Embedded Files
FM & PH – COPD
In module Family Medicine and Public Health
This case follows 76-year-old Mrs Baker and her home visit by the locum GP Dr Murray.
MAIN CASE
Further Case Information – COPD
Guidance and Resources – COPD
In case FM & PH – COPD
Learning Resources
Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.
You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.
Recommended essential reading
· The Saudi Guidelines for the Diagnosis and Management of COPD
· You have previously looked in detail at COPD case of year 4.
· chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-pdf-66141600098245
· Antimicrobial resistance: WHO fact sheets: Problem overview: http://www.who.int/en/news-room/fact-sheets/detail/antimicrobial-resistance
· Prevention and control: http://www.who.int/en/news-room/fact-sheets/detail/antibiotic-resistance
· GOLD_SlideSet_2019_v3-14Nov2018
PCC
· Year 4 PCC sharing information with patients and their carers
· Duties of a Doctor as set out by the GMC
· Guidelines regarding consent and shared decision making
Additional Resources
· NHS Choices: The Antibiotic Awareness Campaign
· 3 minute video by the National Center for Smoking Cessation and Training about how GPs can take 30 seconds to ask and give advice about smoking cessation
· Antimicrobial resistance:Situation in KSA: http://extwprlegs1.fao.org/docs/pdf/sau171813.pdf
· SINA_Easy_Asthma_Flowcharts_ Adult_2016
· COPD Assessment Test CAT English
· الكتيب التعريفي عن برنامج الطب المنزلي (1)
CASE COMPONENT
Case Introduction – COPD
In case FM & PH – COPD
Dr Murray is a locum GP working for the first time at a practice in Stockport. After the morning surgery Dr Imrye, a partner at the practice comes in to discuss the morning’s patients and divide up the paperwork and home visits for the lunch time period.
“I’m happy to do all the scripts, scanning and urgent tasks if you could go to see Mrs Baker who needs a visit. She’s on the home visit list on the computer”
IN PRACTICE:
Have a think about the paperwork that a GP practice has to do daily. What different things have to be done? How are these divided up within your practice? How is the computer used to help in this? Each practice divides up these tasks in a different way; do you think the way it is done at your practice is fair to everyone?
When Dr Murray looks on the computer he sees that Mrs Baker is a 76 year old lady diagnosed with COPD. The duty doctor has already rung the patient and the entry states “Called by carers who are concerned re SOB, lives on own, daughter lives in Plymouth requesting update after, key safe code 1234”
IN PRACTICE:
Have a think about home visits at your practice. How do patients request them? Who, if anyone triages the requests? Who decides who gets a home visit and which doctor attends? Do you think that this is a good system? What are the pros and cons of a locum doing this visit today?
What might Dr Murray want to check in the computer notes before he left to see this patient and why?
Please see your Prescribing skills handbook 1 for further information.
Most of this information will be present on the patient record and may be available as a Transfer of Care record or Patient Summary. You have learnt about this in Week 3 of the GP block when you met Mrs Hall.
Dr Murray notes that Mrs Baker currently smokes 5 cigarettes per day. She has cut down to this amount for the past 12 months, after smoking cessation advice from the GP and then support from the practice nurse.
Here is a useful 3 minute video by the National Center for Smoking Cessation and Training about how GPs can take 30 seconds to help a patient stop smoking
In week 2 of the GP Block you met Brian, who was offered cardio-protective lifestyle and diet advice. You can revise dual processing which you cover in Semester 1, Year 1 and the Lifestyle Change Communication package around lifestyle behaviour change.
Mrs Baker has previously smoked about 20 per day since the age of 15. She has no recent hospital admissions. Her last oxygen oxygen saturations were 95%, recorded 12 months ago when she attended to see the nurse for smoking cessation support.
IN PRACTICE:
You might have already seen lifestyle advice being given. If you haven’t already, try to see a healthcare professional give smoking cessation advice. You might even have dedicated smoking cessation clinics which you might be able to attend. Reflect on how the advice has been received by different patients over the course of your placement.
