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Linda Nazarko OBE discusses the important of diagnostic decision making in non medical prescribing

Dr Linda Nazarko OBE, Consultant Nurse at Ealing Community Services today discussed the importance of diagnostic decision making in non medical prescribing at todays conference in London.

Linda's slides and excellent reference list are located at the bottom of this page - please scroll down

This presentation will examine the use of advanced history taking, physical examination and clinical reasoning and how that can be utilised to formulate a diagnosis, determine treatment options and when clinically appropriate to treat the patient. It will utilise a patient vignette to illustrate these processes. Please note that a pseudonym has been used and details changed to protect patient confidentiality.

 

Consultation model

 

Consultation models help to structure history taking, physical assessment and therapeutic decision making. There is no one “right model” however I find the Calgary-Cambridge model useful (Kurtz & Silverman, 1996: Kurtz et al, 1998; Silverman et al, 1998). This model has been refined by its author’s over the years (Kurtz et al, 2003). It aims to offer “a practical, evidence -based conceptual framework for enhancing communication in medicine” (Kurtz, 2009: P10).  The enhanced model has moved from medical centred care, to patient centred care to care centred on the therapeutic relationship (Kurtz, 2009).  Developing a therapeutic relationship enables the practitioner to understand the patient’s understanding, beliefs and motivation and to use interventions that engaged patients in their care (Dowell et al, 2002).

 

The importance of history taking

 

History taking enables the practitioner to obtain subjective data relating to the presenting problem and other health issues (Bickley & Szilagyl, 2013 PP6-13). In certain circumstances, such as when a person has limited English, has cognitive impairment or language difficulties the person can be considered “vulnerable” and in such circumstances it is important to obtain collateral history (Culo, 2011). The Royal College of Physicians (2012a) also stress the importance of obtaining collateral history in relation to falls.

Epstein and colleagues (2008, P: 1) state that over 80 percent of diagnoses are made solely on the basis of history. Sometimes though this is not the case as the patient vignette below illustrates.

 

Patient vignette

 

Mrs Al Badawi: “fit and well” and “in good health” “tripped while making tea”. Never fallen before, hasn’t been to hospital in years and wants to go home as soon as possible. However on further questioning reports pain her lower back “had it all my life” buts its worse at present following the fall. Patient points to outer aspect of right side of rib cage. Pain does not radiate, is made worse by twisting to the left or turning over in bed, eased by sitting up or lying down. Dizzy “for the last few years”.  Then reports that she’s felt tired and unsteady “for the last few years”. Tries to get lots of sleep but can’t seem to get enough sleep to stop the tiredness. She then reports that she has arthritis of the knees but has never seen a doctor about this as she considers it normal for her age. She then reports that she has had a cholecystectomy many years ago, has hypertension and type two diabetes (diet controlled).

 

Medication history

 

In Mrs Al Badawi’s case she is prescribed Amlodipine 10mg OM, Paracetamol 500mg two tablets QDS, Zopiclone 3.75mg two tablets nocte. Over the counter medication were movilat gel (as required) to knees. Nytol two 25mg tablets every night (to help with sleep). The active ingredient is diphenhydramine hydrochloride, a sedative antihistamine (NHS Choices, 2015)

 

Social history

Social history is important, it enables us to view a person holistically, to get a sense of who the person is, what ability and limitations the person has and the level of support the person receives from family and friends.

Mrs Al Badawi came to the UK in 1975 and raised her family. She has never worked outside the home. She speaks only a few words of English.  She lives in her own home, a three bed roomed house but divides her time between England, Canada and the US. Mrs Al Badawi stays with her daughters in York, New York and Montreal for at least six months a year. When she is resident in London her son takes her shopping once a week and her daughter in law takes her to the hairdressers once a week. She is independent with ADLs and is a good cook.

