OHFP.indb 74 OHFP.indb 74 30/05/2014 16:17 30/05/2014 16:17 75 WRITING IN THE NOTES 16.9.14 10:20 WR ST4 (Ackerman) Problem: Admitted last night with central chest pain ?ACS Progress: Pt co mfortable. No further chest pain. P70 reg, BP 132/81, RR 15, Sats 99% on room air. CXR show s bilateral pleural effusions (Wrong patient CJF) Rpt ECG \223\203, no new changes. Imp \200 Atypical chest pain, unlikely to be cardiac. \223\205 \200 Await cardiac markers \200\224if \223\203, \222 c \200\223 no f/u. \200 Pt wants to discuss risk factors when family arrive. Dr C J Flint F1 Bleep 3294 16.9.14 11:12 d/w with pt and wife Pt wanted to talk about cardiac risk factors. Given British Heart Foun dation lea \202 et on risk factors and talked about lifestyle changes. Cardiac nurse will see pt before discharge. Rpt cardiac markers \223\203. Pt much relieved. \222 later. Dr C J Flint F1 Bleep 3294 16.9.14 15:34 Review, F1 (Flint) No change. TTO completed. \222 . Dr C J Flint F1 Bleep 3294 Fig. 2.2 Example of entries in medical notes. 16/9/14 09:00 Mrs Jones \200\231 current problems: 1 Left lower lobe pneumonia \200\223 on day 2 IV co-a moxiclav 2 Atrial \201 brillation (Z009) \200\223 on digoxin and warfarin 3 Hypertension \200\223 well controlled on ramipril 4 Previous CVA (2009) with right sided weakness 5 Pr evious left knee replacement (2002) 6 Not able to manage at home \200\223 needs increased package of care prior to D/C Fig. 2.3 Example of a problem list. _OHFP.indb 75 _OHFP.indb 75 30/05/2014 16:17 30/05/2014 16:17 76 CHAPTER 2 Life on the wards Common symbols in the notes Home Normal Plan Left Right Temperature Diff erential diagnosis Diagnosis Impression Prescr iption or drugs Symptoms Treatment Investigations On examination Negative Positive Equivoca l Presence noted Present signifi cantly Present in excess History of Discussed with or disc ussion with Ward round Review Follow-up Asked to see patient In-patient Out-patient Complai ns of or complaining of Patient With At Eating and drinking Nausea and vomiting Diarrhea an d vomiting Bowels open Passing urine Bloods No/negative (as in previous MI) Primary Secon dary Tomorrow morning Nursing Staff \222 \223\203 \223\205 \223\201 \223\207 \223\211 dd/DD/DD/ZZ x/Dx/Z Imp Rx Sx Tx Ix O/E \200\223ve +ve +/ \200\223 + ++ +++ h/o d/w WR r/v f/u ATSP IP OP c/o Pt c \200\223 @ E+D N+V D+V BO PUing blds 1 2 mane N/S OHFP.indb 76 OHFP.indb 76 30/05/2014 16:17 30/05/2014 16:17 77 ANATOMICAL TERMS AND PLANES Anatomical terms and planes The anatomical position Anatomical planes Coronal or frontal plane Sagittal plane Axial, transverse or horizontal plane Fig. 2.4 The anatomical position and anatomical planes. Commonly used anatomical terms and their meanings Anterior/ventral Contralateral Coronal/frontal plane Distal Inferior/caudal Ipsilateral Lat eral Medial Palmar Plantar Posterior/dorsal Prone Proximal Radial Front of the body On the opposite side Divides anterior from posterior Away from the trunk Away from the head On the same side Away from the midline Towards the midline Pertaining to the palm of the hand Pertaining to the sole of the foot Back of the body Face down positio n Close to the trunk The lateral (thumb) aspect of the forearm Divides left side from right side Towards the head Face up position Sagittal plane Superior/cephalic Supine Transverse/horizontal/axial plane Divides upper and lower sections Ulnar The medial (little fi nger) aspect of the forearm _OHFP.indb 77 _OHFP.indb 77 30/05/2014 16:17 30/05/2014 16:17 78 CHAPTER 2 Life on the wards Discharge summaries (TTOs/TTAs) \200\230TTOs \200\231 or \200\230TTAs \200\231 (to take o ut or away) are summaries of the patient \200\231s admission from the ward doctors sent to the patient \200\231s GP and are often the most complete summary written. TTOs are written on a computer (very occasionally by hand with carbon copies); you should receive training o n the local system as part of induction. They form a point of reference at future clinic vi sits or admissions. They also provide clinical coding informa- p tion with which the hospit al bills primary care for care provided. p y p TTOs should contain the following information \200 Patient details: name, DoB, hospital n umber, address \200 Consultant and hospital ward \200 Presenting complaint, clinical fi ndings, and diagnosis \200 Investigations/procedures/operations/treatment, including any complications Treatment on discharge and instructions to the GP, including medications stopped and reasons why Follow-up arrangements \200 Your name, position, and bleep number. When to write TTOs TTOs should be written as soon as you know the patient is likely to be d ischarged. This allows the drugs to