Primary Care UiTM: December 2010

Tuesday, December 28, 2010

Discussions with Primary Care Lecturers

Please feel free to use this section to post topics covered during the DISCUSSION session with the primary care lecturers at each of your Klinik Kesihatan attachment.

Interesting Cases to Share

I hope you will use this section to post any interesting cases seen during your consultation sessions in KKTE/ KKSB either whilst sitting with the primary care lecturers or with the FMS/ MO's. You can also include interesting experiences encountered whilst sitting with the Staff Nurse, Pharmacist, Lab technicians, Dietician, Physiotherapist and MA's in the procedure room.

Tips on Sharing Informations in this Website

Uitm have long moved away from the "Spoon Feeding Era" whereby medical students are being "Fed" with informations along the learning process. Nowadays, medical students are encouraged to use a "Adult Learning Approach" whereby students are expected to use CRITICAL THINKING and formulate a systematic way of learning with some guidance from their lecturers. This website is created exclusively for all primary care UiTM medical students in the effort to uphold this new self learning approach.

The main purpose of this website is to initiate discussion and sharing informations learnt throughout the 8 weeks of Primary Care posting. I hope that each time you see a case with a lecturer during consultations, you will write down the case in this website under the relevant headings and also provide any tips learnt from your lecturer during the consultation, e.g. tips on history, examination, management and diagnosis. You may also want to share interesting cases that you have seen whilst sitting with the MO in KKTE/ KKSB.

This website is also meant for you to share topics covered during the discussion on each of your klinik kesihatan sessions. Group 1 may cover different aspect of the topics listed in your primary care handbook. So Group 2 can learn as well when Group 1 posts the informations learnt via this website and vice versa.

I will asisst with any of your queries or misunderstandings with the help of the other lecturers in primary care.

For any questions in this website asking on how to manage the patient, I expect you to give a complete and concise answer in the following format:
1) Relevant history:
       - History of presenting illness (HOPI)
       - Systemic Review
       - PMH/ PSH
       - SH
       - DH (allergies)
       - FH
       - ICE

2) Relevant examinations:
       - General Observation (Go)
       - Vital signs (Vi)
       - Relevant Systematic examination approach (e.g. start with the hands, radial pulse, eyes ..)

3) Appropriate management which should include the PLIMA:
       - Patient Education
       - Lifestyle Changes
       - Investigations
       - Medications
       - Appointment/ Safety Netting

For the Drug Discussion, the answer should be in the following format:
List down the relevant drugs available first then divide each drug into the following category: (please refer to the MIMS website)
1) Generic Name
2) Route of administration (Oral, IV, IM, SC, Inhaled, Nebulised) and Dosage for each route
2) Mode of Action (Pharmacodynamics/ Pharmacokinetics)
3) Side effects
4) Contraindications
5) Pregnancy Category
6) Precautions (for example in children and breastfeeding)
7) Drug interactions

You may also quote any useful website related to the topic being discussed. One very good example of an answer related to a HEADACHE CASE can be found in the following website:

http://www.medscape.com/viewarticle/537504

All the best!

Wednesday, December 22, 2010

Constipation

A 55-year-old lady presents with x1/12 ho constipation alternating with normal bowel habits.

Question 1: What are the differential diagnoses?

Question 2: How would you approach and manage this patient?

Drug Discussion: What are the medications available for constipation? What are the drugs' mode of action and common side effects?

This is an example for answering the questions in this blog. You can copy and paste this template adjusting where ever relevant.

You may put one or more drugs that you know of in the drug discussion question. Answers for the drug discussion can be found on the MIMS website.

Question 1: What are the differential diagnoses?

