Self-Directed Clinical Learning

Self-Directed Clinical Learning Task Worksheet

ECPD Syndicate No.

08V139

Worksheet No.

1

Consultation Date*

24.10.2008

Patient Details*

27F. Caucasian. Graduate

Consultation Summary*

Patient came in to receive a repeat prescription of Lithium for bipolar disorder. She wanted to reduce her dosage, or if possible stop taking the Lithium altogether, since she plans to get pregnant to avoid harmful effects of Lithium on the fetus. Urine and blood sample was taken to test for blood Lithium level.

Identified Learning Need*

Find out more about bipolar disorder.

Learning Objective(s)

1. To briefly describe bipolar disorder and its prevalence.

2. To list the symptoms of bipolar disorder.

3. To identify and briefly evaluate two common pharmacological treatments of bipolar disorder.

Information Sources Used

1. Dinan, Timothy G. Lithium in Bipolar Disorder. BMJ, April 2002, 324, 989-990.

2. Kumar, Parveen and Clark, Michael. Clinical Medicine. 6th ed. London: Elsevier Saunders Limited, 2005.

3. National Health Service (NHS). Bipolar Disorder [online]. 15 June 2008. Available at <http://www.nhs.uk/conditions/bipolar-disorder/Pages/Introduction.aspx?url=Pages/what-is-it.aspx> [15 February 2009]

4. Verberne, Thomas JP. Bipolar Affective Disorder. BMJ, April 2002, 324, 976.

Answers / Information / Learning Achieved

1. Bipolar disorder is a condition that causes the mood swings from one extreme to another over periods of time. Bipolar sufferers usually shift from an episode of “mania” or feeling very high to “depression” or feeling very low. Due to this characteristic, it was originally known as maniac depressive disorder. Bipolar disorder is usually distinguished from normal mood swings since they may last over a long period of time and the severity of the symptoms interfere with daily life. The manifestation of symptoms may be different for each individual, differing in the number of episodes or periods of stability. About 1 in 100 people are affected, men and women equally, and it tends to run in families. People of ages 18-24 years are most commonly affected, but it can nonetheless occur at any age.3

2. The symptoms of bipolar disorder can be divided into two phases, usually beginning with the depression period then followed by the mania period.3

Depression: sadness, hopelessness, feeling worthless/empty, lack of energy, self-doubt, pessimism, trouble sleeping and waking, apathy, guilt/despair, suicidal thoughts/attempts (in 50% of patients4)

Mania: elation/euphoria, talking quickly, energetic, ambitious, feeling of self-importance, distracted easily, irritation/agitation, not sleeping, not eating, engaging in pleasurable activities that may cause negative consequences (e.g. spending too much money)

3. Pharmacological treatments

-Lithium carbonate/citrate is a highly effective long term mood stabilizer, and the most commonly prescribed drug for bipolar disorder in the UK.1,3 It is readily absorbed by the gastrointestinal tract and up to 95% can be excreted by the kidney.4 It is, however, a known cause of birth defects such as spina bifida and side effects such as hypothyroidism (in 5-10%) and weight gain (in 25%)1,2. Lithium has a small therapeutic window and therefore a regular blood test must be performed to maintain and measure blood lithium levels (<1.5 mmol/L) to prevent side effects (e.g. diarrhea, vomiting).2,3

The patient is taking lithium regularly, but is concerned about the dosage since she plans to get pregnant and is worried about birth defects. She would like to decrease the dosage, claiming that her symptoms have not surfaced for quite a while. Consequently, her blood was drawn to check for lithium levels to further assess her viability for pregnancy.

-Anticonvulsant medicines such as Valproate are normally used together with lithium in cases that do not respond to lithium or have serious side effects due to lithium. Valproate seems to be beneficial in patients who have frequent cycles.1 Like lithium, it yields many risks to the unborn fetus, and therefore usually used alongside an effective birth control.3 Valproate is generally still second in popularity to lithium as a treatment for bipolar disorder.

Self-Directed Clinical Learning Task Worksheet

ECPD Syndicate No.

08V139

Worksheet No.

2

Consultation Date*

7.11.2008

Patient Details*

23M.Caucasian.

Consultation Summary*

Patient came to change and get a repeat prescription for wound dressings following surgery to remove his pilonidal sinus.

Identified Learning Need*

Find out more about pilonidal sinus.

Learning Objective(s)

1. To briefly describe pilonidal sinus, the population at risk, and risk factors.

2. To outline 2 theoretical causes of pilonidal sinus.

3. To describe the surgical treatment of pilonidal sinus and post-treatment care of patients.

Information sources used

1.Bascom, John. Surgical Treatment of Pilonidal Disease. BMJ, April 2008, 336, 842-843.