be dispensed from drugstore as soon as possible so that the patient \200\231s discharge is not delayed. See Fig. 2.5. \200 Begin to enter inform ation on the TTO at the earliest opportunity; check any queries with your team, particularl y regarding the principal diagnosis \200 Check the duration of the medication for dischar ge (eg ABx) and stop any unnecessary drugs (eg prophylactic low-molecular-weight heparin) Check drug doses and frequencies with the BNF, your seniors, a pharmacist or by calling you r hospital \200\231s drug information-line Check required follow-up appointments, give details and be clear on who will arrange them(e g the ward clerk or the clinic administrators) \200 Phone the GP if the patient needs an early check-up, has a poor social situation, or self-discharges. It may take several days f or a TTO to reach the GP: written instructions such as check K+ in 3/7 are unsafe \200 Hand the TTO and the patient \200\231s drug chart to the patient \200\231s nurse or inform them that you have completed it to avoid unnecessary bleeps \200 If you are unsure whethe r the TTO has been done check the drug chart; there is often a tick in a box showing if TTOs have been dispensed Discuss the diagnosis, results, and discharge plan with your patient; if they understand th e management plan they are more likely to comply. Controlled drugs for TTOs These are slightly more complex, but can still be written by F1 d octors in most trusts. They must include all the information in Table 2.1. CD pre- scriptio ns are only valid for 28d from the date of signing and only 30d of g p CDs can be dispensed on a single prescription. See also Fig. 2.6. p p g Examples of controlled drugs Morphine, diamorphine, pethidine, fentanyl, alfentanil, remife ntanil, methadone, methylphenidate (ie Ritalin ), cocaine. OHFP.indb 78 OHFP.indb 78 30/05/2014 16:17 30/05/2014 16:17 79 DISCHARGE SUMMARIES (TTOS/TTAS) Table 2.1 Controlled drug TTOs must meet the following requirements The prescriber \200\231s name and work address \200 Signed and dated by the prescriber \200 All the information included in a regular TTO. \200 The drug name, dose, frequency and route \200 If the drug is a \200\230preparation \200\231 (ie liquid) state the conce ntration \200 The total volume (ml) or weight (mg) of the preparation or the total number of tablets/capsules/patches in words and fi gures. Content rules Drug rules Discharge form McBurney City Hospital Name: Eleanor Rigby DOB: 26/06/1932 Hospital number: W876470 Ward: E4 NHS/Private Presenting complaint: Chest pain Diagnosis: Musculoskeletal ch est pain Co-morbidities: Anxiety, L THR 2001 Investigations: ECG shows LBBB, cardiac marker s Discharge Plan/Additional notes to GP: Has had some toothache recently, advised her to se e a dentist Discharge Medications: Consultant: Dr Singh Date of admission: 15/09/2014 Date of discharge: 16/09/2014 In-patient/Out-patient/Daycase Frequency Drug Dose Route Duration GP to continue? Co-amoxiclav 625mg TDS PO 5d No Paracetamol No 1g QDS PO 7d Morphine oral solution 10ml BD PO 5d No Total = 100ml (one hundred milliliters) (10mg/5ml) Follow up? None required Print name \200 Flint \200 Date: 16-09-2014 Signature C J Flint Fig. 2.5 Sample TTO. Morphine oral solution (10mg/5ml); dose: 10ml/12h PO for 5 days. Total = 100ml (one hundred milliliters) Morphine sulfate MR 10mg capsules; dose: 10mg/12h PO for 14 days. Total = 280mg (two hundre d and eighty milligrams) Fentanyl 50 patch; dose: one patch every 72 hours for 14 days. Total = 5 (five) patches Fig. 2.6 Sample TTOs for controlled drugs excluding the patient and prescriber \200\231s de tails. _OHFP.indb 79 _OHFP.indb 79 30/05/2014 16:17 30/05/2014 16:17 80 CHAPTER 2 Life on the wards Fitness to work notes1 As the most junior member of the team, the writing of \200\230fi t notes \200\231 (Statement of fi tness for work, Form Med 3) will usually fall to you. These notes provide evidence that your patient has a condition that will impact upon their fi tn ess to work and enables statutory sick pay and social secu- rity payments. You can advise t hat a patient is not fi t for work or may be fi t for work under restricted conditions. A separate form (Form Med 10) may be required for periods of time spent as a hospital inpa tient. These forms are available in both electronic and paper formats from the Department f or Work and Pensions \200\223 ask the ward clerk for advice. A sample is shown below in Fi g. 2.7. Usage Typical uses include surgical patients who have been admitted routinely for a procedure and require time off work to recover post-operatively. Medical patients may also require time to convalesce, whilst patients with wounds or injuries