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Y5 Emergency Medicine > 2 - GP > Flashcards

2 - GP Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

When do you need to produce a sick note for a patient?

A

After a week of them self-certifying their illness

Can’t forward date but can back date

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2
Q

Who else apart from a doctor/GP can sign a sick note as of July 2022?

A
  • Nurses
  • OTs
  • Pharmacists
  • Physiotherapists
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3
Q

If a patient has a condition or is undergoing treatment that could impair their fitness to drive how should you manage this?

A
  • explain this to the patient and tell them that they have a legal duty to inform the DVLA
  • tell the patient that you may be obliged to disclose relevant medical information about them, in confidence, to the DVLA or DVA if they continue to drive when they are not fit to do so
  • document any advice you have given to a patient about their fitness to drive in their medical record
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4
Q

If a patient cannot understand that they are not fit to drive e.g dementia patient, what should you do?

A

Inform the DVLA yourself as soon as possible

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5
Q

If a patient is still driving and has not informed the DVLA after you have told them to do so, what should you do next?

A
  • If a patient refuses to accept diagnosis, you can suggest they seek a second opinion, and help arrange for them to do so. You should advise the patient not to drive in the meantime
  • Make every reasonable effort to persuade them to stop. If you do not manage to persuade the patient to stop driving, or you discover that they are continuing to drive against your advice, you should consider whether the patient’s refusal to stop driving leaves others exposed to a risk of death or serious harm
  • Before contacting the DVLA or DVA, inform the patient of your intention to disclose personal information. If the patient objects to the disclosure, you should consider any reasons they give for objecting. You should tell your patient in writing once you have done so, and make a note on the patient’s record
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6
Q

What are the DVLA rules for epilepsy/seizures?

A
  • First unprovoked/isolated seizure: 6 months if no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months
  • For patients with established epilepsy or those with multiple unprovoked seizures:
    • qualify for a driving licence if they have been free from any seizure for 12 months
    • if there have been no seizures for 5 years (with medication if necessary) a ’til 70 licence is usually restored
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7
Q

If someone on AEDs comes off of these drugs, what are the DVLA rules?

A

Should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose

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8
Q

What are the DVLA rules for syncope?

A
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9
Q

What are the DVLA rules for stroke/TIA?

A
  • stroke or TIA: 1 month off driving, may not need to inform DVLA if no residual neurological deficit
  • multiple TIAs over short period of times: 3 months off driving and inform DVLA
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10
Q

What are the DVLA rules for the following:

  • Craniotomy
  • Pituitary tumour
  • Narcolepsy
A
  • Craniotomy e.g. For meningioma: 1 year off driving
  • Pituitary tumour: craniotomy: 6 months; trans-sphenoidal surgery ‘can drive when there is no debarring residual impairment likely to affect safe driving’
  • Narcolepsy/cataplexy: cease driving on diagnosis, can restart once ‘satisfactory control of symptoms’
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11
Q

What are the DVLA rules for chronic neurological conditions e.g MS, MND, Parkinson’s?

A

DVLA should be informed, complete PK1 form (application for driving licence holders state of health)

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12
Q

What are the DVLA rules for a subdural haematoma?

A
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13
Q

What are the DVLA rules for the following:

  • Severe anxiety or depression with any of the following: significant memory problems, significant concentration problems, agitation, behavioural disturbance or suicidal thoughts
  • Acute psychotic disorder
  • Hypomania or mania
  • Schizophrenia
  • Pervasive developmental disorders and ADHD: may be able to drive but must inform the DVLA
  • Mild cognitive impairment: may drive and need not inform the DVLA
  • Dementia: may be able to drive but must inform the DVLA
  • Mild learning disability: may be able to drive but must inform the DVLA
  • Severe disability: must not drive and must notify the DVLA
  • Personality disorders: may be able to drive but must inform the DVLA
A
  • Severe anxiety or depression: must not drive and must notify the DVLA
  • Acute psychotic disorder: must not drive during acute illness and must notify the DVLA
  • Hypomania or mania: must not drive during acute illness and must notify the DVLA
  • Schizophrenia: must not drive during acute illness and must notify the DVLA
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14
Q

What are the DVLA rules for the following?

  • Pervasive developmental disorders and ADHD
  • Mild cognitive impairment
  • Dementia
  • Mild learning disability
  • Severe disability
  • Personality disorders
A
  • Pervasive developmental disorders and ADHD: must inform the DVLA
  • Mild cognitive impairment: need not inform the DVLA
  • Dementia: may be able to drive but must inform the DVLA
  • Mild learning disability: may be able to drive but must inform the DVLA
  • Severe disability: must not drive and must notify the DVLA
  • Personality disorders: must inform the DVLA
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15
Q

What are the DVLA rules for angina and ACS?

A
  • ACS: 4 weeks off driving, 1 week if successfully treated by angioplasty
  • Angina - driving must cease if symptoms occur at rest/at the wheel
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16
Q

What are the DVLA rules for angioplasty and CABG?

