A
Fever
Focused History
o
o
o
o
o
o
o
Duration of symptoms, acute or chronic?
Nature of symptoms - intermittent or constant, rigors, sweats, temperature
readings?
•
Any suspected source (eg chest infection)?
Associated symptoms (eg pain anywhere, rash, joint swelling, vomiting)'
Urinary symptoms (eg frequency, dysuria, haematuria)
Bowel symptoms (eg abdominal pains, change in bowels, blood in stool)
Chest symptoms (eg dyspnoea, cough, sputum, chest pains)
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o
o
o
o
o
Neurological symptoms (eg headache, visual changes, focal neurological
symptoms)
*
. \
Drug history (eg paracetamol)
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.
•
•
Previous medical history (eg IBD)
* .• <
Immunisation history
•
/ ’•
Family history (eg connective tissue disease)
. " •
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ARORA
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o
Key Red Flags
o
o
o
Unexplained fever (eg pyrexia of unknown origin)
Systemically unwell (eg tachycardia, fatigue, vomiting, petechiae)
Suspected malignancy (eg weight loss, mass)
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Fever
Psychosocial / Impact
o
o
o
o
o
o
Occupational history, environment, hobbies and activities of daily living
(eg swimming)
,
Sexual history and other risk factors for BBV (eg tattoos)
Dietary and exercise history
Recreational drugs (eg IVDU), smoking, alcohol history
Travel history, including activities (eg swimming. TB and malaria risk)
Any stress, depression or anxiety symptoms?
••
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r ®
Fever
ARORA
o
Examination to consider
o
o
o
o
o
Basic Obs (including temp, BP, HR, RR, 02 sats)
General examination (eg pallor, jaundice, rashes, lymphadenopathy)
Examination to find source and depending on symptoms (eg cardiovascular,
respiratory, abdominal, neurological)
Urinalysis
ECG, if appropriate (eg suspected endocarditis)
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Fever
Key
o
o
o
o
o
U
J
Differentials
Infective (eg malaria, viral infection)
Malignancy (eg haematological cancer, solid tumours)
Immunological (eg sarcoidosis, rheumatoid arthritis)
Investigations depend on suspected cause, age etc
o Bloods including cultures, MSU, lumbar puncture, CXR
Management depends on suspected cause
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Domestic Violence
Two main presentations - asking for help vs cues that unfold
Look for cues early
o Story doesn't match
o Self negative talk
o Over praise or protection of partner
1
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*
✓ •
B
o Some clear questions if suspected
o How is your relationship?
o Do you have any arguments?
o When you argue, do they get angry?
o When they get angry, what do they do?
•
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• 1
&
F
Domestic Violence
ARORA
o
Focused History
o Nature of domestic violence and abuse
o Duration of domestic violence and abuse
o Who is alleged perpetrator(s)?
. •
o Any escalation since it started?
‘ V
o Does the patient feel safe?
.
•
o Are they afraid of their partner or someone else they know?
’ '
o Has anyone ever hit/ abused or threatened them in any way? What happened, •
when and did they seek help?
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•
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o Psychological abuse (eg manipulation, coercion)
■'
o Emotional abuse (eg neglect, fear)
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o Sexual abuse (eg unintended or concealed pregnancies, rape, delayed antenatal care, STI)
o Financial abuse (eg control of bank accounts and finances)
o Any health-seeking behaviours (eg missed appointments, chronic unexplained symptoms)?* •
o Any recent pregnancies or separation?
* .• <
o Previous medical history (eg disability, chronic illness, psychiatric disease)
•
o Drug history (eg hypnotic agents)
. 'Jy •
o Anyone else in family/household affected?