may require workplace adjustments during their recovery period on return to work. Patients can self-certify for t he fi rst week of any illness so do not require a note if they will be able to return to wo rk within this time. Never instruct a patient to see your GP for a sick note where the ne ed for this can be anticipated at the time of discharge \200\223 the duty to provide a Med 3 rests with the doctor with clinical responsibility for the patient. Format You should fi ll in the patient \200\231s name, a brief explanation of their needs (sickness absence, ad justments to the workplace, or modifi ed duties), and accurate clinical diagnosis (without mentioning intimate details that might be damaging to the wellbeing of patient for their em ployer to discover). Sign and date the form. You need to give an appropriate amount of time for the patient to recover from their illness as reasonably anticipated at the time of dis charge, up to a maximum of 3mths. If recovery takes longer than you anticipate, the patient can then see their GP for a further note. S A M P L E Fig. 2.7 Example of Statement of Fitness for Work (Med 3). Reproduced with permission from the Department of Work and Pensions. (cid:27)www.dwp.gov.uk/ healthcare-professional/news/s tatement-of- \201 tness-for-work.shtml 1 Useful guidance available at (cid:27)www.rcplondo n.ac.uk/sites/default/ \201 les/completion-statement- \201 tness-for-work.pdf OHFP.indb 80 OHFP.indb 80 30/05/2014 16:17 30/05/2014 16:17 81 REFERRALS Referrals Referring a patient to another medical team can be one of the most diffi cult par ts of the job. The other doctor is often very busy and will inevitably know more about the patient \200\231s condition than you (hence the referral). At times it can feel like they a re trying to make you feel stupid \200\223 this is rarely the case. Consider this from the point of view of the other doctor: They need to establish: \200 How unwell the patient i s \200 How urgently they need to be seen \200 What investigations have already been don e and what still need to be done to assist them in their review If they are the right person to see them. You will often be asked to refer a patient by you r senior: Ask them directly: \200 Why does the patient need referring? \200 What do the y want the other team to do (advise over the phone, formal review, take over care, see in c linic, procedure/operation)? How urgent is the referral? Next, think about what information the other doctor will want. Many specialties have additional components to history and examination that you will need t o be able to describe, see the pages in the history and examination chapter; if necessary, go and examine the patient yourself: Breast surgery b p141 Hematology b p140 Psychiatry Cardiology b p128 Neurology Dermatology b p138 Obstetrics Endocrine b p137 Oncology ENT Gastro Gynecology b p156 Pediatrics b p160 b p373 b p132 Renal b p158 Respiratory b p130 b p140 Rheumatology b p146 b p144 Opht halmology b p142 Urology b p154 b p131 Orthopedics b p146 Vascular surgery b p128 b p164 Before referring make sure you have the following in front of you: \200 Hospital notes wi th patient \200\231s name, DoB, hospital number and ward \200 Obs chart (including latest set and trends) and the patient \200\231s drug card \200 Most recent results or serial r esults sheet. Phone the relevant specialist, introduce yourself and say, \200\230My consul tant has requested that I refer one of our patients who has [medical condi- tion] with the view to [taking over care, advising on treatment, etc] \200\231. Off er a brief summary of their condition and management; look up the relevant condition or referral page (above) before calling so that you know what you are talking about. It is ne ver acceptable to make a referral for a patient you know little about just because it s on the jobs list. Always know what investigations have been performed so far, and what the res ults were \200\223 sit at a computer with these already called up when you make the call. Before you put the phone down determine exactly what action the specialist will do and when this will take place. Write the referral and outcome in the notes along with the specialis t \200\231s name and bleep number. _OHFP.indb 81 _OHFP.indb 81 30/05/2014 16:17 30/05/2014 16:17 82 CHAPTER 2 Life on the wards Referral letters The basics These may be used for within hospital referrals (using a specifi c referral slip ) or for referral to outpatient clinics or other hospitals (use hospital headed notepaper). 