Domain – Cardiovascular health (case)

Lila, a 55-year-old woman, presents with fluctuating epigastric pain for a few days. She thinks that her symptoms might have improved slightly after taking an antacid. She has a past medical history of type 2 diabetes and hypertension. On examination, the patient is pale. Her vital signs are all within normal limits. BMI is 35. Heart sounds are dual and regular, and chest sounds clear. Abdomen is soft, with mild discomfort in the epigastrium.

What strategies might you use to get a clear history? How might your history-taking approach be different if Lila lived in a remote Aboriginal or Torres Strait Islander community?

Who else might be able to provide further history?

What if Lila were from a non-English speaking background?

How would you find out Lila’s ideas, concerns and expectations?

What if she became very anxious when you indicated her condition was serious?ChatGPT

History Taking Strategies

1. Open-Ended Questions: Start with open-ended questions to let Lila describe her symptoms in her own words. For example, “Can you tell me more about the pain you have been experiencing?”
2. Symptom Chronology: Clarify the onset, duration, frequency, and pattern of the epigastric pain. Ask questions like, “When did you first notice the pain?” and “How long does it last when it occurs?”
3. Aggravating and Relieving Factors: Determine what makes the pain better or worse. For instance, “What were you doing when the pain started?” and “Did anything make the pain better or worse?”
4. Associated Symptoms: Inquire about any other symptoms that might be related, such as nausea, vomiting, weight loss, or changes in bowel habits. Ask, “Have you noticed any other symptoms along with the pain?”
5. Past Medical History and Medications: Given her history of type 2 diabetes and hypertension, review her medications and control of these conditions. “How have you been managing your diabetes and hypertension?”
6. Family History: Ask about any family history of gastrointestinal issues, cardiovascular diseases, or cancers. “Is there a family history of similar symptoms or significant illnesses?”
7. Lifestyle Factors: Discuss lifestyle factors such as diet, alcohol intake, smoking, and physical activity. “Can you tell me about your diet and physical activity levels?”
8. Psychosocial Factors: Consider stress, anxiety, or recent life changes that might impact her health. “Have you been experiencing any stress or significant life changes recently?”

Considerations for Remote Aboriginal or Torres Strait Islander Communities

1. Cultural Sensitivity: Be aware of cultural differences and seek to understand the patient’s cultural background. Use culturally appropriate communication methods.
2. Health Literacy: Assess and accommodate for varying levels of health literacy. Simplify medical jargon and use visual aids if needed.
3. Community Involvement: Engage with local health workers, community elders, or family members who can provide additional context and support. Inquire if there are any community practices or beliefs that might influence her health or treatment preferences.
4. Language and Communication: Use interpreters if necessary, and ensure that all communication is clear and respectful. Allow more time for consultations to build trust and understanding.

Considerations for Non-English Speaking Background

1. Interpreter Services: Arrange for a professional interpreter to ensure accurate and effective communication. Avoid using family members as interpreters to prevent miscommunication and maintain confidentiality.
2. Cultural Sensitivity: Be mindful of cultural norms and practices that may influence Lila’s healthcare beliefs and practices. Respect cultural differences and ask about any specific cultural needs.
3. Health Literacy: Assess Lila’s understanding of medical concepts and provide information in a clear, straightforward manner. Use visual aids or written materials in her preferred language.

Finding Out Lila’s Ideas, Concerns, and Expectations

1. Ask Directly: Use questions like, “What do you think might be causing your symptoms?” and “What are your main concerns about your health right now?”
2. Elicit Expectations: Inquire about what she hopes to achieve from the consultation. “What do you expect from this visit?” and “What are you hoping we can do for you?”
3. Active Listening: Listen actively to her responses, acknowledge her concerns, and validate her feelings. This builds rapport and encourages open communication.

Addressing Anxiety About Serious Conditions

1. Reassurance and Empathy: Provide reassurance by acknowledging her feelings and expressing empathy. “I understand that this situation is concerning for you. Let’s work together to find out what’s going on.”
2. Clear Information: Explain the situation clearly, avoiding medical jargon, and provide information about the next steps in a calm and reassuring manner. “We’ll do some tests to understand better what might be causing your symptoms.”
3. Support Systems: Involve family members or friends for emotional support if appropriate. Offer to arrange follow-up appointments to monitor her condition and provide ongoing support.
4. Managing Anxiety: If anxiety persists, consider referring her to a mental health professional for additional support. Encourage relaxation techniques and provide resources for managing anxiety.

Clinical Guidelines and Risk Assessment

1. Cardiovascular Risk Assessment: Use the Australian Cardiovascular Disease Risk Calculator to assess Lila’s risk. This will involve considering her age, gender, smoking status, systolic blood pressure, total cholesterol, HDL cholesterol, and history of diabetes.
2. Lipid Management: Follow the guidelines from the National Heart Foundation of Australia, which recommend lipid-lowering therapy for patients with diabetes and hypertension to reduce cardiovascular risk.
3. Hypertension Management: Refer to the Hypertension Guidelines from the Heart Foundation. Ensure that Lila’s blood pressure is well-controlled with appropriate antihypertensive medication.
4. Diabetes Management: Ensure her diabetes is well-managed according to the Australian Diabetes Society guidelines, including regular monitoring of HbA1c levels, and appropriate lifestyle and pharmacological interventions.