According to Murtagh, the differential diagnoses of chronic constipation are:

1. Probability diagnosis:

a. Simple constipation

b. Low fibre diet and bad habit

2. Serious disorder not to be missed

a. Intrinsic neoplasia: CA colon, rectum or anus

b. Extrinsic malignancy: Lymphoma, ovarian CA

c. Hirschsprung’s (children)

3. Pitfalls (often missed)

a. Impacted faeces

b. Local anal lesions

c. Drug/ purgative abuse

d. Hypokalemia

e. Depressive illness

f. Acquired megacolon

g. Diverticular disease

h. Rarities:

i. Lead poisoning

ii. Hypercalcemia

iii. Hyperparathyroidism

iv. Dolichocolon (large colon)

v. Chaga’s disease

vi. Systemic sclerosis

4. Seven masquerades checklist:

a. Depression

b. Diabetes (rarely)

c. Drugs

d. Anemia (under nutrition)

e. Thyroid (hypo)

f. Spinal dysfunction (severe only)

g. UTI (usually chronic constipation causes UTI as a result of urinary retention caused by the hard faeces )

5. Is the patient trying to tell me something?

a. May be functional

i. Depression

ii. Anorexia nervosa

*Drugs:

opiate analgesics, antidiarrheal agents, anticholinergic agents, antihistamines, antiparkinsons drugs, BDZ, barbiturates, cough mixtures, muscle relaxants, CCB (Verapamil), Tricyclic antidepressants, diuretics (that causes hypokalemia)

Question 2: How would you approach and manage this patient? - By taking relevant history, performing relevant examination and formulating a relevant management plan

1) Relevant history:
History of presenting illness (HOPI)

· Start with Introducing yourself and clarifying patients name, age and occupation

· Followed by open ended question (What bought you to clinic today? How can I help you?)

· Proceed with close ended question:

1. How long have you had the constipation

2. Bowel habit: Frequency of BO and bowel consistency, any PR bleed/ mucus

3. Any alternating diarrhea

4. Any UTI symptoms

5. Any Abdominal pain? If yes, what is the pain like, pain score, where is the pain, any radiation of the pain? Relieving and aggravating factors or associated sx

6. Dietry history

7. Ssx of Hypothyroidism, Depression

8. Dhx – TRO any drugs that cause constipation

· Systemic Review: (Top to Toe)

CNS : Fits, Faints, Funny turns (headache/ weakness)

RS/ CVS: Chest pain, SOB, Palpitation

Abdo: Abdominal pain, BO – any problem passing motion, PU – any urinary problem

Muskuloskeletal – Joint pain, Joint swelling, Muscular pain

Female – LMP, menses, Menopause

· PMH/ PSH

· SH

Married/ Single/ Divorced

Lives in

Unemployed/ Work as

Smoking: cigarettes/ day

Alcohol:

Illicit drugs:

Diet:

Exercise:

· DH

Allergies:

Medications: Name, Dose, Frequency, Duration, Side effects/ problems

Traditional medications: Name, duration

· FH (need TRO pTB, DM, HPT, BA, IHD, Dyslipidaemia, Premature CVD in the family)

Mother: (Alive and well? or passed away at ?age due to what reason)

Father : (Alive and well? or passed away at ?age due to what reason)

Siblings: (How many siblings, all well?)

Children: (How many children, all well?)

· ICE (Give example of questions on how to elicit the ICE)

I – Do you have any idea what might be the cause of the constipation?
C – Is there anything in particular that you are worried about with regards to the constipation?
E – Besides getting treatment for your constipation, is there anything else that you would like us to do for you ?

