AKT Flashcards
Red flags in limping child
- Pain waking the child at night — may indicate malignancy.
- Redness, swelling, or stiffness of the joint or limb — may indicate infection or inflammatory joint disease.
- Weight loss, anorexia, fever, night sweats, or fatigue — may indicate malignancy, infection, or inflammation.
- Unexplained rash or bruising — may indicate haematological or inflammatory joint disease, or child maltreatment.
- Limp and stiffness worse in the morning — may indicate inflammatory joint disease.
- Unable to bear weight or painful limitation of range of motion — may indicate trauma or infection.
- Severe pain, anxiety, and agitation after a traumatic injury — may indicate neurovascular compromise or impending compartment syndrome.
- A palpable mass — may indicate malignancy or infection.
Limping child
Referral for urgent specialist assessment should be arranged if the child
- Has a fever and/or red flags suggesting serious pathology.
- Is suspected of being maltreated.
- Is younger than 3 years of age — transient synovitis is rare in this age group; septic arthritis is more common.
- Is older than 9 years of age with painful or restricted hip movements (in particular internal rotation) — to exclude slipped upper femoral epiphysis.
Driving ban for persistent alcohol misuse, misuse of cannabis, amphetamines, ecstasy and psychoactive drugs
Stop driving and inform DVLA
until >6 months free
Group 2
1 year
Needs assessment
Driving ban for alcohol dependence, misuse of heroin, morphine, methadone, cocaine, methamphetamine and benzos
Stop driving and inform DVLA
Free for >1 year
Normalisation of blood parameters
Group 3
Abstinence for 3 years
Cease driving after coronary angioplasty for
> 1 week if successful
4 weeks if unsuccessful
Dont need to inform DVLA
Cease driving after PCI
> 1 week
Don’t need to inform DVLA
Cease driving after CABG
4 weeks
Don’t need to inform DVLA
Driving and angina
Cease driving if symptoms occur at rest, with emotion or at the wheel
Dont need to inform DVLA
Driving and heart failure
No restrictions unless:
- NYHA class IV (severe)
(Unable to carry out physical activity without discomfort, symptoms at rest)
Need to form DVLA if NYHA class IV
Driving and hypertension
No restrictions for group 1
Group 2 stop if >180/100 until controlled
Driving and arrhythmias
Stop driving if likely to cause incapacity. Can resume driving when underlying cause controlled for >4 weeks
Cease driving for >2 days after successful catheter ablation
NO need to inform DVLA unless symptoms disabling/ distracting
Group 2
Must inform DVLA
Must not drive if causing / likely to cause incapacity.
May be considered if underling cause identified, symptoms controlled for >3 months, LFEV >40%
Driving and pacemakers
Cannot drive for a week
Must inform DVLA
6 weeks for group 2
Driving and stroke
Group 1
Must stop driving, no need to notify DVLA
Can restart driving after 1 month if good recovery
Need to inform DVLA if persistent neurological deficit after 1 month (will need assessing)
Group 2
Must stop driving and notify the DVLA
May re start after 1 year if full recovery - needs assessment
Driving and TIA
Group 1
Single TIA
no need to notify DVLA
must not drive for 1 month
Multiple TIAs
must not drive and must notify the DVLA
Multiple TIAs over a short period will require no driving for 3 months
Driving may resume after 3 months if there have been no further TIAs
-
Group 2
As per stroke
Must stop driving and notify the DVLA
May re start after 1 year if full recovery - needs assessment
One week driving ban
Successful angioplasty
PCI
Pacemaker
4 week driving ban
Unstable angina
NSTEMI
Unsuccessful Angioplasty
CABG
Heart Valve Surgery
Driving and AAA
> 6cm inform DVLA
6-6.5 annual review
6.5cm disqualified
Group 2 >5.5cm disqualified
ICD and driving
For symptomatic VT and prophylaxis
symptomatic VT 6/12
prophylaxis 4/52
Permanent disqualification for group 2
Driving and T2DM on diet, metformin and GLP1 analogues
No restriction no need to inform DVLA.
Group 2 on metformin must inform DVLA.
GLP 1 analogues
Semaglutide
aka Ozempic
BMI >35
Driving and T2DM on medications with risk of hypoglycemia
Group 1
No more than 1 hypo in last 1y
(and >3m)
Under regular review
Group 2
No hypoglycemic events in last year
Full hypo awareness
Monitor CBG 2x day
Driving in insulin dependent diabetes
Group 1
Must notify DVLA, can drive if:
- No more than 1 hypo in 12 months
- Full hypo awareness
- CBG monitoring 2 hours before driving and every 2 hours while driving
Continuous interstitial fluid glucose monitoring acceptable for group 1 only.
