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.

Tennis Elbow

Tennis elbow is quite a common presentation at general practice. The diagnosis is usually quite straight forward, occasionally, it is complicated by referred neck pain. Most of the time, the patient will be able to tell you the diagnosis is Tennis Elbow.


What is the management?

• There are many treatments available. Why ? Because none is effective. 
• Treatments include:
• physiotherapy: ultrasound, manual therapy
• NSAIDs: oral, topical. Some mild benefit with topical NSAID gel. 
• ESWT: no benefit. Cochrane recommended against it. 
• Surgery: no evidence. Final Resort. 
• Platelets rich plasma : no definite conclusion can be drawn. No benefit has been shown so far. 
• orthotic device : no definite conclusion can be drawn. 
• GTN patch: not mentioned in cochrane. Usually used in combination with an exercise program. 

I looked at cochrane review, there is no evidence for any particular treatment.

The following is a succinct summary from reference 1. 

Essentially, in acute stage, watch and wait. 

Subacute stage, refer to physiotherapy or structured exercise program. 

Chronic stage, can try cortisone injection. Refer for specialist opinion. 

• 

Patient handout: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/elbow-pain
(I read quite a few handouts online and I found the one from the victoria state government to be the most accurate and up to date)

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781883/

2. http://www.cochrane.org/CD001821/MUSKEL_orthotic-devices-for-the-treatment-of-tennis-elbow

Approach to tiredness/fatigue

Tiredness/chronic fatigue: diagnostic strategy model

Probability diagnosis

• Stress and anxiety
• Depression
• Viral/postviral infection 
• Sleep-related disorder (e.g. sleep apnoea)

Serious disorders not to be missed

• malignant disease
• cardiac arrhythmia (e.g. sick sinus syndrome)
• cardiomyopathy
• anaemia 
• hidden abscess
• haemochromatosis
• HIV infections 
• Hepatitis C

Pitfalls

• 'Masked' depression
• Food intolerance
• Coeliac disease
• Chronic infection (e.g. lyme disease)
• Incipient CCF
• Fibromyalgia
• Lack of fitness
• Drugs: alcohol, prescribed, withdrawal
• Menopause syndrome
• Pregnancy
• Neurological disorders
• post-head injury
• CVA
• Parkinson disease
• Kidney failure
• Metabolic (e.g. hypokalaemia, hypomagnesaemia)
• Chemical exposure (e.g. occupational)
• Rarities
• Hyperparathyroidism
• Addison disease
• Cushing syndrome
• Narcolepsy
• Multiple sclerosis
• Autoimmune disorders

Minimal investigations from John Murtagh General practice 5th edition:

• FBE
• ESR/CRP
• TFTs
• Coeliac serology
• LFT
• CMP
• BSLs
• Iron studies
• Urine MCS

Visible Haematuria

I have been seeing a 57 M in the last few weeks. He is a new patient to the clinic. He has significant history of ETOH abuse and heavy smoker. Around 2 weeks ago, he came to me with a jar which had his urine in it. There was visible haematuria. I sent him for a renal ultrasound and it was returned normal. I was re-assured by the result until I discussed this with one of the GPs today and did a bit of reading myself.

Some key points about visible haematuria:

1. 20 % of people with haematuria has urological malignancy.
2. Visible haematuria requires urgent urology referral.
3. CT urography is the preferred imaging investigation
4. Women have a poorer outcome in bladder cancer often because of delay in investigations.
5. The following flow chart shows the recommended approach:

6. Do not delay referral because you need to wait for the investgating results

7. Risk factors for bladder malignancies:

References:

Australian Doctor How to treat series Visible haematuria.

Quick start of contraception

Quick start of contraception

Traditionally, contraception methods are started within the first 5 days of menstrual cycle. It becomes a problem when a woman comes to you for contraception during mid cycle. If you tell her to wait, she may become pregnant before she gets her next period. Quick start of contraception tries to tackle that.

Essentially, the process can be summarised in 3 steps:
1. Establish pregnancy status
2. Choose contraception method
3. Follow up

1. Establish pregnancy status 

• Pregnancy can be excluded if :
• -ve pregnancy test + no sex in the last 3 wks
• no sex since last period
• using contraception correctly and reliably
• within the first 5 days of menstrual period 
• < 21 days post part
• < 5 days post abortion or post miscarriage 
• Pregnancy cannot be excluded:
• needs follow up pregnancy testing, the current Australian guideline is in 4 weeks time

2. Choose contraception method 

• If pregnancy can be excluded: can choose any contraceptive method. Don't forget COCP, Vaginal ring, DMPA, LNG IUD and Levonorgestrel take 7 days to work. POP takes 3 days. Copper IUD effective immediately
• If pregnancy cannot be excluded
• tell her that there is a chance she could be pregnant, if it is appropriate, offer her emergency contraception 
• inform choices available for contraceptions: 
• Vaginal ring, COCP, POP, levonorgestrel have not shown to have teratogenic effects in babies. 
• DMPA injection is long acting, so it is less perferrable but also no evidence of teratogenicity
• IUD and Copper IUD not preferred as can cause miscarriage

3. Follow up 

• Women in whom the pregnancy status cannot be excluded: needs pregnancy test in 4 weeks. (This is the current Australian recommendation. Other guidelines have different timeframe)

Resources:

1. Flow chart for quick start contraception(American version, follow up testing time frame different)

2. Family planning victoria quick start guideline