Smoking Cessation Counselling

[usmlemaniac]

Mr. Newman is a 35 year old white who came in because he wishes to quit smoking. His vital signs are T=98 P=76 RR=19 BP= 120/70. Your job is to counsel this patient to quit smoking. You have 15 minutes to do an History and Physical exam and 10 minutes to write your notes. Begin.


Knock, knock, this is Dr. Smith. May I come in?

Please come in.

Hi, I am Dr. Smith. Nice to meet you Mr. Newman.

Nice to meet you.

So you are here because you are concerned about your use of cigarettes, correct?

Yes, doctor. I know it is bad to smoke but I can't seem to quit.

How much do you smoke?

I smoke a pack a day for 10 years.

As your doctor, my job is to help keep you healthy. I’m worried about your smoking and I want to help you quit. Quitting smoking is the most important thing you can do to stay healthy. I am going to ask you a couple of questions to evaluate what are the best ways to help you ok.

OK.

On a scale of one to ten, with one being not at all important and ten being the most important thing you can think of, how important is it to you to quit smoking?

I think it's a 9.

Why not less?

I think I begin to have bronchitis or COPD that my mom had and died from. So I think it is very important to me to quit smoking.

On a scale of one to ten, with one being not at all ready and ten being very ready, how ready are you to quit smoking right now?

I think I am ready. I think I want to quit now.

On a scale of one to ten, with one being not at all confident and ten being very confident, how confident are you that you can quit smoking?

I think a 5.

Why not less?

I want to quit but most of my friends are still smoking so I am not that confident.

Have you ever attempted to quit smoking before?

Yes, I did try but I wasn't successful.

It might take a couple of trials before success. So don't feel discourage. I am confident that you will be successfully. Do you know what works best for you previously?

I think if I don't go out with my smoker friends then I do better.

Do you know what did not work for you previously?

The Nicoderm patch. It did nothing for me.

Here are the plans I came up with:

Pick a special day that you want to quit smoking. It could be today, it could be Sunday, or it could be your birthday. What is your day?

I think I will start on Sunday because I go to church on that day.

Good.

Next, I want you to go home and clean up all your ashtrays. Put them away where you can't even smell it. Clean up your car's astray. Deordorize it so you can't even smell the nicotine. Smelling nicotine is like smelling food. It makes you want to have a cigarettes.

Next, tell family, friends, and coworkers about quitting and request understanding and support.

The first few weeks of quit attempt you might anticipate some nicotine withdrawal symptoms include: tobacco craving, restlessness, anxiety, irritability, difficulty concentrating, headaches, drowsiness or stomach upset.

I will also give you a medication called bupropion SR. It will help you with your nicotine craving and reduce your withdrawal symptoms.

We will provide support to you. You can call my nurse with any concerns. Also, we will make a schedule follow up in 2 months.

Any questions?

No.

I am going to take a listen to you, ok.

ok.

PE:
Generally: patient is a bit anxious. well nourish male in NAD.
HEENT: NCAT, MMM, PERRLA, no thyromegaly.
CV. RRR no M/G/R S1,S2
Res: CTA B, no W/R/R
Abd: ** present, NTTP, No masses, No organomegaly
Ext: MAEW, +2 pulse PD.

Differential Diagnosis:

Alpha1-Antitrypsin Deficiency
Chronic Obstructive Pulmonary Disease
Depression
Emphysema
Lung Cancer, Non-Small Cell
Lung Cancer, Oat Cell (Small Cell)
Myocardial Ischemia

Workups

Pulmonary Funtion Test... All patients with a smoking history should get a PFT

[Asclepius1]

Can we say that we will give the patient smoking cessation brochures to help him quit smoking?

[usmlemaniac]

Can we say that we will give the patient smoking cessation brochures to help him quit smoking?

Good idea.

5 A's that all physician should know about smoking cessation:

1. ASK about smoking at every opportunity
Physicians and other healthcare professionals should inquire about the smoking habits of patients and whether the areas where they live and work are entirely smoke-free. In the African American community, the inquiries shouldn’t only come from people who work in the health professions. Everyone in the community has a role to play in bringing about a smoke-free community. People often ask their elders for advice on health issues. The barber shop, the beauty parlor, the worship service, the community basketball league are all places where the issue of smoking can be raised.

