addressed?”
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 1
HEPATOLOGY
CONTENTS LIST
CONTENTS LIST
Hepatology - Haemochromatosis 365
•
Chronic heart failure
 Cardiomyopathy, conduction defects, arrhythmia
•
Hypogonadism
•
Bone mineral density loss
•
More prone to infection
P R O GNOS IS
•
If Diagnosed before onset of cirrhosis and diabetes patients will
have a normal life expectancy
•
If diabetes is present, there is a 4.3 increased relative risk of death
•
If cirrhosis is present, there is a 2.4 increased relative risk of death
•
11% increased risk of dying of cancer (especially hepatocellular
carcinoma)
CO M MU NIC AT I ON/ETH ICS
Topic: Genetic counselling regarding diagnosis and screening of
family members, or consent prior to ordering the HFE test.
KEY POINTS:
• Initiate the session
 Greet patient, introduce oneself and your role
 Establish Rapport
 Identify reason for consultation
 To discuss the implications of a positive diagnosis of
haemochromatosis in terms of genetic screening for the
patient’s family.
KEY
POINT
Use the CalgaryCambridge Framework
for Communication
•
Providing the correct amount and type of information
 Assess patient’s starting point
 “What is your understanding of your diagnosis?”
 “Are you aware as that there is a genetic component
to HH?”
 “Are you aware that there is a screening programme in
order to identify those with the genetic component in
order to help prevent the development of complications?”
HEPATOLOGY
CONTENTS LIST
RCSI
36 6 Hepatology - Haemochromatosis
CONTENTS LIST
 Chunks and Checks
 “How do you feel about genetic testing and screening?”
 “Do you have any concerns about screening?”
 “What is your understanding of the treatment and the
long-term management for haemochromatosis?”
•
Aiding Accurate Recall and Understanding
 Organises explanation and plans related to the patient’s
perspective
KEY
POINT
Genetic screening has
a wider impact than
just the patient being
tested. For example,
think about the impact
testing for the Hunting
Gene, or BRACA gene
would have on a family.
The initial consultation
to discuss testing may
need to be followed
up with a further
consultation, where
you meet a wider
family group.
FURTHER
READING
 Uses clear & concise language
 “A blood test will be able to tell us what gene mutation
is causing your haemochromatosis”
 “The gene may be passed on to offspring. Your partner
and children should be screened for the gene”
 “If anyone tests positive, through screening, we can
arrange follow up for them to avoid them developing
complications.”
•
Achieving a shared understanding incorporating the patient’s
perspective
 Relates explanations to patient’s perspective

Provides opportunities and encourages patient to contribute
 “Do you have any questions or concerns at this point?”
 “Is there anything that has been unclear up until this
point?”
•
Closing the session: Planning and shared decision-making
 Explores management options
 Forward plan and summarise session
 Final check patient comfortable with plan and all concerns
have been addressed.
F U RTH ER R EAD ING
•
2010 EASL guidelines
available here
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 1
HEPATOLOGY
CONTENTS LIST
37 4 Hepatology - Wilson’s Disease
KEY
POINT
Guide to Professional
Conduct and Ethics
for Registered
Medical Practitioners
8th Edition 2019:
o 17.1 Genetic
testing can help to
diagnose an illness
or help to predict the
development of an
illness in the future.
Patients must have
counselling about the
possible consequences
of genetic testing
before you seek their
consent
KEY
POINT
Use the CalgaryCambridge Model of
Communication
CONTENTS LIST
C OMMUNICATIO N/ETH I CS
Topic: Consent and genetic counselling of a patient with
suspected Wilson’s Disease
KEY POINTS:
• Initiate the session
 Greet patient, introduce yourself and explain your role
 Establish Rapport
 Identify reason for consultation
 Genetic counselling and consent for genetic testing for
Wilson’s Disease
•
Providing the correct amount and type of information
 Assess patient’s starting point
 "What is your understanding of your diagnosis?”
 “Are you aware that there is genetic component to your
condition and that it can be tested for?”
 “How do you feel about genetic testing?”
 “Do you have any concerns?”
 Chunks and Checks
 “Wilson’s Disease is an autosomal recessive disorder.
What is your understanding of this?”
•
Aiding Accurate Recall and Understanding
 Organises explanation and plans related to the patient’s
perspective
KEY
POINT
Genetic screening has
a wider impact than
just the patient being
tested. For example,
think about the impact
testing for the Hunting
Gene, or BRACA gene
would have on a family.
The initial consultation
to discuss testing may
need to be followed
up with a further
consultation, where
you meet a wider
family group.
 Uses clear & concise language
 “Autosomal recessive conditions, means that there is a
25% chance of a child being affected, a 50% chance of a
child being an asymptomatic carrier and 25% chance of a
child being unaffected nor a carrier.”
 “Genetic testing is recommended for siblings and
children of affected persons with Wilson’s Disease,
in order to manage people early and prevent the
development of complications”
 “A blood test will be able to tell us if you and your family
have the genetic mutation”

“If anyone tests positive, through screening, we can
arrange follow up for them to avoid them developing
complications.”
 Elicit patient’s beliefs, reactions and feelings
 “How do you feel about this so far?”
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 1
HEPATOLOGY
CONTENTS LIST
Hepatology - Wilson’s Disease 375
CONTENTS LIST
•
Achieving a shared understanding incorporating the patient’s
perspective

Relates explanations to patient’s perspective
 Provides opportunities and encourages patient to contribute
 “Do you have any questions or concerns at this point?”
 “Is there anything that has been unclear up until this
point?”
•
Closing the session: Planning & Shared decision-making
 Check that patient accepts plan and all concerns are addressed
FU RTHE R RE A DING
•
2012 EASL guidelines on Wilsons Disease
HEPATOLOGY
CONTENTS LIST
available here
ONLINE
RESOURCE
RCSI
38 4 Hepatology - Primary Sclerosing Cholangitis
CONTENTS LIST
C OMMUNICATIO N/ETH I CS
KEY
POINT
Use the CalgaryCambridge model for
communication
Topic: Consent for OGD for variceal surveillance in established
cirrhosis
KEY POINTS:
• Initiate the session:
 Greet patient, confirm their name and introduce yourself
 Establish rapport
 Identifies the reason for the consultation:
 Consent for an OGD for surveillance of varices secondary
to liver cirrhosis due to PSC
•
Providing the correct amount and type of information
 Assess the patient’s starting point
 “What do you understand about the procedure?”
 “Do you know why this is recommended?”
•
Aiding accurate recall and understanding
 Chunks and Checks

