Case Study of clinical decision making in practice

This assignment was written by a Community Matron working in a Primary Care setting for a local GP surgery. Using a case study approach, it aims to illustrate a clear, logical account of clinical decision making in the practice environment, whereby the patient was fully assessed, differential diagnosis reached, and effectively treated, furthermore, through a collaborative model of consultation (Rudisill et al 2006) and working, professionals pooled knowledge and resources and carers were educated to reduce further incidences of the problem illustrating the benefits of proactive care from the Community Matron ( Boaden, Dusheiko and Gravelle 2005).

The patient was chosen for this study as this was the third incidence of the presenting condition in as many months, making it obvious to the practitioner that whilst the problem had been treated on previous occasions, further investigation of the condition and a constructive, concerted approach was needed to prevent future recurrences and to maintain patient comfort.

In accordance with the Nursing and Midwifery Council’s Code of Conduct (NMC 2009), consent was granted by the patient prior to undertaking the study and names changed to protect identity and maintain confidentiality, for this reason the patient will be referred to as Jack Lowe and his wife as Linda. Multiple complex pathologies and socioeconomic conditions influenced the development of the patient’s skin condition, due to the constraints of word allowance it was not possible to elaborate on all the contributing factors; for the purpose of this assignment, the practitioner aimed to give a brief overview of pathologies and to concentrate on consultation and clinical decision making from a primary and secondary prevention perspective

Jack had been registered with the Community Matron for eighteen months; he had a history of coronary heart disease having experienced a cerebrovascular accident resulting in right sided hemi paresis with reduced mobility ten years ago, and a diagnosis of type 2 diabetes two years ago. Following a history of poor diabetic control, Jack was referred to the Community Matron by his Gp in June 2008 to provide ongoing education and support for Jack and Linda in order to more effectively manage Jack’s condition and minimise complications of diabetes (DoH 2001). Information, education and psychological support is the cornerstone of diabetic care (DoH 2001); the Diabetic Specialist Nurse proved an invaluable resource to the Community Matron who was subsequently able to provide dietary advice to Jack and Linda both verbally and written using a patient handbook (NICE 2002a). This approach proved successful and diabetic control improved, consequently Community Matron visits were reduced to a monthly

support and monitoring regime. However, carers recently noticed a skin problem during morning visit (see Appendix 2) and referred Jack to the Community Matron for reassessment.

Systematic and sensitive assessment has been a key government policy in primary health and community care (RCN 2004); accurate medical history taking is vital as this is arguably the most important aspect of consultation (Crumbie and Walsh 2006) with 80% of diagnoses formulated on the interview alone (Epstein, Perkin, Cookson and Bono 2003). Skin problems constitute 15% of GP consultations; essential management requires a history of the complaint as well as background information, including general health and concurrent treatment (Parker 2009).

Following a full explanation, reassessment (appendix 1), took into consideration the personal areas involved and the possibility that the condition was sexually transmitted; sensitive questioning of sexual history was undertaken and noted. Information was gained using a variety of methods, including open questioning of Jack, wife Linda, medical notes, hospital discharge letters and Care Agency daily records.

Whilst interviewing Jack it became apparent that he was feeling depressed, further questioning confirmed that Jack had been feeling depressed for some time (Patient Health Questionaire-PHQ 9 completed and filed in Jack’s notes with a copy to GP), Linda had been ill with a cold earlier in the year and had snapped at Jack, he said that he felt that he was a burden and refused to be persuaded otherwise becoming very tearful during the consultation.

After further discussion, Linda agreed that she had been finding it difficult to cope and agreed to accept more help during the day; referrals were made to social services and to crossroads to provide day sitting service to allow Linda time to herself. Antidepressants were discussed for short-term relief of symptoms but both Jack and Linda felt that with extra support they would both improve.

Assessment tools to aid memory and ensure relevant information is identified include mnemonics whereby an easily remembered acronym associates with list items (mnemonic). Mnemonics have been used since the second century BC (Nager and Heinrichs 2009), whilst SOCRATES is generally used by medical professionals as a pain assessment tool to gain insight into patient’s condition (http://en.wikipedia.org/wiki/Socrates-(pain assessment), the practitioner could find no validation of this tool, although Clayton et al (2000) use this

acronym in their study, they too fail to highlight the origins of the acronym and provide no validation or references. A plethora of mnemonics can be found to assist in consultation and assessment http://www.medicalmnemonics.com/), acronyms considered, included SWIPE (starts, worse, improves, pain, episode), LOSTWAR (location, onset, severity, worsening, alleviating and radiating), nevertheless, the practitioner found SOCRATES easy to remember and relevant to Jack’s condition, pertinently, she found this particular tool an invaluable resource when gaining a concise history of the presenting problem(See appendix 2).