 

Physical examination

 

Physical examination aims to provide objective data that complements the history (Bickley & Szilagyl, 2013 PP13-23). Over 80 percent of diagnoses are made solely on the basis of history (Epstein et al,2008). Physical examination can validate a differential diagnosis made when taking the history or raise questions that lead to the practitioner re-checking the history with the patient or obtaining further collateral history.

 

Nailing the diagnosis

 

The Calgary Cambridge model refers to this process as “explanation and planning”. This involves putting together information obtained from the history, physical examination and the results of any tests to formulate a diagnosis.  Figure one outlines the process.

Figure one: Formulating the diagnosis

 

In some cases the practitioner will have a single diagnosis and a single treatment measure.  In other cases treating the patient will consist of dealing with a series of interlocking pieces.

 

Therapeutic decision making and treatment options

 

Therapeutic decision making and treatment options are patient specific.  They must be tailored to the individual patient and the patient should be fully involved in this process. In Mrs Al Badawi’s case history taking and physical examination have yielded clinical findings. Let’s explore the implications of clinical findings, red flags and identify any further required information and tests. The clinical findings were

1.Arcus senilis

2.Bilateral carotid thrill and bruits and reported history of 60 percent carotid artery stenosis

3. Tenderness on percussion 11th intercostal space posterior chest right side no bruising or abrasions noted.

4. Concurrent use of prescribed and over the counter night sedation.

 

History taking, physical examination and discussion with Mrs Al Badawi and her family enable us to work together to formulate a plan of care. This is a team effort and consists of the following actions:

 

  1. Check if recent lipid levels are available if not check lipid profile (NICE, 2014c).
  2. Establish her current level of diabetic control by checking HB1Ac (NICE, 2008),
  3. Obtain details of carotid dopplers and letter relating to this from GP
  4. Review chest x-ray.  Ask physiotherapist to assess and we will develop treatment plan.
  5. Discontinue use of Nytol, reduce zopiclone to 3.75mg nocte. Consult with pharmacist and GP to tail off zopiclone whilst avoiding withdrawal.
  6. Sleep diary to determine quantity, quality and character of sleep. This will enable development of sleep hygiene measures.
  7. Lying and standing blood pressure x 8 readings to check for possible postural hypotension (RCP, 2012a).
  8. Neurological observations 48 hours as mandated by (RCP, 2012a) and hospital policy, in case of late onset neurological problems e.g. subdural haematoma.
  9. MDT falls risk assessment including physiotherapy to improve balance, gait and confidence, occupational therapy assessment.
  10. Occupational therapist to carry out home visit to identify and modify any identified modifiable environmental risks (Gillespie et al, 2012).
  11. Ongoing therapy on discharge to further improve mobility.
  12. Medication passport giving details of prescribed medication and indications on discharge and education relating to medication. Pharmacist to arrange

 

 

Forward planning and closing the session

 

Following history taking and physical assessment the next steps are to communicate with the patient and the MDT team. Mrs Al Badawi wishes to regain mobility and confidence so that she can visit her daughter in Canada next month. She would like to feel less tired and was unaware that her medicines could be making her more tired and prone to falls. I explained to Mrs Al Badawi that my findings suggest that the medicines she is taking in an effort to fell less exhausted are actually making her feel more tired and increasing her risk of falls.I also explain that I wish to discuss her treatment with her GP as she may require blood thinning (anti-platelet) and cholesterol reducing medicines. I explain that we would like to discover if there is anything else we can do to cut the risk of falls.She consents to further investigations and treatment including changes to medication.

 

This case history illustrates the importance of careful history taking including ascertaining all medications taken, thorough assessment, medication review and communication with the patient and healthcare professionals involved in her care.

When to treat and when to refer

Nurses, like their medical colleagues, should refer patients if the care the patient requires is outside their ability.  If in doubt the nurse should heed the advice of medical colleagues such as Dr Lasanga (1964)

 “I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery”.