Organises and explains procedure to the patient in
language they can understand
 Check’s patient’s understanding periodically.
 “The procedure is called an oeosophagogastroduodenoscopy or OGD. It involves
a doctor who uses an instrument called an endoscope to
look at the inside lining of your oesophagus (food pipe),
stomach and duodenum (first part of the small intestine).”
 “This is done so that we can get a good view of the
blood vessels along your oesophagus to check to see if
they have become swollen and dilated because of the
problem that you have with your liver.”
 “This is important because if these blood vessels get
too swollen there is a chance they could cause bleeding,
and even become life-threatening.”
 “You may receive sedation for the procedure, where you
may be slightly aware but not completely asleep.”
 “Do you have any questions so far?”
 Benefits of Procedure
 “If the swollen blood vessels are identified during the
procedure, we can immediately treat them by a
procedure called ‘banding’. This will prevent them from
enlarging.”
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 1
HEPATOLOGY
CONTENTS LIST
Hepatology - Primary Sclerosing Cholangitis 385
CONTENTS LIST
 Risks of the procedure:
 “As with every procedure there are some risks. Commonly, bloating, abdominal discomfort, and bruising at the injection side can occur. You may also feel
drowsy and disorientated for some time after receiving
sedation.”
 “1 in 1,000 will experience bleeding from the oesophagus (food pipe), stomach or duodenum. This is
often minor and can generally be stopped through the
endoscope. Rarely, it can be more significant bleeding
where surgery or interventional radiology is needed to
stop the bleeding.”
 “1 in 5,000 will accidentally get a hole (perforation) in
the oesophagus, stomach or duodenum. This can cause
a leak of stomach contents into the abdomen. If a hole
is made, you will be admitted to hospital for further
treatment which may include surgery”
•
Achieving shared understanding: Incorporating the patient
perspective
 Provide opportunity and encourage the patient to contribute.
 Elicit patient’s beliefs reactions and feelings
•
Closing the session: Planning and shared decision-making
 Negotiate a mutually acceptable plan
 Forward plan and summarise session
 Check patient is comfortable with plan and has no further
questions
FU RTHE R RE A DING
•
UK PSC Guideline (BSG)
HEPATOLOGY
CONTENTS LIST
available here
ONLINE
RESOURCE
RCSI
39 6 Hepatology - Primary Biliary Cholangitis
CONTENTS LIST
C OMPLICATIONS
•
Osteoporosis (↓Vitamin D)
•
Hypercholesterolaemia and xanthomas
•
Cirrhosis and associated complications
•
PBC recurrence post liver transplant (30% after 10 years)
P RO GNOSIS
•
Once jaundice develops survival < 2 years
•
Early stage with treatment may have normal life-expectancy
C OMMUNICATIO N/ETH I CS
Topic: Consent for OGD for variceal surveillance secondary to
cirrhosis in PBC
(See chapter on ‘PSC’ for full Calgary-Cambridge communication
model example)
F U RTH ER READ ING
ONLINE
RESOURCE
•
2017 EASL guidelines for PBC
•
Bezafibrate for PBC- 2018 NEJM BEZURSO trial
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 1
available here
available here
HEPATOLOGY
CONTENTS LIST
CONTENTS LIST
Nephrology - Self-Assessment 457
SELF -A S S E S S ME N T
CO M MU NIC AT I ON/ETH ICS TO PICS
Topic: Obtaining consent to commence haemodialysis
KEY POINTS:
• The procedure:
 Haemodialysis is a procedure that will be needed to carry out
several times per week. It takes approximately 3-4 hours
per session. It functions to replace the work of the kidneys.
It cleans the blood by removing waste products normally
functioning kidneys would remove. During haemodialysis the
patient will need to be attached to the machine via tubes
connected to your permcath/fistula/ central line, are
therefore largely confined to the bed during that time.
 During the procedure, the patient may need blood tests, or
receive blood products.
•
Benefits
 Haemodialysis is a life-sustaining process. It is not however a
cure for the kidney damage
 It will improve some of the symptoms you have been having
•
Risks
 Bacterial or viral contamination of blood (including Hep B
and Hep C), which may cause sepsis or long-term infection
and disease including liver disease
 Bleeding due to blood clotting problems or disconnection of
the rubes
 Clotting of access site
 Infection or bleeding at access sites (permcath, central line,
fistula)
 Allergic reaction and shock
 Cardiac arrest or shock
•
Common Side effects during procedure
 Light-headedness or fainting (typically due to fluid removal
during dialysis)
 Nausea
 Palpitations
NEPHROLOGY
CONTENTS LIST
RCSI
45 8 Nephrology - Self-Assessment
CONTENTS LIST
•
Alternative options
 Peritoneal dialysis
 Kidney transplant
 No haemodialysis: this will result in death without spontaneous kidney damage recovery
Topic: Obtaining consent for a renal biopsy in glomerulonephritis
with acute kidney failure
KEY POINTS:
• Introduction
 “Hello my name is_____, I am one of the doctors on the
kidney team currently looking after you”
 “I’d like to discuss a procedure with you, and get your consent for this.”
•
Providing the Correct Amount and Type of Information
 Assess patient’s starting point
 “Would you prefer me to call you Malik or Mr. Abbas?”
 “Have you ever needed this procedure done before?”
 Gives explanation at appropriate times
 Chunks and checks
 “You initially came to us with signs and symptoms of
kidney damage.”
 “This was confirmed on the blood and urine tests that we
conducted”
 “Currently, we do not have a diagnosis for the cause of
the kidney damage. This makes treating the underlying
problem more difficult”
 Give explanations at appropriate times avoiding jargon
•
Aiding Accurate recall and understanding
 Organise your explanation and divide it into sections
 Use explicit sign-posting
 “In order to get a clearer diagnosis for the cause of your
kidney damage, a biopsy of the kidney would be helpful
to guide the right treatments for you”
 “I’d like to go through the procedure itself, benefits of
doing the procedure, risks of the procedure and
alternative options for this procedure”
 Use repetition and summarising to reinforce the information
 Use concise language that’s easily understood
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 1
NEPHROLOGY
CONTENTS LIST
CONTENTS LIST
Nephrology - Self-Assessment 459
 “The procedure is performed at your bedside. You will
be asked to lie on your back. An Ultrasound is used to
guide the biopsy needle. Local anaesthetic is used
to numb the area for the biopsy. Once the area is numb,
a kidney biopsy needle is used to take a sample of the
tissue. You may feel the movement or pressure of the
needle but you should not feel pain.”
 “After the procedure you will need to lie on your back
for 6 hours, this will help compress the biopsy site to help
prevent complications.”
 “The benefits of doing the kidney biopsy would be to
help diagnose the problem that has led to your kidney
injury. It will also help guide the correct treatments that
are likely to be effective for your condition”
 “Early correct treatment, helps avoid long-term kidney
damage”
 “There are several risks with the procedure”
 “Infection, bleeding (uncommonly this can be severe),
pain at the biopsy site., passing blood in the urine
or heavy clots in the urine ( risk of 1 in 100), the ned for
a blood transfusion due to blood loss, rarely a
nephrectomy (removal of the kidney) may be needed to
stop the bleeding ( 1 in 1000 to 1 in 1500), death is
possible from the procedure”
 The risks should be given in chunks and check with
the patient how much information they wish to
receive.
 Use visual methods of conveying information
 Check patient’s understanding
 “Do you have any questions so far, Mr Abbas, or is there
anything that is not clear to you?”
•
Achieve a shared understanding: incorporating the patient’s
perspective
 Relate explanations to previously elicited concerns or beliefs
 Provide opportunity and encourage patient to contribute
 Picks up and responds to verbal and non-verbal cues
 Elicit patient’s belief, reactions and feelings and addresses
where necessary
NEPHROLOGY
CONTENTS LIST
RCSI
46 0 Nephrology - Self-Assessment
CONTENTS LIST
•
Planning: Shared Decision Making
 Shares own thinking as appropriate: thoughts, and dilemmas
 “I believe a biopsy can be helpful here to ensure you get
onto the right therapy as soon as possible, and hopefully
avoid long-term kidney damage”
 Involve the patient and offer choices
 “There is the option of starting a treatment and monitoring your kidney’s response without a biopsy”
 Ascertain the level of involvement the patient wishes in
making the decision and negotiate a mutually acceptable
plan
 Checks with patient if accepts plan and concerns have been
addressed
 “Do you consent to proceeding with the kidney biopsy?”
 “Do you have any further concerns or queries that we
have not yet discussed?”
•
Closing the Session
 Contracts with patient regarding the next steps for patient
and physician
 “If you consent to proceeding, Mr. Abbas, please read
and sign this consent form. I will then arrange for you to
have the procedure tomorrow morning”
 Ensure an appropriate point of closure, summarise the
session briefly and final check the patient is
comfortable with the plan
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 1
NEPHROLOGY
CONTENTS LIST
CONTENTS LIST
Endocrinology - Self-Assessment 549
SELF -A S S E S S ME N T
CO M MU NIC AT I ONS AND ETH ICS
Topic: Discussion with patient with type 2 Diabetes around
lifestyle modifications secondary to presentation HHS.
KEY POINTS:
• Initiate the session
 Greet patient, obtain patient’s name, introduce self
 Demonstrates respect and interest, and attends to patient’s
physical needs
•
Providing the correct amount and type of information
 Chunks & checks
 ‘Mr Sullivan can you tell me about your condition and the
problems that you have been having?’
 ‘you have a very important role to play in managing
your diabetes not only with your medication but also with
diet and exercise.’
