Read an Excerpt
CSA Practice Cases for the MRCGP
By Prashini Naidoo, Sonali Bapat Scion Publishing Limited
Copyright © 2016 Scion Publishing Limited
All rights reserved.
ISBN: 978-1-911510-02-4
CHAPTER 1
CASE 1 Fazeela Amir
INFORMATION FOR THE PATIENT
You are Fazeela Amir, a 52-year-old primary school teaching assistant. You have come to see the doctor to discuss your diabetic medication over Ramadan. You started taking gliclazide earlier this year. The follow-up blood tests showed that it was controlling your blood sugars well. A friend told you that the dose of your medication may need to be changed over Ramadan, so you've come to see the doctor for advice.
You are a devout Muslim. You observe Ramadan and fast from sunrise to sunset – during this time you will not eat food or take any fluids. You have not fasted when you were pregnant, but made the days up later in the year.
You have changed the type of food you cook. You used to cook food with higher fat and sugar but since your diabetes and your husband's cholesterol problems, you use less oil and less sugar. You have started to use more nuts, low calorie sweeteners and fruit in your baking.
You do gentle exercise, usually a 30 minute walk every day. You'd like to continue with your walking and think that it may be best to do the walking after the evening meal (iftar).
You present to the doctor expecting to discuss the changes you should make to your medication over Ramadan. It has not occurred to you not to fast.
Information to reveal if asked
General information about yourself:
• You work as a primary school teaching assistant. You enjoy the work. It is not a physically demanding job.
• You tend to cook most of your meals from scratch. You occasionally eat out. Over Ramadan, you intend to eat at home. Either you or a family member will do the cooking.
• You eat meat and vegetables. You prefer savoury fried snacks and your husband has a sweet tooth. However, Ramadan for you is about abstention and sacrifice, so you tend to cook plain and wholesome food over this period.
• You have never smoked tobacco and do not drink alcohol.
Further details about your condition:
• You have been diabetic for five years, initially diet controlled. Last year, you took your metformin as usual and continued with your fast.
• One of the Muslim teachers at the school said she didn't know if you could take your medication and still fast; her father had to change his insulin injections at Ramadan.
Your ideas:
• You do not see your diabetes as an illness that prevents you from fasting. You also don't see how fasting could be damaging to your health. You think that you make too little hormone to move the sugar you eat around your body, so if you fast, you have less sugar which is better for your health.
• Most of the diabetic Muslims you know fast. The only ones who do not fast are people who are very sick, pregnant or in hospital.
• Over the years, you have tended to maintain your weight during Ramadan. Your husband loses a bit of weight but he soon puts it on after the fast with Eid.
• You are prepared to take tablets with the morning and evening meal; luckily nothing is needed during the fasting hours. You want to continue with your exercise.
• You do not like testing your blood sugars. If asked to test blood glucose regularly, you seem a bit daunted. You are not sure if this is allowed during the fast.
Your concerns:
• You are worried about being advised against fasting. You are worried that the doctor may not understand your religious beliefs nor recognise how important this is to you.
Your expectations:
• You expect to get information about whether you need to change your diabetes medication over the fast.
Medical history
• You consider yourself to be healthy. You do not currently have any side-effects from your current medication.
Social history
• You are happily married. One child is at University studying psychology and one is working overseas.
• You enjoy your current social life.
Information to reveal if examined
If the doctor asks to do your blood pressure, hand him/her a card saying "BP 130/80".
SUGGESTED APPROACH TO THE CONSULTATION
Targeted history taking:
• Obtain details of the fast. When and what will she eat? When and how much will she drink? What exercise will she undertake?
• How does she normally take her medication?
• How does she see her diabetes affecting or being affected by the fast (her ideas)?
• How well controlled is Fazeela's diabetes? It is important to stratify Fazeela's risk over Ramadan into high, moderate or low risk. Has she had any hypoglycaemic episodes, especially in the last three months? Does she have any acute illness? Is she prone to catching minor illness at work? Does she do heavy physical activity with her job or in her leisure time?
• What are her concerns? Is she worried about the dose and timing of medication over Ramadan? Is she worried about doing more blood sugar monitoring?
• What are her expectations? Does she expect specific dietary and exercise advice; medication changes; referral to Diabetes specialist clinics or follow-up bloods after Ramadan?
• Is she prepared to change her medication?
Targeted examination:
• This case does not require the candidate to perform a targeted physical examination.