By incorporating these strategies, you can provide comprehensive and culturally sensitive care to Lila, ensuring her symptoms are thoroughly investigated and managed in line with Australian guidelines.

What other past medical or family history may be important?

Are there investigation results in Lila’s file that may be of interest?

Important Past Medical and Family History

Past Medical History:

1. Gastrointestinal Issues: Specifically ask about past episodes of similar pain, peptic ulcer disease, GERD, gallstones, or pancreatitis.
2. Cardiovascular Disease: Given her age, diabetes, and hypertension, inquire about ischemic heart disease, angina, or previous myocardial infarction.
3. Renal Disease: Diabetes and hypertension increase the risk of chronic kidney disease.
4. Gynecological History: Any history of gynecological issues or surgeries which might be relevant for her age group.
5. Medications: Detailed review of all current and past medications, including any non-prescription drugs, herbal supplements, and recent changes in medication.
6. Surgical History: Any past abdominal surgeries such as cholecystectomy, bariatric surgery, or appendectomy.

Family History:

1. Gastrointestinal Cancers: Family history of colorectal, gastric, or other gastrointestinal cancers.
2. Cardiovascular Disease: Family history of coronary artery disease, stroke, or peripheral artery disease, especially at a young age.
3. Diabetes: Family history of type 2 diabetes and associated complications.
4. Breast and Ovarian Cancer: Given her age and gender, it’s relevant to ask about family history of breast or ovarian cancer.
5. Autoimmune Diseases: Family history of autoimmune conditions like celiac disease or inflammatory bowel disease (IBD).

Investigation Results of Interest

Age, Gender, and Ethnicity-Specific Screening:

1. Blood Tests:
   • Complete Blood Count (CBC): To check for anemia, infection, or other hematological abnormalities, especially given her pallor.
   • Liver Function Tests (LFTs): To assess liver health.
   • Amylase and Lipase: To rule out pancreatitis.
   • Electrolytes, Urea, and Creatinine: To assess kidney function.
   • HbA1c: To evaluate her diabetes control.
   • Lipid Profile: Given her age, gender, and cardiovascular risk factors, it’s important to assess cholesterol levels.
2. Imaging:
   • Abdominal Ultrasound: To evaluate for gallstones, liver disease, or other abdominal pathology.
   • Upper Gastrointestinal Endoscopy: If there is suspicion of peptic ulcer disease or GERD not responsive to initial treatment.
3. Cardiac Investigations:
   • ECG: To rule out any cardiac cause of her epigastric pain, especially given her risk factors for coronary artery disease.
   • Echocardiogram: If there is suspicion of heart failure or structural heart disease.
4. Age and Gender-Specific Screening:
   • Mammography: Regular screening for breast cancer is recommended for women aged 50-74 years in Australia.
   • Cervical Screening Test: As part of the National Cervical Screening Program, recommended every five years for women aged 25-74 who have ever been sexually active.
   • Colonoscopy: Given her age, regular screening for colorectal cancer (FOBT every two years for people aged 50-74, or colonoscopy if indicated).
5. Diabetes Monitoring:
   • Urine Microalbumin: To check for early signs of diabetic nephropathy.
   • Retinal Exam: To screen for diabetic retinopathy.

Ethnicity Considerations:

For Aboriginal or Torres Strait Islander patients:

• Consider higher cardiovascular risk and the need for more frequent screenings.
• Increased prevalence of chronic diseases such as diabetes, hypertension, and renal disease.

What investigations need to be ordered, and in what timeframes?

Would your approach be different if Lila were a healthy 25 year old with associated shortness of breath?

What if she were an elderly person living in a high-dependency nursing home unit?

Investigations and Timeframes for Lila (55-year-old woman with Type 2 Diabetes and Hypertension)

Immediate Investigations:

1. ECG: To rule out any cardiac cause of her epigastric pain, given her risk factors (immediate).
2. Complete Blood Count (CBC): To check for anemia or infection (within 24 hours).
3. Liver Function Tests (LFTs): To assess liver health (within 24 hours).
4. Amylase and Lipase: To rule out pancreatitis (within 24 hours).
5. Electrolytes, Urea, and Creatinine: To assess kidney function and electrolyte balance (within 24 hours).
6. HbA1c: To evaluate diabetes control (within 24 hours).
7. Lipid Profile: Given her cardiovascular risk factors (within 24 hours).

Short-term Investigations:

1. Abdominal Ultrasound: To evaluate for gallstones, liver disease, or other abdominal pathology (within a week).
2. Upper Gastrointestinal Endoscopy: If there is suspicion of peptic ulcer disease or GERD not responsive to initial treatment (within a week to a month).

