Care of the Acutely Ill Person by sdfwerte


Statement 7 of the RCGP Curriculum
Statement 7 - Overview
   Recognise, assess and manage acutely ill patients

   Be competent in Out of Hours care

   Awareness of ethical issues and dilemmas

   Use investigations, referral / admission appropriately

   Prioritisation, time and stress management skills
Dangerous Diagnoses
•   Myocardial Infarction
•   Pulmonary Embolus
•   Subarachnoid haemorrhage
•   Appendicitis, intestinal obstruction / perforation
•   Meningitis
•   Aneurysms
•   Ectopic pregnancy
•   Acute psychosis / mania
•   Conditions with risk of visual loss
Dangerous Symptoms?
   Chest pain
   Breathlessness
   Headache
   Abdominal pain
   Childhood fever
   Acute-on-chronic psychiatric symptoms
   Various eye / facial symptoms
The Decision to Admit….
   What is your experience of admitting patients to
    hospital or referring them to other teams?

   What options are available to the GP for the
    management of acutely ill patients?
“I was rushed into hospital”
   When considering these cases:
   Use “retrospectoscope” and magic wand freely!
   Consider as wide a list of options as possible
   Consider the implications of admission for the
    patient, family, GP, hospital and society as a whole
   Don’t forget that the doctor’s knowledge, skills,
    workload and confidence can all affect the decision
    to admit a patient
Not for further hospital admission
   Mr A has severe Parkinson’s disease. Over the course of 5 years, he has gone from being an
    active, retired farmer, to being wheelchair bound and highly dependent on his wife and adult
    children. He was admitted three months ago with a fractured hip, and after surgery spent a
    number of weeks in a local nursing home, before going home with a care package which
    included five daily visits from carers (including at night to turn him), regular district nurse and
    Parkinson’s specialist nurse visits and social worker contact. Following this he developed
    aspiration pneumonia and was once again admitted for over a month. His swallow was unsafe
    on admission, but later improved, and although he was considered for a PEG, no decision was
    made. The discharge letter from Dene Barton says “Should this discharge break down, he
    should be considered for nursing home placement NOT further hospital admissions”. He lives
    with his wife, who is registered with a different GP practice.
   You are called to see him one afternoon, as he is sweaty and not drinking. His wife tells you
    that she rang “the night people” two days ago to come and see him, but they told her it was
    not an emergency. He has deteriorated since, though it is not clear why she waited until now to
    ring. On examination, Mr A is conscious and orientated, although his wife reports increasing
    confusion. He is pale, clammy and breathless, with tachycardia, tachypnoea and hypotension.
    He has focal signs at his right lung base. He has not passed urine today, and is noted to cough
    when attempting to drink water. His wife feels she cannot cope with him at home, but he
    expresses no preference about where he should be treated.
Unplanned admission in terminal care
   Mr E is 90 years old and has oesophageal carcinoma, which has been
    palliatively treated with a stent. He continues to deteriorate slowly, with
    general weakness, loss of weight and fatigue. He expresses a firm desire
    to die at home, which his 88 year old wife supports. She is profoundly
    deaf, so has relied on him especially for telephone use, but they have very
    supportive neighbours who ring on her behalf when needed. As Mr E
    deteriorates, he develops intractable vomiting and abdominal pain, and a
    syringe driver is set up, which is largely effective in relieving these
    symptoms. However, he also becomes more confused and keeps trying to
    get out of bed. Early one morning, he falls, and an ambulance is called.
    The paramedics feel he is no longer safe at home, and take him to hospital.
    He is admitted but dies a few hours later.
   When you see his wife the following week, she is devastated that he did not
    die at home, as he wished. She feels very guilty that the paramedics
    seemed to think she could not look after him.
Does he really need admission?
   You are duty doctor on a busy post bank-holiday Tuesday. Your colleague saw a child with
    asthma this morning and asked them to come back for review at 6pm. Their clinical notes read
    as follows:
   “During the day, normal self and running around playing normally. Last night he was waking
    every 2 hours with SOB, increased respiratory rate and Dad reports intercostals recession.
    Needed several puffs of his ventolin every two hours. Currently using 20mcg a day of inhaled
    steroid (only started recently). Yesterday pt visited an animal farm. RR=24, very mild
    intercostal recession, lungs initially clear, on repeat auscultation audible wheeze (likely
    transmitted upper airway sounds). Pt showing no signs of respiratory distress. No cyanosis.
    Dad would like to see how pt is during the day before deciding re admission.”
   When you see the child, he is alert but sitting quietly on his mum’s lap. She reports that he has
    needed salbutamol every 2-3 hours during the day. On examination, his heart rate is 120 and
    his respiratory rate 40. He has moderate lower chest insuction. There are coarse creps all over
    the right lungfield, which almost clear after coughing. Pulse oximetry is 93-94%.
   You decide to admit the child for further assessment. The paediatric doctor thinks you should
    nebulise the child first, to see whether that helps before you consider sending him in.
Hanging on at home by a thread
   Mrs W is 85 and lives alone, though she has supportive friends and neighbours. Her past
    medical history includes COPD, hypertension, osteoporosis and osteoarthritis of the right
    shoulder and both knees. In the past couple of years, she has had a couple of short admissions
    resulting from acute-on-chronic problems coupled with a decrease in mobility and ADL. Last
    month, she was admitted via A&E with coffee ground vomiting and found to have acute
    gastritis. Her lisinopril and diltiazem were stopped during this admission, but the discharge
    letter and a follow up phone call do not reveal a reason for this. She is currently taking
    strontium, omeprazole, seretide, amitriptylline 25mg and paracetamol. She does not tolerate
    opioid analgesics.
   Since she was discharged from hospital ten days ago, you have had one or two phone calls a
    day from the patient herself or the carers who visit three times daily. She has had three home
    visits; one for an exacerbation of COPD, one to check her over following a fall and a third
    when she was too distressed over the phone to identify the problem – it turned out that she
    had lost her amoxicillin tablets, which were found under the sideboard. Her mobility has been
    deteriorating, and on several occasions the carers have arrived to find her standing by the
    phone and unable to return to her chair without help. An urgent referral to occupational
    therapy has been made.
   Today, a carer phones to report that they have been unable to get her out of bed because her
    legs and feet are painful. Another visit is arranged.
Unable to manage at home
   Mr B is 97 years old and lives alone with occasional help from his family.
    He has hypertension and Ca prostate treated with hormones. His last PSA
    was 15 (an improvement) and he decided to defer his injection as it makes
    him feel unwell. He has become much frailer in the past three months, and
    is low in mood following a distraction burglary and an argument with his
    daughter. He vividly remembers watching unsuccessful resuscitation on his
    mother, and his notes contain a living will which forbids heroic measures to
    save his life. He has also expressed a wish to stay out of hospital, though
    when he had pneumonia last year agreed to admission when he went “off
    his legs”. He takes bendroflumethiazide and paracetamol.
   You are called to see him one day because he cannot get out of bed. He
    has thoracic back pain which is severe but intermittent. His legs feel weak
    and numb, although sensation is objectively intact. He is lying on his side,
    and cannot be moved enough to conduct a formal examination, but there
    are no signs which enable you to make a diagnosis. He does not want to
    go to hospital if it is possible to avoid it, but recognises that he cannot care
    for himself at the moment. His son reports that he has been a bit confused.
Pneumonia- admission options
   Mrs S is 35 and usually fit and well. She presents in
    morning surgery with a two day history of left sided
    pleuritic pain, cough and dyspnoea. On examination,
    she looks as though she is in pain and has an area of
    dullness and reduced air entry at the left base. There is
    a slight rise in respiratory rate, a low grade fever, and
    a tachycardia of 96. Her calves are soft and non-
    tender, she is not obese and does not take any regular
   Supplementary question: what factors would you take
    into account when deciding whether or not to admit
    individual patients with suspected pneumonia to
  Which sort of sick note?
  How long for?
   48 year old lady with a sedentary job, who had a
    hysterectomy last week and has dropped her
    discharge letter in to the surgery