Clinical management:
• Having stratified her into a moderate risk category (she is on a sulphonylurea), build on her existing idea that she is perfectly capable of fasting but there are certain times when it is important to be sensible and not fast, such as if she becomes unwell with an acute illness, or develops symptoms of dehydration, hypo- or hyperglycaemia.
• Discuss the timing and size of meals. If she is having a smaller meal (one-third of her calories) before sunrise and a larger meal (two-thirds of her calories) after sunset, then she could continue metformin 850mg bd, atorvastatin 20mg at night but reduce gliclazide to 40mg in the morning and stay on gliclazide 80mg at night.
• Despite the reduced dose of sulphonylurea, if her BG drops below 3.9 or goes above 16.7mmol/L, you would advise her to break her fast. The chances of such swings in BG are further reduced by following a healthy diet. Reassure her that BG monitoring during fasting is not considered as breaking one's fast. BG need only be undertaken if she suspects a low glucose or feels unwell.
• Discuss diet: she intends to have a 'wholesome' diet, which is entirely appropriate. Complex carbohydrates (beans, rice, lentils) and high fibre foods (wholegrain bread, vegetables, salads, nuts, dates) should be baked or grilled rather than cooked with saturated fats, or if shallow frying or making curry, use olive oil rather than ghee. She is quite correct to avoid Indian sweets (mithai). It may be better to avoid coffee which encourages diuresis and hydrate with other fluids instead.
• Discuss exercise: doing 30 minutes of walking after the larger evening meal is entirely appropriate.
• Address the patient's concerns about being advised not to fast. Fazeela is being proactive and seeking advice early. If she puts small changes in place, her risk of being unwell during Ramadan is reduced. However, if she does become unwell despite her best efforts, especially if BG is <3.9 or >16.7mmol/L, then she should really consider breaking her fast and perhaps do the missed fast days later in the year.
• Address the patient's expectations about medication changes.
• Arrange follow-up, possibly with a repeat HbA1c after Ramadan, to change medication doses back to usual regimes.
Interpersonal skills:
This case tests the doctor's ability to respond sensitively to a patient's request to a change in her diabetic treatment for religious reasons.
Good communication with the patient:
• is sensitive to her beliefs and values.
• explores what the patient wants to achieve and gives tailored advice to help her reach these goals safely.
• involves discussing how to take medication during Ramadan, how to monitor for problems and what to do if problems arise.
Poor communication with the patient:
• makes the patient feel that her beliefs and values are being dismissed without consideration; the doctor seems motivated by his or her own strongly held beliefs.
• recites the advice in a protocol-driven manner; there is little to and fro discussion; the doctor is not seen to build on ideas the patient has offered. Most of the talking, especially in the second half of the consultation, is being done by the doctor.
• displays little or no curiosity in the patient as a person.
BACKGROUND KNOWLEDGE REQUIRED FOR THIS CASE
Gilani, A (2011) Ramadan and your diabetic patient. NHS, Greater Glasgow and Clyde.
http://library.nhsggc.org.uk/mediaAssets/My%20HSD/ 2011-05-31RAMADAN_RESOURCE_PACK.pdf
Those who are considered Islamically exempt from fasting are:
• the frail and elderly
• children
• those who have a chronic condition whereby participating in fasting would be detrimental to their health
• those who cannot understand the purpose of fasting, i.e. those who have learning difficulties or those who suffer from severe mental health problems
• travellers (those travelling greater than 50 miles)
• those acutely unwell
• pregnant and breast-feeding women
* Considered to be temporarily exempt. Fasts must be made up at a later date but if unable to do so then fidyah must be given (fidyah is when those who are considered exempt and do not fast can compensate by giving alms to the poor).
Relevant literature
For an excellent flow chart on how to manage medication, see:
http://sitelife.bmj.com/ver1.0//Content/images/store/13/3/ ad981831-14f2-4c9fb34b-60f6b6544a57.Full.jpg
CHAPTER 2
CASE 2 Christina Whittaker
INFORMATION FOR THE PATIENT
You are Christina Whittaker, a 42-year-old Operating Department Practitioner (ODP), who has come to get a sick note for work.
You saw a GP 4 days ago and were sent to the hospital with an acute abdomen. The ultrasound scan did not show an inflamed appendix; the internal scan showed free fluid and a thickened womb lining. You went on to have a CT scan which showed a small cyst on your adrenal gland, which you were told was an incidental finding but will require a follow-up MRI, for which an appointment will be posted to you. The hospital doctors suspect that you had a ruptured ovarian cyst. They sent you home on analgesia, and said they would send you an appointment for Gynae outpatients to discuss the thickened womb lining and ovarian cysts. You had PCOS in the past, for which you had taken metformin but your symptoms improved and you stopped metformin 4 years ago.