Regular Screening:

1. Mammography: If not done recently, as part of regular screening for breast cancer (schedule if due).
2. Cervical Screening Test: As part of the National Cervical Screening Program (schedule if due).
3. Colonoscopy or FOBT: For colorectal cancer screening (schedule if due).

Adjustments Based on Different Scenarios

If Lila were a Healthy 25-Year-Old with Associated Shortness of Breath

1. Immediate Investigations:
   • ECG: To rule out any cardiac cause, especially considering shortness of breath (immediate).
   • Complete Blood Count (CBC): To check for anemia or infection (within 24 hours).
   • Chest X-ray: To rule out any pulmonary cause for her symptoms, such as pneumonia or pneumothorax (within 24 hours).
2. Short-term Investigations:
   • Spirometry: To assess for any underlying respiratory conditions like asthma or COPD (within a week).
   • Echocardiogram: If there is suspicion of a structural heart problem (within a week).
3. Further Investigations:
   • D-dimer: If there’s a high suspicion of pulmonary embolism (immediate).
   • CT Pulmonary Angiography: If D-dimer is elevated or clinical suspicion of pulmonary embolism is high (immediate).

If Lila were an Elderly Person Living in a High-Dependency Nursing Home Unit

1. Immediate Investigations:
   • ECG: To rule out cardiac causes of her epigastric pain (immediate).
   • Complete Blood Count (CBC): To check for anemia or infection (within 24 hours).
   • Liver Function Tests (LFTs): To assess liver health (within 24 hours).
   • Electrolytes, Urea, and Creatinine: To assess kidney function (within 24 hours).
   • Blood Cultures: If there is any suspicion of infection (immediate).
2. Short-term Investigations:
   • Abdominal Ultrasound: To evaluate for gallstones or liver disease (within a week).
   • Chest X-ray: To rule out pulmonary causes, especially in an elderly patient who might not exhibit typical symptoms of pneumonia or heart failure (within 24 hours).
   • Urinalysis: To check for urinary tract infection, which can present atypically in the elderly (within 24 hours).
3. Additional Considerations:
   • Cognitive Assessment: To evaluate any underlying cognitive impairment which might affect history taking and management (scheduled as needed).
   • Medication Review: Comprehensive review of all current medications to identify any potential side effects or interactions (immediate).

Summary of Timeframes:

• Immediate (within 24 hours):
  • ECG
  • CBC
  • LFTs
  • Amylase and Lipase
  • Electrolytes, Urea, and Creatinine
  • HbA1c
  • Lipid Profile
  • Chest X-ray (if indicated)
• Short-term (within a week to a month):
  • Abdominal Ultrasound
  • Upper Gastrointestinal Endoscopy
  • Echocardiogram (if indicated)
  • Spirometry (if indicated)
  • Colonoscopy or FOBT (if due for screening)
  • Cognitive Assessment (if indicated)
• Regular Screening (scheduled as needed):
  • Mammography
  • Cervical Screening Test

Would you consider doing an ECG given Lila’s cardiac risk factors? If the ECG were normal, what would your next steps be? If the ECG showed ST elevation in leads V1 and V2 with concomitant depression elsewhere, how would your management change?

What resources could you call on for help if you diagnosed an ST elevation myocardial infarction (STEMI) and were practising in a major city?

How would your approach differ if you were in a rural practice three hours from the nearest hospital?

What other health professionals would you consider involving in Lila’s long-term care?

ECG and Cardiac Risk Factors

Considering an ECG:

Given Lila’s cardiac risk factors, including her age, type 2 diabetes, hypertension, and symptoms of epigastric pain, an ECG is warranted to rule out any cardiac cause for her symptoms. Epigastric pain can sometimes be a presentation of cardiac ischemia, especially in women.

If the ECG Were Normal:

If the ECG is normal, the next steps would include:

1. Further Cardiac Evaluation:
   • Cardiac Enzymes: Measure troponins to rule out myocardial infarction.
   • Repeat ECGs: If symptoms persist or change, repeat the ECG to monitor for any evolving cardiac changes.
   • Stress Testing: Consider a stress test to evaluate for ischemic heart disease if clinical suspicion remains high.
2. Gastrointestinal Evaluation:
   • Abdominal Ultrasound: To assess for gallstones, liver disease, or other abdominal pathology.
   • Upper GI Endoscopy: If GERD or peptic ulcer disease is suspected and not responsive to initial treatment.
3. Metabolic and Systemic Assessment:
   • Complete Blood Count (CBC): To check for anemia or infection.
   • Liver Function Tests (LFTs): To assess liver health.
   • Amylase and Lipase: To rule out pancreatitis.
   • Electrolytes, Urea, and Creatinine: To assess kidney function.
   • HbA1c: To evaluate diabetes control.
   • Lipid Profile: To assess cardiovascular risk factors.

If the ECG Showed ST Elevation in Leads V1 and V2 with Concomitant Depression Elsewhere:

This finding suggests an anterior ST-elevation myocardial infarction (STEMI). Immediate management changes are required.