 ‘These changes can be small but can make a big difference to your health’
 They can be difficult to follow all of the time but they are
important your future well being.’
 Address any concerns or knowledge gaps the patient has
 Give explanation at appropriate times
•
Aiding Accurate Recall and Understanding
 Organises Explanation (discrete sections with logical sequence)
 ‘The changes we would like you to make revolve around
getting enough exercise and being aware of your sugar
intake.’
 Exercise
 Even a small amount of exercise 30mins per day of
light exercise including walking can help to reduce your
weight and therefore help you to get control of your
diabetes.
 Weight reduction is key to help you to manage your
blood sugars and reduces other risk factors including
high blood pressure.
ENDOCRINOLOGY
CONTENTS LIST
RCSI
55 0 Endocrinology - Self-Assessment
CONTENTS LIST
 You should try and build up exercise slowly and gradually
and be aware that this may mean that you will need less
medication.
 Diet
 Being aware of your sugar intake is very imporntant in
managing your sugars. The ideal is to cut out all
processed sugars entirely such as sweets and chocolates
and to be aware of the sugar content of other foods and
drinks such as orange juice which can have a very high
sugars.
 It can be helpful to keep a diary of your food to see what
you are eating.
 Check patient’s understanding periodically
 ‘Do you have any questions so far, Mr Sullivan ?’
• Achieving a Shared Understanding: Incorporating the patient’s perspective
 How do you feel about making these changes?
 ‘Do you need any further clarification?’
 Elicit patient’s beliefs, understanding and reactions
 Pick up and respond to patient’s verbal and non-verbal cues
•
Planning: Shared Decision Making
 Relate explanations to patient’s perspective
 Provide opportunity to encourage patient to contribute
 ‘These changes will help to contribute to you staying well
and staying on track with your diabetes.’
 Involve patient & explore management options
 Negotiate a mutually acceptable plan
 ‘I can provide you with some literature and link you in
with our specialist nurse who has some more information
about how to practically apply these strategies.’
 Checks with patient if they accept the plan and concerns
have been addressed
•
Closing the session
 Summarise session
 Safety net
 ‘Should you have any other questions or queries then please come back to me and ask me and I can get
you the information.
 Final check patient agrees and is comfortable with the plan
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 1
ENDOCRINOLOGY
CONTENTS LIST
CONTENTS LIST
Endocrinology - Self-Assessment 551
Other topics to consider
Diabetes Mellitus
• Patients should also be educated on the symptoms of
hyperglycaemia, including blurred vision, thirst, frequent
urination, or tiredness, and should see their physician
immediately if these occur
•
If patients smoke, they should be strongly advised to quit, and
offered appropriate treatments as needed
•
Patients should be up to date with their vaccination schedule
•
The physician should help the patient plan how often to check
blood glucose. The most likely times would be before each meal
and at bedtime. Patients may also check 2 hours after meals and
when exercising.
•
Patients should usually have an HbA1c performed every 3 months
Addison’s Disease
• Patients with Addison's disease should be instructed to carry a
medical alert (bracelet or card) warning about their condition and
what should be done in case there is loss of consciousness or
major trauma, stress, or infection
•
Patients should be empowered by careful education, so that they
know when to increase replacement doses appropriately (e.g.,
when febrile, or vomiting, or in preparation for elective surgical
procedures)
•
Patients should have syringes with hydrocortisone (100 mg).
These should be administered in an emergency, and NOK should
be trained in case of unconsciousness or major trauma. If
available, prefilled syringes should be provided.
•
Lifestyle modification (including maintenance of a healthy weight,
regular exercise, avoidance of alcohol excess, dietary salt
restriction, and smoking cessation). Dietary salt restriction may
reduce the dose of aldosterone blocking drug required
ENDOCRINOLOGY
CONTENTS LIST
RCSI
CONTENTS LIST
Ge ro n to lo gy - Self-Assessment
69
SELF -A S S E S S ME N T
CO M MU NIC AT I ON AND ETH ICS
1.
Use the Calgary Cambridge method of giving information to
explain the diagnosis of dementia to a patient and their carer.
Set up the consultation with few physical barriers adopting
open posture and using positive communication skills including
active listening. Chunk information for the patient and check for
understanding. Assess for capacity
KEY POINTS:
•
Establish baseline understanding of condition and impact to
date.
•
Counsel the patient around long-term sequelae of the disease.
•
Discuss progressive and ongoing nature of the disease sensitively
•
Discuss the pathophysiology of the dementia
•
Discuss the pharmacological management and their progression.
•
Discuss adaptations to the home and the ongoing role of the
MDT in managing the disease.
•
Counsel around supports outside of the hospital.
•
Provide literature and valid online information for further selfdirected research.
•
Allow the patient and their carer to ask questions.
ETHICS: CAPACITY ASSESSMENT; CONSENT V ASSENT
2.
Communicating diagnosis of delirium and its implications to a
family member/caregiver.
Using the Calgary Cambridge model of communication as a guide.
Set up the consultation with few physical barriers within the
room. Adopt an open posture and body language. Use positive
communication skills including active listening using nodding and
appropriate eye contact. Chunk information for the family member
and check for understanding.
KEY POINTS:
•
Establish the diagnosis and the key points of the diagnosis and
the areas of deficit.
GERONTOLOGY
CONTENTS LIST
SCAN
HERE
Calgary Cambridge
method
or click here
TOP
TIP
CURVES for
assessment of capacity
Choose/Communicate
- Can the patient
communicate their
decision to you and
can they make a choice
between the options
Understand - Can they
understand what you
are saying. A good way
of deciding on this is
to get them to repeat
back in their own
words what they are
being asked.
Reason - Can they
provide logical
explanations of what
is being asked and
their own logic for their
conclusion
Value - Is the patient's
decision in line
with their values as
previously or otherwise
known.
Emergency - In times
when there is a
threat to life capacity
assessment may be
done afterward.
Surrogate in the
absence of capacity
is there a surrogate
to advocate for the
patient in their best
interest.
RCSI
70
G ero n t o l o g y - S e l f - A sse ssme n t
CONTENTS LIST
•
Discuss/outline the aetiology and key percipients.
•
Outline strategies for lessening delirium.
•
Discuss some of the possible risks.
•
Outline the long-term complications.
•
Counsel on possible supports within the hospital and the community upon discharge.
•
Counsel on the impact of the physical environment with regard
to lessening symptoms.
3.
Discussing strategies for maintaining well-being and reducing
frailty with a patient.
Using the Calgary Cambridge model of communication as a guide.
Set up the consultation with few physical barriers within the
room. Adopt an open posture and body language. Use positive
communication skills including active listening using nodding and
appropriate eye contact. Chunk information for the family member
and check for understanding.
KEY POINTS:
•
Establish that frailty is a health state rather than diagnosis.
•
Establish the key features that are assessed when assessing
frailty.
•
Discuss/outline contributing factors and ways of combatting/
reversing these.
•
Counsel on possible supports within the hospital and the community upon discharge.
•
Outline the long-term complications.
•
Counsel on the impact of the physical environment with regard
to lessening symptoms.
4.
Counselling regarding Anticoagulation for atrial fibrillation
post stroke
5.
Discussing with a patient the importance of engaging in
moderate to heavy exercise following a stroke.
6.
Discussion regarding functional deficits that may be present
post stroke and the role of each of the MDT members in
rehabilitating these deficits.
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CONTENTS LIST
CONTENTS LIST
Ne u ro lo gy - Self-Assessment 163
SELF -A S S E S S ME N T
CO M MU NIC AT I ON AND ETH ICS
Topic: Discussion with a patient with newly diagnosed epilepsy
about the need to start on an anti-epileptic medication
KEY POINTS:
•
Driving
 The patient must cease driving immediately
 In Ireland, a person with epilepsy can drive provided they have
been free of seizures for one year and are certified fit to drive
by a doctor
• Triggers
 Discuss the importance to avoid alcohol and maintain good
sleep hygiene
• Family members
 Educated around recognising a seizure and when to administer medications
• Fertility
 Some anti-epileptic medications are teratogenic, and patients
need to be advised of this and about appropriate
contraception
Topic: Discussion of genetic testing in Huntington’s disease and
its implications
KEY POINTS:
•
Huntington’s disease has an AD inheritance pattern, is invariably
fatal and currently has no cure
•
Testing is fraught with bioethical dilemmas
•
Testing one family member has implications for other family
members and their offspring
 If one member does not wish to know, and the other tests
positive or negative, it can affect them
 Having a positive test for the gene unfortunately does not
change the outcome and can add to anxiety
 Testing can alleviate anxiety by remove uncertainty
NEUROLOGY
CONTENTS LIST
RCSI
CONTENTS LIST
Rhe u m ato lo gy - Self-Assessment 265
SELF -A S S E S S ME N T
CO M MU NIC AT I ON/ETH ICS
Topic: Explaining the risks and benefits to starting methotrexate
medication for rheumatoid arthritis.
KEY POINTS:
• Initiate the session:
 Greet patient, obtain patient’s name, introduce self