1 Try to make referral letters as professional as pos- sible. It is essential that the refe rral contains the following information: \200 Who you are and how to contact you \200 W ho the patient is (full name, DoB, hospital number, address) \200 Why you want them to be seen. Fig. 2.8 is an example of an referral letter for you to follow. Diagnoses List all the patient \200\231s active diagnoses and relevant past diagnoses; try to put the ones most relevant to the specialty you are referring to near the top. Presenting complaint Start with a statement telling the other doctor what you would like th em to do (eg see on the ward, in clinic, or give written advice). Give a brief description of the patient \200\231s presentation and management during this admission as if you were w riting a discharge summary. Medical information This will form the bulk of the referral. Think carefully about what inf or- mation will help the other doctor in deciding when to see the patient and how to manage them; see the relevant history and examination page (b p123). Try to set the referral out like a brief medical clerking and make sure you include: \200 Relevant investigation resu lts \200 Latest medications \200 Relevant social history (particularly if this will aff ect how they are seen in clinic, eg poor mobility, language diffi culties). Finishing the referral You should write your name, post and consultant \200\231s name. If s ending an outpatient or inter-hospital referral, you should also include who the letter is copied to ( \200\230cc \200\231 stands for carbon copy) which will include the notes and GP . It is recommended practice to send a copy to the patient though this varies between trust s and doctors. Sending the letter Ask your ward clerk for assistance. Print off several copies, sign them and ensure it is clear where each copy should be sent. Faxing a letter If you need to fax a copy then include a header sheet. This is simply a pie ce of paper saying who the fax is to, who it is from and the number of pages (and whether t his includes the header sheet). You may need to add a number to the fax number to get an ou tside line, eg \200\2309 \200\231. File the faxed letter and the sent message confi rmatio n (with date and time sent) in the patient \200\231s notes. 1 Non-urgent outpatient referrals to other specialties should go through the patient s GP, since payment comes from their budget. If this is required, a note should be made on the di scharge summary with specifi c details of why this referral is being recommended. Urgent re ferrals (especially for suspected malignancies) can still be made directly. Check with the consultant recommending the referral. OHFP.indb 82 OHFP.indb 82 30/05/2014 16:17 30/05/2014 16:17 83 REFERRAL LETTERS Dr Charles Flint McBurney City Hospital McBurney McB1 4CT Dr I N Haler Respiratory Consultant McBurney City Hospital McBurney McB1 4CT 17th September 2014 Dear Dr Haler, Re: Eleanor Rigby, DoB 26/06/32, Hospital No. W876470 Diagnoses: (1) COPD (2) Musculoskeletal chest pain (3) LBBB (4) Hiatus hernia Please review Mrs Rigby in your respiratory clinic to treat her deterioration in respirator y function with COPD. Mrs Rigby is an 82-year-old lady who presented with chest pain. She w as admitted overnight and diagnosed with musculoskeletal chest pain following normal repeat cardiac markers. She was discharged on 16/9/2014. During her admission she was noted to ha ve reduced exercise tolerance (from 200m to 50m). Her latest ABG on air is: PaO2 PaCO2 9.3kPa 6kPa We feel that her COPD is the likely cause of her limited mobility and she has been referred for repeat respiratory function tests. PMH She was diagnosed with COPD by you 3 years ago following respiratory function tests which showed an FEV1 of 65% predicted. She has not had any acute exacerbations in the last year. DH She is currently on: Salbutamol inhaler Tiotropium inhaler Symbicort inhaler (200/6) Bendroflumethiazide 2 puffs 18mcg 2 puffs 5 mg PRN OM BD OM SH She lives alone but gets home help for cleaning. She can walk about 50m with a stick. Sh e stopped smoking 30 years ago after 50 pack years. Yours sincerely, Dr Charles Flint F1 to Dr N Stemi cc GP Eleanor Rigby Notes Fig. 2.8 Example of a referral letter. _OHFP.indb 83 _OHFP.indb 83 30/05/2014 16:17 30/05/2014 16:17 84 CHAPTER 2 Life on the wards Investigation requests Increasingly, these are handled electronically. For paper forms, com plete: \200 Full name and at least one other patient identifi cation detail (ie DoB, hospital number or address); G+S/X-match requires at least two more \200 Status (in-patie nt/out-patient) and location (ward or home address) \200 Name, position, and contact deta ils of doctor ordering the test \200 Date, test(s) requested and reason for request Clini cal information Appropriate information on request forms aff ects how