Immediate Management for STEMI:

1. Activate Emergency Response:
   • Call for immediate emergency medical services.
   • Notify the nearest hospital with a cardiology unit about the incoming STEMI patient.
2. Initial Medical Management:
   • Aspirin: Administer 300 mg orally (chewed).
   • P2Y12 Inhibitor: Administer a loading dose of clopidogrel, prasugrel, or ticagrelor.
   • Anticoagulation: Start unfractionated heparin or low molecular weight heparin.
   • Nitroglycerin: If not contraindicated, for pain relief and to reduce cardiac workload.
   • Oxygen: If hypoxia is present (oxygen saturation <90%).
   • Morphine: For pain relief if needed.
3. Prepare for Reperfusion Therapy:
   • Primary PCI: Preferred reperfusion strategy, ideally within 90 minutes of first medical contact.
   • Thrombolysis: If PCI is not available within 120 minutes, administer thrombolytic therapy.

Resources for Help in a Major City:

1. Cardiology Team: Immediate referral to an interventional cardiologist for primary PCI.
2. Emergency Department: Coordination with the ED for rapid transport and treatment.
3. Ambulance Services: Emergency transport to a PCI-capable facility.
4. Intensive Care Unit (ICU): For post-reperfusion care.

Approach in a Rural Practice Three Hours from the Nearest Hospital:

1. Immediate Stabilization:
   • Follow the same initial medical management steps as above.
   • Administer thrombolytic therapy if PCI is not feasible within 120 minutes.
2. Transport Arrangements:
   • Arrange for air or ground transport to the nearest PCI-capable hospital.
   • Ensure continuous monitoring and support during transport.
3. Coordination with Receiving Facility:
   • Communicate with the receiving hospital to prepare for the patient’s arrival and subsequent care.

Long-term Care Involvement:

1. Primary Care Physician: For ongoing management of diabetes, hypertension, and other chronic conditions.
2. Cardiologist: For follow-up care post-STEMI, including cardiac rehabilitation and secondary prevention.
3. Diabetes Educator: To assist with diabetes management and lifestyle modification.
4. Dietitian: For nutritional advice to manage diabetes, hyperlipidemia, and weight.
5. Exercise Physiologist: To design a safe and effective exercise program.
6. Psychologist or Counselor: To provide support for anxiety or depression, especially post-MI.
7. Pharmacist: For medication management and adherence support.

Summary:

1. ECG: Should be done immediately given Lila’s risk factors.
2. Normal ECG: Proceed with further cardiac, gastrointestinal, and systemic evaluations.
3. STEMI: Immediate emergency management, reperfusion therapy, and coordination with appropriate facilities.
4. Resources in Major City: Utilize cardiology teams, emergency services, and ICU.
5. Rural Practice: Stabilize, administer thrombolytics if needed, and arrange for rapid transport.
6. Long-term Care: Involve a multidisciplinary team for comprehensive management and follow-up.

How could you use this situation as a prompt to educate Lila, her family and her community about the different presentations of acute coronary syndrome?

How would you approach this in a remote Aboriginal or Torres Strait Islander community? Who would you involve?

What information resources are there for non-English speaking communities? Would your practice benefit from multilingual health-promotion pamphlets in your waiting room?

Educating Lila, Her Family, and Community About Acute Coronary Syndrome (ACS)

General Approach:

1. Start with the Basics:
   • Explain what ACS is, including the different types: unstable angina, NSTEMI, and STEMI.
   • Discuss common and atypical symptoms, emphasizing that symptoms like epigastric pain, nausea, and fatigue can also indicate a heart attack, especially in women and diabetics.
2. Use Simple Language:
   • Avoid medical jargon. Use terms like “heart attack” instead of “myocardial infarction” and “heart problem” instead of “ischemia.”
3. Interactive Education:
   • Use visual aids like diagrams and charts to explain how the heart works and what happens during a heart attack.
   • Encourage questions and provide clear, concise answers.
4. Personalized Advice:
   • Discuss Lila’s specific risk factors and what her symptoms might indicate.
   • Provide actionable steps for recognizing symptoms early and seeking immediate help.
5. Preventive Measures:
   • Educate about lifestyle changes that can reduce the risk of ACS, such as healthy eating, regular exercise, smoking cessation, and medication adherence.
6. Family Involvement:
   • Encourage family members to learn about ACS symptoms and the importance of early intervention.
   • Discuss creating an emergency plan, including knowing how to use emergency services and recognizing when to call for help.

Approach in a Remote Aboriginal or Torres Strait Islander Community:

1. Cultural Sensitivity:
   • Respect cultural beliefs and practices. Use culturally appropriate communication methods.
   • Involve community elders and local health workers to bridge cultural and language gaps.
2. Community Engagement:
   • Organize community meetings or health talks in collaboration with local health services.
   • Use storytelling, which is a traditional way of sharing knowledge, to explain ACS and its symptoms.
3. Visual Aids and Demonstrations:
   • Use visual aids that are culturally relevant and easy to understand.
   • Demonstrate emergency response actions, such as calling for help and performing basic first aid.
4. Involve Local Health Workers:
   • Train local health workers to recognize ACS symptoms and provide basic first aid.
   • Ensure they have the resources and knowledge to educate others in the community.
5. Language and Communication:
   • Use interpreters if needed to ensure clear communication.
   • Provide information in the local language and use simple, clear terms.