A
  • Angioplasty (elective) - 1 week off driving
  • CABG - 4 weeks off driving
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17
Q

What are the DVLA rules for an ICD and pacemaker insertion?

A
  • Pacemaker insertion - 1 week off driving
  • Implantable cardioverter-defibrillator (ICD)
    • if implanted for sustained ventricular arrhythmia: cease driving for 6 months
    • if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers
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18
Q

What are the DVLA rules for a catheter ablation to correct an arrhythmia?

A

2 days off of driving

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19
Q

What are the DVLA rules for a AAA?

A
  • 6cm or more - notify DVLA. Licensing will be permitted subject to annual review
  • 6.5 cm or more - disqualifies patients from driving
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20
Q

What are the DVLA rules for a heart transplant?

A

Do not drive for 6 weeks, no need to notify DVLA

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21
Q

If a patient has insulin dependent diabetes they must inform the DVLA. What criteria do patients need to fulfil for a Group 1 licence?

A
  • Adequate awareness of hypoglycaemia
  • No more than 1 episode of severe hypoglycaemia while awake in the preceding 12 months
  • Practices appropriate glucose monitoring as defined in the box below (testing even on non-driving days if want group 2)
  • Meets the visual standards for acuity and visual field
  • Under regular review
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22
Q

Apart from insulin treated diabetes, which other diabetic patients need to inform the DVLA?

A

Any tablets that can induce hypoglycaemia e.g sulfonylureas

Need to do same glucose testing as insulin dependent and have awareness of hypos

If diet controlled or other tablets no need to inform DVLA

23
Q

If a patient with insulin dependent diabetes wants to apply for a group 2 licence, what do they need to do?

A
  • No severe hypoglycaemic event in the previous 12 months
  • Full hypoglycaemic awareness
  • Adequate control of the condition by regular blood glucose monitoring at least twice daily and at times relevant to driving with 3 months of history on BM machine
  • Demonstrate an understanding of the risks of hypoglycaemia
  • No other debarring complications of diabetes
24
Q

During advanced care planning, how can you phrase a ceiling of care question?

A

If you had a chest infection/MI (reversible illness), would you want to be admitted to hospital for treatment/antibiotics etc

25
Q

What legality do you need to consider when doing advanced care planning?

A

It is not black and white, can be changed at any time

Do you want a LPA? Need to go to solicitors for this

26
Q

What principles do you need to consider when facing an ethical challenge in healthcare?

A
  • Do we need to know more information?
  • Benefit vs Harm
  • Fairness and equity
  • Honesty and truth telling
  • Is there a law/professional guidance about this?
27
Q

How can you do a medication review?

A
  • Which ones are you taking?
  • Taking them every day?
  • How are you taking them e.g from dossette box, with water?
  • When are you taking them?
  • Any OTC medication?
  • Any side effects?
  • Any anticholinergic burden?
  • Check QRISK score
28
Q

What are medically unexplained symptoms?

A

Persistent symptoms for which adequate examination and investigation does not reveal sufficiently explanatory structural or other specified pathology

29
Q

What are some risk factors for chronic MUS?

A
  • Multiple symptoms
  • Duration of symptoms
  • Functional impairment;
  • Psychosocial stress
  • Psychological comorbidity
30
Q

If you suspect a patient has MUS and they are requesting more investigations what can you say to the patient?

A
  • Discuss the likelihood of planned blood tests and other investigations being normal to prevent them being disappointed that nothing has been found
  • Discuss advantages and disadvantages of further investigations
  • Share your uncertainty with the patient
31
Q

What are some syndromes that originated as MUS?

A
32
Q

How can medically unexplained symptoms be managed?

A
  • Focus on impact of symptoms and treating this impact not searching for a diagnosis
  • Tell the patient that you believe their symptoms are real but you don’t know what is causing them
  • Delivering proactive care and making regular follow-up appointments at fixed intervals
  • Psychological interventions are the best e.g CBT
33
Q

If you offer a patient with MUS counselling and they ask if you think it is all in their head what can you say?

(Important card)

A
  • I think what you are experiencing is real to you but I don’t know what the cause of this is
  • Explain other syndromes started as unknown e.g AIDS, Downs, and years down the line they got medical explanations as research came out so down the line there may be an explanation for their symptoms
  • The strain of dealing with these symptoms is bound to have an emotional effect on you so good to talk
  • Other people having the same symptoms as you have tried it and have found it helped them to cope
34
Q

What is another word you can use for MUS?

A

Functional syndrome/symptoms

35
Q

If there is a patient with MUS that you think fit a syndrome, e.g IBS, and they question and say are you sure, what can you do?

A
  • Offer a second opinion
  • Refer them to a specialist to help rule out anything we may have missed but write in the referral letter what you think it is and that you are happy to take back over care if they agree with your diagnosis
  • Offer patients an interim treatment of IBS treatment. Keep the patient-doctor relationship going and offer them another appointment to show them you haven’t been upset by them asking for another opinion
36
Q

What is the definition of fibromyalgia?

