presentations and consultations workshop · npo, iv ppi, bloodwork (e.g. type & screen, cbc,...
TRANSCRIPT
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
PresentationsandConsultationsWorkshop
HandoutPackage(WorksheetsandReferenceMaterials)
SessionLearningObjectives:
1. Practiceastructuredprocessforpresentingclinicalcasestoapreceptor(F-SOAP)
2. Identifytoolsthatsupportaclinicalconsultationrequest(e.g.RAAPID,ROCA)
3. Practiceastructuredprocessforcommunicatingwithconsultants(5Cs)
4. Listelementstoincludeinwrittenclinicalconsultation
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
CasePresentations:F-SOAPMODEL
Component Notes
FRAMEStable/Unstable
IDCC
RelevantPMhx
STORYHPI
Pertinentpos/neg
OBJECTIVEDATA
VitalsPhysicalExam
Ix
ASSESSMENT
DDX(workingdx,
dangerousddx,commonddx)
PLAN
SymptomaticTxIx/ManagementDisposition
PatientEducation
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
CasePresentation:PracticeCasePrompt
69yoFintheED.Shetellsyouthatshecameintotheofficetodaybecauseshehasbeenhavingsomechestdiscomfort.Itstarted3hoursagowhileshewassittingwatchingWheelofFortune.Itdoesn’tgetworsewhenshetakesadeepbreathinorradiateanywhere,butshehasbeenfeelingalittlenauseousoverthepast3hourswithit.Shedescribesitasmoreofapressuresensationandratesit6/10presently.She’sneverhadthisbefore.Shedoesn’thaveanyinfectioussymptomsandshehasn’tfeltlight-headedorfainted.Shedeniesanypalpitations,sweats,positional,orexertionalchangetothechestpressuresensation.Shealsohasn’ttravelled,hadsurgery,orsufferedanyrecentinjuries.Shetellsyouthatshesmokes,butdoesn’ttakeanyrecreationaldrugsoralcohol.Herfatherhadaheartattackatage70andhermotherhadasthma.SheisonmetforminforDM,RamiprilforHTN,andatorvastatinforDL.Shehasnoallergies.She’sneverhadaheartattackbefore.Onexam:
• Vitals:Temp37.3,HR90,RR22,Sats94%RA,BP110/77• Neuro:GCS15,pupilsequalandreactive,normalstrengthtoallfourlimbs• CVS:JVPnormal,S1/S2normal,nomurmursorextraheartsounds,strongandregular
pulse• Resp:lungsareclear,noincreasedworkofbreathing,herchestpainisnotreproducible
onpalpation.Whenaskedtopointtothelocationofherchestdiscomfort,shepressesonhersternum.
• Abdo:Soft,non-tender,non-distended,shehasoldscarsforpreviousappendectomy• Extremities:nocalfswellingortenderness
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
CasePresentation:F-SOAPFeedbackChecklist
Learnerachievesthefollowing:
FRAME:c Stable/unstablec Age&genderofpatientc Chiefcomplaint
STORY:
c EasytofollowHPI,whichpaintsaclearpictureofwhat’sgoingonc FocusedPMHx,Meds,All,SocHx,FamHx(includedonlyifitcontributesto
narrowingdowntheddxforthechiefcomplaint)
OBJECTIVE:c Startswithvitalsignsc Focusedreportofsignificantphysicalexamandinvestigationfindings
ASSESSMENT:
c Sharesmostlikelydiagnosis(es)basedonencounterc Includesaddx(3minimum)thathasdangerousddxandotherddxalternatives
PLAN:
c Symptomatictreatmentc Furtherinvestigationsandmanagementplanc Considersadispositionplanc Patienteducation
STYLEPOINTS:
c Organizedflowtopresentationc Sign-postsimportantsectionsofpresentation(e.g.“Myoverallassessmentis__)c Deliveryisataneasy-to-understandpacewithappropriatepausesandvolume
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
Consultations:5CModel
Component Notes
ContactIdentifyparties
CoreQuestionE.g.Follow-up,
furtherevaluation,admission,definitive
management.
