Showing posts with label case study. Show all posts
Showing posts with label case study. Show all posts
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.
Tuesday, 14 February 2017
Case 4: A suspicious haematoma
A 75 years old man presented with an enlarging left thigh lump after he fell down from a roof 6 months ago.
He saw a general practitioner few weeks after the injury. Two ultrasounds were performed and the diagnosis of a large intramuscular haematoma was made. He was advised to manage the swelling with warm compress and simple analgesic.
He re-presented today because he noticed that the lump was enlarging and it started to affect his walking, however, there was minimal pain. In addition, he reported weight loss of around 10 kg and feeling fatigue over the last few months.
Physical examination revealed a large firm immobile mass in the medial-posterior aspect of the left thigh. There was significant oedema on his left leg. There was no evidence of neuromuscular compromise of the extremity.
An urgent MRI was performed. (Figure 1)
Figure 1
1. What does the MRI show?
Case continues: Patient was referred to an orthopaedic surgeon with a special interest in sarcoma. A biopsy confirmed the diagnosis of a myxofibroidsarcoma.
2. Could this lesion be associated with his injury?
3. Can the use of imaging differentiate a soft tissue sarcoma from a benign haematoma ?
4. Is the delay in diagnosis of soft tissue tumour common?
5. How would you manage this patient?
1. The MRI showed a large intra muscular mass with heterogeneous enhancement measuring in the posteromedial thigh. It rose the possible diagnosis of a sarcoma.
2. An association between trauma and soft tissue sarcoma has been suggested for over 200 years.(5) Currently, there is no evidence to say that the relationship is causal. The usual history is of a traumatic incident occurring shortly prior to the awareness of the mass. Because of the relatively short time frame, we think that the trauma merely brings the patient's attention to the mass. (5)(7).
3. Even with the advances in modern technology, we cannot use imaging to safely differentiate a soft tissue sarcoma from a haematoma. (2,5,7,8). Gomez et al reported three cases similar to our case study. All three patients had history of trauma prior to consulting their family physicians with lumps. They had MRIs and CTs, and were all initially reported as haematomas. This highlights the difficulty in differentiating malignant tumour from a benign haematoma using imaging alone. The imaging results need to be interpreted in the context of clinical history and examination. When there is enough clinical suspicion of a soft tissue sarcoma, patient should be referred to a specialist unit for biopsy. (8)
4. The delay in diagnosis of soft tissue sarcoma is a common problem. Many studies were conducted in an attempt to identify the sources of delay. (2,3,4) The identified sources of delay include patient delay in presentation, mis-diagnosis, and waiting for investigations such as imaging and biopsy. The average time frame between the onset of symptoms to patient presentation is around 12 months, and the average time frame between patient presentation to referral to a specialist unit is 13.5 months.
Sarcoma is a rare tumour. There are around 800 new cases diagnosed in Australia per year. Most general surgeons or general practitioners will only encounter a soft tissue sarcoma once or twice in their careers. Therefore, it is important to be vigilant and treat any lump greater than 5 cm or deep to the fascia as sarcoma until proven otherwise.
5. Studies have shown that early referral to a specialist unit improves survival rate and treatment outcome. Imaging and biopsies at non-specialist units are often inadequate and further delay the diagnosis. Poor biopsy techniques can potentially complicate future surgical excisions. Hence, an early referral for biopsy or management is recommended.
Case continue
Further imaging at the specialist unit showed pulmonary metastases. He underwent radiotherapy and definite surgical excision. The surgical excision was of palliative intent due to his pulmonary metastases. At the time of writing, he had returned home and recovered well from his surgery. He will require regular review and ongoing surveillance .
Key points:
- Any lumps greater than 5cm in diameter or deep in fascia should be treated as sarcoma until proven otherwise.
- Imaging results need to interpreted in the context of clinical history and examination. A biopsy is required to exclude soft tissue sarcoma.
- An early referral to a specialist unit provides the best survival rate and treatment outcome.