Group 2
Above plus:
- Annual review by diabetes consultant of last 3 months readings
- Need to complete D2 form / D4 medical examination form (vision)
- Must use glucose monitor that can store 3m readings
Driving and parkinson’s/MS
Can drive as long as medical assessment confirms driving not impaired
Driving and epilepsy / multiple unprovoked seizures
Must not drive, must notify DVLA
Must not drive for 1 year after date of last seizure
If seizing only asleep - 1 year
Should not drive for 6 months after stopping/ reducing medication
Group 2
Has to be seizure free off medication for 10 years before license considered
First unprovoked seizure and driving
Must not drive, must notify DVLA
Must not drive for 6 months after date of first seizure or 12 months if there is an underlying cause which could increase seizure risk.
Group 2 licence
Driving must cease 5 years from first seizure. May be restored if neurologist assess risk <2% and not on medication.
Transient loss of consciousness / collapse and driving
Group 1
While standing - can drive dont need to inform DVLA
While sitting - can drive if there is an avoidable trigger that wont occur whilst driving. Otherwise must be assessed to have <20% annual risk.
Group 2
Must not drive and must notify DVLA. Assessment for treatable underlying cause.
Cardiovascular syncope and driving
Must not drive and must notify DVLA
Group 1
Can resume after 4 weeks if cause identified and treated. If no cause identified revoked for 6 months.
Group 2
Can resume after 5 months if cause identified and treated. If no cause identified revoked for 12 months.
ACS (inc. MI) and driving
Group 1
Must not drive but need not notify DVLA. Can continue driving after 1 week if successful PCI and…
- No other revascularization planned
-LVEF >40%
- no other disqualifying condition
if not met then 4 weeks
Group 2
Must not drive and must notify the DVLA. May be considered for a licence after 6 weeks if exercise tolerance met and LVEF >40%.
Flying in unstable angina, uncontrolled HF, severe valvular disease
Should not fly
Flying in uncomplicated MI
7-10 days
Flying in complicated MI
4-6 weeks
Flying post CABG
7-14 days
Flying post PCI
5 days
Flying post pneumonia
Once clinically improved
Flying post pneumothorax
2 weeks after drainage
1 week post CXR
Flying post open abdominal surgery
10 days
Flying post laparoscopic procedure
24 hours
Flying post colonoscopy
24 hours
Flying post plaster cast
24 hours if flight <2 hours
48 hours if flight > 2 hours
Flying and pregnancy
NO travel >36/40 or >32/40 multiple pregnancy
Flying and anaemia
Hb >80 safe
Number of deaths from asthma / year (2016)
1410
Chi-squared test
utilised to compare observed results with those that are expected under a certain hypothesis.
Mann-Whitney U test
non-parametric test assesses differences between two independent groups when the dependent variable is ordinal or continuous but not normally distributed.
Adrenaline dose
< 6 months
100 - 150 micrograms
(0.1 - 0.15 ml 1 in 1,000)
Adrenaline dose
6 months - 6 years
150 micrograms (0.15 ml 1 in 1,000)
Adrenaline dose
6-12 years
300 micrograms (0.3ml 1 in 1,000)
Adrenaline dose
Adult and child > 12 years
500 micrograms (0.5ml 1 in 1,000)
Reduction of non-HDL cholesterol after starting statin?
40% after 3 months
Consider increasing from 20 to 80mg if not achieved
When should q risk not be used ?
- type 1 diabetics
- patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or albuminuria
- patients with a history of familial hyperlipidaemia
When to consider familial hypercholesterolaemia ?
- total cholesterol >7.5
- family history of premature coronary artery disease (event before 60 in first degree relative)
The ankle brachial pressure index (ABPI)
1 = normal
<0.5 suggests severe arterial disease.
Compression treatment is contraindicated.
> 0.5 - < 0.8 suggests the presence of arterial disease or mixed arterial/venous disease.
0.8 to 1.3 suggests no evidence of significant arterial disease.
Compression may be safely applied in most people.
> 1.3 may suggest the presence of arterial calcification, such as in some people with diabetes, rheumatoid arthritis, systemic vasculitis, atherosclerotic disease, and advanced chronic renal failure.
For values above 1.5, the vessels are likely to be incompressible, and the result cannot be relied on to guide clinical decisions.
Moderate asthma attack in adults
Increasing symptoms;
Peak flow > 50-75% best or predicted;
No features of acute severe asthma.