Demonstrates respect and interest, and attends to patient’s
physical needs
•
Providing the correct amount and type of information
 Chunks and Checks
 ‘Mrs Byrne can you tell me about your condition and
the problems that you have been having?’
 ‘What medications have you been taking so far?’
 ‘Have you heard of a medication called methotrexate?’
 ‘What do you know about it?’
 Address any concerns or knowledge gaps the patient has
 Give explanation at appropriate times
• Aiding Accurate Recall and Understanding
 Organises Explanation (discrete sections with logical sequence)
 ‘Methotrexate is a very useful medication that we use in
the treatment of RA and other conditions.’
 ‘It is an immune modulator, which means that it works to
decrease your own body’s immune response.’
 ‘It is known as a disease altering medication or DMARD’
 ‘It is once a week medication so you would only have to
remember to take it once a week.’
 ‘As with any medication or procedure there are a certain
things that you need to be aware of before you take this
medication.’
 ‘Generally most people have very little if any side effect
however it is important that you are aware that it can
have serious side effects that we will monitor at your
clinic visits but that if you feel are happening you should
contact us immediately.’
RHEUMATOLOGY
CONTENTS LIST
RCSI
26 6 Rh e u m a t o l o g y - S e lf - Asse ssme n t
CONTENTS LIST
 These include
 Liver damage. (Explain hepatotoxicity including
jaundice nausea and vomiting.) We will monitor your
liver function with blood tests closely at the start and
then less as we are sure that it is causing no damage.
 Pulmonary fibrosis. Methotrexate can cause lung
damage and make you become short of breath
however this is a rare side effect and again we would
be monitoring you for signs of this.
 As this medication works to decrease your immune
response there is an increased risk of you picking up
infection.
 There is a chance that this medication could disrupt
how your bone marrow works.
 We would be monitoring for all of these side effects
closely and if they are likely to happen then they are
more likely to happen when you first start taking the
medication. However we would monitor you at every
visit.

