Rural Patient with Multiple Health Issues

2024.1 Case 6B

Care Priorities

1. Chest Pain on Exertion
   • Primary Concern: Evaluate for potential cardiac issues.
   • Differential Diagnosis: Angina, myocardial infarction, musculoskeletal pain.
   • Immediate Actions: ECG, troponin levels, referral to cardiologist.
2. Suboptimal Diabetes Control
   • Glycemic Management: Review and adjust diabetes medications, consider insulin if necessary.
   • Lifestyle Modifications: Diet and exercise counseling, diabetes education.
   • Monitoring: Regular blood glucose monitoring, HbA1c tests.
3. Increased Alcohol Consumption
   • Assessment: Quantify alcohol intake, assess for dependency.
   • Counseling and Support: Provide resources for alcohol cessation, refer to addiction services if needed.
   • Liver Function Monitoring: Regular LFTs to monitor for improvement or further deterioration.
4. Deranged Liver Function Tests
   • Differential Diagnosis: Alcohol-related liver disease, non-alcoholic fatty liver disease, hepatitis, medication effects.
   • Further Investigations: Ultrasound, liver biopsy if indicated, hepatitis serology.
   • Management: Address underlying cause, monitor LFTs, consider hepatologist referral.

Discovery of Pancreatic Mass

• Initial Steps:
  • Imaging: CT scan, MRI to characterize the mass.
  • Referral: Urgent referral to gastroenterologist or oncologist.
  • Biopsy: Obtain tissue sample for histopathology.
• Management Plan:
  • Multidisciplinary Approach: Engage surgical, oncology, and palliative care teams.
  • Treatment Options: Discuss surgery, chemotherapy, radiation therapy based on staging and patient’s overall condition.
  • Support Services: Provide psychological support, nutritional counseling, and palliative care as needed.

Follow-up Plans

• Post-referral Monitoring:
  • Regular Follow-ups: Schedule frequent reviews to monitor progress and response to treatment.
  • Communication: Ensure clear communication with specialists and update the care plan based on their recommendations.
  • Safety Netting: Provide patient with information on when to seek urgent care if symptoms worsen.

Considerations for Rural Setting

• Service Availability:
  • Local Resources: Identify available local services and support.
  • Telehealth: Utilize telehealth services for specialist consultations to minimize travel.
• Barriers to Care:
  • Transportation: Assist with transportation options for medical appointments.
  • Service Delays: Advocate for expedited referrals and diagnostic tests when necessary.

Common Pitfalls to Avoid

1. Misplaced Prioritization:
   • Avoid: Focusing on diabetes, weight loss, or gout over the urgent chest pain.
2. Misdiagnosis of LFT Derangement:
   • Avoid: Assuming alcohol is the sole cause without considering other potential causes.
3. Ignoring Rural Context:
   • Avoid: Making multiple referrals without considering the patient’s rural setting and potential delays.
4. Narrow Focus:
   • Avoid: Focusing on a single issue and missing other critical health problems.
5. Generic Problem List:
   • Avoid: Providing a non-specific problem list that doesn’t address the patient’s unique situation.
6. Lack of Follow-up Plan:
   • Avoid: Failing to establish a clear follow-up plan after referrals.
7. Management of Comorbidities:
   • Avoid: Neglecting the management of co-existing health conditions.