As an ODP, you have some background medical knowledge. You suspect that the PCOS has become symptomatic and one of the cysts ruptured, giving you the severe pain 4 days ago. The pain has eased considerably. You are taking paracetamol during the day, co-codamol at night, regular diclofenac which the hospital supplied, to good effect and without side-effects. You want the GP today to sign you off work for a week. You don't think you can make good decisions while on the medication and you need a bit of time to recover before returning to Orthopaedic theatre work.
You would also like to restart metformin. You used metformin for PCOS for a few years. You don't remember having side-effects. One day you stopped taking it; your symptoms did not recur, so you stayed off the medication and you didn't mind the irregular light periods. You did not get on with the combined pill: you developed migraine, mood swings and put on weight. Your family is complete; you husband has had a vasectomy.
You present to the doctor wishing to discuss your PCOS. Your opening statement is "So, it looks like my polycystic ovaries are playing up again".
Information to reveal if asked
General information about yourself:
• You work at the district general hospital as an ODP.
• You really enjoy your work and feel that as a hospital employee, the consultants treating you there are giving you personalised care.
• Your teenage son and your husband were slightly shocked by your hospital admission, but you only stayed in for one night. Your husband has returned to work.
Further details about your condition:
• If specifically asked, you have never suffered from acne, greasy skin or hirsutism. You have had irregular periods – they tend to be light, lasting only 3–4 days and occurring every 6–8 weeks. You also have difficulty losing weight. You did not have difficulty getting pregnant. You had an uneventful pregnancy. The original diagnosis of PCOS was made on a scan and because you had such irregular periods. You don't remember there being a problem with your blood tests.
• You are an only child. You do not have a family history of PCOS. Your dad has hypertension.
• You do not want to take hormones. You think that you are too old and too overweight to take the Pill. You prefer to take metformin. It worked well for you. You think you ran out of tablets one day and you were supposed to make an appointment to get a repeat prescription but something happened, and before you knew it, 2 months had passed. You felt well during those 2 months and thought that maybe you didn't need treatment with metformin any longer.
Your ideas:
• You think that your acute abdomen could have been a ruptured ovarian cyst because of your PCOS and the free fluid found on the ultrasound scan. You are a little bit worried about the small cyst that the CT discovered on your adrenal gland, but you read up about adrenal cysts on the internet and found that most cysts are benign and even if they are malignant, they tend to be non-functioning adenomas. You also read that a follow-up MRI, which the hospital is scheduling, is a good investigation.
• You have been referred to Gynae to discuss the 'thickened' womb lining. You intend to keep this appointment but if this is all due to PCOS, you'd like to go back on your metformin now.
Your concerns:
• You are worried that the Gynae outpatient appointment may take a few weeks to come through and you'd rather not have another ruptured ovarian cyst while waiting, so you'd like the GP to start the metformin today.
Your expectations:
• You expect a sick note for work and a prescription for metformin.
Medical history
You are in good general health, and are not on long-term medication. You get the occasional migraine, usually stress-related, but taking paracetamol, ibuprofen and lying down tend to help to resolve the attack.
Social history
You are happily married.
You are one of the senior ODPs and you instruct trainee ODPs during their placements in orthopaedic theatre.
Information to reveal if examined
Abdominal examination – soft and slightly tender R lower quadrant.
If the doctor asks to weigh you, hand him/her a card saying "BMI 28".
SUGGESTED APPROACH TO THE CONSULTATION
Targeted history taking:
• What are Christina's symptoms now?
• What is her understanding of her recent illness and the hospital's management plan?
• What are her concerns? Is she worried about the adrenal cyst, the thickened womb lining, the risk of another ovarian cyst rupture?
• What are her expectations: does she want you to interpret the radiology findings for her, obtain a copy of the discharge summary, coordinate her care, order any outstanding investigations, provide a sick note, treat the PCOS prior to her Gynae appointment?
• How was her PCOS originally diagnosed? What are her current symptoms? What are her treatment options?
• What does she already know about PCOS and lifestyle changes (losing weight; reducing carbohydrates and increasing physical activity) to improve insulin resistance?
• Does she have contra-indications to co-cyprindiol or combined hormonal contraception (CHC)?
(Continues...)
Excerpted from CSA Practice Cases for the MRCGP by Prashini Naidoo, Sonali Bapat. Copyright © 2016 Scion Publishing Limited. Excerpted by permission of Scion Publishing Limited.
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