FAME – 1

Task 1 & 2
27 / 2 /1432:
Doctor Name: Naila Ali Salim Omer
PHCC: Addar Albeda
Email: dr.naila@yahoo.com
Mobile number: 0508035162

Case 1:
Salma, aged 31 years old, consult you to discuss the results of an ultrasound
scan arranged by yourself, the scan shows polycystic ovaries.
How are you going to conduct in real practice at primary health care
unit?
As Salma is my patient and Iam the one who ask for ultrasound scan,
it means that I know her complain and history and examination
already and Iam putting a differential diagnosis for her condition, but
to deal with her polycystic ovaries as part of her management plan:
By applying a good communication skill and applying the verbal and
non-verbal communication (SOFTEN) I will conduct her
consultation using the Pendleton's Seven Task Consultation (1987):
1 – Finding why she came or her RFE (Reason For Encounter) and
from there I will start my consultation and try to discover her ICE:
After greeting her by her name and welcomed her to sit and asking
her how are you?
Asking her so you bring the ultrasound result, is anyone tell you
something about the result?
Using the communication skills appropriately …
2 – After telling her the result in small junks, considering other
problems as the infertility or irregular cycles or acne or obesity and
other risk factors
3 – Choosing with the patient an appropriate action for each problem
as management of obesity, acne, irregular cycles or infertility, as the
management may be different if the patient wishes pregnancy or
contraception and this may need to prioritize the action to take.

4 – Achieve a shared understanding of the

problem with the patient and respond to every
question she asked as:
What is polycystic ovary syndrome? Why I get it?

If your hormones don't work in the normal way, your ovaries

might make too many eggs. Those
eggs turn into many cysts. The cysts are like little balloons filled
with liquid.
What causes PCOS?
Doctors don't know what causes PCOS, but you may have a
problem with the way your body uses blood sugar (glucose).
Because of this problem, the hormones that control your ovaries
and menstrual periods can become abnormal
Does PCOS cause me long-term problems?
Yes, you are more likely to get high blood pressure or diabetes.
This means you have a greater risk for strokes and heart attacks.
Because of irregular menstrual periods, women with PCOS are more
likely to be infertile (unable to get pregnant). They may also have a
higher risk for cancer of the uterus or breast.
5 – Involving the patient in the management plan by informed shared
decision making after explaining to her the plan and management
benefits and pitfall
Patient may ask: can I be managed?
Yes, you might need to lose weight, and we have to put a plan for
your weight reduction
Medicine can help with your menstrual cycle, abnormal hair growth
and acne.
If you want to have a baby, there are medicines that may help you
get pregnant.
6 – Using time and resources to good advantage, as every minute or
question should be used for patient management and education and
motivation
7 – Establish and maintain a relation with the patient that help to
achieve other task, adherence to the management plan, education,
motivation and follow up
 Case 2:
Salwa, a 45 –years old Egyptian woman, has a BMI (body mass index) 45
kg/m2.
Current Medications:
 Hydrocholrothiazide 25 mg daily
Current visit:
 BP 140/85
 Weight 115 kg
 Chest clear, no rales or jugular venous distension
Question:
How would you approach to this patient?
a) Is communication skill necessary to handle this patient?
Yes, as 70% of patients can be diagnosed with only communication
skill and patient satisfaction increase when he or she has good
communication with his doctor and it's very necessary and important
for every patient management and specially to this patient as she
have a chronic condition and sensitive situation and it's very
difficult to be managed unless there is good communications skill
and very good patient – doctor relationship as her satisfaction and
adherence to management plan and follow up increased by good
communication.
SO
Putting the patient at ease:
This is an obese patient so the environment should be ready, big
door, big chairs at waiting room and at doctor office, chair should be
near the doctor's chair 15 – 45 cm apart and facing the doctor chair,
 the office should be arranged and clean and the doctor in a clean
good suit and appearance, door should be closed as this patient need
privacy and also for other patients, and no noise or distraction or disturbance
of the patient or the doctor and the doctor using verbal and non-verbal
communication, smiling, open posture, forward lean, touch, eye contact and
nod (SOFTEN).
Establishing a good rapport, stand to greet the patient and welcomed her, call
her by her name or favorite nickname, and present yourself and name to her
Establishing the reasons for consultation by asking open ended questions like
how can I help you, and let the patient express her presenting problem fully to
know her ICE and encourage her to speak and use the silence appropriately
and to show listening and attention by nodding and reflection, and showing
embassy and using verbal and non-verbal language and no interruption , no
loss of eye contact, no direct questions or guiding questions or why or yes and
no questions or sudden change of topic or loss of feedback and rephrasing her
questions simply and clearly and attention to her verbal cues.
To explain to her the diagnosis, management plan prognosis and complication,
using appropriate, directive and sharing and clear and understandable
language, and to give her clear information and can give directive diagrams
and booklets, and give her opportunity for shared decision making
And all this after obtaining the patient consent to her management which now
an implied consent for my management in the PHCC but if I want to examine
her I can ask her can I examine your chest or abdomen.