the test is per- form ed and reported; too much information is better than too little. Justify the investigation requested, even if a simple blood test. Always consider if a test is really required, no ma tter how trivial \200\223 daily routine bloods are often unnecessary, waste resources an d cause patient discomfort. \200 Blood tests Brief clinical details may be acceptable, eg \200\230chest pain \200\231, \200\230suspected PE \200\231. Some tests require more information, eg blood fi lms, antib odies, hormones, drug levels (doses and timing of doses), genetics \200 Histology Describ e the macroscopic appearance of the tissue as well as the clinical suspicions, radiology fi ndings and any specifi c questions Microbiology As a bare minimum include the sample type (eg urine) and current/recent antibiotics; the more information you include the better the microbiolog ist will be able to interpret laboratory results Radiologygy see y b p85. \200 Radiology see b p85. Chasing results As a junior doctor, a large proporti on of your time will be spent checking results. This used to involve chasing endless piec es of paper which were prone to going astray. With the move to full computerisation, most r eports are now easily avail- able: Simply keep track of the investigations you have request ed then check the results systems regularly. Nonetheless, there are a few tips to consider: \200 For urgent results, particularly where there might be a delay in transcription (eg radiology reports) or uploading onto the system (eg biochemistry/ hematology) you can call the lab, or reporting room (or attend in person). You will be interrupting a colleague doin g their job, so do not abuse this privilege \200 Blood samples reaching the lab early in the day will be processed fi rst; it can help to beat the rush that will hit the labs after the phlebotomists do their rounds \200 Rarer tests may only be run on samples reaching t he lab by a certain time, or on certain days of the week, or may even need to be send to an outside lab \200\223 fi nd out local policies and, if in doubt, call the lab before takin g the sample Bloods requiring urgent processing should be marked as such; indiscriminate use of this fac ility will delay genuinely critical results. Arrange an urgent porter (or take to the lab y ourself ). At top speed, biochemistry results take around 20 \200\22330min and hematology r esults around 30min. For microbiology results, preliminary evidence of positive cultures is usually reported at 48h; otherwise consider telephoning the lab at this stage to see if there is any preliminar y growth. Positive results will be further cultured and tested over subsequent days to give a more detailed analysis For histology, all biopsies taken with a provisional diagnosis of malignancy should be processed urgently, but this depends upon sample being correctly marked at the ti me; call the pathology secretaries if there is any doubt or delay. Be careful not to make i mportant decisions on preliminary results \200\223 if there is an urgent clinical situatio n in which you are unsure whether to act on a specifi c result, ask your seniors. OHFP.indb 84 OHFP.indb 84 30/05/2014 16:17 30/05/2014 16:17 85 RADIOLOGY Radiology Since Wilhelm R ntgen s fi rst hazy images of the bones of his wife s hand in 18 95, radiological imaging has revolutionized the approach of physician and surgeon alike in diagnosis and treatment. Imaging modalities \200 X-rays exploit the diff erent absorbance of a pulse of X-ray radiation by diff erent anatomical structures and foreign bodies. This allows the visualization and distinction of metal, bone, soft tissue, fat, fl uid and air \200 Fluoroscopy uses X-ray images acquired in real time, often with addition of a contrast material, eg coronary angiogram or barium swallow \200 CT uses a series of 2D X-ray images acquired in diff erent planes to construct cross-sectional 3D images. IV or PO contrast can be used to accentuate, eg blood vessels or the GI tract MRI uses strong magnetic fi elds to align hydrogen nuclei (protons) within tissues. Disturbance of the axis of these protons by radiowaves allows the recording of radiowaves emitted as the protons return to baseline. MRI off ers excellent soft tissue imaging and does not require ionizing radiation exposure. Image acquisition can be slow an d require multiple diff erent sequences whilst the patient lies in a cramped space Ultrasound exploits the diff erential refl ection of high-frequency sound waves to visualize structures, including soft tissues in real time. Overlying air and fat c ompromise signal quality, and bone penetration is poor \200 Nuclear medicine depends upon the detection of radiation