~ //
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Domestic Violence
• fI
Key Red Flags
o
o
o
o
Imminent and/or severe risk
Injuries
Suicidal risk
Children
•
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•
•
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V*
• 1
Domestic Violence
ARORA
o
Psychosocial / Impact
o
o
Impact on quality of life, occupation, hobbies and activities of daily living
Recreational drugs, smoking, alcohol history - for patient and alleged
perpetrator(s)
o Sexual history, relationship issues
o Any self-esteem issues? Any stress, depression or anxiety symptoms?
o Discussion regarding cultural factors (eg honour violence, forced marriage) and
stigma
o Discussion regarding support groups and what help is available (eg safety plan)
4
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Domestic Violence
Examination to consider
o
o
Mental state examination
o
Examination of any injuries, if relevant
Management of adult
o
Clear advice
o 'Tb/s is illegal... not your fault... don't need to put up with this"
o Advice, numbers, organisations...
o
•
Ultimately up to them if competent
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Domestic Violence
Management of child
o Buffer your discussion about needing to take things further
o Be open, clear, honest
o Get ready for 'but doctor they'll take my kids away'
•• ¥
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Adult Safeguarding
I
If in doubt need to take some form of action
o
Examples may include
o
Conscious harm eg
o Violence, neglect, stealing, bullying, emotional abuse
• • V*
V
/T
o
Unconscious harm eg
o Acopia. unhygienic conditions, dementia
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*
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Adult Safeguarding
ARORA
4
o
May need open questions to start
o 'Do you fee/ safe at home?*
o 'How do you fee/ about going home?"
o "You seem a little frightened when I mention home?"
o
Understand support systems
o Who do you live with?
o Who comes to the house?
o Who do you talk to?
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Adult Safeguarding
Check for low mood and anxiety
o
May need to develop environment of safety
o Take your time...'
**
o “I'm here to listen and help wherever possible'
o May need to discuss confidentiality
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Adult Safeguarding
Clear advice where needed
o
o
o
o
"Violence, stealing, harm is not acceptable"
"None of this is your fault"
"Your sa fety/wellbeing is my main concern"
"This is something that the police deal with all the time"
IF
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r
ARORA
F
Adult Safeguarding
o
Management
o
o
o
o
o
4
J
Advise of clear need to discuss with relevant team/social services etc
Discuss clearly what will happen next
Advise of other benefits that these organisations can have eg support,
finances etc
Discuss support systems eg friends who they can call to discuss etc
May need to arrange further assessments eg capacity checks, memory
reviews etc
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r
Social Acopia
ARORA
(elderly)
o
May be due to patient themselves or relative concern
o
Focused History
o Current home situation
o Family in home, distance, visit frequency, concerns
o Carers and their current input
o Any reason why not had help so far?
o Any safety issues
o Stairs, mobility, falls, driving
o Any memory changes?
o Mood concerns
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Social Acopia
ARORA
(elderly)
o
Housing
o How long lived there?
o Too big, ? thought of downsizing
o Stairs in the house, bathrooms upstairs and downstairs?
o Any Occupational Health input?
o Thoughts on respite care
o
Mobility and impact of frailty, conditions eg OA
o
Finances
o Pension. Benefits
o Any current support eg CAB, bank
o
Polypharmacy? Recent medication review
o
Any adult safeguarding concerns or currently social services input?
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Social Acopia
ARORA
(elderly)
Management
o
Consider setting up an MDT/case conference eg at home or practice to cover
several issues in a short time
o
'seems like a lot of people could potentially be involved here... let's see if we can get
some of us together'
o
Who to consider calling (depending on issues discovered)
•
o Patient, carers, relatives, social services, physio, OT, pharmacy, district nurse,
CAB etc
y
•• ¥
Ha’
Palliative Care
ARORA
Where in the Palliative care journey is the patient?
o Just diagnosed, come to terms, decision stage, last few weeks, last few hours etc
♦
Can't cover everything: Skim broad areas and then focus
Acknowledge 3 areas of Palliative care
o Physical - pain, nausea, constipation, confusion, secretions etc
o Mental - mood, anxiety, fear of dying, guilt etc
o Practical - carers, support systems, finances, syringe driver, medication delivery etc
•♦
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Palliative Care
• f
Time is paramount
e\/
.
Don't assume what their main concerns are * ask clearly.„
o "Can I ask right now, what seems to be worrying or troubling you most?"