References:
4. Stiller CA, Passmore SJ, Kroll ME, Brownbill PA, Wallis JC, Craft AW. Patterns of care and survival for patients aged under 40 years with bone sarcoma in Britain, 1980-1994. Br J Cancer 2006 Jan 16;94(1):22-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16317433
5. Soft tissue sarcomas of the extremities. Blake A. Morrison. Available at
6. Uptodate pathogenetic factors in soft tissue and bone sarcomas
7. http://www.bcmj.org/article/soft-tissue-sarcomas-extremities-how-stay-out-trouble
8. High grade sarcomas mimicking traumatic intramuscular hematoms: a report of three cases. Pablo Gomez and jose Morcuende Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888428/pdf/1555-1377v024p106.pdf
He saw a general practitioner few weeks after the injury. Two ultrasounds were performed and the diagnosis of a large intramuscular haematoma was made. He was advised to manage the swelling with warm compress and simple analgesic.
He re-presented today because he noticed that the lump was enlarging and it started to affect his walking, however, there was minimal pain. In addition, he reported weight loss of around 10 kg and feeling fatigue over the last few months.
Physical examination revealed a large firm immobile mass in the medial-posterior aspect of the left thigh. There was significant oedema on his left leg. There was no evidence of neuromuscular compromise of the extremity.
An urgent MRI was performed. (Figure 1)
Figure 1
1. What does the MRI show?
Case continues: Patient was referred to an orthopaedic surgeon with a special interest in sarcoma. A biopsy confirmed the diagnosis of a myxofibroidsarcoma.
2. Could this lesion be associated with his injury?
3. Can the use of imaging differentiate a soft tissue sarcoma from a benign haematoma ?
4. Is the delay in diagnosis of soft tissue tumour common?
5. How would you manage this patient?
1. The MRI showed a large intra muscular mass with heterogeneous enhancement measuring in the posteromedial thigh. It rose the possible diagnosis of a sarcoma.
2. An association between trauma and soft tissue sarcoma has been suggested for over 200 years.(5) Currently, there is no evidence to say that the relationship is causal. The usual history is of a traumatic incident occurring shortly prior to the awareness of the mass. Because of the relatively short time frame, we think that the trauma merely brings the patient's attention to the mass. (5)(7).
3. Even with the advances in modern technology, we cannot use imaging to safely differentiate a soft tissue sarcoma from a haematoma. (2,5,7,8). Gomez et al reported three cases similar to our case study. All three patients had history of trauma prior to consulting their family physicians with lumps. They had MRIs and CTs, and were all initially reported as haematomas. This highlights the difficulty in differentiating malignant tumour from a benign haematoma using imaging alone. The imaging results need to be interpreted in the context of clinical history and examination. When there is enough clinical suspicion of a soft tissue sarcoma, patient should be referred to a specialist unit for biopsy. (8)
4. The delay in diagnosis of soft tissue sarcoma is a common problem. Many studies were conducted in an attempt to identify the sources of delay. (2,3,4) The identified sources of delay include patient delay in presentation, mis-diagnosis, and waiting for investigations such as imaging and biopsy. The average time frame between the onset of symptoms to patient presentation is around 12 months, and the average time frame between patient presentation to referral to a specialist unit is 13.5 months.
Sarcoma is a rare tumour. There are around 800 new cases diagnosed in Australia per year. Most general surgeons or general practitioners will only encounter a soft tissue sarcoma once or twice in their careers. Therefore, it is important to be vigilant and treat any lump greater than 5 cm or deep to the fascia as sarcoma until proven otherwise.
5. Studies have shown that early referral to a specialist unit improves survival rate and treatment outcome. Imaging and biopsies at non-specialist units are often inadequate and further delay the diagnosis. Poor biopsy techniques can potentially complicate future surgical excisions. Hence, an early referral for biopsy or management is recommended.
Case continue
Further imaging at the specialist unit showed pulmonary metastases. He underwent radiotherapy and definite surgical excision. The surgical excision was of palliative intent due to his pulmonary metastases. At the time of writing, he had returned home and recovered well from his surgery. He will require regular review and ongoing surveillance .