emitted by the decay of radiolabels attached to substances with affi nity for certain body tissues. Positron emission tomography (PET) is a specifi c form of nuclear medicine that typically uses radiolabelled glucose analogs to detect regions of metabolic activity, eg in cancer. These techniques are especially powerful when combined w ith anatomical imaging approaches such as CT to increase localization (eg PET/CT). Requesting Selecting, performing, interpreting and managing medical imaging resources falls to the specialty of radiology. These doctors often have little direct contact with your pa tient and depend upon eff ective communication from you to select and prioritize imaging mo dalities (including appropriate use of contrast agents and imaging sequences), as well as i nform their image inter- pretation; always include specifi c clinical questions on request forms. Radiologists have a vital duty to limit unnecessary exposure to ionizing radia- tion . Doses involved can range from minimal (eg CXR: <1% annual back- ground radiation exposure ) to substantial (eg contrast CT C/A/P: 10yr background radiation). Even a trivial radiati on exposure will be associated with an appreciable cancer risk to a population if performed often enough.1 Always ensure you know why any investigation you are asked to request is ne eded, how urgent it is, and how it will change the patient \200\231s manage- ment. For less urgent investigations or simple X-rays, it is usually enough to submit a request giving su ffi cient clinical information. For more urgent or specialist imaging, request the scan or fi ll in the form, then phone or go to the radiology department, and speak to the duty radi ologist. Be polite, explain why the test has been requested (and by whom), and ask if there is any way it could be performed today if necessary. If this fails and the test is very ur gent, your registrar should discuss with the radiologist directly. 1 Converting low-dose ra diation exposure to cancer risk is fraught with diffi culty; attempts to extrapolate from cancer rates in those exposed to very high dose radiation are unsound. The general principle must be to keep exposure As Low As Reasonably Possible (ALARP). _OHFP.indb 85 _OHFP.indb 85 30/05/2014 16:17 30/05/2014 16:17 86 CHAPTER 2 Life on the wards Pain Worrying features diHR, diBP, diRR, dGCS, sweating, vomiting, chest pain. Think about Headache (b p358), chest pain (b p241), abdominal pain (b p289), back pain (b p 356), limb pain (b p448), infection (b p482; common post-operative, musculoskeletal, chroni c pain. Ward round Assess daily the eff ectiveness of analgesia (whether pain hinders activity (cou ghing, getting out of bed etc)) and about side eff ects (drowsiness, nausea, vomiting and c onstipation). Ask about (SOCRATES) Site, Onset, Character, Radiation, Alleviating factors, Timing (durati on, frequency), Exacerbating factors, Severity, associated features (sweating, nausea, vomi ting); PMH stomach problems (acid refl ux, ulcers), asthma, cardiac problems; DH allergies, tolerance of NSAIDs, analgesia already taken and perceived benefi t; SH?drug abuse. Obs iH R and iBP suggests pain; RR, pupil size and GCS if on opioids. Look for source/cause of pai n. Investigations These should be guided by your history and examina- tion; none are specif i cally required for pain. Treatment No patient should be left in severe pain, consider tit rating an IV opioid after an antiemetic (b p304). Use the steps of the WHO pain ladder (Tab le 2.4). Ensure regular analgesia is prescribed, with ade- quate PRN analgesia for breakthr ough pain. If a patient has moderate or severe pain start at step 3 or 4; using paracetamol and NSAIDs reduces opioid requirement and consequently side eff ects. Table 2.4 WHO pain ladder Strong opioids Weak opioids NSAIDs Paracetamol (cid:57) (cid:57) (cid:57) (cid:57) Step 3 (cid:57) (cid:57) Step 2 (cid:57) (cid:57) Step 4 (cid:57) Step 1 Paracetamol contraindications moderate liver failure; side eff ects rare. \200 Paracetamo l 1g/4h, max 4g/24h PO/PR/IV. NSAIDS good for infl ammatory pain, renal or biliary colic an d bone pain; contraindications (BARS) Bleeding (pre-op, coagulopathy), Asthma, Renal diseas e, Stomach (peptic ulcer or gastritis). 