Normal speech
Severe asthma attack in adults
Any one of the following:
Peak flow 33-50% best or predicted;
Respiratory rate ≥ 25/min;
Heart rate ≥ 110/min;
Inability to complete sentences in one breath.
Life threatening asthma attack in adults
Any one of the following in a patient with severe asthma:
Peak flow < 33% best or predicted;
Arterial oxygen saturation (SpO2) < 92%;
Partial arterial pressure of oxygen (PaO2) < 8 kPa;
Normal partial arterial pressure of carbon dioxide (PaCO2) (4.6–6.0 kPa);
Silent chest;
Cyanosis;
Poor respiratory effort;
Arrhythmia;
Exhaustion;
Altered conscious level;
Hypotension.
Moderate acute asthma in children
Able to talk in sentences;
Arterial oxygen saturation (SpO2) ≥ 92%;
Peak flow ≥ 50% best or predicted;
Heart rate ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years;
Respiratory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5 years.
Severe acute asthma in children
Can’t complete sentences in one breath or too breathless to talk or feed;
SpO2 < 92%;
Peak flow 33–50% best or predicted;
Heart rate > 140/minute in children aged 1–5 years; heart rate > 125/minute in children aged over 5 years;
Respiratory rate > 40/minute in children aged 1–5 years; respiratory rate > 30/minute in children aged over 5 years.
Life-threatening acute asthma in children
Any one of:
SpO2 < 92%;
Peak flow < 33% best or predicted;
Silent chest;
Cyanosis;
Poor respiratory effort;
Hypotension;
Exhaustion;
Confusion.
When to admit acute asthma
- Patients with features of severe or life-threatening acute asthma should start treatment as soon as possible and be referred to hospital immediately following initial assessment
- Patients with moderate acute asthma should be treated at home or in primary care and response to treatment assessed.
Doses of nebulised salbutamol in acute asthma
5mg >5 years
2.5mg 2-5 years
Oxygen driven, flow rate 6 L /min
If nebs not available give inhaler via spacer.
Consider ipratropium bromide nebs if unresponsive
Target oxygen sats in acute asthma
94–98%
First dose of prednisolone for asthma in adults
40-50mg
First dose of prednisolone for asthma in children >5 years
30 - 40 mg
First dose of prednisolone for asthma in children 2-5 years
20 mg
First dose of prednisolone for asthma in children <2 years
10 mg
The ankle brachial pressure index (ABPI)
1 = normal
<0.5 suggests severe arterial disease.
Compression treatment is contraindicated.
> 0.5 - < 0.8 suggests the presence of arterial disease or mixed arterial/venous disease.
0.8 to 1.3 suggests no evidence of significant arterial disease.
Compression may be safely applied in most people.
> 1.3 may suggest the presence of arterial calcification, such as in some people with diabetes, rheumatoid arthritis, systemic vasculitis, atherosclerotic disease, and advanced chronic renal failure.
For values above 1.5, the vessels are likely to be incompressible, and the result cannot be relied on to guide clinical decisions.
Salbutamol large volume spacer to relieve asthma symptoms in adults
4 puffs initially followed by 2 puffs every 2 mins according to response up to 10 puffs
Salbutamol large volume spacer to relieve asthma symptoms in children
Puff every 30-60 seconds up to 10 puffs.
Repeat every 10-20 mins according to response
When to refer to respiratory with acute asthma
If had two asthma attacks in last 12 months
How to calculate units alcohol
Volume in (mls x ABV) /1000
Alcohol use disorder identification tool (AUDIT)
Low risk
Score < 7
Alcohol use disorder identification tool (AUDIT)
Increasing risk (hazardous)
Score 8 - 15
Alcohol use disorder identification tool (AUDIT)
Higher risk (harmful)
Score 16-19
Alcohol use disorder identification tool (AUDIT)
Possible dependence
Score >20
FRAMES ?