How many ‘smoking pack years’ has Mrs Baker smoked for (to nearest whole pack)?
· 20
· 35
· 50
· 60
· 75
· 80
· 60
.Correct answer.
Smoking pack years = number of packs of cigarettes smoked per day (based on 20 cigarretes per pack) x years the person smoked that number of cigarettes.
So, in this case, Mrs Baker has smoked 20 cigarettes per day (= 1 pack) from age 15 to age 75 (=60 years). She is 76 now and smoked 5 cigarretes per day ( = quarter of a pack) for the past 1 year.
Therefore, for this case, smoking pack years = (1 x 60) + (0.25 x1) = 60.25 = 60 to nearest pack year.
Further Case Information – COPD
In case FM & PH – COPD
When Dr Murray arrives, having let himself in with the key from the key safe as instructed, he finds Mrs Baker in her bed and is immediately concerned. Before he has even started to take a history from Mrs Baker, he notices:
· Unkempt environment
· Patient confined to bed
· Short of breath at rest
· Use of accessory muscles / gripping the chair / leaning forward
· Empty inhalers around
· Audible wheezing from some distance
· Purse lipped breathing
Between gasps Mrs Baker tells him that she started her rescue pack 3 days ago and ‘feels no better’. She has pursed lip breathing and oxygen saturations of 92%. She has been unable to get out of bed for the past day due to her breathlessness.
What is a Rescue Pack?
A rescue pack, also known as ‘rescue medicaiton’ is a supply of steroids to be started if the person with COPD notices increased shortness of breath affecting their activities of daily living (ADLs), or antibiotics if they have more or discoloured sputum.
The person should be advised to seek medical attention if they start, or are unsure if they should start, medication and should have written information about this.
An example of information given to a patient with ‘rescue medication’
After a thorough history and examination confirms his first impression that Mrs Baker is having an exerbation of her COPD and thinks she would benefit from hospital admission.
According to the American Thoracic Society (ATS) and European Respiratory Society (ERS) COPD exacerbations can be divided into:
Before Dr Murray can discuss his assessment with Mrs Baker, she suddenly says ‘I hope you’re not going to tell me I need to go up to that hospital’.
Dr Murray will need to be aware of the patient’s rights to make a decision, assuming he or she has the information and help they need to make the decision and has capacity, even if this choice is different to that of the doctor, and even if the doctor considers that the patient’s decision may put them at risk.
GMC: Consent guidance: Presumption of capacity
You have had a reminder about capacity in Week 2 of this block and in week 3 case of Acute Confusion.
Part of what we do as doctors every day is explaining potential risks and benefits honestly of certain actions to patients. This is part of forming partnerships with patients. You have come across this during Week 2 of the GP block, and here is another example. You can remind yourself here of GMC guidelines.
This is also in agreement with your ‘Duties of a Doctor’ as set out by the GMC
Dr Murray starts by asking Mrs Murray why she has said what she has. He hopes to discover her perspective, and her ideas, concerns and expectations. This is an important step in ‘breaking bad news’ strategy and sharing information with patients, which you have come across during Year 4 PCC sessions and in Week 2 of this GP Block.
Mrs Baker answers with ‘you end up coming out of that hospital in a box’.
Dr Murray tries to encourage Mrs Baker to talk more about her thoughts behind this statement, but she is quiet and seems not to want to expand on it. Dr Murray outlines the benefits and risks of the treatment options. Mrs Baker is active in this discussion, but then is quiet and looks thoughtful.
Dr Murray notices her looking over to some photographs. He asks her about them and she becomes quite animated talking about her life as an actress and her husband John.
When he asks about John, Mrs Baker explains that he died 10 months ago in the local hospital on the stroke ward.
Mrs Baker admits that she is worried that if she goes into hospital, she will end up on the stroke unit, where her husband died. However, she knew even before Dr Murray visited that she would be better off in hospital as she is ‘struggling too much this time’.