Information Resources for Non-English Speaking Communities:

1. Multilingual Pamphlets:
   • Have pamphlets available in multiple languages in the waiting room.
   • These should cover the basics of ACS, symptoms to watch for, and steps to take in an emergency.
2. Online Resources:
   • Direct patients and their families to reputable websites that offer health information in various languages (e.g., Healthdirect Australia, Heart Foundation).
3. Community Support Groups:
   • Connect non-English speaking patients with community support groups that offer health education and resources in their language.
4. Use of Interpreters:
   • Utilize professional interpreters during consultations to ensure understanding and provide accurate information.

Benefits of Multilingual Health-Promotion Pamphlets:

1. Accessibility:
   • Ensures that all patients, regardless of language proficiency, have access to important health information.
2. Enhanced Understanding:
   • Helps non-English speaking patients understand their health conditions and the steps they can take to manage them.
3. Improved Health Outcomes:
   • Educated patients are more likely to recognize symptoms early, adhere to treatment plans, and make informed health decisions.
4. Community Trust:
   • Demonstrates respect for cultural and linguistic diversity, building trust and rapport with the community.
5. Empowerment:
   • Empowers patients and their families to take an active role in their health care, leading to better overall health outcomes.

By using these strategies, you can effectively educate Lila, her family, and her community about ACS, tailoring your approach to meet the specific needs of different cultural and linguistic groups. This ensures that everyone has the knowledge and resources to recognize and respond to ACS symptoms promptly.

How would you approach this situation if an ECG showed changes consistent with acute coronary syndrome and the patient refused to go to hospital? What supports would you be able to call on?

Immediate Approach

1. Understanding the Refusal:
   • Open Dialogue: Engage in a calm and empathetic conversation to understand her reasons for refusing hospitalization. It could be fear, previous bad experiences, cultural beliefs, or logistical issues.
   • Address Concerns: Address her concerns directly. Provide reassurance and information to alleviate fears or misconceptions.
2. Educate on Risks:
   • Explain Urgency: Clearly explain the severity of ACS and the potential consequences of not receiving hospital care, including the risk of death or permanent heart damage.
   • Consequences of Delay: Emphasize that timely treatment can significantly improve outcomes.
3. Offer Alternatives:
   • Immediate Interventions: Offer to initiate immediate treatments like aspirin, nitroglycerin, and other medications in the clinic while preparing for potential hospital transfer.
   • Reassure Continuity of Care: Ensure her that she will be well cared for and that her comfort and wishes will be respected at the hospital.
4. Involve Family and Support Systems:
   • Family Discussion: Involve her family or close friends in the discussion to provide additional support and encouragement.
   • Community Leaders: If she is from a remote Aboriginal or Torres Strait Islander community, involve community elders or local health workers who can provide culturally appropriate support and reassurance.
5. Document the Conversation:
   • Medical Records: Document her refusal and the details of the conversation, including the information provided and her reasons for refusal.

Supports and Resources

1. Multidisciplinary Team:
   • GP and Nursing Staff: Collaborate with your clinic’s team, including nurses and other GPs, to provide comprehensive care and monitoring.
   • Cardiologist Consultation: If possible, arrange a telehealth consultation with a cardiologist for immediate advice and intervention strategies.
2. Emergency Services:
   • Ambulance Services: Coordinate with local ambulance services to be on standby in case she changes her mind or her condition deteriorates.
   • Community Health Services: Engage local health services that may offer home visits and monitoring.
3. Cultural and Language Support:
   • Interpreters: Use interpreters if language barriers exist to ensure she fully understands the situation.
   • Cultural Liaison Officers: Engage cultural liaison officers if available, to provide culturally sensitive support.

If She Continues to Refuse Hospitalization

1. Ongoing Monitoring and Care:
   • Frequent Monitoring: Arrange for frequent monitoring either at the clinic or via home visits if feasible.
   • Symptom Management: Provide medications to manage her symptoms and prevent complications as much as possible.
2. Patient Education:
   • Warning Signs: Educate her on the warning signs that should prompt immediate medical attention (e.g., worsening pain, shortness of breath, fainting).
   • Emergency Plan: Develop an emergency plan with her, including who to contact and when to call for help.
3. Follow-Up:
   • Regular Check-Ins: Schedule regular follow-up appointments to reassess her condition and reinforce the importance of hospital care.