 

How to work with others to enhance care

Many people requiring healthcare are old and have complex conditions.  In many cases the older person requires the skills of a team rather than one person.  Team members can come from a range of disciplines including physiotherapy, pharmacy and occupational therapy. Building strong teams can and does make a huge difference to outcomes.

 

 

References

American  Geriatrics Society (2012)  American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society. New York

http://www.guideline.gov/content.aspx?id=37706

http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf

Accessed 17th May 2015

Bickley, LS, Szilagyl, PG (2013) Bates’ guide to Physical Examination and History Taking. 12th edn. Lippincott Williams & Wilkins, Philadelphia.

 

British National Formulary (BNF) (2014). BNF 68: September 2014-March 2015. British Medical Association and Royal Pharmaceutical Society, London.

Chua BE, Mitchell P, Wang JJ, Rochtchina E (2004). Corneal arcus and hyperlipidemia: findings from an older population. Am J Ophthalmol. 137:363–365.

Culo S (2011). Risk assessment and intervention for vulnerable older adults BCMJ: 53:8: 421-425.

http://www.bcmj.org/articles/risk-assessment-and-intervention-vulnerable-older-adults

Accessed 17th May 2015

Dowell J, Jones A, Snadden D (2002). Exploring medication use to seek concordance with 'non-adherent' patients: a qualitative study. British Journal of General Practice. 52: 24-32.

http://bjgp.org/content/bjgp/52/474/24.full.pdf

Accessed 17th May 2015

Electronic Medicines Compendium (eMC) (2013). Nytol Original 25mg Tablets. eMC, Surrey.

https://www.medicines.org.uk/emc/medicine/14222

Accessed 17th May 2015

Electronic Medicines Compendium (eMC) (2014a). Zopiclone 7.5mg Tablets eMC, Surrey.

https://www.medicines.org.uk/emc/medicine/26364/SPC/Zopiclone+7.5mg+Tablets/

Accessed 17th May 2015

Electronic Medicines Compendium (eMC) (2014b). Nytol Original 25mg Tablets. eMC, Surrey.

https://www.medicines.org.uk/emc/medicine/14222

Accessed 17th May 2015

Electronic Medicines Compendium (eMC) (2015). Zopiclone 7.5mg Tablets. eMC, Surrey.

https://www.medicines.org.uk/emc/history/26364

Accessed 17th May 2015

Epstein O, Perkin D, Cookson J, Watt IS, Rakhit R, Robins AW, Hornett GAW (2008).  Clinical Examination: With STUDENT CONSULT Access.  4e Mosby Elsevier Philadelphia.

Fernandez A, Sorokin A, Thompson PD (2007). Corneal arcus as coronary artery disease risk factor. Atherosclerosis. 193:235–240.

Fernandez AB, Keyes MJ, Pencina M, et al (2009). Relation of corneal arcus to cardiovascular disease (from the Framingham Heart Study Data Set). The American Journal of Cardiology. 103:64-66.

Gray SL, Anderson ML, Dublin S, Hanlon JT, Hubbard R, Walker R, Yu O, Crane PK, Larson EB (2015) . Cumulative Use of Strong Anticholinergics and Incident Dementia: A Prospective Cohort Study. JAMA Intern Med. 7663. [Epub ahead of print]

http://archinte.jamanetwork.com/article.aspx?articleid=2091745

Accessed 17th May 2015

Health and Social Care Information Centre (2015). National Diabetes Audit 2012-2013 Report 2: Complications and Mortality Findings about the quality of care for people with diabetes in England and Wales Report for the audit period 2012-2013. Health and Social Care Information Centre, Leeds.

http://www.diabetes.org.uk/Upload/NDA%20Report%202%20Complications%20and%20Mortality%20Audit_interactive.pdf

Accessed 17th May 2015

Johansson EP, Wester P (2008). Carotid bruits as predictor for carotid stenoses detected by ultrasonography: an observational study. BMC Neurol. 8:23

http://www.biomedcentral.com/1471-2377/8/23

Accessed 17th May 2015

Kurtz S & Silverman J (1996). The Calgary-Cambridge Observation Guides: an aid to defining the curriculum and organising the teaching in Communication Training Programmes. Med Education 30: 83-89