2) Relevant examinations:
       - General Observation (Go): Hydration status, alert, pink, cahectic/ overweight, poor eye contact (depression)
       - Vital signs (Vit): BP, P
       - Relevant Systematic examination approach

Radial pulse: bradycardia (hypothyroidism) or tachycardia (anemia)

Eyes: pallor

Abdomen: Mass

PR: Mass, TRO Hirschprung’s disease in children

3) Appropriate management which should include the PLIMA:

- Patient Education: Inform the likely diagnosis from the history. May need further investigations TRO other causes of constipation

              - Lifestyle Changes: increase fluid, fibre and fruits such as
               banana, papaya (FFF), Exercise
           - Investigations:
               B(bloods): TFT, PTH, FBC (Hb), Tumour markers (CA 125,
                                 CEA), electrolytes
                U (urine): UFEME (if pt have ssx of UTI)
                R (radiology): plain AXR, CT abdomen
                O (others): -
       - Medications: Refer to Drug Discussion
       - Appointment/ Safety Netting: Arrange for appointment to
         review the symptoms after adopting the lifestyle changes and
         taking medications prescribed and also to review the results of
         investigations.

        Safety Netting: TCA stat if increasing abdominal pain with
        vomiting and NBO or no flatus passed (ssx of intestinal
        obstruction)

Drug Discussion 1: Lactulose

Generic Name	Lactulose
Route of Administration	Oral, Syrup
Dose/Freq	*Adult* 15ml TDS/ PRN (max dose 45mls)
Side effects	Diarrhoea (dose-related), nausea, vomiting, hypokalaemia, bloating and abdominal cramps. Potentially Fatal: Dehydration and hypernatraemia on aggressive treatment.
Contraindications	Galactosaemia, intestinal obstruction. Patients on low galactose diet.
Pregnancy category	Category B
Special Precautions	Monitor electrolyte imbalance. Lactose intolerance; diabetics
Mode of action	Lactulose promotes peristalsis by producing an osmotic effect in the colon with resultant distention. In hepatic encephalopathy, it reduces absorption of ammonium ions and toxic nitrogenous compounds, resulting in reduced blood ammonia concentrations. Onset: 48 hr. Absorption: Not appreciable (oral). Metabolism: Via colonic flora to lactic acid and acetic acid. Excretion: Faeces, urine (as unchanged drug).
Administration	May be taken with or without food. (May be taken with meals to reduce GI discomfort.)

Bronchial Asthma

A 22-year-old Chinese lady who works at a kindergarten presents to you at a Klinik Kesihatan with x1/12 ho of cough. She has occassional runny nose but no fever. She has a background ho bronchial asthma since 10 years old. She is currently not on any follow up for her bronchial asthma and is on MDI salbutamol PRN.

Question 1: What relevant history would you like to know from this patient and what examinations would you like to carry out? How would you manage this patient?

Question 2: What is the level of asthma control in this lady if she admitted to have coughs every night and day for the past x1/12, takes 2 puffs of MDI salbutamol 3x/ week and easily develops shortness of breath and lethargy during work? On which treatment step is she on and how would you manage her further?

Drug Discussion: What are the mode of action and common side effects of inhaled salbutamol? What are the different types of inhaled glucocortocoids available? What are their mode of action and common side effects?

TB

A 26-year-old Indian gentleman, known schizophrenia presented to you in a Klinik Kesihatan. He was bought in by his relative with the complaints of being aggressive at home. The patient was restless and uncooperative during the consultation. Hence you decided to refer the patient to the Hospital. At the Emergency Dept, the patient was triaged to the Yellow Zone (Immediate care) in view of his mental state. Upon further questioning by the medical officer on duty, he admitted to have x1/12 ho dry cough associated with on and off fever. He also had loss of appetite and loss of weight within that 1 month period. However, he denied any night sweats, haemoptysis or any TB contact. He also complained of shortness of breath which is progressively worsening over the past x1/52. Below is his CXR done in the Emergency Dept:

Question 1: What are the findings of his CXR?

Question 2: What are the differential diagnoses (prolonged cough)?

Question 3: Lets say the patient was stable, did not have schizophrenia and was not aggressive on presenting to you at the Klinik Kesihatan with the above complaints, how would you approach and manage this patient?

Question 4: If he was confirmed to have pTB, how would you screen his wife and 3 years old child for TB?

Drug Discussion: What are the anti-TB medications and regime available? What are the drugs' mode of action and common side effects?