csa courses cases snoring.pdf

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CSA course case CSA prep 2011

CSA course cases CANDIDATES BRIEF

Patient medical records Name: Paul Phillips (42 year old) Past medical history: Hypertension, back pain with sciatica Drug history: Ramipril 2.5mg od, amitriptyline 50mg on

Last consultation 2 years ago Dr Singh: MRI scan back shows small bulge at level L4/L5. Pt complaining of ongoing back pain for several years. Has only tried paracetamol. Keen to try other medications. Pain shoots to his left leg. No red flags. Offered anitriptyline tablets and rw







CSA course cases Snoring ACTORS BRIEF Background: You are Paul Phillips a 42 year old Taxi driver Approach: You are casually dressed, and speak with a cockney accent. You have a laid back persona Opening statement: Doc I need some help with my ZZZs History Open history:

Your misses thinks you snore loudly everyday but you do not think you have a problem. She reports that it wakes the baby and kids up all night

Your misses reports its been going on for several years but now for the last 1 year it is intolerable. She has had to purchase ear plugs but feels it doesnt work. She has been shaking me or kicking me a few times but you are completely unaware

Now she is sleeping in the next room with the kids as she cannot take it anymore. She is exhausted by having disturbed sleep and attending to the kids who wake up all time throughout the night. She is feeling tired all the time because of your snoring

CUE: You are getting worried about the number of nights she is spending away from your bed Reveal history if asked:

You are working longer hours driving your taxi to pay for the bills with the new baby and feeling drained and run down all the time

CUE: You have a lingering headache when you get up and can find it difficult to concentrate so you get a quick nap at work and it disappears

You get a quick nap by parking the car on the hard shoulder on the motorway to get twenty winks Your wife states she has had to shake you because she swears that you hold you breath when you

sleep but you thinks she is making it up as thats just daft. It happens about twice a night but shes making it up as its nonsense

After a hard days work you go to the pub and enjoy a drink and a bit with your mates most week days. You have a bit more on the weekend with friends watching the football

CUE: Your mood is so-so. You are a bit down how your marriage is on a downward path because of the snoring

You do not have any fever sweats, cough or colds. You do not suffer from sore throats







You do not feel colder than normal, or have dry skin or neck swellings You do not have any nasal congestion or nasal problems Ideas: You dont think you have a snoring problem (in denial) but only came because the misses

forced you. Concerns: You are worried it is affecting your marriage and may eventually lead to a separation. You

are growing apart since she is sleeping away from your bed Expectations: You would like some sleeping tablets so that you can go into a deeper sleep so it would

not bother your wife. Also you would like some ear plugs of your own to stop your wife whining about it so much!

Medical history

You were told you have a back problem and find the only way to ease the pain is lying on your back without pillows

You have high blood pressure and started on medication for it You do not suffer from tonsillitis, hypothyroidism or hayfever or rhinitis

Drug history

You take amitriptaline tablets regularly for the back and finds it works well. You take 1 tablet regularly at night

You take blood pressure medicines

Social history

You smoke 25 cigarettes a day since you were a teenager. It helps relaxes the nerves before you get home

You have 2 children, Andrew aged 6months and Kevin aged 5 years. Your older child also moan about how much you snore. He has started calling you the Noisy Gruffalo

You drink 2 pints of beer a day with friends and think that you are just under the limit when you drive home. You drink 3 pints on the weekends with mates.

You have a small nightcap (1 shot of whisky) just before you sleep Diet: You eat food on the go. Mostly fast food burgers, chips and bacon and eggs. Occupation: you work as a taxi man and mainly do the airport routes so on the motorways all the time Family history

You are not aware of any medical problems in your family







If the doctor suggests you have sleep studies then accept but suggest he is may be taking his snoring too seriously and some sleeping tablets should do the trick

You are happy to take on board lifestyle advice given to you i.e. reduce alcohol, loose weight, stop smoking

If doctor says he is worried that your symptoms are affecting your driving reassure the doctor and be dismissive

If the doctor suggests it can affect your health i.e. inc risk of IHD, CVA etc then be surprised and be attentive to the advice

You are willing to bring your wife to the next appointment, but think referrals to couples therapy or counselling is for weak people

Snoring EXAMINER DATA GATHERING Positive indicators:

Gathers information regarding presenting complaint. i.e. OSA morning headaches, apnoea, lack of freshness in the morning

Attempts to excludes other pathology i.e. tonsillitis, hypothyroidism Makes likely diagnosis of OSA Request to perform a targeted examination i.e. examine neck (goitre), neck circumference, BP, neck

circumference etc

Negative indicators:

Fails to identify based on probabilities a likely diagnosis of OSA Fails to take a history of precipitants analgesia, sleep posture, alcohol and nightcap

INTERPERSONAL SKILLS Positive indicators:

Develops good rapport with the patient for patient to feel comfortable to discuss health beliefs Allows for an environment to discuss marital strain as well as impact at work Explores ICE and request for sleeping tablets

Negative indicators:

Fails to explore the social context of the symptoms and impact on marriage or work Fails to develop rapport with the patient and is doctors centred







CLINICAL MANAGEMENT SKILLS: Positive indicators:

Offers lifestyle advice re: dietary (cut down chocolates, caffeine), advise about sleep hygiene and link of diet and sleep in making headaches worse

Recommend patient to complete Epworth sleepiness scale Advice posture advice avoid sleeping on back use pillows to ensure sleeps on one side Consider changing or stopping TCAs Advice reduce or stop smoking and particularly alcohol Advise about risk associated health problems with OSA (IHD, CVAs)

Negative indicators: Fails to offer adequate lifestyle advice Offers sedatives to patient to improve sleep

CARDS

Vitals

BP 135 / 74 Pulse 65 bpm BMI 32 Weight 89 kg

Examination

Cardiovascular exam normal Respiratory exam normal

Neck circumference 47cm Throat no enlarged tonsils or

nasal polyps No goitre

csa courses cases snoring.pdf

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