CommunicateF-SOAP
What’sdonesofar
CollaboratePlannextsteps
ClosetheLoop
Clarifyresponsibilitiesandsummarizeplan
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
Consultations:PracticeCasePrompt
ID:Stablecondition52yoMadmittedtoMTUformildpancreatitisCC:Newlydevelopedmelenastoolsx2episodesHPI:AdmittedtoMTU3daysagoforconfirmedmildpancreatitis.2episodesofmelenastoolstoday,butotherwisenonausea,vomiting,diarrhea,orfever/chills.PMHx/SHx:ETOHabuse(noliverdiseaseorvarices),pepticulcerdiseaseFHx:Non-contributoryMeds:NoneRelevantExamFeatures:
Vitals:Temp37.3,HR90,RR22,Sats94%RA,BP110/77Mildepigastricdiscomfort,butnon-peritoniticabdomenandrectalexamsignificantforsmallamountofmelenastoolonly.
Treatmentstarted:
NPO,IVPPI,bloodwork(e.g.Type&Screen,CBC,INR/PTT)
ScriptforConsultantRoleinthepracticescenario
o Duringthecollaborationphase:o Promptthelearnerforcasehistoryifyoufeelnotenoughinformationhasbeen
giveno Askaboutinterventionsandinvestigationsdoneorstartedsofar(ifnotalready
providedbylearner)o Then:“Iagreewithyourassessment.Thissoundslikeanon-urgentupper
endoscopytoinvestigatefurther.Wecanorganizetheproceduretobedonetomorrowmorning.PleasekeepthepatientNPOandcontinuewithyourcurrenttherapy.Letusknowifanythingchangesorthepatientdeteriorates.”
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
Consultations:5CsFeedbackChecklist
Learnerachievesthefollowing:
CONTACT:c Identifiesname,rank,serviceforselfandconsultant
COREQUESTION:
c Leadswithclearlyarticulatedreasonforconsultc Includesurgency/timelineofrequest
COMMUNICATE:
c Communicatespatient’scaseinanorganizedfashion(e.g.F-SOAP)c Outlineswhathasbeendonesofar(intermsofinvestigationsandmanagement)
COLLABORATE:
c Workswithconsultanttodeterminenextsteps
CLOSETHELOOP:c Repeatsplanandconfirmsroles/responsibilities
STYLEPOINTS:
c Organizedflowtoconsultationc Deliveryisataneasy-to-understandpacewithappropriatepausesandvolume
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
WRITTENCONSULTATION:SAMPLETEMPLATE
To:Consultant<Contact>CC:Patient’sGP.Re:PatientXY,ID#Date:MM-DD-YYYYReasonforReferral:<TheCoreQuestionfortheconsultant>Patientcontactinfo:workingphonenumber(doublecheckthiswiththepatient)DearDr.XPatientXYisa__yoM/Fevaluatedat______onMM-DD-YYYYfor<ChiefComplaintorsuspected/confirmeddiagnosisifavailable>.<CommunicatewithF-SOAP><Remembertocommunicateyourinvestigationsandmanagementinitiatedthusfar><CollaborateandClosetheloopby:discussingwhatyou’rehopingthenextstepswouldbe,providingashortsummary,andthankingtheconsultant>Thankyouforyourassistance.Signed,XX,designation
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
RAAPID:SUPPLEMENTARYINFORMATION
RAAPID:§ Referral,Access,Advice,Placement,InformationandDestinationserviceinAlberta§ Callcentrethatcoordinatesconsultsandtransfersbetweenhealthcareprovidersand
centreswithintheprovince(ruralandurban)RAAPIDContactInformation:
§ RAAPIDNorth:everythingnorthofRedDeer(includingEdmonton):o 1-800-282-9911
§ RAAPIDSouth:everythingsouthofRedDeer(includingCalgary):o 1-800-661-1700
When you call RAAPID, youwill be greetedby anoperatorwho coordinates calls. There is astandardformattofollowwhencontactingRAAPID(don’tworry,ifyoudon’trememberthis,theRAAPIDoperatorwillpromptyouforthefollowing):
§ Stabilityofpatient§ Yourname§ Nameofyourstaff§ Siteyouarecallingfrom§ PatientsPHN(albertahealthcarenumber)§ Whoyouwanttotalkto(EmergDoc,Specialist,etc)§ Reasonforcallingconsultantandbriefstory
TheRAAPIDoperatorwillusuallyendthecallsotheycancontacttheconsultantandwillcallyoubackoncetheconsultantisonthelinesoyoucanpresentthecasetotheconsultingphysiciandirectly.Alternatively,theymaytransferyoutotheconsultantrightaway.Thisisusuallyastaff-to-stafforresident-to-staffservice,butyoumaybeaskedtohelpcontactRAAPIDifyouareworkingataruralsite.