Recent blood test results reviewed (appendix 3), vital signs of blood pressure, pulse, and temperature recorded, and shown to be within normal limits, no pyrexia was noted which precluded infection, weight, BMI, waist measurements and random capillary blood glucose levels were taken and compared to previous results.

Whilst there appeared little change in general observations, Jack had gained 5kg in weight with a proportional 7cm increase in girth measurements, Hba1c levels had increased from 6.3% in June 2009 to 7.8% in January 2009; also his eGFR had decreased from 49ml/min in June 2009 to 44ml/min in January 2010.

Medication (appendix 1) was reviewed to assess if this may have contributed to the condition and whilst Aspirin, Bisoprolol and Xismox all have itching and rash listed as a side effect, this is indicative of an allergic reaction which occurs suddenly (BNF 2009), over the counter medication and herbal remedies were also explored and Jack confirmed that he only used prescription medication, and therefore it was perceived medication could not have initiated the problem. Jack has no documented allergies to medication which could possibly have caused a rash, and has not been receiving antibiotic therapy which may have predisposed him to fungal infections (Hilson 2002). Jack’s wife confirmed that no new topical agents or laundry powders have been used recently which may have triggered a skin reaction (Parker 2009).

Following history taking and full explanation, consent for examination was obtained. Whilst Jack was well known to the practitioner and a confident, professional relationship established, sensitivity was shown to the fact that he would be partially undressed during the procedure, examination was then conducted in the privacy of the bedroom with the curtains and windows closed, pertinently, a clean sheet was used to cover areas not under scrutiny to ensure only the relevant areas of Jack’s body remained uncovered at one time during the procedure to maintain dignity, Linda was present throughout the examination at Jack’s request. Physical examination

was then undertaken using the skills of inspection and palpation, the senses of touch, listening and smell, physical findings from the examination were then integrated into the diagnostic process.

According to Epstein, Perkin, Cookson and Bono (2003) there is a tendency to focus on the localised area of skin but as an organ in its own right skin should be fully examined to gain maximum information. A full examination in good light is essential to identify details necessary to formulate a differential diagnosis, these include, site, distribution, pattern, colour, heat, flat or raised surface and any ulceration (Chadha 2009 Bickley and Szilagyi). A careful inspection ruled out rash or dry skin problems elsewhere on the body, however, the skin between the groins extending onto the scrotum was intensely reddened, cracked in skin folds, covered in a moist rash with a creamy curd discharge, well defined borders and scaling on the edges, small satellite lesions outside the scaly borders and a ‘yeast like’ odour was present. On palpation, the skin felt damp, heat radiated from the skin and the area was sore when touched. Nevertheless palpation of the inguinal area revealed no pain, or lymph node enlargement, Jack was apyrexial and said that he felt well apart from the skin problem indicating no outward signs systemic infection.

Clinical decision making is often fraught with uncertainties, however, expert diagnosticians maintain a degree of suspicion throughout the assessment process, consider a range of potential explanations, then generate and narrow their differential diagnosis, based on own experience, familiarity with the evidence related to various diagnoses, and understanding of their individual patient. Ultimately, diagnosis is confirmed or ruled out by combining findings from physical examination and history and comparing them to findings from diagnostic studies which closely match presentation of the problem (Goolsby and Grubbs 2006).

A plethora of skin conditions exist which were initially considered including eczema (or dermatitis), the commonest inflammatory condition accounting for 30-40% of dermatology consultations (Forslind and Lindberg 2003), flexural psoriasis had some features and associated factors i.e. affecting skin folds but as no lesions elsewhere on the body and no history of psoriasis this was only fleetingly considered, whilst distribution, symptoms and appearance of incontinence dermatitis was almost identical to Jack’s condition, he had in situ a

fully functioning urethral catheter and no faecal or urine leakage problems which could have initiated the condition.

Following reassessment, consideration of medical, social history, physical findings and clinical manifestations of the disease, only five conditions were included in the diagnostic process (appendix 4). Differential diagnosis of Intertrigo was initially included but discounted as the area had signs of skin infection not associated with Intertrigo which is an inflammatory condition and not an infection (Parker 2009), Erythrasma, and Bacterial Intertrigo were considered as the localisation, namely skin folds fit the inclusion criteria and then discarded as images of Erythrasma and Bacterial Intertrigo were too dissimilar to Jack’s rash, coupled with the fact that the yeasty smell and white areas on the skin appeared more consistent with fungal rather than bacterial infection.