Tool for brief advice in alcohol XS
Feedback - compared to others
Responsibility - up to them
Advice - how to calculate units
Menu - support groups
Empathy
Self efficiency - encouragement
Acamprosate
EtOH XS
Alters balance between excitatory and inhibitory neurotransmission, eases cravings, impacts enjoyment
Some GPs
Naltrexone and disulfiram
EtOH XS
Reduces cravings by increasing side effects of drinking, headache, nausea etc
Specialists only
Nalmefene
EtOH XS
Opioid antagonist. Reduces craving for further drinks. Reduces overall consumption
> 85% in GP
Recommended drinking
<14 units spread over 3 days
No safe level
Cancers associated with EtOH
Breast
Oesophagus
Oral cavity and pharynx
Liver
Colorectal
‘BOCOL’
Illnesses associated with EtOH
Hypertension
Arrhythmias
Strokes (haemorragic)
Pneumonia / LRTI
Cirrhosis of liver
Epilepsy
Pancreatitis
Facial features of foetal alcohol syndrome
Low nasal bridge
Flat midface
Ear abnormalities
Indistinct philtrum
Micrognathism
Thin upper lip
Epicanthal folds
Short palpebral fissures
Adrenaline in anaphylaxis
Adults / Child >12
500mcg / 0.5ml
1:1000 IM
If no response repeat after 5 mins
Adrenaline in anaphylaxis
Child 6-12
300mcg / 0.3ml
1:1000 IM
If no response repeat after 5 mins
Adrenaline in anaphylaxis
Child 6 months - 6 years
150 mcg / 0.15ml
1:1000 IM
If no response repeat after 5 mins
Adrenaline in anaphylaxis
Child < 6 months
100-150mcg - 0.1-0.15ml
1:1000 IM
If no response repeat after 5 mins
Indications of adrenaline in anaphylaxis:
- Horseness of voice
- Wheeze
- Shortness of breath
- Shock
- Stridor
- Swelling of the tongue and cheek
- Facial swelling
NOT florid hives on the trunk
NOT neck urticaria
Which type of reaction is Anaphylaxis defined as?
Type I IgE mediated hypersensitivity reaction
Percentage of antibiotics prescribed in primary care
80%
FeverPAIN score
Fever (last 24 hours)
Purulence on tonsils
Attend rapidly (<3 days after onset)
Severely inflamed tonsils
No cough or coryza
1 point for each
0-1 13-18% - no abx
2-3 34-40% - delayed Rx
4-5 62-65% - abx
Centor criteria
Tonsillar exudate
Cervical lymphadenopathy
No cough or coryza
Fever
<15 + 1
>44 - 1
0-2 3-17% no abx
3-4 32- 68% - delayed Rx
5-6 - abx
Mental Capacity Act (2005)
- It must be assumed that an adult is able to make his/her own decisions, unless it has been shown otherwise.
- All reasonable help and support should be given to assist a person to make their own decisions and
communicate those decisions, before it can be assumed that they have lost capacity. - Every adult has the right to make decisions that may appear to be unwise or strange to others.
- If a person lacks capacity, any decisions taken on their behalf must be in their best interests.
- If a person lacks capacity, any decisions taken on their behalf must be the option least restrictive to their rights and freedoms.
- Capacity is decision-specific.
2-stage test of capacity:
- Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?
- Does the impairment mean the person is unable to make a specific decision when they need to?
People can lack capacity to make some decisions, but have capacity to make others. Mental capacity can also fluctuate with time –someone may lack capacity at one point in time, but may be able to make the
same decision at a later point in time.
Medical examiners seek to answer three questions:
- What caused the death of the deceased?
- Does the coroner need to be notified of the death?
- Was the care before death appropriate?
Medical examiners answer these by providing independent
scrutiny, with three elements:
- A proportionate review of relevant medical records
- Interaction with the doctor completing the Medical Certificate of Cause of Death
- Interaction with the bereaved, providing an opportunity to ask questions and to raise concerns
Notification of death to the coroner/procurator fiscal
The death was due to…
- poisoning of any kind or contact with a toxic substance
- the use of a medicinal product, the use of a controlled drug or psychoactive substance
- violence, trauma, injury or self-harm, neglect, including self-neglect
- a person undergoing any treatment or procedure of a medical nature
- an injury or disease attributable to any employment held by the person during the person’s lifetime
- The cause of death is unknown
- The identity of the deceased in unknown
- The registered medical practitioner suspects that the person died while in custody
- The person’s death was unnatural but does not fall within any of the above circumstances
Practices can require a patient to register elsewhere if?
They have moved outside of the practice’s area
The relationship has broken down irretrievably
- In cases of violence or abuse this can be immediate (police involvement generally required)
- Other instances require evidence of consideration, which should include a written warning, which remains valid for 12 months
- Practices should write to the PCO/NHSE with details of the affected
patient - The removal takes effect on the 8th day hereafter, or 8 days after ongoing treatment ceases if relevant
Gillick competence
Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment.
Who can issue a MED3 cert?
Doctor, nurse, physio, OT or pharmacist
A Med3 may be issued on the day that you assessed your patient or later if you consider:
- that it would have been reasonable to issue a Statement on the day of the assessment
- after consideration of a written report from another doctor or registered health care professional
How long can an MED3 be issued for?