Legal and Ethical Considerations

1. Capacity Assessment:
   • Evaluate Decision-Making Capacity: Ensure that she has the capacity to make an informed decision. If there is doubt, a formal assessment may be needed.
   • Informed Consent: Ensure that her refusal is informed and voluntary.
2. Ethical Duty:
   • Respect Autonomy: Respect her autonomy while also fulfilling your duty to inform and protect her health.
   • Balance Risks and Benefits: Carefully weigh the ethical considerations of respecting her wishes versus the potential benefits of hospital care.

By following these steps and leveraging available resources, you can provide the best possible care for Lila while respecting her autonomy and addressing her concerns.

How would you record this consultation if Lila were a new patient to the clinic, was acutely unwell and had not brought any identification documents?

How would you ensure Lila is not lost to follow-up?

Recording the Consultation

Initial Documentation

1. Basic Information:
   • Record Lila’s name, age (55 years), and gender.
   • Note that she is a new patient without identification documents.
   • Document her self-reported medical history: type 2 diabetes, hypertension, and current symptoms (fluctuating epigastric pain).
2. Clinical Presentation:
   • Document presenting symptoms, onset, and progression.
   • Note physical examination findings: pale appearance, normal vital signs, BMI 35, dual and regular heart sounds, clear chest sounds, soft abdomen with mild epigastric discomfort.
3. Investigations and Results:
   • Record ECG findings: any changes consistent with acute coronary syndrome (e.g., ST elevation in leads V1 and V2 with concomitant depression elsewhere).
   • List any other investigations performed and their results.
4. Management Plan:
   • Detail the immediate management steps taken (e.g., administering aspirin, nitroglycerin, etc.).
   • Document the discussion regarding the need for hospitalization, her refusal, and the reasons for her refusal.
   • Note any medications provided and monitoring arrangements made.
5. Patient Education and Support:
   • Record the educational information provided about ACS, the risks of not going to the hospital, and the symptoms that should prompt immediate medical attention.
   • Note any support systems contacted, such as family members or community health workers.
6. Follow-Up Plan:
   • Clearly outline the follow-up plan, including scheduled appointments and home visit arrangements if applicable.
   • Document any additional referrals made, such as to a cardiologist via telehealth.

Ensuring Lila is Not Lost to Follow-Up

1. Immediate Follow-Up Arrangements:
   • Schedule a follow-up appointment within 24-48 hours to reassess her condition.
   • If possible, arrange for a nurse or community health worker to visit her at home to monitor her condition and reinforce the importance of follow-up care.
2. Contact Information:
   • Obtain and verify all available contact details (phone number, address).
   • If she does not have her own phone, try to obtain contact information for a family member or close friend.
3. Patient Registration System:
   • Create a provisional patient record in the clinic’s electronic health system with the information provided.
   • Assign a temporary ID if necessary and update it once she can provide identification documents.
4. Community Involvement:
   • Engage local community health services or Aboriginal and Torres Strait Islander health liaison officers to provide support and help maintain contact with Lila.
   • Ensure that they are aware of her condition and the importance of follow-up.
5. Clear Communication:
   • Clearly communicate the follow-up plan to Lila, emphasizing the importance of attending follow-up appointments and what to do if her symptoms worsen.
   • Provide written instructions if she is literate or ensure a trusted person has this information.
6. Documentation:
   • Keep detailed and accurate records of all communications and attempts to follow up.
   • Use a reminder system within the clinic’s patient management software to alert staff to check on Lila’s follow-up status.
7. Multidisciplinary Team Approach:
   • Involve other health professionals in her care, such as a primary care physician, diabetes educator, cardiologist, and community health workers.
   • Ensure that all team members are aware of her case and the need for vigilant follow-up.

Are you able to do an ECG if there was no nurse available?

Are your IV cannulation skills up to date?

Does your clinic have a process for labelling drawn-up medications to minimise medication errors in a stressful situation? Is there a protocol for who would be the scribe in an emergency?

Protocol for Labelling Drawn-Up Medications

Goal:

To ensure that all medications drawn up are correctly labelled to minimize medication errors, particularly in high-stress situations.

Procedure:

1. Preparation:
   • Gather all necessary supplies: syringes, labels, markers, and the medication to be drawn up.
   • Wash hands thoroughly and use gloves if necessary.
2. Label Creation:
   • Prepare labels before drawing up medications whenever possible.
   • Use pre-printed labels that include fields for the medication name, dose, date, time, and initials of the person drawing up the medication.
   • If pre-printed labels are not available, use a blank label and a permanent marker to clearly write the necessary information.
3. Drawing Up Medication:
   • Double-check the medication name, concentration, and expiration date before drawing it up.
   • Draw up the required dose, ensuring accuracy.
4. Immediate Labelling:
   • Immediately label the syringe with the pre-prepared or hand-written label.
   • The label should include:
     • Medication name (e.g., “Morphine”)
     • Dose (e.g., “5 mg”)
     • Date and time (e.g., “17/05/2024 14:30”)
     • Initials of the person who drew up the medication (e.g., “ABC”)
5. Double-Check:
   • If possible, have a second healthcare professional verify the medication, dose, and label before administration.
   • Both professionals should initial the label if verification is performed.
6. Documentation:
   • Document the medication administration in the patient’s medical record, including the name of the medication, dose, time, and initials of the administering staff.