Check patient’s understanding periodically

‘Do you have any questions so far, Mrs Byrne?’
•
Achieving a Shared Understanding: Incorporating the patient’s perspective
 How do you feel about taking this medication?
 ‘Do you need any further clarification?’
 Elicit patient’s beliefs, understanding and reactions
 Pick up and respond to patient’s verbal and non-verbal cues
•
Planning: Shared Decision Making
 Relate explanations to patient’s perspective
 Provide opportunity to encourage patient to contribute
 ‘This medication has been shown to help stop the progression of RA and to reduce the likelihood of disability and disease activity.’
 Involve patient & explore management options
 Negotiate a mutually acceptable plan
 ‘We can do the screening blood test for you today and
then look to start the medication next week if you would
like?’
 Checks with patient if they accept the plan and concerns have
been addressed
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RHEUMATOLOGY
CONTENTS LIST
CONTENTS LIST
Rhe u m ato lo gy - Self-Assessment 267
•
Closing the session
 Summarise session
 Safety net

‘‘Should you have any other questions or queries
then please come back to me and ask me and I can get
you the information.
 Final check patient agrees and is comfortable with the plan
Topic in communication that could be covered in clinic review:
• Joint assessment: DAS28-CRP score
•
Assess for extra-articular involvement shine
•
Medication compliance and complications
•
Screen for comorbidities: Infections, Osteoporosis, CVD risks,
depression
•
Vaccination: yearly flu vaccination, & vaccinate against pneumococcal pneumonia
•
Assess for impairment of physical function: HAQ, grip strength
•
Return to work (occupational health): may need adjustments
•
Lifestyle advice: healthy eating, regular exercise, smoking cessation
• Family planning annals
 E.g. Methotrexate/Leflunomide CI in pregnancy
Systemic Lupus Erythematous
• Patients with SLE should be advised to avoid excessive sun exposure and to use a sunblock with a sun protection factor (SPF)
of ≥15.
•
In women of reproductive age, conception and pregnancy-
related issues should be discussed early in the disease course so
that specialist advice can be given and patients counselled
regarding outcomes in relation to disease-related activity.
•
Although >50% of all lupus pregnancies are completely normal,
all pregnant lupus patients would be considered high risk and be
managed by a specialist obstetric team. Scleroderma
Raynaud's prevention.
Patients should:
•
Maintain central body temperature
•
Protect their hands
•
Minimise scratching, to avoid secondary infection
•
Use frequent emollients for pruritus
•
Avoid smoking.
RHEUMATOLOGY
CONTENTS LIST
RCSI
Haematology - Self-Assessment 383
CONTENTS LIST
SELF -A S S E S S ME N T
Practice communication scenarios or discussing medical ethics with
others. Below are worked examples and further topics with some
key points for exploration that might arise within the haematology
specialty.
CO M MU NIC AT I ON/ETH ICS
Topic: Obtaining consent to give a blood transfusion (if patient
unable to consent this should be discussed with the next of kin at
an appropriate time).
KEY POINTS:
• Initiating the Session & Establishing rapport
 Greats patient, confirms their name and introduces self
 Demonstrates respect and interest
 “Good afternoon, I am one of the doctors on the
Haematology team looking after you. Could I check your
name and date of birth you please?”
 “Nice to meet you, how would you like me to address
you? Julie or Mrs. Fleming?”
KEY
POINT
No persons outside the
courts can consent to
treatment on behalf of
an incapacitated adult.
Treatment should
be provided, in
consultation with the
NOK, acting in the
patient’s best interests.
• Identifies the reason for consultation

“We, your team, would recommend for you to receive
a blood transfusion. I’m here to discuss this with you, and
to provide you with information around the benefits and
risks of this, in order for you to make an informed
decision about this treatment.”
•
Providing the correct amount and type of information
•
Chunks & checks
 Give information about procedure in manageable chunks and
check patient’s understanding.
 “Your blood count, also called haemoglobin, is very low.”

“This is due to the bleed from your bowel that you had
when you came into hospital.”

“Because the blood count is very low, it has been making
you feel the symptoms you mentioned to us this
morning such as feeling very tired, lethargic, and having
chest pain when walking with, Mary, the physiotherapist.
HAEMATOLOGY
CONTENTS LIST
RCSI
38 4 Haematology - Self-Assessment


•
CONTENTS LIST
“These symptoms have impacted your rehabilitation”
“Is there anything I haven’t been clear on, or you’d like
to ask me about at this point?”
Aiding accurate recall and Understanding
 Organises explanation using concise and easy to understand
language.
 Uses repetition and summarisation if needed
 “A blood transfusion, would help bring the blood count
back towards normal levels”

“A blood transfusion is given as an infusion via the
cannula you have, here at your bedside”

“Before giving a transfusion, I would need to take a
blood sample that tells us your blood type”
•
Achieving a shared understanding

Relates explanation to patient’s perspective

Ask the patient what information is helpful

“Would you find it helpful if I talked through the benefits
and risks of giving/receiving a unit of blood?”

Benefits of the blood products:
 “It would improve your symptoms of fatigue, tiredness
and chest pain.”

“It may help you progress in rehab”

“Rehabilitation is a step closer to getting back home”

Risks of the procedure

“Common side effects include a fever, rash or itching”

“Uncommonly, giving you too much blood may result in you developing shortness of breath”
 “Giving the blood, also includes unavoidable antibodies
in the product, which may complicate future pregnancy
or complicate giving you a transplant in the future if you
needed it”

“Rarely the wrong blood type may be given to you that
can result in a very serious immune reaction”
 “Very rarely, blood borne disease may be transmitted
through the transfusion”

Risk of not doing the procedure
 “Your blood count may take a very long time to recover
by itself”
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HAEMATOLOGY
CONTENTS LIST
Haematology - Self-Assessment 385
CONTENTS LIST
 “The haemoglobin could drop further to dangerous
levels”

“Very low blood counts or haemoglobin can result in
heart attacks and calf pain, because of the low oxygen
levels moving around your body”

“Would you like me to explain anything further?”

Provides opportunity and encourages patient to contribute

Elicits patient’s beliefs and reactions

•
“What are your thoughts?”
Planning: Shared decision making
 Involves the patient and encourages them to contribute their
own ideas and explores management options with patient
 Negotiates a mutually acceptable plan & checks with patient if
they accept the plan and if all of their concerns have been
addressed
 “Do you consent to receive a blood transfusion?”
•
Closing the Session
 Contracts with the patient the next steps
 “If you’re agreeable, I will ask you to sign the consent
form. Just because you’ve signed the form, does not
mean you cannot change your mind at any point.”

