Where you are:
FY2 in GP surgeryWho the patient is:
Lucy Clark, 55-year-old woman, has made an appointment to see you.Other information you have:
You had referred her to the hospital for per rectal bleeding. She had sigmoidoscopy done which showed bleeding polyp. Histology was done which confirmed benign adenoma and some dysplastic changes. The specialist would like to perform a colonoscopy. The patient would like to talk to you about it.What you must do
Talk to her & address her concerns.
Concerns:
- Why do I need another camera test when the biopsy showed benign?
- Is sigmoidoscopy not enough?
- Do you think it could be cancer?
- How long will the procedure last?
- Are there any complications?
- Will you put me to sleep, doctor?
- Will I be in pain?
- Do I need any preparation?
Candidate Information
- Note that you should explain the procedure to the patient in a simple and understandable manner.
- This particular patient is anxious about the procedure.
- The candidate should provide information to reassure the patient and allow the patient to make an informed decision about the procedure.
- Analyse the main complaint, not too many questions as you need to have more time to address the concerns the patient will have.
- Don’t waste time asking too many DDs.
Patient information
- You presented to your GP a few weeks ago with 2 episodes of blood in your stool.
- Your GP referred you to the specialist who performed sigmoidoscopy. They found some polyps, which they removed and sent to lab for histology. Results showed benign polyps. You were quite happy everything was going well.
- While having sigmoidoscopy done, you had discomfort and you’re not keen about having this procedure again. Since polyp removal; no bleeding.
- You are not happy doctor asked to do another camera test. You live with your husband, and he can come and get you. It is not a problem.
- You are normally fit and well and not under any regular medications.
- None of your family member has such problems.
- Last time you had colonoscopy, it was very embarrassing for you, this is why you do not want to go through it again. You also had severe discomfort. They did not offer sedatives initially until halfway .
Data Gathering
- FOCUSSED HISTORY.
- ALWAYS CHECK CURRENT CONDITION Associated symptoms D: Do you have any tummy pain? Diarrhoea? Constipation? Nausea/vomiting? D: Fever? Loss of appetite? Weight loss? Tired? Weakness? (FLAWS) Check red flags
- P2 PAST HX D: Has this ever happened before? P: No. D: Have you ever been diagnosed with any medical conditions in the past or any bleeding disorders? Or any heart problems? P: No. D: About the previous camera test how did it go? D: Did you have any problems or challenges while having it done? D: Did you have any bothering Sx afterwards, like pain or bleeding from back passage?
- MAFTOSA + DESA D: Few questions regarding your lifestyle now, do you smoke? Alcohol? Diet? D: Mrs Clark, are you under any medication like blood thinners or anything else? D: Any allergies? Any family hx of a similar condition
- SOCIAL,MOOD, ICE D: Do you have any idea why you have been sent here? (Do ICE, always assess her knowledge to save time. If they know, don’t explain, if they don’t know, then explain) P: I have been told I will be having a colonoscopy. D: Yes, do you have any concerns at this point?
- Patient Refusing again and again
Management and concerns
- (DESA) or lifestyle modifications
- ARMMS:- Advice: − A few hours of monitoring are required until sedation wears off. − Needs someone to pick her up. − The effects of the sedative may last up to 24 hours, we therefore advise you not to:
- Drive or ride any type of bicycle for at least 24 hours.
- Operate any type of electrical or mechanical equipment/ machinery for at least 24 hours.
- Sign any legally binding documents for at least 48 hours.
- Drink any alcohol for at least 24 hours.
- Not be responsible for young children, disabled or dependent relatives for at least 24 hours.
- You can eat as you normally would.
- Rest quietly for the remainder of the day and if possible have someone stay with you overnight.
- Q:-Is sigmoidoscopy not enough as the biopsy showed it was benign?
D: I am afraid not, as there is a chance you may have polyps further up the bowel which might turn into bowel cancer if they are not removed. So we need to check that there are no more polyps further up the bowel and that there is nothing else going on. Unfortunately, having a polyp is one of the risk factors of developing cancer so we need to check the whole colon and remove any we find. (Deal with the concern clearly) - Q:- Alright, can you explain the procedure to me?
D: A colonoscopy is a simple camera test where we will be passing a lubricated, flexible tube, which has a camera on the tip, up through your back passage and into your bowels to visualise your bowels from the inside. The camera will help us see what is going on inside. We will pass gas into your bowels to inflate them so that we can see things more clearly. We may need to take pieces of tissue from any abnormal areas to be examined in the lab. - Q: How long will the procedure last?
- Q:Will you put me to sleep, doctor? D: For this procedure you will not be put to sleep, but we will give you some sedatives through your veins to help you relax.
- Q:Will I be in pain? D: You may feel the camera go in, but it should not hurt.
- Q:Do I need any preparation? D: Well, − before the procedure you will need to empty your bowels for a better view. − You will need to have a special diet a couple of days before the procedure. − We will also give you laxatives to take a day before the procedure, which will help you clear your bowels.
- Q: What happens after a colonoscopy?
D: You’ll then be moved to the recovery room. The nurses will monitor you until you’re ready go home. You might be at the hospital for around 2 hours from getting there, to going home. P: Are there any complications? D: Most colonoscopies are done without any problems. However, like any procedure, there are a few complications that might occur: − The sedative may make you feel drowsy and tired for several hours afterwards. − There is a risk of damage to the bowels. (Perforation/puncture of the bowel) − You might experience fever after the procedure. (infection) − Abdominal discomfort (bloating). − You may also have some blood in your poo or bleeding from your bottom. If any of the above occur, we will manage you accordingly. - Q: Dr why did you not do a colonoscopy from the beginning ? I can appreciate it is not easy to go for another procedure again, but we usually start with the non-invasive one and if there is anything abnormal found, then we do the more invasive procedure. I know you are saying you had a bad experience last time, I really apologise for that. (Address the concern about the previous one as pain or sick leave )
- Safety Netting: − If any of the following happen, you will need to come back.
- Pain
- bleeding
- fever