Example Label:

Medication: Morphine
Dose: 5 mg
Date: 17/05/2024
Time: 14:30
Initials: ABC

Protocol for Scribe in an Emergency

Goal:

To ensure that all actions and communications are accurately recorded during an emergency situation to facilitate effective treatment and legal documentation.

Procedure:

1. Designation:
   • The scribe role should be pre-assigned during shift handovers or as part of the emergency response team.
   • If an emergency occurs without a pre-designated scribe, the team leader should quickly assign a scribe.
2. Responsibilities:
   • The scribe’s primary responsibility is to document all events, actions, and communications during the emergency.
   • The scribe should not be involved in direct patient care to ensure they can focus solely on documentation.
3. Equipment:
   • The scribe should have access to a clipboard, pen, and emergency documentation forms.
   • If available, an electronic device such as a tablet or laptop can be used for real-time documentation.
4. Documentation:
   • Record the patient’s name, date, and time of the emergency.
   • Document the sequence of events, including:
     • Initial presentation and symptoms
     • Vital signs at regular intervals
     • Medications administered, including doses and times
     • Procedures performed and their outcomes
     • Communications with family members and other healthcare professionals
     • Decisions made and the rationale behind them
5. Communication:
   • The scribe should communicate regularly with the team leader to ensure all critical information is captured accurately.
   • If there are any unclear details, the scribe should seek clarification immediately.
6. Post-Emergency:
   • After the emergency, the scribe should review the documentation with the team leader and other involved staff to ensure accuracy and completeness.
   • The documentation should be added to the patient’s medical record and used for debriefing and quality improvement purposes.

Example Documentation Entry:

14:30: Patient presents with chest pain and shortness of breath. BP 150/90, HR 110, SpO2 92%.
14:32: ECG performed, showing ST elevation in leads V1 and V2.
14:34: Administered 300 mg aspirin orally. Drawn up and labelled 5 mg morphine, administered at 14:36.
14:40: Patient refusing hospital transfer. Discussed risks and benefits. Family notified.
14:50: Vital signs reassessed: BP 145/88, HR 105, SpO2 94%. Repeat ECG normal.

What would your safety-netting approach be in such a situation?

How would you approach the initial consultation if it was made over telehealth?

Safety-Netting Approach

Goals:

To ensure Lila’s safety by providing clear instructions on what to do if her condition worsens, ensuring follow-up, and maintaining communication.

Immediate Safety-Netting Steps:

1. Clear Communication:
   • Explain the Seriousness: Reinforce the seriousness of her condition and the potential risks of refusing hospital treatment.
   • Symptoms to Watch For: Clearly outline which symptoms should prompt immediate medical attention, such as increased chest pain, shortness of breath, fainting, or severe weakness.
2. Written Instructions:
   • Emergency Plan: Provide written instructions on what to do if her symptoms worsen, including calling emergency services and the nearest hospital’s contact information.
   • Symptom Checklist: Give a checklist of warning signs to watch for and the actions to take.
3. Contact Information:
   • Emergency Contacts: Ensure Lila and her family have the clinic’s contact information and the emergency number for immediate assistance.
   • Follow-Up Appointment: Schedule a follow-up appointment within 24-48 hours to reassess her condition and reinforce the importance of further evaluation.
4. Support System:
   • Involve Family or Friends: Ensure her family or friends understand the situation and can help monitor her condition and encourage her to seek help if needed.
   • Community Health Workers: If applicable, engage community health workers to check on her and provide additional support and education.
5. Documentation:
   • Document the safety-netting measures discussed, including all advice given and follow-up arrangements.

Safety-Netting Summary:

• Provide written and verbal instructions on symptoms and actions to take.
• Ensure clear communication channels with the clinic and emergency services.
• Schedule and document follow-up appointments and involve support systems.

Approach for Initial Consultation Over Telehealth

Goals:

To effectively assess Lila’s condition, provide immediate management advice, and ensure appropriate follow-up through telehealth.

Steps:

