Who you are:
You are an F2 working in GP clinic.Who the patient is:
Angel Di Maria aged, 55, presented to you for his first follow-up. Patient has diabetes mellitus. Patient has been admitted to the hospital due to cellulitis four weeks ago and was treated for it with antibiotics. During the admission, patient was newly diagnosed with hypertension. On discharge, patient was prescribed with some medications.What you should do:
Please talk to the patient, take focused history, check his/her blood pressure and discuss further management with the patient. This is patient’s first review after being diagnosed with high blood pressure.
D: Hello my name is doctor (name) I am one of the doctors here in the GP clinic, am I talking to Angel?
P: Yes.
D: Can I have your full name and date of birth please?
P: (Confirms name)
D: I can see from my notes that you had been admitted to the hospital 4 weeks for an infection. How did that go?/ Can you tell me what happened?
P: Yes, doctor it was four weeks ago when I was diagnosed with cellulitis, and I was admitted to the hospital. I was treated with antibiotics, I recovered later well. During that period, I was diagnosed with high blood pressure and I have come here for my review today.
Rapport Admission.
D: Thank you for coming, may I ask you how you’re feeling today? How is your leg?
P: Much better.
D: Are you in any pain or fever now?
P: No not really doctor.
D: I’m glad to hear that. How was hospital stay back then?
P: Aah doctor it was dreadful…
D: I am sorry to hear that. How was the care by the doctors and the nurses?
Did anything in particular happen?
P: No not like that I am just not really fond of being hospitalised.
D: Well, I can understand that, if I am not mistaken you have been prescribed some medication for your high blood pressure?
P: Yes doctor (points towards Enalapril).
D: I am here today to discuss your medications with you. and I would like to explore a bit about your health generally to check how you’re recovering. Would that be alright?
P: Sure doctor.
Note
• In this station, dose will be written already, the purpose is actually making
the patient understand. Taking focused Hx and addressing his concerns.
• Talk slowly and always ask the patient
– Are you following me ?
– How does that sound ?
D: Do you have any specific concerns that you would like me to tackle with you today?
P: I don’t like the medication This blood pressure medication gave me a cough.
D: May I ask why you think it’s the medication that’s giving you a cough?
P: I have been taking these (point towards Aspirin and Statin) for a long time and I never had any problems. I am sure it is because of my blood pressure medication. I don’t want to take this medication.
D: We do have other medicine options that we can discuss but if you don’t mind, I would like to know more about the cough?
P: Okay.
P1 Cough ODIPARA:
D: When did you start having this cough? Onset and duration
P: Few weeks ago since I started taking the medicine.
D: So you didn’t have any cough before you started your medications?
P: No.
D: Is there anything that makes it better or worse?
P: Nothing.
D: Any change since it started? Getting worse? Getting better? Course
P: No.
D: Any discharge, phlegm or blood with this coughing?
P: No, its dry.
Associated Sx and DDX
D: Any fever, flu-like symptoms ? (Pneumonia)
P: No.
D: Any headache? Any dizziness? Any visual problem? (HTN Sx)
D: Any chest pain. SOB or heart racing? (Heart Failure Sx)
P: No.
Explore Medication:
D: How about the medicine, are you taking it as prescribed?
P: I was but I stopped taking it 3 weeks ago after I had the cough.
D: Any symptoms after you stopped taking your blood pressure medication?
P: No.
P2
D: Any similar cough in the past?
P: No.
D: Do you have any other longstanding medical conditions?
P: Yes I have DM.
Explore briefly
D: For how long?
P: 10 Years.
D: How do you manage it?
P: My diabetes is controlled by diet.
D: Are you taking any medications for it?
P: No doctor.
D: Is it well controlled?
P: Yes.
D: Do you go for your GP appointments and annual check-ups regularly?
P: Yes I frequently come to my GP here and he says my diabetes is well-controlled.
D: That’s great.
DM Sx
D: Any problems with going to the toilet or your weight recently?
DM complications:
D: Any unusual sensation in any of your hands or feet?
D: Have u ever been hospitalised for any reason, other than this last admission?
P: No.
MAFTOSA:
D: Since when have you been taking these Aspirin and statin?
P: 10 years.
D: Do you take them regularly?
P: Yes doctor.
D: Are you currently on any other medications apart from those you mentioned?
P: No.
D: Do you have any allergies?
P: No.
D: Any Family Hx of similar cough problems?
P: I am not sure.
D: What do you do for a living?
P: I’m an architect.
DESAS
D: Tell me about your diet?
P: It’s quite healthy I think.
D: Do you do physical exercise?
P: No.
D: Do you smoke?
P: Yes/no
D: Do you drink alcohol?
P: Yes occasionally.
D: Have you been stressed about anything lately?
P: Yes/No
Examination
D: Is it OK if I take your vitals and your blood pressure now and also examine and listen to your chest as well?
EX: 170/100.
Provisional Diagnosis
- Thank you for bearing with me Angel. From you have told me so far (Mention postives), I agree with you that you probably have the cough as a side effect of the BP medication you were prescribed which actually does cause a persistent dry cough.
- From the examination I have done, your blood pressure is pretty high at the moment and it is probably because you haven’t taken your blood pressure medication in the last few weeks. This can be serious as well of we don’t manage it properly. Is everything making sense to you Angel?
Management:
Seniors:
- I will discuss this with my seniors. We will probably change your medication to another one that hopefully you can take without any problems this time.
Investigation: Routine and CXR
Treatment:
- We will change your medication to another group of medication (ARBs). I will double check your new medication with my book as well.
- Please don’t stop your medication without consulting one of the doctors here fiirst and take them regularly as we prescribed, otherwise you may face many problems in the future if your blood pressure remains high. It can damage your blood vessels, heart and brain. If you at any time develop any side effects,
- please feel free to come back to us.
S/E of ARBs: Dizziness, headache, drowsiness, nausea, vomiting, diarrhoea, elevated potassium levels.
Advice About DESAS as before
Safety net:
− HTN complications: Chest pain, SOB, cough, vision, weakness anywhere in your body.
− DM complication and Sx: Frequent trips to toilet, weight loss.
NOTE:
- Sometimes the patient is on Amlodipine complaining of Ankle oedema (a common side-effect of CCBs). Same approach and change to other medicine after revising with your senior, and confirm with your BNF book.
- If the patient is insisting to know the substitute, then say ACE inhibitors (Ramipril)
- Always remember that you don’t have to mention drug name or dose yourself unless the patient asks you specifically and if it happens try to give a smart answer like ‘I’ll check with senior and BNF’.