• \
Who else is/can be involved?
o
Medical
.
o Palliative care team, district nurses. Macmillan nurses. Hospice, OOH
.
o
Non-medical
o Carers, relatives, support groups, religious figures
•
. jA
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I
$
Palliative Care
ARORA
o
Can you help increase their comfort level?
o Physical health eg syringe drivers, PCA pump, 'just-in-case* box
o Mental health eg support groups, family support
Have they had the right choices so far? Eg
o Home vs hospice?
o How much information do they want to know?
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Palliative Care
Discuss DNR where appropriate
o
'Has anyone discussed the last few moments with you?"
o
'Is now a good time to do so?"
/
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Genetics scenarios
ARORA
o
Condition examples
o
Autosomal recessive
o Thalassaemia. Sickle cell disease. Haemochromatosis. Cystic fibrosis.
Wilson's disease, PKU
o Autosomal dominant
o Huntington’s disease, Marfan's, Ehlers-Danlos, Adult PKD, von
Willebrand's, familial hypercholesterolaemia
o
X-linked recessive
o Haemophilia A/B, Duchenne, Red/green colour blindness
o
X-linked dominant
o Fragile X Syndrome, Rett's Syndrome
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Genetics scenarios
3 bubbles are present as usual
Avoid classic genetics autopilot
o Going back to the beginning of time
o What is a gene, what is a chromosome...
o Where’s my pen, it’s a genetic case!
o
"Some genes are stronger than others...'
o
'We can’t change our genes but we can do a lot of work around them...
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Genetics scenarios
o
Before giving numbers
o What do we already know?
o Who’s been tested already?
o What do they know already (about testing or condition)?
o
Remember there are other, non-genetic issues to talk about as well*
•
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e
Genetics scenarios
Things to discuss may include
o
o
o
o
o
o
o
o
o
Genetic clinic referral
Pros and cons of genetic testing
How genetic testing is done
Support organisations for particular conditions
Management of physical symptoms
Management of fear, anxieties
Discussion with other family members eg for screening/testing
Impact of diagnosis on life plans, education, work etc
Discussion around having children
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< .
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ARORA
r
r
Learning Difficulty
scenarios
•
•i
•J
/
Large variety of presentations
J
Basic consultation and data gathering as per standard case eg ear infection, pill request \
®
• vw
\
3 bubbles are present as usual
Clear focus on communication
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Learning Difficulty
scenarios
Think about Consent/Capacity
o
Each decision needs to be checked, each time
o
o
o
o
Understood information?
Retained information?
Weighed up information?
Communicated decision?
J •
•
•
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■J
Learning Difficulty
scenarios
Consider any Safeguarding concerns
o Both due to others and not due to others
o Physical, emotional, sexual, neglect
o Consider talking to patient alone
o Discuss with colleagues/carers/relatives
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Travel Scenarios
Pre-travel scenarios
o
o
o
o
o
o
o
o
Where going?
How long for?
Who with?
Where staying eg hotel, backpacking
Are immunisations tailored to time of year and place?
Any risks for flying eg anaemia, recent surgery etc
Quick medication review eg warfarin monitoring
'Have you got any travel insurance / health insurance?'
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___________________________________________________________________________________________________________________________________________________________ J
Travel Scenarios
ARORA
o
Post-travel scenarios
o
Unwell/fever?
o Think malaria. TB. hepatitis etc
o
Need for sexual history?
o Think HIV/STI risk
o
Post-flight?
o Think DVT/PE
o Any medical input abroad?
o Documentation, new medications, test results etc
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Ethical scenarios
•
Hopefully the ethics part is common sense
Need to clarify what is an ethical challenge and what is a legal challenge
o eg ethically signing a fit note vs legally signing a fit note
o eg ethical disclosure of information vs legal disclosure of information •
o 'Flipping' the ethics back the other way sometimes helps
o eg right to refuse treatment
o eg confidentiality
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•v1
A
Challenging part can be communicating the ethics
o
• I
• . x
•••
• iA
//
•’
Ethical scenarios
Be clear but empathetic when discussing ethical situations
o
"We have certain duties and obligations as clinicians towards our patients..."
o
*7 can see that this doesn't seem fair/correct to you at this point, but hopefully
you can see the reasoning behind what we’re saying...
• •• "
.
/
•
o
7 do appreciate that this isn't an ideal situation for you at present...
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•