2. National Health Service (NHS). Pilonidal Sinus [online]. 4 February 2009. Available at <http://www.nhs.uk/conditions/pilonidal-sinus/Pages/Introduction.aspx?url=Pages/what-is-it.aspx> [18 February 2009]

3. Patient UK. Pilonidal Sinus. October 2006. Available at: <http://www.patient.co.uk/showdoc/27000662> [7 November 2008]

4.Yabe, T and Furukawa, M. The origin of pilonidal sinus: a case report. The Journal of Dermatology, September 1995, 22(9), 696-699.

Answers / Information / Learning Achieved

1. A pilonidal sinus is a “tunnel-like” channel that occurs at the natal cleft, the area between two buttocks, above the anus. As the name ‘pilonidal' suggests, a pilonidal sinus usually contains hairs which may become infected producing swelling, pain, and a pus-discharging abscess.

Pilonidal sinus is more common in men than women (since men are generally hairier than women). It is also prevalent among young adults and teenagers (aged 15-30) and rare among adults over 40 years of age2,3. According to the NHS2, a mere 26 people out of 100,000 will suffer from pilonidal sinus annually in England.

Risk factors of pilonidal sinus include2,3:

-occupation with prolonged sitting -obesity (BMI>30)

-irritation of area affected - family history of pilonidal sinus

-having abnormally excessive hair

2. A particular cause of pilonidal sinus is unclear. Two of these theories include2,4:

1. Congenital theory: a congenital defect (e.g. dimple) in the natal cleft predisposing the area to be affected by ingrown hair, forming a sinus. This theory is supported by the fact that pilonidal sinus tends to run in families.

2. Acquisition theory: external factors such as friction or pressure damage hair follicles and result in ingrown hair which irritates the skin and cause infection. This theory is supported by patients with pilonidal sinus arising from prolonged sitting or those who wear tight clothing.

Despite several explanations of the cause of pilonidal sinus, the generally acknowledged cause is ingrown hairs that cause irritation and inflammation.2,3

3.If the symptoms are rather acute, incision and drainage of the abscess may have to be done often. Persistent and reoccurring pilonidal sinuses are treated surgically. Two methods, the wide excision and the excision and primary closure, can be used1. In the wide excision technique, the sinus and an area of skin surrounding the sinus is excised. The wound is left open which may take several weeks to heal and involve frequent changing of dressings. However, recurrence is unlikely. With the excision and primary closure technique, the sinus is excised and the wound is stitched up. This allows rapid healing of the wound, but yields a higher chance of infection following the procedure as well as a higher chance of recurrence. The patient chose the wide excision technique, therefore requiring constant change of dressings, but minimizing recurrence.

After the surgery, wound care should include2,3:

-keep the area clean and dry -wear loose clothing

-avoid using soap -shaving regularly even after the wound has healed

-frequently remove damp dressings and replace with dry dressing

Self-Directed Clinical Learning Task Worksheet

ECPD Syndicate No.

08V139

Worksheet No.

3

Consultation Date*

7.11.2008

Patient Details*

24.F.Caucasian

Consultation Summary*

Patient came in for a “coil fitting” or an intrauterine device insertion. She has a history of idiopathic menorrhagia and is therefore inserting a hormonal levonorgrestrel intrauterine device.

Identified Learning Need*

Find out about the uses of intrauterine devices.

Learning Objective(s)

1. To briefly describe what is meant by an intrauterine device and explain the process by which it is inserted into the body.

2. To identify 2 common uses of intrauterine devices, briefly describing their mechanisms.

3. To evaluate the usage of intrauterine devices in relation to one of the uses mentioned in 2.

Information Sources Used

1.National Health Service (NHS). Intrauterine device (IUD). Available at: <http://www.nhs.uk/conditions/intrauterine-device(iud)/Pages/Introduction.aspx?url=Pages/Whatisit.aspx> [25 February 2009]

2.Progesterone IUD is effective for menorrhagia. BMJ, June 2004, 328.

3..Rose, Sally B. Pain and Heavy Bleeding with intrauterine contraceptive devices. BMJ, September 2007, 335, 410-411.

4.World Health Organization. Intrauterine devices- technical and managerial guidelines for services. Geneva: World Health Organization, 1997.

Answers / Information / Learning Achieved

1.An intrauterine device (IUD), otherwise known as “coil” or “loop”, is a device made of plastic or copper that is usually inserted into the uterus for the purpose of contraception. It is a T-shaped device with two pieces of string that are left coming through the opening of the cervix and the vagina. There are several steps involved in the IUD fitting. The size of the uterus has to be approximated prior to the procedure for an accurate placing. The procedure usually takes place during periods of menstruation. Any existing sexually transmitted infections will have to be screened for. The device is then inserted through the cervix into the womb through the vagina that is being held open. Stretching of the cervix during the procedure may result in discomfort; therefore anesthetics may be an option. A check up will be arranged at certain intervals during the first year to ensure correct placement. There are currently generally two types of IUDs, copper coil and hormonal levonorgrestrel intrauterine system.