Mrs Baker sits and is quiet for a few moments, and then surprises Dr Murray by saying ‘And John would say I’m being a silly fool’. She smiles, and asks Dr Murray to arrange the ambulance for admission. Dr Murray is satisfied that she has capacity to make this decision. Mrs Baker also asks if Dr Murray could update her daughter who lives in Plymouth about her admission, which Dr Murray does whilst with Mrs Baker, who is also involved with this conversation.
CASE COMPONENT
Background Science – COPD
In case FM & PH – COPD
Full guidelines relating to COPD can be found here:
NICE: Chronic obstructive pulmonary disease in over 16s: diagnosis and management
You have previously looked in detail at COPD case.
In Year 5 infectious diseases you will also have/have had chance to prescribe different antibiotics for different organisms.
Antibiotic Resistance
You can remind yourself of this topic on antibiotics and their appropriate use and stewardship.
GPs will often prescribe an antibiotic based on local antibiotic guidelines. This aims to help reduce the risk of antibiotic resistance.
Since antibiotics have been used more and more over this this century, some bacteria have been adapting and finding ways to survive against them. This means that some antibiotics are losing their effectiveness, as bacteria become ‘resistant’.
To slow down the development of antibiotic resistance, GPs (like all other healthcare professionals) try to only use antibiotics appropriately. This means using the right drug, at the right dose, for the right patient, at the right time and for the right duration. To help with that, GPs refer to ‘antibiotic prescribing policies’ which guide use within a locality. The issue of antibiotic resistance has prescribing implications at an individual, national and global level.
You can find out more about antibiotic resistance at:
· NICE Choices: The Antibiotic Awareness Campaign
IN PRACTICE:
Ask if your GP can show you their local prescribing guidelines documents or direct you to a web link.
You have had a session in PCC in Year 4 about ‘how’ we have these difficult conversation with patients, in relation to best practice limiting patient choice and the ethical issues surrounding this. Reflect back on this and the communication strategies for how this is achieved which you practiced with a simulated patient.
Primary Prevention
Smoking cessation is an example of primary prevention. If you would like to revise the different types and definitions they are well summarised here by the institute of work and health.
This article is also helpful in the context of prevention of chronic respiratory disease.
CASE COMPONENT
Case Conclusion – COPD
Case Conclusion – COPD
In case FM & PH – COPD
After handing over care to the Paramedic, Dr Murray returns to the GP Practice to write up the notes on the computer. Dr Murray also discusses the case with Dr Imrye, ensuring it is safety handed over to her own GP. Dr Murray later reflects on the case in his portfolio, about how to ensure that patients have the correct information on which to base their decisions.
A week later, Mrs Baker is out of hospital, having been admitted to the respiratory ward (noCASE COMPONENT
Formative Assessment – COPD
A COPD ‘rescue pack’ is prescribed by a GP:
· For all patients who want one
· For patients diagnosed and closely monitored with COPD, identified by their GP as being able to benefit from prompt use of steroids and/or antibiotics
· For any patients who have difficulty getting to the GP practice
· For any patient with a family history of COPD
· For patients diagnosed and closely monitored with COPD, identified by their GP as being able to benefit from prompt use of steroids and/or antibiotics
.Correct answer.
A patient who has smoked 30 cigarettes a day for the last 10 years has a smoking history of:
· 10 pack years
· 15 pack years
· 20 pack years
· 30 pack years
· 40 pack years
· 15 pack years
.Correct answer.
See above for how to calculate: number of packets of cigarretes per day (based on 20 cigarrettes per pack) x number of years smoked them for. Here, smoking pack years = (30 ÷ 20) x 10 = 15.
You must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment.
True
False
This is true. The GMC states: ‘You must only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes’.
GMC Consent guidance: Presumption of capacity
t the stroke unit) and determined to give up smoking.
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