b) Give reason that shared decision making will enhance the

compliance of patients in general and specific to this
patient?
 Shared decision making is an approach where clinicians and
patients communicate together using the best available evidence
when faced with the task of making decisions, where patients are
supported to deliberate about the possible attributes and
consequences of options, to arrive at informed preferences in making
a determination about the best action and which respects patient
autonomy, where this is desired, ethical and legal.
The physician should offer the patient information that will help him
or her:
 Understand the likely outcomes of various options of
management plan
 Think about what is personally important about the risks and
benefits of each option
 Participate actively in decisions about medical care and
appreciates her role and encourages her participation
So if the patient understand and share in decision of his
management plan surely he will be adherent and compliant to his
decision and especially in chronic health condition and lifestyle
related condition
And for this patient of grade 3 obesity and hypertention as a
comrbid condition, she should be engaged in self care management,
as she is the one who can mange herself as most management plan
depend on her as the life style modification as the diet modification
and exercise modification is the main management options for her
 C) Discussing with her the risk for heart attack is breaking bad news?
Bad news is any information which adversely and seriouslyaffect an individual
view of his or her future.
So discussing with her the risk of heart attack which are associated with the
obesity is considered bad news, and communicating to her this news well is
essential part of professional practice, and breaking to her this bad news
skillfully can motivate and improve the management plan but breaking the bad
news in a bad way may burden the management plan, and the communication
skills from the start is continuum to breaking bad news till management plan
and follow up plan and there are many approach to this task but I can use the
ABCDE approach, which is:
 A: advanced preparation
 B: building a therapeutic relationship and environment
 C: communicating well
 D: dealing with the patient and family reaction
 E: encouraging and validating emotion
Also there are other co-morbidities that can be discussed with her as T2DM,
osteoarthritis, Ca-colon …

d) Discuss the overall management of this patient:

First assessment and classification of her obesity:
This patient is grade 3 obesity
This table showed classification of obesity according to BMI
Classifying overweight and obesity
Classification BMI kg/m2
Healthy weight 18.5 -24.9
Overweight 25 -29.9
Obesity1 30 – 34.9
Obesity11 35 – 39.9
Obesity 111 more than 40
 Telling the patient her BMI and how it affects her risk and long term problem
using good communication skills and breaking bad news skills and informed
shared decision making about the management plan and follow up
As this patient BMI put her at grade 3 obesity she a candidate for diet,
physical activity, drugs and surgery, but step by step management:

1 - Assessing her lifestyle, co-morbidities and willingness to change,

including:
 Presenting symptoms and underlying causes of obesity
 Eating behavior
 Risk factor and co-morbidities as for this patient hypertention, and the
increased risk for T2DM, cardiovascular disease, dyslipedemia, and sleep
apnoea, and check for lipid profile, glucose, liver function test and renal
function test and thyroid function test
 Lifestyle – diet and physical activity
 Environmental, social and family factors, including family history of
overweight and obesity and co-morbidites
 Willingness to motivation to change
 Potential of weight loss to improve health
 Psychological problems
 Medical problems and medication
 Offer regular long term follow up and ensure continuity of care
 To choose any choice of intervention through informer shared decision
making
 Tailor the weight-management program to the patient preferences and
initial fitness and health status and lifestyle
 Put with the patient a realistic targets for weight loss, usually a
maximum weekly of 0.5 – 1 kg aiming to lose 5 -10 % of the original weight
 and maintaining lost weight (the change to maintenance typically happens
after 6 -9 months of treatment
 Physical activity: should include every day activity and other activities as
walking, swimming and stair climbing and it should be continued even if
weight loss not achieved and it should be at least 30 minutes of moderate
intensity physical activity on 5 or more days in session or several shorter
ones lasting 10 minutes or more
 And 45 – 60 minutes may be needed to prevent obesity and 60 -90
minutes to prevent regaining weight
 Diet: advise to improve diet even no weight loss
 Reducing caloric intake, but according to food preference and using a
flexible approach
 Energy intake should be less than energy expenditure
 Usage of balanced diet
 Base meals on starchy food
 Eat plenty of fibre-rich food
 Eat at least 5 portions of fruits and vegetables a day in place of food high
in fat and calories
 Eat low fat diet
 Decrease as much as possible fried food and high sugar drinks
 Eat breakfast
 Watch the portion of food size you eat
 Avoid much alcohol
 Family support after patient consent
 Drug treatment should be considered after starting diet and exercise and
if target goals are not reached
 Orlistat should be used and continued for longer than 3 months only if
patient at least lose 5% of their initial body weight since starting drug
 treatment or for 12 months for weight maintenance after discussing the
potential benefit and limitations with the patient

 If life style modification ( diet and exercise) and drug treatment are not
successful in 6 months we will refer for Bariatric surgery as she has 45
kg/m2 BMI and hypertention