A

Widespread pain throughout the body with tender points at specific anatomical sites.

Often co-morbid fatigue, mood and sleep difficulties

37
Q

Where are the common sites of pain in fibromyalgia?

A
  • Low back with/without radiation to the buttocks and legs
  • Neck and across the shoulders
38
Q

What are some symptoms of fibromyalgia?

A
  • Pain at multiple sites
  • Fatigue
  • Sleep disturbance
  • Morning stiffness
  • Paraesthesiae
  • Feeling of swollen joints (with no objective swelling)
  • Problems with cognition (eg, memory disturbance, difficulty with word finding)
  • Headaches (may be migrainous)
  • Light-headedness or dizziness
  • Fluctuations in weight

Symptoms worse in cold weather and stress

39
Q

What are some risk factors and differential diagnoses for fibromyalgia?

A

Risk factors

  • Women
  • Aged 20-40
  • Family history
  • Co-morbid rheumatological conditions
40
Q

What are some differential diagnoses for fibromyalgia?

A

Always do TFTs, ESR, Autoantibodies to rule out other causes

41
Q

How is fibromyalgia diagnosed?

A

Widespread body front and back, right and left and both sides of the diaphragm for at least 3 months

and

Widespread pain index (WPI) is 7 and symptom severity (SS) scale score is 5, or WPI equals 3 to 6 and SS scale score of 9

and

The patient does not demonstrate any other disorder that would otherwise explain the pain

42
Q

What are some hypotheses for fibromyalgia?

A
  • Peripheral and central hyperexcitability at spinal or brainstem level
  • Altered pain perception
  • Somatisation
43
Q

How can fibromyalgia be managed?

A

Tailor it to individual patient

  • Explanation
  • Specific realistic goals
  • Aerobic exercise: has the strongest evidence base
  • CBT
  • Medication: pregabalin, duloxetine, amitriptyline
  • Aqua training
44
Q

What is the definition of chronic fatigue syndrome? (ME)

A

Post-exertional malaise (main symptom)

  • Delayed fatigue followed by a slow recovery period

Cognitive dysfunction

  • Short-term working memory problems, concentration and attention span. ‘Brain fog’.

Unrefreshing sleep pattern

  • In more severe cases there may be a reversal of normal sleep rhythm (i.e, being awake at night but sleeping during the day).

Autonomic nervous system dysfunction/dysautonomia involving orthostatic intolerance

  • An inability to sustain physical or mental activity whilst standing.
45
Q

What investigations can you do for suspected CFS?

A

Exclude other pathology

e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening and also urinalysis

46
Q

How can CFS be managed?

A
  • CBT
  • Graded exercise therapy - a formal supervised program, not advice to go to the gym as can worsen symptoms
  • ‘Pacing’ - organising activities to avoid tiring
  • Low-dose amitriptyline may be useful for poor sleep
  • Referral to a pain management clinic if pain is a predominant feature
47
Q

A lot of CFS patients are often housebound as activity can make their condition worse, what are some important things to consider?

A
  • Vitamin D supplements
  • Pressure ulcers
  • DVT risk
  • Risk of contractures
48
Q

What is the most important part of management for a CFS patient?

A

Energy Management Plan

Plan each day’s activities, conserve energy resources for the most important tasks

Schedule rest periods to avoid individuals overtaxing themselves, and to improve the quality of sleep

49
Q

ADD CHRONIC PAIN AND MEDICAL UNCERTAINTY LOs!!!!!!!!!!!!!!!

A

SICK NOTE LENGTH IN WORDS

CHECK DVLA DRIVING FOR DIABETES COMPLICATIONS AND IMPARED HYPO AWARENESS

CHECK METHADONE DVLA ADVICE

50
Q

Who can you signpost women with domestic violence to?

A

Women’s Aid

Freeva

51
Q

If you cannot contact your safeguarding lead, who else can you contact about safeguarding concerns?

A

Duty Social Worker - can find details on council website

52
Q

Before ordering an investigation what 3 things need to be done?

A

How will this change my management?

  1. Clinical assessment
  2. What will I do if the test is +ve/-ve/borderline
  3. Explain to pt what test involves and get consent
53
Q

If someone is refusing an investigation what do you need to do?

A

Check capacity

54
Q

What is the management for mechanical lower back pain?

A

Advice

  • stay physically active and exercise

Analgesia

  • NSAIDS first-line
  • PPI co-prescribed if over 45
  • NICE guidelines on neuropathic pain should be followed for patients with sciatica

Other possible treatments

  • Group exercise programme
  • Manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) ‘but only as part of a treatment package including exercise, with or without psychological therapy.’
  • Radiofrequency denervation
  • Epidural injections of local anaesthetic and steroid for acute and severe sciatica

Y5 Emergency Medicine (14 decks)

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