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
ROCA:SUPPLEMENTARYINFORMATION
ROCA:§ RegionalOnCallApplicationinCalgary§ MostlearnerswillencounterthisduringMTUInternalMedicinerotationsinCalgary§ Thisishowyoulookupcontactsforon-callservicesinCalgary(eg.generalsurgery,
cardiology,etc)HowtoUseROCA:
1. NavigatetotheAHSInsitepage(thisisthedefaultbrowserpageonallAHScomputersifyouopenaninternetexplorerwindow).
2. FindtheROCAlinkeitheroftwoways:a. TypeROCAintothesearchbar,thenclicktheROCAhyperlinkforCalgary&Areab. Ontheright-handsideoftheAHSInsitehomepage,under“ContactCentre”,click
the“On-Call/ROCA”hyperlinkforCalgary&Area3. Youwillseethefollowingscreen:
4. Entertherelevantfields(time-frame,siteofinterest,service)andclickthecircled“view”buttontoseewhoisoncallforthatservicetodayvs.“viewcalendar”toseewhoisoncalloverthecalendarmonth
5. Eachindividualoncallwillhaveapagernumberlistedundertheirname.6. Usethepagernumberlistedtopagetheindividualandarrangeaphoneconsult.
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
CALGARYPAGINGSYSTEM:SUPPLEMENTARYINFORMATION
HowtousetheAHSpagingsystem:1. NavigatetotheAHSInsitepage(thisisthedefaultbrowserpageonallAHScomputersif
youopenaninternetexplorerwindow).2. FindthePaginglinkonthehomepageandclickit:
3. Clickthelinkfor“CalgaryAreaPagingSystem”4. Youwillseethefollowingscreenpopupandcansendpagesbypagernumberorname
5. Besuretoincludeinyourpage:yourname/initials/pgrnumber,briefreasonforpage(eg.“newconsult”),patientinitialsorlastname,phonenumberforconsultanttocall.
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
SPECIALISTLINK
www.specialistlink.ca
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
TIPS ON HOW TO MAKE CONSULTS MORE EFFECTIVE (Compiled in 2015 by Anthony Seto)
GIM – Calgary PGY-3, Calgary PGY-3, Kingston PGY-3
o Accurate vitals o Ensure to complete workup and avoid anchoring bias o Responses to treatment so far o Synthesis of what we think is happening and provisional diagnosis o Goals of care
Surgery – Calgary PGY-2
o Try to have a diagnosis in mind and avoid consulting when the patient is still undifferentiated
o Remember to have labs back and imaging completed Psych – Calgary PGY-3
o Avoid consulting automatically if, in a previous chart, the patient was seen by psych in past
o Remember to go through psych screening Q’s: psych illness symptoms, substances, suicidal ideation, and social/housing
o Consult ED SW first if primarily social/housing/financial/drug detox issue Ortho – Calgary PGY-3
o State the issue/problem right away o Keep mechanism fairly brief, unless it involves some relevant
information such as syncope o Neurovascular examination
Radiology – Calgary PGY-3
o Please provide history. Avoid simply putting the question (e.g. r/o PE) as the “history”, but provide some context and story.
o Include hx cancer or hx surgery, because it frames way incidental findings are interpreted
Obsgyne – Vancouver PGY-3
o Remember to do pelvic exam o Obs history, Rh status
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
Cardiology – Calgary Staff, Calgary Fellows, Edmonton Fellow o Ask Goals of Care so cardiology knows how aggressive to be o Look up relevant data, i.e. past history on Netcare o Think about whether CCU vs ICU vs IM vs FM is best; fellows find it
challenging with pan-consults o Have the appropriate blood work before consultation
Neuro – Calgary Staff, Calgary PGY-3
o Is the patient already known to neuro? Gives a point of contact and background information.