“In order for us to proceed with the blood transfusion, I
will need to come back to you in a few moments to take
a blood test for your blood type.”
 Final checks
 “Is there anything else you’d like to ask or discuss with
me?”
 “Are you happy for me to go ahead and prescribe the
blood?”
HAEMATOLOGY
CONTENTS LIST
RCSI
38 6 Haematology - Self-Assessment
KEY
POINT
A derivative of blood
products such as IV
albumin (as used in
liver failure) may or
may not be accepted
by a Jehovah’s witnessthis is an individual
decision and should
be discussed with
the patient before
prescribing
CONTENTS LIST
Topic: Life-threatening bleed in a patient who is a Jehovah’s
Witness
KEY POINTS:
• Jehovah witness is a Christian denomination religion in which
members believe that it is against their God to receive blood
products. This may lead to medical challenges for the patient’s
care if blood products or surgery is required. Many regard the
non-consensual transfusion of blood products as a physical
violation.
•
Jehovah’s Witnesses can have differing beliefs around receiving
blood products. This is why it is important to discuss this with
the patient. Moreover, if the patient is incapacitated, and this is
being discussed with the NOK, bear in mind the family may not
share or agree with your patient’s religious beliefs, and the wishes
of the patient are paramount. No other persons can consent on
behalf of another adult.
 The majority of Jehovah Witness patients will refuse all blood
products
 A minority do not believe their God prohibits blood products
and will therefore accept blood transfusion if required
 Some will accept blood plasma fractions or a reinfusion of
their own blood
•
An adult patient who has capacity has the right to refuse or
consent to treatment. Therefore, an adult patient has the right
to refuse a life-saving blood transfusion (differs and becomes
more challenging in the cases of children)
•
In Ireland, there are hospital liaison committees to support
and offer guidance to a Witness patient going through a medical
procedure.
Topic: Breaking Bad News: New cancer diagnosis (AML)
KEY POINTS:
• Prepare adequately for the consultation, ensuring you’ve read all
of the patient’s background medical history and have all of their
test results and anticipated some of the questions they may have
after hearing the news.
•
SPIKES Framework is a helpful model for structuring the consultation. Also use the Calgary-Cambridge Model for giving
information in conjunction.
 S- Setting
 Choose a comfortable, private and quiet room
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HAEMATOLOGY
CONTENTS LIST
CONTENTS LIST
Haematology - Self-Assessment 387
 This may not always be possible, but avoid standing in a
corridor
 Have tissues available and ensure you are uninterrupted
 Check with patient if they would like a family member or
friend in with them
 P- Perception
 Establish the patient’s starting point and what they
already know or what they might be expecting
 Discuss the events leading up to the diagnosis: symptoms, investigations, scans, biopsies
 I- Invitation
 Check if the patient is ready to receive their results today.
Some patients may recognise it is not the news they
hoped for and may want to put off the results
 K - Knowledge
 Deliver the information in sizeable chunks (warning
shots), avoiding medical jargon
 Leave pauses to allow the patient to digest what you’re
telling them
 Provide the diagnosis in clear and unambiguous language
 E- Emotions and Empathy
 Ensure you tone is respectful, slow and clear
 Recognise and respond to emotions
 If you do not know information or answer to their question, tell them that you do not know and make
an effort to find accurate information as soon as is possible or after discussion with their specialist
 S- Strategy and Summary
 Make a plan together and inform the patient what the
next steps are
 Written material can be helpful
 Ensure the patient’s questions and concerns have been
addressed
 Highlight where the patient can go for more questions or
concerns
 Offer to inform family members or NOK for them if they
wish
HAEMATOLOGY
CONTENTS LIST
RCSI
38 8 Haematology - Self-Assessment
CONTENTS LIST
Topic: Consultation around fertility and the effects of
chemotherapy on future fertility
KEY POINTS:
• Chemotherapy can affect male or female fertility- the effects of
which may be temporary or permanent.
•
For younger females, it may also result in early menopause
•
During chemotherapy, a person may still be able to become
pregnant, but the chemotherapy is harmful to the growing foetus.
It is therefore important to discuss reliable contraceptive methods
during chemotherapy and sometime afterwards (duration should
be advised based on regime and specialty but majority would
advise waiting >2 years after chemotherapy)
•
There are several ways to try to preserve fertility and the options
should be discussed with your patient, such as freezing embryos,
freezing eggs or freezing ovarian tissue (rarer)
•
Other fertility options include: using donor eggs, using donor
sperm, using donated embryos, surrogacy or adoption.
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HAEMATOLOGY
CONTENTS LIST
CONTENTS LIST
Infectious Disease - Self-Assessment 443
SELF -A S S E S S ME N T
CO M MU NIC AT I ON & ETH ICS
Topic: HIV diagnosis
KEY POINTS:
• HIV remains a disease with significant stigma attached. This stems
largely from the route of transmission. There is really only one risk
factor for HIV acquisition; being human.
•
Though verbal consent is still sought in most settings for testing,
universal testing is now the norm in many settings. All pregnant
woman in Ireland are offered testing. Only by expanding testing
and treating those infected will incidence fall.
•
Patient-doctor confidentiality is important in HIV diagnosis
•
In a High Court Decision delivered on the 21st February 2018
Judge Michael Twomey ruled that a teenager’s HIV status was
not to be disclosed to his suspected sexual partner. The Child
and Family agency sought clarification from the courts whether a
breach in confidentiality was permitted to inform his suspected
sexual partner about his HIV diagnosis, to prevent harm occurring
to them. The court ruling issue.
 Legal Test
 Patient confidentiality breach may occur “on the balance
of probabilities that the failure to breach confidentiality
creates a significant risk of death or very serious harm to
an innocent third party”
 HIV Infection
 The court determined that HIV, although a serious
condition, is no longer a terminal one but rather a chronic infection that can be managed. And therefore
the court had ruled that HIV is not “very serious harm” to
justify breaching a patient’s confidentiality, and
transmission risk can be reduced through the use of
condoms.
 Societal Issues
 If permission had been granted to breach confidentiality,
this may impact the medical profession in the future.
It may mean that medical professions could decide
to disclose the diagnosis to the partner, or even be
responsible if they failed to breach confidentiality and
INFECTIOUS DISEASE
CONTENTS LIST
RCSI
44 4 Infectious Disease - Self-Assessment
CONTENTS LIST
harm came to a third party. Furthermore, it may prevent
those with STD seeking help or treatment from medical
professions out of fear of the doctor disclosing
information to their partner.
Topic: Majority of global burden of Dengue Fever is in areas of
poverty
PRACTICE
YOURSELF
KEY POINTS
• Discuss global health inequalities, in the context of Dengue fever
and other infectious diseases
•
ONLINE
RESOURCE
For further reading on health inequalities in Dengue Fever
available here
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INFECTIOUS DISEASE
CONTENTS LIST
CONTENTS LIST
Dermatology - Atopic Dermatitis/ Eczema 461
CO M P L IC ATION S
•
Staphylococcus (superimposed infection)
•
Recurrent conjunctivitis
•
Eczema herpeticum
 This is a rapid development of numerous monomorphic,
punched-out erosions with haemorrhagic crusting, vesicles
may or may not be present
P R O GNOS IS
•
AD impacts all aspects of patient’s quality of life and emotional
well-being
•
Patients with AD have an increased risk of cardiovascular disease
CO M MU NIC AT I ON/ETH ICS
Topic: Encourage compliance with daily luke-warm baths
emollient
FU RTHE R RE A DING
•
Eichenfield LF et. al, Guidelines of care for the management of
atopic dermatitis: Journal of the American Academy of
Dermatology. 2014 Jul
•
Silverberg JI. Comorbidities and the impact of atopic dermatitis.
Annals of Allergy, Asthma & Immunology. 2019 Apr 26.
DERMATOLOGY
CONTENTS LIST
PRACTICE
YOURSELF
FURTHER
READING
RCSI
CONTENTS LIST
Dermatology - Psoriasis 471
CO M MU NIC AT I ON/ETH ICS
Topic: Explaining the risks versus benefits of biologic treatment
with the view of commencing therapy
•
Providing the Correct Amount and Type of Information
 Assess patient’s starting point
 “Would you prefer me to call you John or Mr. Reilly?”
 “Mr. Reilly, have you heard of the drug Infliximab before?”
 “What do you know about this medication?”
 Gives explanation at appropriate times
 Chunks and checks
 “Infliximab is an immunosuppressant therapy”
 “It is a type of medication called a ‘biologic.’”
 “It is given as an infusion over 3 hours every 8 weeks”
 “Do you understand all of this information so far, or is
there anything you’d like me to explain further?”
 “The benefit to you in starting Infliximab is that it could
improve your psoriasis and help with the uncomfortable
constant itch you have mentioned, where the other
medications we have tried have failed to do”
 “Although considered relatively safe, like all drugs it
does have some side effects, although not everyone will
experience these. Would you like me to go through
these with you now?”
 “The side effects include sinusitis, increased risk of
infection both new and recurrence of latent infections,
increased risk of non-melanoma skin cancers, allergic
reaction, worsening of heart failure, and very rarely
lymphoma or nervous system disorders (demyelination)”
 “Do you have questions on any of this information, or
need me to clarify anything further?”
 “In order to reduce the risk of developing some of these
side effects, we check the bloods for any latent infections
and treat these before you start on Infliximab, and we
monitor your bloods regularly while on treatment”