2. ADVISE all smokers to quit
The advice for smokers to quit should be a constant message from health professionals and others who work with African Americans. Studies have shown that when doctors and other health professionals talk seriously with their patients about smoking, quit rates increase.[10] While most of these studies have not addressed specifically African American populations, there is every reason to believe that repetition of the message will be effective.

3. ASSESS readiness and motivation to quit
The Stages of Change model is based on the idea that people have to be ready to make major behavioral changes and that the readiness can occur suddenly or over time.[11] The model also recognizes that in trying to overcome an addictive behavior like smoking, people sometimes take a few steps forward and then a few steps back. In fact, it has been said that the best predictor of whether a person will be successful in quitting smoking is past attempts. On average, five to seven failures occur before a smoker quits for good.[12]

4. ASSIST with smoking cessation
The health professional can assist a smoker who wants to quit by recommending and/or prescribing nicotine replacement therapies (NRTs) and counseling, if appropriate. NRTs include gum, patches, inhalers and nasal sprays that contain nicotine. Although nicotine is addictive, there are many other chemicals and additives in tobacco products and those substances do the real damage to the body. Because NRTs do not contain these other chemicals, the Food & Drug Administration (FDA) has approved use of these products. However, focus groups with African Americans have found real resistance to using NRTs because they see NRTs as a "crutch" and do not believe they work. Other recent studies have found that many smokers are concerned that the nicotine levels in NRTs may be harmful. While all NRTs were originally prescription-only, some now have been approved as over-the-counter medications, and no longer require prescription. NRTs are only supposed to be used for a limited period of time to help the body adjust to nicotine withdrawal; they are not for permanent nicotine replacement. In addition to the NRTs, some medications that do not contain nicotine, such as the prescription tablet Zyban, have been quite effective in lessening nicotine withdrawal. Medicines that help smokers quit are most effective when used in conjunction with counseling and support.

5. ARRANGE to follow-up
While some African American smokers can quit "cold turkey," most cannot. Follow-up and continuing support is important – from the healthcare community and from non-smoking friends, co-workers and family. Telephone counselors are often available on hotlines operated by federal and state agencies or voluntary health organizations like the American Cancer Society. Self-help booklets on quitting are available. And in some cases, community-based support groups or classes may be the added incentive that is needed for a smoker to quit.

[Insulin]

Dear Usmlemaniac,

Thx for those great mnemonics and good design of the case.

May I kindly ask you to explain the abbreviations you used in Physical Exam part? I'm terrible, terrible with English abbreviations and I could not understand the following ones (I only know HEENT - Head, Ears, Eyes, Nose, Throat and ** - bowel sounds, right?):

HEENT: NCAT, MMM, PERRLA
CV. RRR no M/G/R S1,S2
Res: CTA B, no W/R/R
Abd: ** present, NTTP, No masses, No organomegaly
Ext: MAEW, +2 pulse PD

Thx a lot :?

[Asclepius1]

Dear Usmlemaniac,

Thx for those great mnemonics and good design of the case.

May I kindly ask you to explain the abbreviations you used in Physical Exam part? I'm terrible, terrible with English abbreviations and I could not understand the following ones (I only know HEENT - Head, Ears, Eyes, Nose, Throat and ** - bowel sounds, right?):

HEENT: NCAT, MMM, PERRLA
CV. RRR no M/G/R S1,S2
Res: CTA B, no W/R/R
Abd: ** present, NTTP, No masses, No organomegaly
Ext: MAEW, +2 pulse PD

Thx a lot :?

HEENT - Head, ears, eyes, nose throat
NCAT- normocephalic atraumatic head
MMM- moist mucous membrane
PERRLA- pupil equal round reactive to light and accommodation
RRR- regular rate and rhythm

m/g/r murmur gallop rubs
**- bull shit
NTTP - nontender to palpation
MAEW- moving all extremities well

[yaha]

thanks a lot....got a gud idea as to how to get over such a case...but should we ask the scale of 1 to 10 for d 1st few questions?