   Med5 “I have not seen you, but on the basis of a
    written report…..”
   The gynaecologist should have done it!
   Man with sprained ankle, seen in A&E last week, off
    work for a week, phones up to ask for a few more
    days. You haven’t received a casualty note.

   Med3 “I have examined…”
   Cross out and write “telephone consultation”
   Or see the patient yourself
   17 year old college student with a sore throat for
    the last three days

   Sick notes not usually necessary for students
   Medical reports are not core NHS service
   Guidance is available for exam absence
   55 year old bank worker with chest infection for
    two days

   Self-certificate (SC2)
   55 year old bank worker with chest infection who
    has already had 7 days off sick; you saw him five
    days ago

   Med5 “I examined you on the following date”
   55 year old bank worker with chest infection for
    two days, whose manager won’t accept a self-

   Private certificate
   23 year old unemployed man, who complains of
    severe, unremitting back pain, with no clinical

   Med3
   Benefits agency award incapacity benefit
   23 year old unemployed man, who complains of
    severe, unremitting back pain, with no clinical
    findings, who you regularly see playing football in
    the local park

   Refuse Med3?
   RM7
   Benefit cheats hotline!
   45 year old employed woman undergoing
    chemotherapy for breast cancer and has been unfit
    to work for five months, whose employer wants to
    know when she will return to work

   Med3 for employer
   GP / occupational health report (non-NHS)
   45 year old employed woman undergoing
    chemotherapy for breast cancer and has been unfit
    to work for six months, whose employer has stopped
    paying her sick pay

   Med3 for benefits agency
   Med4 on request
   IB113 on request
Sick Notes

   Are legal documents; watch for fraud
   For statutory sick pay or employers ONLY
   Have a street value
   Conflict of interest for the GP?
   Being off work is bad for your health
Summary: For Acute Care you need:

   Clinical knowledge and skills
   Knowledge of services available
   Organisational and time management skills
   Ability to stratify and manage risk
   Next session: Wed 8th October
   Rheumatology and musculoskeletal medicine

   Out of Hours

   Somerset GP Educational Trust

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