Key points:
- Any lumps greater than 5cm in diameter or deep in fascia should be treated as sarcoma until proven otherwise.
- Imaging results need to interpreted in the context of clinical history and examination. A biopsy is required to exclude soft tissue sarcoma.
- An early referral to a specialist unit provides the best survival rate and treatment outcome.
References:
Cancer Council Australia Sarcoma Guidelines Working Party. Clinical practice guidelines for the management of adult onset sarcoma.
Sydney: Cancer Council Australia. [Version URL: http://wiki.cancer.org.au/australiawiki/index.php?oldid=138276, cited 2017 Apr 11].
Available from: http://wiki.cancer.org.au/australia/Guidelines:Sarcoma
2. Ashwood N, Witt JD, Hallam PJ, Cobb JP. Analysis of the referral pattern to a supraregional bone and soft tissue tumour service. Ann R Coll Surg Engl 2003 Jul;85(4):272-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12855033.4. Stiller CA, Passmore SJ, Kroll ME, Brownbill PA, Wallis JC, Craft AW. Patterns of care and survival for patients aged under 40 years with bone sarcoma in Britain, 1980-1994. Br J Cancer 2006 Jan 16;94(1):22-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16317433
5. Soft tissue sarcomas of the extremities. Blake A. Morrison. Available at
6. Uptodate pathogenetic factors in soft tissue and bone sarcomas
7. http://www.bcmj.org/article/soft-tissue-sarcomas-extremities-how-stay-out-trouble
8. High grade sarcomas mimicking traumatic intramuscular hematoms: a report of three cases. Pablo Gomez and jose Morcuende Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888428/pdf/1555-1377v024p106.pdf
Wednesday, 8 February 2017
Case 3: Lung function test
68 yr old male came for regular check up.
He had a lung function test last year.
He used to be a heavy smoker, quit last year. His exercise tolerance is limited to around 50m.
What is your diagnosis ?
With a long smoking history and shortness of breath, this lung function indicates Chronic Obstructive Pulmonary Disease (COPD) . COPD is confirmed by the presence of persistent airflow limitation. FEV1/FVC < 0.7.
The problem we are having now is that we over diagnose people with COPD. Around 20-30% of patients who have a diagnosis of COPD has never had spirometry. Remember, COPD is a spirometry diagnosis.
What are your differential diagnoses?
COPD has many causes including asthma, smoking, occupation exposures, and anti tripsin 1 deficiency.
Is this severe disease ?
The current classification from lung foundation Australia classify this patient with severe disease.
He had a lung function test last year.
He used to be a heavy smoker, quit last year. His exercise tolerance is limited to around 50m.
What is your diagnosis ?
With a long smoking history and shortness of breath, this lung function indicates Chronic Obstructive Pulmonary Disease (COPD) . COPD is confirmed by the presence of persistent airflow limitation. FEV1/FVC < 0.7.
The problem we are having now is that we over diagnose people with COPD. Around 20-30% of patients who have a diagnosis of COPD has never had spirometry. Remember, COPD is a spirometry diagnosis.
What are your differential diagnoses?
COPD has many causes including asthma, smoking, occupation exposures, and anti tripsin 1 deficiency.
Is this severe disease ?
The current classification from lung foundation Australia classify this patient with severe disease.
How would you manage this patient?
This patient requires multi-disciplinary approach.
- GP management plan and TCA
- Prevention of exacerbation: flu vaccination and pneumococcal vaccination
- Stop smoking
- Optimise medications: use COPD stepwise treatment flowchart (link)
- COPD action plan
- Refer to lung rehabilitation or physiotherapist or exercise physiologist to improve lung function
- Regular review and assess inhaler techniques
According to the latest COPD guideline, severe COPD with more than 2 exacerbations per year should be managed by LABA + Inhale corticosteroid.
Reference:
1. COPD-X concise guideline
Subscribe to:
Posts (Atom)