10% of asthmatics are NSAID-sensitive, try a low do se if they have never used them before. Avoid use in the elderly. Increased risk of CVA/MI; side eff ects worsen renal function, GI bleeding (upper and lower \200\223 co-prescribe a PPI or high-dose H2-blocker for those at risk: \211 65 yrs, previous peptic ulcer, use of other medicines with GI side eff ects, or major comorbidity). Both NSAIDs and COX-2 inhibi tors are associated with increased risk of MI and CVA; use with caution in those at risk. \200 Ibuprofen 400mg/6h, max 2.4g/24h PO, weaker anti-infl ammatory action, but less risk of GI ulceration Diclofenac 50mg/8h, max 150mg/24h PO/PR (also IM/IV, see BNF). OHFP.indb 86 OHFP.indb 86 30/05/2014 16:17 30/05/2014 16:17 87 PAIN COX-2 inhibitors are similar to NSAIDs and share an increased risk of MI and CVA, but with less risk of gastroduodenal ulceration. Weak opioids Dependence and tolerance to opioids do not occur with short-term use for acute pain. Consider prescribing regular laxatives and P RN antiemetics, use with caution if head injury, iICP, respiratory depression, alcohol into xication; side eff ects N+V, constipation, drows- iness, hypotension; toxicity dRR, dGCS, p inpoint pupils (see Table 2.5). \200 Codeine 30 \200\22360mg/4h, max 240mg/24h PO/IM, con stipating \200 Dihydrocodeine 30 \200\22360mg/4h, max 240mg/24h PO, constipating \200 T ramadol 50 \200\223100mg/4h, max 400 \200\223600mg/24h PO/IM, stronger than others and less constipating for long-term use. Table 2.5 Weak opioid to oral morphine converter Drug and dose (oral route) Codeine 8mg Codeine 30mg/6h Dihydrocodeine 10mg Dihydrocodeine 3 0mg/6h Tramadol 50mg Tramadol 100mg/6h Equivalent to oral morphine 0.7mg oral morphine 10mg oral morphine/24h 1mg oral morphine 12 mg oral morphine/24h 5mg oral morphine 40mg oral morphine/24h Paracetamol and weak opioid combinations useful for TTO analgesia; it is better to prescrib e the components separately in hospital: \200 Co-codamol 30mg codeine and 500mg paracetam ol; two tablets/6h PO, nurses must give 8/500 dose if 30/500 not specifi ed Co-dydramol 10mg dihydrocodeine and 500mg paracetamol; two tablets/6h PO Co-proxamol contained dextropropoxyphene and has been withdrawn owing to its potential toxicity and poor analgesic properties. Some patients may still be t aking this, but it is not prescribed to new patients. Strong opioids morphine is used for s evere pain. Use regular fast-acting opioids for acute pain with regular laxatives and PRN o r regular antiemetics. See \200\230weak opioids \200\231 for cautions, side eff ects and t oxicity. Use only one method of administration (ie PO, SC, IM, or IV) to avoid overdose: \200 Oral eg Sevredol or Oramorph 10mg/2 \200\2234h \200 SC/IM morphine 10mg/2 \200 \2234h or diamorphine 5mg/2 \200\2234h \200 IV titrate to pain; dilute 10mg morphine into 10ml H2O for injections (1mg/ml), give 2mg initially and wait 2min for response. Give 1mg/2min until pain settled o bserving RR and responsiveness. Long-acting opioids are used after major surgery or in chronic pain. Use standard opioids i nitially until morphine requirements known (b p93) then prescribe a regular long-acting dos e along with PRN fast-acting opioids to cover breakthrough pain (equivalent to 15% or one-s ixth of daily requirements). Laxatives will be needed. \200 Oral MST dose = half total daily oral morphine requirement (b p93) given every 12h, usually 10 \200\22330mg/12h, max 400mg/24h \200 Topical fentanyl patch lasts 72h, available in 12 \200\223100micrograms/h doses. Naloxone given orally anta gonizes the constipating eff ects of opioids, but is metabolized on fi rst pass through t he liver and does not interfere with analgesic eff ects. Compound preparations oxycodone/na loxone preparations (eg Targinact ) may be of benefi t for chronic pain relief in those wh o develop painful constipation despite regular laxatives. _OHFP.indb 87 _OHFP.indb 87 30/05/2014 16:17 30/05/2014 16:17 88 CHAPTER 2 Life on the wards Other analgesic options/adjuncts Nefopam a non-opioid analgesia that can be given with paracetamol, NSAIDs, and opioids; con traindications epilepsy and convulsions; side eff ects urinary retention, pink urine, dry m outh, light-headedness. \200 Nefopam 30 \200\22390mg/8h PO. Hyoscine butylbromide gives g ood analgesia in colicky abdo pain; contrain- dications paralytic ileus, prostatism, glauco ma, myasthenia gravis, por- phyria; side eff ects constipation, dry mouth, confusion, urine retention. \200 Buscopan (hyoscine butylbromide) 20mg/6h PO/IM/IV. Diazepam acts as a muscle relaxant, eg spasm with back pain contrain- dications respiratory compromise/failure , sleep apnoea side eff ects drowsiness, confusion, physical dependence (use for short-term only). \200 Diazepam 2mg/8h PO. Quinine used for nocturnal leg cramps; contraindications haemoglobinuria, optic neuritis, arrhythmias; side eff ects abdo pain, tinnitus, confusion . \200 Quinine 200mg/24h PO \200\224at night. Patient-controlled analgesia (PCA) a syring e driver that gives a bolus of IV opioid (usually morphine, but occasionally tramadol or fe ntanyl) when the patient activates a