1. Establish Connection:
   • Ensure a reliable and private connection for the telehealth consultation.
   • Verify Lila’s identity and confirm her contact information and current location in case of emergency.
2. History Taking:
   • Detailed History: Ask about the onset, duration, and characteristics of her epigastric pain, any associated symptoms (nausea, sweating, shortness of breath), and any recent changes in health or medication.
   • Past Medical History: Review her history of type 2 diabetes, hypertension, and any previous cardiovascular or gastrointestinal issues.
   • Medication Review: Ask about all current medications, including over-the-counter and herbal supplements.
3. Visual Assessment:
   • Visual Examination: Ask Lila to show her face and upper body via the camera. Assess for pallor, diaphoresis, or any visible distress.
   • Guided Self-Examination: Instruct Lila on how to palpate her abdomen and describe any tenderness or pain accurately.
4. Immediate Management:
   • Symptom Management: Advise on the use of any available medications that can provide immediate relief, such as antacids for suspected GERD.
   • Emergency Symptoms: Emphasize the importance of seeking immediate medical help if she experiences severe symptoms, such as chest pain radiating to the arm or jaw, severe shortness of breath, or fainting.
5. Referral and Follow-Up:
   • Urgent Referral: Strongly advise a visit to the nearest emergency department if her symptoms are severe or suggestive of ACS.
   • Follow-Up Plan: Arrange an in-person follow-up consultation at the clinic as soon as possible, ideally within 24-48 hours.
6. Safety-Netting:
   • Emergency Plan: Provide clear instructions on what to do if her symptoms worsen before the follow-up visit, including contacting emergency services.
   • Contact Details: Ensure she has the clinic’s contact information and understands how to reach out if needed.
7. Documentation:
   • Document the telehealth consultation thoroughly, including all advice given, medications recommended, and follow-up arrangements.

Additional Considerations for Telehealth:

• Use of Technology: Utilize telehealth platforms that allow for secure video calls, document sharing, and e-prescribing if necessary.
• Patient Education: Provide electronic resources or links to reputable websites for additional information about her condition and management.

Do you feel confident in identifying and managing a deteriorating patient or a cardiac arrest in the clinic’s treatment room?

If not, what extra training could you undertake?

As a healthcare provider, it is crucial to regularly assess and update your skills and knowledge to confidently manage deteriorating patients and cardiac arrests. It is essential to have up-to-date training in emergency protocols and regularly practice these skills.

General Steps for Managing a Deteriorating Patient

1. Early Recognition:
   • Monitor Vital Signs: Regularly check and document vital signs (BP, HR, RR, SpO2, temperature).
   • Observe Symptoms: Look for signs of clinical deterioration such as increased breathlessness, chest pain, confusion, agitation, or decreased consciousness.
2. ABCDE Approach:
   • A – Airway: Ensure the airway is clear. Look for any obstructions or signs of airway compromise.
   • B – Breathing: Assess breathing rate, depth, and effort. Administer oxygen if needed and consider non-invasive ventilation if appropriate.
   • C – Circulation: Check pulse, blood pressure, and capillary refill time. Start IV access and provide fluids if indicated.
   • D – Disability: Assess neurological status using the AVPU scale (Alert, Voice, Pain, Unresponsive) or GCS (Glasgow Coma Scale).
   • E – Exposure: Fully expose the patient to identify any other signs of deterioration or injury while maintaining dignity and warmth.
3. Immediate Interventions:
   • Administer necessary medications (e.g., nitroglycerin for chest pain, glucose for hypoglycemia).
   • Use appropriate interventions such as oxygen therapy, IV fluids, or calling for immediate help.
4. Escalation:
   • Call emergency services (000 in Australia) if the patient continues to deteriorate or if you suspect a life-threatening condition.
   • Prepare for potential transfer to a higher level of care.

Guidelines for Managing Cardiac Arrest

1. Immediate Recognition and Call for Help:
   • Recognize signs of cardiac arrest (unresponsiveness, no normal breathing, no signs of circulation).
   • Call for help immediately, alerting clinic staff and emergency services (000 in Australia).
2. Start CPR:
   • Chest Compressions: Start chest compressions at a rate of 100-120 per minute and a depth of at least 5 cm (2 inches) for adults. Allow complete chest recoil after each compression.
   • Rescue Breaths: If trained and able, provide rescue breaths at a ratio of 30 compressions to 2 breaths. If not trained or unable, perform compression-only CPR.
3. Use an AED (Automated External Defibrillator):
   • Attach the AED as soon as it is available. Follow the AED prompts to analyze the heart rhythm and deliver a shock if indicated.
4. Continue CPR:
   • Continue CPR cycles (30:2) with minimal interruptions. Reassess rhythm and check for signs of life every 2 minutes or as directed by the AED.
5. Advanced Life Support:
   • If advanced life support (ALS) trained, integrate advanced interventions such as securing an airway, providing advanced medications (e.g., epinephrine), and performing advanced cardiac monitoring.
6. Transfer to Hospital:
   • Once the patient is stabilized or if ROSC (Return of Spontaneous Circulation) is achieved, transfer the patient to the nearest hospital for further management.

Extra Training Opportunities

1. Advanced Life Support (ALS) Courses:
   • Enroll in ALS courses provided by the Australian Resuscitation Council or equivalent organizations.
2. Basic Life Support (BLS) Certification:
   • Regularly renew your BLS certification and ensure all clinic staff are certified.
3. Simulation Training:
   • Participate in simulation training to practice managing emergencies in a controlled, realistic environment.
4. Continuing Medical Education (CME):
   • Attend CME workshops and seminars focused on emergency medicine and acute care.
5. Team Training:
   • Engage in team-based training exercises to improve coordination and communication during emergencies.
6. Online Resources and Courses:
   • Utilize online resources, such as those offered by the ARC, for up-to-date guidelines and training modules.