Thursday, 4 May 2017
Re: Cast study 9 Breaking bad news
Today, I saw a patient who may have a potential diagnosis of lung cancer. As a junior GP, I do not break bad news often. Breaking bad news is similar to other skills, it takes preparation and practice with a set of framework. There are many guidelines and acronyms out there, the acronym I used is called "SPIKE".
SPIKE stands for:
S: Setting up the interview
P: Assessing the patient's perception
I: Obtaining the patient's invitation
K: Giving knowledge and information to the patient
E: Addressing patient's emotions with empathetic response
In my own experience, preparation is the key. Clean up your room, tell the receptionist to hold the calls, check the investigations and look up anything that you are uncertain. Finally, prepare yourself emotionally. Breaking bad news require energy so I tend to take a small break from the last patient so that I can concentrate on the next consultation.
I usually break the bad news in two separate consultations. The first consultation I tell them about the diagnosis and organise a referral for them to see a specialist. Then, I will ask them to return in 1 week. Returning after 1 week serves two purposes. One is to answer any questions that they may have. Two is to make sure that they have an appointment with the specialist. You will be surprised by the number of times that the patients returned after a week and still have not made an appointment.
Finally, look after yourself. Breaking bad news is exhausting. Take breaks before and after breaking bad news. Debrief with other colleagues or your supervisors if you need to.
Wednesday, 3 May 2017
Re: Case study 8 Patch of numbness
60 yr old man presented with 1 year history of left lateral thigh numbness.
He saw a different GP 1 year ago and was diagnosed with sciatica. The numbness resolved after a few weeks. This episode started again around 2-3 weeks ago.
His main complaint was numbness on the lateral part of his thigh. It tended to get worse with prolonged walking and standing. There was no associated weakness on his lower limb. There was no back pain
On examination, you mapped out the area of sensory change on his left lateral thigh. The lower leg neurological examination was normal. The straight leg raise was negative.
Question 1
What is your diagnosis ?
Question 2
What can you do about it ?
Answer 1
This is lateral cutaneous nerve of thigh entrapment. The nerve gets trapped when it passes through the inguinal ligament. It is a pure sensory nerve so motor function is not affected.
It is more common in obese people and also associated with diabetes.
Answer 2
Nothing. There is really not much you can do. You tell them to lose weight and you warn them about wearing tight pants or belt which may compress on the nerve. Most of the time, the symptom resolves by itself. In some occasions, it persists and anti epileptic may help.
He saw a different GP 1 year ago and was diagnosed with sciatica. The numbness resolved after a few weeks. This episode started again around 2-3 weeks ago.
His main complaint was numbness on the lateral part of his thigh. It tended to get worse with prolonged walking and standing. There was no associated weakness on his lower limb. There was no back pain
On examination, you mapped out the area of sensory change on his left lateral thigh. The lower leg neurological examination was normal. The straight leg raise was negative.
Question 1
What is your diagnosis ?
Question 2
What can you do about it ?
Answer 1
This is lateral cutaneous nerve of thigh entrapment. The nerve gets trapped when it passes through the inguinal ligament. It is a pure sensory nerve so motor function is not affected.
It is more common in obese people and also associated with diabetes.
Answer 2
Nothing. There is really not much you can do. You tell them to lose weight and you warn them about wearing tight pants or belt which may compress on the nerve. Most of the time, the symptom resolves by itself. In some occasions, it persists and anti epileptic may help.
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