Tinea Cruris is commonly caused by the fungus Trichophyton rubrum and looked remarkably similar; however, this diagnosis was discounted as there was fungal rash to scrotum which was inconsistent with Tinea Cruris and no Tinea Pedis (maceration of interdigital web folds) consistent with the condition (Brannon 2009). Whilst a KOH test, performed by examining skin scrapings under a microscope, would have given an absolute diagnosis, the practitioner felt confident that as the description of Candidal Intertrigo (Brannon 2004) most closely matched the physical manifestations and characteristic distribution of Jack’s skin condition, coupled with the fact that Intertrigo Candida had been previously diagnosed and treated if not eradicated, this appeared the most likely diagnosis.

In order to effectively treat the skin problems one must first consider the underlying pathology of the condition. The skin is the largest organ of the body and forms a barrier between the internal organ and the external environment as people age, less efficient micro-circulation results in reduced blood flow, skin becomes drier, less elastic and more permeable, making it more susceptible to damage (Ousey 2005). Elderly people, therefore like Jack who are obese and less mobile, have increased prolonged occlusion in areas such as groins, resulting in more moisture and warmth in skin.

Intertrigo occurs when two occluded, moist surfaces of skin rub together with the resulting friction setting up the inflammatory process (Parker 2009). Following activation by cells present in tissues, macrophages, dendritic cells, histiocytes, Kuppfer cells and mastocytes inflammatory mediators are released and vasodilation increases blood flow, causing itching, redness and heat, the blood vessels become more permeable resulting in oedema and the

release of bradykinin increases sensitivity to pain (http://en.wikipedia.org/wiki/Inflammation). This cycle continues due to the constant chafing stimulus provided by the two skin surfaces leading to chronic inflammation and a moist warm environment where Candida can thrive (Gullo 2009). Key aims of the health professional in treating Candidal infections are identifying and encouraging the management of underlying predisposing risks as this will improve symptoms and minimise recurrence(Parker 2009).

Candidal (yeast infections) are commonly caused by Candida Abicans, which is normally present on body surfaces, colonisation with the fungus (Mims et al 2001) has an increased incidence in obese, the immunosuppressed, and diabetic patients with increased prevalence in the elderly and in those with poor personal hygiene (Weller et al 2008, Parker 2009), antibiotic therapy is also known to predispose the patient to fungal infections (Hilson 2002). Interestingly, whilst it is generally accepted that diabetics are more prone to Candida Albicans infection, the practitioner could find only scant explanation for this, Hall and Hall (2009) and Laube and Farrell (2002) suggest that high blood glucose levels encourage proliferation of bacteria and attacks from microbials and fungal infections, Mims et al (2001) agree and also propose that skin sepsis is poorly controlled in diabetics probably due to defective chemotaxis and phagocytosis in polymorphs which show impaired energy metabolism, they add that in vitro, the energy of polymorphs is rapidly restored by the addition of insulin.

Following diagnosis and identification of multifactoral elements and risk factors, treatment was commenced, primarily to eradicate the Candida infection and secondly through a structured programme of health promotion, and collaborative working, risk factors were reduced to minimise recurrence.

Treatment options considered included therapeutic and non therapeutic options.

Therapeutic treatment is aimed at secondary prevention whereby therapy is commenced to treat the condition and prevent further complication. Whilst Candida Albicans is a common infection in the elderly (Hall and Hall 2009), invasive candiadasis (candidaemia) occurs when the pathogen become systemic and is associated with significant mortality and morbidity (Gullo2009, Candiadasis http://en.wikipedia.org/wiki/Candidiasis ).

Guidelines show (BNF 2009) that therapeutic interventions of Candidal Intertrigo are confined to topical treatment with an Imidazole cream with an added steroid component where inflammation is present. The decision not to treat the skin inflammation with combined antifungal and steroid cream was based on the fact that steroid therapy is contraindicated in

occluded groin areas where dermal uptake of the steroid may be systemically increased, signs of infection reduced, and itching made worse (Watkins 2004, Brannon 2004).