2.The major use of the copper intrauterine devices is contraception. The copper in the device is released into the body, causing an increase in the amount of white blood cells in the surrounding (namely the uterus, the oviducts, and the cervix). This increase in white blood cells kills off sperm and makes it more difficult for the egg to travel in the oviduct. The general mechanism is therefore to prevent fertilization rather than implantation4. Once the coil is fitted, it will act effectively for three to ten years with a 98-99% of success1, but is only used in 6% of women in the UK3 despite its effectiveness.

Another use of intrauterine devices, although still unofficial in several countries, is to treat menorrhagia or excessive and prolonged periods. In treating menorrhagia, a type of intrauterine device called the hormonal levonorgrestrel has to be used as opposed to the original copper intrauterine device which will yield the opposite effect (increased bleeding). This newer model therefore serves as an alternative for women who cannot tolerate the copper, but still retains contraceptive properties.3 This model of IUD works by slowly releasing the hormone levonorgrestrel, a substances common in hormonal contraceptives which is also effective in treating menorrhagia.2The patient is using the hormonal levonorgrestrel intrauterine system to cope with menorrhagia.

3.The usage of intrauterine devices as contraception will be evaluated1,3,4:

Advantages

Disadvantages

-Reversible unlike sterilization

-Effectiveness does not depend on user's behavior

-Cost effective in the long run

-does not protect user from sexually transmitted infections (STIs)

-initial pelvic pain and bleeding

-copper IUDs can cause heavier and longer periods

Self-Directed Clinical Learning Task Worksheet

ECPD Syndicate No.

08V139

Worksheet No.

4

Consultation Date*

7.11.2008

Patient Details*

65.F.Caucasian.Housewife

Consultation Summary*

Patient is new to the GP practice after moving here due to problems in her previous practice. She had recently lost a family member and was very upset throughout the consultation. A history and a blood pressure measurement were taken.

Identified Learning Need*

Find out more about how people cope with loss.

Learning Objective(s)

1. Outline the physical and psychological changes people may go through during loss.

2. Suggest beneficial non-pharmacological treatments to help cope with loss, both personally and with professional help.

Information Sources Used

1. GPs need models for managing bereavement. BMJ, July 1999, 319(7205).

2. Kumar, Parveen and Clark, Michael. Clinical Medicine. 6th ed. London: Elsevier Saunders Limited, 2005.

3. Parkes, Colin Murray. Coping with loss: bereavement in adult life. BMJ, March 1998, 316, 856-859.

4. Payne, Sheila, Hum, Sandra, and Relf, Marilyn. Loss and Bereavement. Buckingham: Open University Press, 1999.

5. Stahl, Stephen M. Essential Psychopharmacology of Depression and Bipolar Disorder. Cambridge: Cambridge University Press, 2001.

Answers / Information / Learning Achieved

1.Despite small variable differences in how people respond to loss, there is somewhat a detectable sequence to grieving. According to Parkes3,4, 5, grieving can be divided into the four phases:

1. Numbness: repressed reactions to the event of loss

-Physical: isolation, alcohol/drugs use

-Psychological: apathy, lack of concentration, irrational behavior, being withdrawn

2. Pining: extreme longing for the loss with resulting anxiety

-Physical: crying, loss of appetite, weight loss

-Psychological: diminished concentration, short term memory affected, irritability, depression

3. Disorganization/Despair: reflection on loss in an attempt to repair what went wrong

-Physical: overworking (to occupy self), exhaustion, sleep disturbances, loss of appetite

-Psychological: hallucinations in relation to loss, denial, anger, lack of concentration

4. Reorganization/Acceptance/Resolution: beginnings of recovery from loss

-Physical: weight regained (or even increase in weight), return of appetite

-Psychological: increased awareness of self and surroundings, decreased awareness of loss (except during occasions that may trigger strong feelings e.g. anniversaries)

2.Personal help

An important aspect of coping with loss is to stay healthy (especially during phases of grief that result in loss of appetite). Eating healthy and exercising regular will help reduce anxiety. Resorting to leisure can also help e.g. watch TV, listening to music etc.

Professional help1,3

-anticipate loss: Expecting a loss to occur can help manage resulting reactions. The aim is to balance anxiety at a level that can be dealt with so that it won't result in avoidance (too little anxiety) or breaking down (too much anxiety). This technique help patients come to terms with loss and prevent avoidance of reality, as well as make the information received more manageable.

-discussion with GP: The GP may be able to provide answers about the loss and provide support in the form of “guided mourning”2. The patient may feel they are acting abnormally, but reassurance that their grief is normal by explaining the mechanisms and symptoms of grief may help. It is also useful for the patient to know that there is nothing wrong with expressing grief. Enabling the patient to find closure and helping them move forward will help them emerge stronger after recovering from the loss.

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