o Legible handwriting would be useful for paper forms o Be aware of General Neuro clinic versus Urgent Neuro clinic. Urgent
Neuro clinic is if patient needs to be seen <72h. Resp – Calgary Staff
o Say upfront if you want consult, admission, or both Peds – Edmonton PGY-4, Newfoundland PGY-3
o Tend to miss: if they have a pediatrician or not o Vitals, sick or not sick, do they need immediate attention o Premature? o Growth charts
Plastics – Calgary PGY-3, Manitoba PGY-3
o Do thorough exam
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Neurosurg – Calgary PGY-5 o Spine
§ Duration of signs/symptoms important § Localizing neuro exam § Comorbidities § PMhx of prior spine surgery, surgeon, and location § Red flags: IVDU, fever, wt loss, hx of cancer, etc.
o Please tell surgeon/resident if neurosurgeon should be at bedside urgently to assist with management or expediting appropriate care in deteriorating patient. Sometimes it’s difficult to assess neuro status and urgency over phone.
o Cranial § GCS, focal motor and cranial nerve deficits, pupillary exam, vital
signs § Anticoagulation and antiplatelet agents § Meds confounding exam: etoh, benzos, narcotics, paralytics § Seizure: post-ictal or suspect ongoing seizures/status § Include plan for managing/stabilizing patient § Do not start patients with suspected VP shunt infection, post-op
infected craniotomy, or suspected brain abscess on antibiotics until reviewed with neurosurgery
Ophthalmology – Calgary PGY-3
o Visual acuity o IOP, both eyes for comparison o Acuity of the presenting complaint o Prior history of same o Recent eye surgery o Current ophthalmologist
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
Derm – Calgary PGY-3 o Many consultants request a photo. Derm residents have been told to
use AHS emails as they are encrypted. Hopefully we can develop some sort of system to send photos.
o Most common consults: § Allergic contact dermatitis (e.g. polysporin) § Poorly controlled eczema § Arthropod reactions (e.g. scabies) § Drug eruptions § Vasculitis
o Missed information: § Does the patient have a dermatologist or previous biopsy result? § Drug history (changes or new meds in last 6 months) § Distribution of the lesions § Morphology: site, primary lesion (macule/patch, papule/plaque,
vesicle/bullae), and secondary changes (crust, erosion, ulceration) § All topicals used (OTC and Rx)
ENT – Calgary PGY-3
§ Patient ID, hx, DX, DDX § What have you done so far? (often missed) § What would you like ENT to do? Come and see? Admit? Arrange
f/u? (sometimes missed) § Identify if there is concern for airway
HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017
Uro – Edmonton PGY-2 o Most common consults: gross hematuria, stones, catheters o Gross hematuria
§ How bad is it? § Is it clearing up with a trial of CBI for several hours? Remember to
manually irrigate to clear clots prior to trialing CBI. § ?hx bladder cancer § CT urogram, urinalysis, urine C&S, urine cytology
o Stones § ?signs of infxn (fever, WBC) – would need to stent § size/location of stone on imaging § pain status, pain management § N/V § # of visits to ER for this stone
o Catheters § Why inserted in first place? § Hx of strictures or dilations? § Has ER doc attempted cath? If it’s stuck in shaft, probably a
stricture. If stuck in perineum, probably prostatic issue; if so, give coude tip foley a try.
Vascular – Ottawa PGY-3
o Proper pulse exam § Doppler signals alone don’t mean adequate flow § One needs palpable pulses
o Distinguish between acute and chronic limb ischemia o ?Ruptured aneurysm may appear stable and be triaged lower. Need to
improve communication so these patients seen earlier. Dentistry – Calgary Hospital Dentist
o Some patients led to believe that dental treatment would be free when only some parts may be covered by Alberta Health & Wellness
o Whatever is delineated by Alberta Health and Wellness billing codes would be covered:
§ E.g. cost of consult § E.g. biopsy § E.g. cost of general anesthesia for dental treatment, but only
patients meeting a certain criteria o Consult SW to navigate potential sources for dental coverage