As previous infection responded to a course of antifungal treatment but recurred, advice was sought from the local pharmacist who suggested that recurrence could be partly due to stopping the treatment once condition appeared resolved, he advised that treatment with antifungal creams should be used twice daily for a minimum of two weeks after symptoms cleared. As evidence suggest(BNF 2009) that no one Imidazole more effectively treats fungal infections than the others, the choice of which to prescribe was based on nothing more than the cost of the product, past experience and availability at the small local pharmacy, therefore Clotrimazole Cream 1% 20mg was prescribed by the practitioner (NPF 2009-2011).

Whilst keeping the affected area clean and dry relieves symptoms of inflammation and improves healing (Parker 2009), the practitioner could find no non-therapeutic remedies to treat the fungal infection. Here, non therapeutic treatment relates to primary prevention of the disease process, namely prevention of the disease process occurring (Katz et al 2000). This included lifestyle management to control weight, improve mobility, reduce occlusion of skin in groins, improve blood glucose control, effective skin care, and prompt identification of intertrigo (Gullo 2009, Parker 2009, Hall and hall 2009) to limit the condition and reduce the risk of infection.

Carers were responsible for all Jack’s hygiene needs and played a key part in primary and secondary prevention, in order to ensure effective treatment with continuity of care, written and verbal instructions were needed, consequently a care plan was devised by the practitioner in conjunction with Linda and Jack to incorporate therapeutic and non therapeutic interventions. Whilst accurate research-based information was available on the internet (http://www.library.nhs.uk/skin/SearchResults.aspx?tabID=290&catID=83420), neither Jack nor Linda had access to a computer, therefore downloaded information was printed out and given to Jack to reinforce information contained in care plan.

Following consultation with the Care Agency manager, a copy was then placed in Jack’s file and one at the Care Agency Office.

The empowerment model of health advocated by Katz (2000) suggests that the aim of the health professional is to teach people the skills to take care of their own health. Consequently, Linda and Jack were encouraged to take an active role both in treating his skin condition and in improving general health and well being. Being assertive is advocated in this model, and as

Linda reported that the carers were often in a hurry to complete hygiene within allocated time limits, she was encouraged to be more assertive and to ensure that Jack had sufficient time allowed by social services for his needs, the practitioner agreed to request a reassessment if Linda considered that carer time allotted to Jack insufficient for his needs.

Scrupulous cleaning is essential, however, with ph of 5.5 skin is slightly acidic (Skewes 1996, Hampson 2006) and whilst soap cleans effectively it is alkaline (ph 10-12) and if not rinsed off thoroughly, can elevate the skin’s natural ph, reduce antibacterial property, and encourage fungal growth; lipids naturally present on skin surface are removed making skin drier and affecting barrier function (Warner and Boissey 1999) further increasing the risk of infection.

Linda was advised not to buy perfumed soaps or bubble baths as these can cause allergic reactions and skin dryness (Lievre 1996), an emollient cream was prescribed, carers were advised through the care plan to rinse and dry skin thoroughly to reduce opportunistic fungal growth (Parker 2009). Jack agreed to inform the carers if he was not dry between the groins. A management plan was included in the care plan, as early treatment can often delay or reduce the impact of the condition, carers were therefore encouraged, to closely observe groins for the first signs of the condition, and to report to Linda so that effective treatment could be implemented.

Jack was subsequently referred to the physiotherapist and commenced a weekly programme of physiotherapy, he was encouraged not to use the wheelchair in the home and very slowly his mobility increased, the diabetic nurse visited to advise on diet and Linda was encouraged to participate and try to eat more healthily. About three days into treatment with the antifungal cream, Jack’s skin showed marked improvement, the cream was discontinued after three weeks.

Unfortunately, four weeks later, Linda reported that the condition had recurred, examination of the area showed Jack’s groins only mildly affected by intertrigo with skin folds slightly reddened, no infection was noted therefore a prescription was issued by the practitioner for Actisorb Silver which she advised carers to place between groins, this served to both separate the skin folds as suggested by Practice Nurse (2009) and reduce bacterial skin count (BNF. org 2009. Whilst the practitioner could find no research based evidence to support this decision,

reflection upon practice based evidence illustrated that in the past, placing this dressing on reddened groins reduced redness and prevented further exacerbation.

Fungal infections can be unsightly, chronically itchy and are increasingly being recognised as a threat in critically ill adults and can be life threatening in some adults (Gullo 2009), and whilst Jack had a further recurrence of intertrigo, prompt identification of the condition and treatment reduced severity and prevented the complication of a fungal infection, however with the multifactoral elements of the condition it may recur at a later date. Hopefully, an empowered team approach will minimise risk factors and ensure that these episodes are at least reduced if not prevented.