Give explanations at appropriate times avoiding jargon
DERMATOLOGY
CONTENTS LIST
RCSI
47 2 Dermatology - Psoriasis
CONTENTS LIST
•
Aiding Accurate recall and understanding
 Organise your explanation and divide it into sections
 Use explicit sign-posting
 “There are 3 things we need to do before starting the
medication. The first thing we will need to do is take
blood samples. The second thing we need to do is to
organise for you to get a CXR for screen for TB. And the
third thing we need to do is a Mantoux test”
 Use repetition and summarising to reinforce the information
 Use concise language that’s easily understood
 Use visual methods of conveying information
 “This is an information leaflet about the things we discussed that you can take the opportunity to read now
or take home with you to read later”
 Check patient’s understanding
•
Achieve a shared understanding: incorporating the patient’s
perspective
 Relate explanations to previously elicited concerns or beliefs
 Provide opportunity and encourage patient to contribute
 Picks up and responds to verbal and non-verbal cues
 Elicit patient’s belief, reactions and feelings and addresses
where necessary
•
Planning: Shared Decision Making
 Shares own thinking as appropriate: thoughts, and
dilemmas
 “I believe Infliximab could be the right option for you
to control your psoriasis. It is immunosuppressing which
carries risks, but your quality of life as you have described
it is being significantly impacted by your psoriasis”
 Involve the patient and offer choices
 “How to you feel about starting Infliximab?”
 “Other options are to try an alternate biologic such as
Adalimumab, or continue with topical therapies”
 Ascertain the level of involvement the patient wishes in
making the decision

Negotiates a mutually acceptable plan
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CONTENTS LIST
Dermatology - Psoriasis 473
 Checks with patient if accepts plana and concerns have
been addressed
 “Are you happy to start the process of starting on Infliximab?”
 “Do you have any further concerns or queries that we
have not yet discussed?”
•
Closing the Session
 Contracts with patient regarding the next steps for
patient and physician
 “I’m going to order the blood tests, and necessary
investigations, and you are to book the next
appointment to see me again in 3 weeks time to review
the results”

Ensure an appropriate point of closure, summarise the
session briefly and final check the patient is comfortable
with the plan
FU RTHE R RE A DING
•
DermNetz for further images of Psoriasis available here
DERMATOLOGY
CONTENTS LIST
ONLINE
RESOURCE
RCSI
48 0 Dermatology - Herpes Zoster
CONTENTS LIST
C OMMUNICATIO N/ ETHI CS
Topic: Obtaining consent for a lumbar puncture from a patient
suspected of having VZV intracranial infection.
KEY POINTS ON CAPACITY:
•
The issue of capacity is a very important ethical issue here
Capacity is time and decision specific
5 principles of Capacity
 Presume capacity in all
 Make every effort to support the individual to make a
decision for themselves
 A patient has the right to make an unwise decision
 Decisions acted on for or on behalf of a person who lacks
capacity must be made in their best interests
 Choose the least restrictive option (if there is a chance
the patient may recover capacity, consider if the decision
can be delayed until the person regains capacity)



ONLINE
RESOURCE
In order for a patient to have capacity they must:
 Understand the information given to them
 Retain that information in making the decision
 Use and apply that information to themselves
 Communicate their decision
F U RTH ER READ ING
•
Irish Medical Council Guide to Professional Conduct and Ethics
for registered Medical Practitioners 8th Edition 2019, Chapter 3,
Part 10 available here
•
DermNetz for further clinical images of Herpes Zoster
available here
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DERMATOLOGY
CONTENTS LIST
48 6 Dermatology - Erythema Nodosum
CONTENTS LIST
C OMMUNICATIO N/ETH I CS
Topic: History taking on a patient with Erythema Nodosum to
ascertain likely aetiology of the EN
•
Initiating the session
 Establish initial rapport
 Greet patient and name
 Introduce yourself, your role and nature of interview
 Demonstrate respect and interest to the patient’s physical comfort
 Identify the reason for the consultation
 Identify the patient’s problems
 “What problems brought you to the hospital?”
 Listen attentively to the patient’s opening statement without
interrupting or directing patient’s response
 Confirms list and screens
 “So the painful rash on your shins started last week,
do you have any trouble with your bowels such as
diarrhoea?”
 Negotiates agenda taking both patient’s and physician’s
needs into account
 “I’d like to ask you some more questions that may
help identify the cause for this rash, this will help start
the right treatments for your rash. It may take some
time for the rash to heal”
TOP
TIP
Explore symptoms
of IBD, Sarcoid,
Haematological
malignancies and
infections
•
Gathering Information
 Exploration of patient’s problems
 Encourage patient to tell the story
 Use open and closed questioning technique appropriately
 Listen attentively and facilitate patient’s responses
verbally and non-verbally
 Clarify patient’s statements that are unclear
 Use concise easily understood questions and avoid
jargon
Additional skills for understanding the patient’s perspective
 Actively determine and appropriately explore patient
concerns, beliefs. Expectations and how each problem
affects the patient’s life

R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 2
DERMATOLOGY
CONTENTS LIST
CONTENTS LIST
Dermatology - Erythema Nodosum 487
•
Providing Structure
 Make organisation overt
 Progress from one section to another using sign posting
 “You’ve had intermittent abdominal pains, diarrhoea, with blood and mucous for the last 6
months before the painful rash started on your shins.
I’d like to ask you now more about any previous
medical diagnoses you have.”
 Attend to flow; the interview follows a logical sequence
 Attend to timing of interview and stay on task
•
Building Relationship
 Develop rapport, demonstrate appropriate non-verbal
behaviour, use empathy, provide support and willingness to
help
 Involve the patient: share thinking with the patient and
encourage the patient’s involvement
 “What I’m thinking is now, is that the bowel symptoms
you’ve been having are linked to this rash”
•
Closing the session
 Give preliminary information and checks patient understanding
 Summarise session
 Contract with patient next steps for patient and physician
F URTHER REA D ING
DermNetz: Erythema Nodsoum for further clinical images of EN
available here
DERMATOLOGY
CONTENTS LIST
ONLINE
RESOURCE
RCSI
49 4 Dermatology - Erythema Multiforme
CONTENTS LIST
MA NAGEM ENT
1.
Preventative
 Vaccination of common associated infections: VZV, Hep A,
Hep B vaccinations
2.
Non-Pharmacological
 Majority of cases need no treatment
 Discontinue drug if causative
3.
Pharmacological
 General Principle
 Treat underlying infection and supportive care
 Symptomatic relief
 Oral antihistamines
 Topical corticosteroids
 Oral involvement
 Mouthwashes with local anaesthetic and antiseptic
 If severe mucosal involvement (EM major) patient may
need hospitalisation, and restrict oral intake
 Ocular involvement
 Ophthalmology referral & review
 Recurrent Disease
 Antiviral Prophylaxis for HSV infections
 e.g. Acyclovir 10mg/kg/day for at least 6 months
 If EM fails to respond consider immunosuppressive
therapy e.g. Dapsone, Hydroxychloroquine
C OMPLICATIO NS
•
Significant eye involvement may rarely result in loss of vision
•
Residual mottled skin discolouration
P ROGNO SIS
•
PRACTICE
YOURSELF
Virtually all patients with EM recover with no sequelae
C OMM UNICATION/ ETH I CS
Topic: Discuss vaccination recommendations for prevention for a
patient with vaccine hesitancy
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 2
DERMATOLOGY
CONTENTS LIST
Dermatology - Pyoderma Gangrenosum 503
CONTENTS LIST
CO M MU NIC AT I ON/ETH ICS
Topic: Obtaining consent for a punch skin biopsy
•
Providing the Correct Amount and Type of Information
 Assess patient’s starting point


“Would you prefer me to call you Una or Mrs Fox?”