button. A background infusion rate, bolus dose and max imum bolus frequency can be adjusted to prevent overdose/ pain; changes to the PCA are usua lly undertaken by the pain team (see box). The patient must be alert, cooperative, have IV access and their pain under control before starting. Check hospital protocols. Epidurals are inserted by the anesthetist in theater usually prior to surgery. A local anes thetic infusion ( opioid) anesthetizes the spinal nerves, and usually produces a sensory l evel below which the patient has little or no feeling; if this level rises too high (higher than T4 (nipples)) there is risk of respiratory failure. The anesthetist or pain team (see box) usually look after epidurals and their dosing post-op. Complications include local ha ematoma, abscess (causes cord compression, b p357) or local infection; if there are concern s about an epidural speak to the anesthetist covering acute pain immediately. Syringe driver These are used mainly for palliative analgesia and symptom control (b p93). Pain team Most hospitals have pain teams, often sub-divided into acute and chronic services . These comprise of nurses and a pain specialist (usually an anesthetist). The acute pain s ervice is sometimes run by the Outreach Team. In-patients with pain issues can be referred to the teams for assessment, though ensure all simple measures have been undertaken to addr ess the patient \200\231s pain fi rst, namely identify and treat cause of pain, and ensure the patient is receiving adequate simple analgesia (regular paracetamol, NSAIDs (if not con traindicated), and an opioid, if appropriate). OHFP.indb 88 OHFP.indb 88 30/05/2014 16:17 30/05/2014 16:17 89 PAIN Neuropathic and chronic pain Neuropathic pain is caused by damage to or chronic stimulation of nerve fi bres, eg radiculopathy (nerve root pain), peripheral neuropathy, and phantom l imb pain. The pain tends to be diffi cult to describe or pinpoint and is often aching, burn ing, throbbing, or shooting in nature. Chronic conditions can cause signifi cant pain, eg c hronic pancreatitis, arthritis, post-traumatic, DM, trigeminal neuralgia; there is frequent ly a psychogenic component. Standard analgesia is often ineff ective and the services of a chronic pain spe- cialist should be sought. Commoner chronic pain therapies include: Tricyclic antidepressants given at a low dose; contraindications recent MI, arrhythmias; si de eff ects dry mouth, constipation, sedation. This is the fi rst-line treatment for neurop athic pain according to NICE guidance.1 \200 Amitriptyline 10 \200\22375mg/24h PO. Pregab alin Contraindications hypersensitivity, pregnancy, lactation; side eff ects dizziness, tir edness, cerebellar signs. Can be used instead of ami- triptyline as fi rst-line treatment f or neuropathic pain. \200 Pregabalin 75 \200\223300mg/12h PO. Duloxetine Contraindication s uncontrolled hypertension, pregnancy, seizures; side eff ects nausea, dizziness, somnolen ce, dry mouth. First line for painful diabetic neuropathy. Avoid abrupt discontinuation. \200 Duloxetine 60 \200\223120mg/24h PO. If fi rst-line drugs are unsuccessful, combinatio n therapy with two or more agents can be considered. If this is unsuccessful then referral for a specialist opinion should be considered. The following are examples of more advanced therapies a pain specialist may prescribe. TENS Transcutaneous Electrical Nerve Stimulation is believed to aff ect the gate mechanism of pain fi bres in the spine and/or to stimulate the production of endorphins. Use at a high frequency for acute pain or slow frequency for chronic/neuropathic pain. Steroids and nerve blocks Injections of steroids combined with local anesthetic into joints or around nerves can reduce pain for long periods. This needs to be done by a specialist. Sympathectomy and nerve ablation The ablation of sensory and sympa- thetic nerves by surger y or injection; used as a last resort in some forms of chronic pain. Acupuncture Eff ective in some trials and with a greater evidence base than most complementary therapies. Counseling and cognitive \200\223behavioral therapy (CBT) to develop coping strategies are widely studied in chronic pain and may be considered by appropriately skilled specialists. Concern remains that it make things worse for some patients. Some terms in chronic pain Allodynia Hyperpathia A short episode of discomfort causes prolonged, severe pain Hyperalge sia Discomfort which would otherwise be mild is felt as severe pain Seemingly harmless stimuli such as light touch can provoke pain 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG173 _OHFP.indb 89 _OHFP.indb 89 30/05/2014 16:17 30/05/2014 16:17 90 CHAPTER 2 Life on the wards