Kurtz SM, Silverman JD, Draper J (1998). Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press (Oxford)

Kurtz S, Silverman J, Benson J, Draper J (2003). Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides Academic Medicine. 78:8:802-809

http://www.ncbi.nlm.nih.gov/pubmed/12915371

Accessed 17th May 2015

Kurtz S (2009). Raising the Bar on Clinical Communication in Medicine. Frontiers in Medical and Health Sciences Education Conference, Hong Kong

http://www.med.hku.hk/fme2009/Powerpoint_Prof%20Suzanne%20Kurtz.pdf

Accessed 17th May 2015

Lanzino, G., Rabinstein, A. A., & Brown, R. D. (2009). Treatment of Carotid Artery Stenosis: Medical Therapy, Surgery, or Stenting? Mayo Clinic Proceedings, 84(4), 362–368

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2665982/

Accessed 17th May 2015

Lasagna L (1964) A doctor’s oath. Tufts University, US. http://www.pbs.org/wgbh/nova/doctors/oath_modern.html

(Accessed 25th August 2014)

Nasreddine Z., Phillips N., Bédirian V., Charbonneau S., Whitehead V., Collin I., et al. (2005) The Montreal Cognitive Assessment (MoCA): a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53: 695–699.

Nasreddine Z (2013). MoCA.

http://www.mocatest.org/

Accessed 17th May 2015

NHS Choices (2015). Nytol. NHS Choices.

http://www.nhs.uk/medicine-guides/pages/MedicineOverview.aspx?medicine=Nytol

Accessed 17th May 2015

National Institute for Health and Care Excellence (NICE), (2009). Type 2 diabetes: The management of type 2 diabetes NICE guidelines CG87. NICE, London.

http://www.nice.org.uk/guidance/CG87

Accessed 17th May 2015

National Institute for Health and Care Excellence (NICE) guideline (2014a). Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE, London.

http://www.nice.org.uk/guidance/cg181/resources/guidance-lipid-modification-cardiovascular-risk-assessment-and-the-modification-of-blood-lipids-for-the-primary-and-secondary-prevention-of-cardiovascular-disease-pdf

Accessed 17th May 2015

Pickett CA, Jackson JL, Hemann BA, Atwood JE (2008). Carotid bruits as a prognostic indicator of cardiovascular death and myocardial infarction: a meta-analysis. Lancet 371(9624):1587-1594

Royal College of Physicians (2012a). Falls safe. RCP, London

http://www.rcplondon.ac.uk/projects/fallsafe-care-bundle

Accessed 17th May 2015

Royal College of Physicians, (2012b) Intercollegiate Stroke Working Party. National clinical guideline for stroke, 4th edition. Royal College of Physicians, London.

https://www.rcplondon.ac.uk/sites/default/files/national-clinical-guidelines-for-stroke-fourth-edition_0.pdf

Accessed 17th May 2015

Rubenstein LZ (2006) Falls in older people: epidemiology, risk factors and strategies for prevention Age and Ageing: 35-S2: ii37–ii41

http://www.fondazionemadrecabrini.org/Portals/63/Documenti/Prevention%20strategy.pdf

Accessed 17th May 2015

Silverman JD, Kurtz SM, Draper J (1998). Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)

Future conferences of interest:

Reducing Medication Errors
Wednesday 1 July 2015
Manchester Conference Centre, Manchester

Medicines Optimisation: Ensuring the safe and effective use of medicines
Monday 21 September 2015
Hallam Conference Centre, London

Non-Medical Prescribing for Pain
Tuesday 22 September 2015
Hallam Conference Centre, London

Electronic Prescribing In Hospitals: Moving Forward
Tuesday 6 October 2015
Colmore Conference Centre, Birmingham


Download: Linda Nazarko Presentation

2 June 2015

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