“Have you had a skin punch biopsy before?”
Gives explanation at appropriate times
Chunks and checks
 “The rash you have looks like a condition called Pyoderma gangrenosum.”
 “Have you heard of this condition before? What do
understand about pyoderma gangrenosum?”
 “This condition can look like several other conditions
that result in ulcer formation like this. A skin biopsy
can help make the right diagnosis and therefore inform
the correct treatment options for you”


Give explanations at appropriate times avoiding jargon
•
Aiding Accurate recall and understanding
 Organise your explanation and divide it into sections
 Use explicit sign-posting
 “The biopsy is a day procedure that involves removing a
small piece of skin with local anaesthesia”
 Use repetition and summarising to reinforce the information
 Use concise language that’s easily understood
 Use visual methods of conveying information
 “This is an information leaflet about the things we discussed that you can take the opportunity to read now
or take home with you to read later”
 Check patient’s understanding
•
Achieve a shared understanding: incorporating the patient’s
perspective
 Relate explanations to previously elicited concerns or beliefs
 Provide opportunity and encourage patient to contribute
 Picks up and responds to verbal and non-verbal cues
 Elicit patient’s belief, reactions and feelings and addresses
where necessary
DERMATOLOGY
CONTENTS LIST
RCSI
50 4 Dermatology - Pyoderma Gangrenosum
•
CONTENTS LIST
Planning: Shared Decision Making
 Shares own thinking as appropriate: thoughts, and dilemmas
 “I believe a biopsy can be helpful here to ensure you get
onto the right therapy as soon as possible”
 Involve the patient and offer choices
 “There is the option of starting a treatment and monitoring response without a biopsy”
 Ascertain the level of involvement the patient wishes in
making the decision and negotiate a mutually acceptable
plan
 Checks with patient if accepts plan and concerns have been
addressed


“Do you consent to proceeding with the skin biopsy?”
“Do you have any further concerns or queries that we
have not yet discussed?”
•
Closing the Session
 Contracts with patient regarding the next steps for patient
and physician
 “If you consent to proceeding, please read and sign
this consent form. I will then book an appointment for
you for the procedure as soon as is available”
 Ensure an appropriate point of closure, summarise the
session briefly and final check the patient is comfortable
with the plan
FURTHER
READING
F U RTH ER READ ING
•
Su WP, et al. Pyoderma Gangrenosum: Clinicopathologic correlation and proposed diagnostic criteria. Int. J. Dermatol.
2004; 43:790-800
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 2
DERMATOLOGY
CONTENTS LIST
Dermatology - Bullous Diseases 513
CONTENTS LIST
•
Dermatitis Herpetiformis
 Gluten free diet for life is strongly recommended

Topical Treatments


Dapsone: screen for G6PD deficiency and titrate dose
If intolerant to Dapsone: Ultra-potent topical corticosteroids
e.g. Betnovate or systemic steroids or rituximab
CO M P L IC ATION S
•
Anxiety and depression
•
Secondary bacterial, fungal and viral infections
•
Complications of systemic and immunosuppressive treatments
•
Nutritional deficiencies and dehydration when mucosal involvement present
CO M MU NIC AT I ON/ETH ICS
Topic: Discussion with patient on the importance of adherence of
a gluten-free diet, who has dermatitis herpetiformis and who is
non-compliant with a gluten free diet for their Coeliac disease
KEY POINTS:
• Gluten free diet (GFD) will improve the skin condition
•
It will improve gut function and associated symptoms

Both of these will improve overall quality of life
•
Long-term inflammation from coeliac disease can result in lymphoma (MALToma)
•
See Gastroenterology Chapter: Coeliac Disease for full list of
complications
FU RTHE R RE A DING
The BLISTER trial ‘Bullous Pemphigoid Steroids and Tetracyclines Trial
available here
DERMATOLOGY
CONTENTS LIST
ONLINE
RESOURCE
RCSI
52 0 Dermatology - Dermatomyositis
CONTENTS LIST
MA NAGEMENT
1.
•
Prevention
Manage the underlying condition
•
Screen for malignancy for a minimum of 3 years after presentation
with dermatomyositis to reduce morbidity and mortality
2.
•
Non-pharmacological Treatments
Photoprotection including fully covering clothing and SPF 50
daily
•
MDT input: physiotherapy for muscle weakness, Occupational
therapy for home adaptions, SALT for swallow assessment, and
Dietetics for optimal nutrition
3.
•
Pharmacological Treatments
Topical Cutaneous Treatments
 Corticosteroids
 Tacrolimus
•
Oral Treatments
 Cutaneous treatments
 Hydroxychloroquine
 Azathioprine
 Methotrexate (or sub-cut)
 Muscle inflammation treatments
 Oral steroids e.g. Prednisolone 1mg/kg with slow taper
 Methotrexate (or sub-cut)
P RO GNOSIS
PRACTICE
YOURSELF
•
Most patients require treatment throughout their lifetime, but DM
completely resolves in about 1 in 5 patients
•
Patients who have a disease affecting their heart of lungs, or who
also have underlying cancer, do less well and may ultimately die
from their disease
C OMMUNICATIO N/ETH I CS
Topic: Counsel a patient with dermatomyositis regarding the
risk of malignancy and the screening investigations required and
follow-up needed
R CS I Hand b o o k o f C lin i ca l Me d ic in e 1 st Ed it io n Vo l 2
DERMATOLOGY
CONTENTS LIST
Misce llan e o u s - Self-Assessment 547
CONTENTS LIST
SELF -A S S E S S ME N T
CO M MU NIC AT I ON AND ETH ICS
Topic: Patient refuses treatment for drug toxicity and you are
asked to make a capacity assessment
KEY POINTS:
•
Every adult is presumed to have capacity
•
Capacity can fluctuate by time or day and is decision specific
•
Low MMSE score is NOT a substitute for capacity
•
llness can affect capacity temporarily
•
There are 4 decision-making abilities that constitute capacity

Understanding
 Everything should be done to help the person understand

Expression of choice


Appreciation


The person should be able to express a choice. Frequent
reversal of choice may be considered lack of capacity
The person needs to be able to weigh up the facts of the
decision and apply the facts to themselves
Reasoning
 The person needs to be able to infer consequences of
their choice
MISCELLANEOUS
CONTENTS LIST
RCSI