During the first 6 months of sickness, the new Statement can be issued for no longer than 3 months
After six months: There is no limit on the duration of a fit note if the condition has lasted longer than six months and is clinically appropriate.
Statutory Sick Pay
- Up to £116.75/week if you’re too ill to work.
- Paid by employer for up to 28 weeks.
- Paid from the 4th day onwards – unless a repeat episode within eight weeks.
- You can’t get less than the statutory amount but you can get more if your company has a sick pay scheme.
To qualify for Statutory Sick Pay (SSP) you must:
- be classed as an employee and have done some work for your employer
- have been ill for at least 4 days in a row (including non-working days)
- earn at least £123 (before tax) per week
- tell your employer you’re sick before their deadline - or within 7 days if they don’t have one
Employment and Support Allowance (ESA)
You can apply for Employment and Support Allowance (ESA) if you have a disability or health condition that affects how much you can work.
ESA gives you:
Money to help with living costs if you’re unable to work, support to get back into work if you’re able to.
You can apply if you’re employed, self-employed or unemployed.
Personal Independence Payment (PIP)
Personal Independence Payment (PIP) can help with extra living costs if you have both:
- a long-term physical or mental health condition or disability
- difficulty doing certain everyday tasks or getting around because of your condition
You can get PIP even if you’re working, have savings or are getting most other benefits.
There are 2 parts to PIP:
a daily living part - if you need help with everyday tasks
a mobility part - if you need help with getting around
Carer’s Allowance
You could get £81.90 a week if you care for someone at least 35 hours a week and they get certain benefits.
You do not have to be related to, or live with, the person you care for.
You do not get paid extra if you care for more than one person.
If someone else also cares for the same person as you, only one of you can claim Carer’s Allowance.
Bereavement Support Payment
You may be able to get Bereavement Support Payment if your partner has died.
When your partner died, you must have been:
- under State Pension age
- living in the UK or a country that pays bereavement benefits
- married to your partner, in a civil partnership with them, or living with them as if you were married
Your partner must have either:
- paid a certain amount of Class 1 or Class 2 National Insurance contributions in any one tax year since 6 April 1975
- died because of an accident at work or a disease caused by work
Maternity Allowance
Maternity Allowance is a payment you can get when you take time off to have a baby.
You could get it if you:
- are employed but cannot get Statutory Maternity Pay (SMP)
- are self-employed
- have recently stopped working
- take part in unpaid work for the business of your spouse or civil partner
You can get Maternity Allowance for up to 39 weeks.
SR1 – Special Rules
The Special Rules allow people nearing the end of life to:
- get faster, easier access to certain benefits
- get higher payments for certain benefits
- avoid a medical assessment
An adult or child is nearing the end of life when they are likely to have less than 12 months to live.
The SR1 form has replaced the DS1500 form.
a fast tracked claim to the following benefits (for which they are eligible):
* Personal Independence Payment
* Universal Credit (UC)
* Employment and Support Allowance
* Disability Living Allowance (DLA) for children
* Attendance Allowance (AA)
Classes of CDs
Schedule one
Requires license to possess, e.g. medicinal cannabis
Classes of CDs
Schedule two
Most opioids, amphetamines,
* Subject to safe custody requirements and CD register
Classes of CDs
Schedule three
Gabapentinoids, Midazolam and Temazepam, Buprenorphine
* Safe custody requirements but no CD register (certain exceptions)
Classes of CDs
Schedule four
All other Benzodiazepines, anabolic steroids
* Not subject to safe custody requirements, invoices kept for two years
Classes of CDs
Schedule five
Codeine/Dihydrocodeine available for OTC use
* Invoices kept for two years
Safe custody of controlled drugs
- Locked metal cabinet, anchored to wall or floor by unexposed bolts, not
labelled. - Access limited to authorised individuals.
- Destruction from stock must be witnessed by an authorised individual.
Controlled drugs in doctor’s bag:
- Must be locked, left in boot of a car if necessary but never overnight
- Restocking from CD cupboard must be witnessed
Patient Group Directives
- All medication being given must be prescribed
- PGD (patient group directive)
- Written instructions for the supply or administration of medicines to
groups of patients who may not be individually identified before
presentation for treatment. - Signed by doctor and pharmacist
- PCO level, not individual practices
- Administered by qualified professional e.g. nurse, paramedic.
Patient-Specific Directives
If not a registered HCP (e.g. an HCA), a PSD (Patient-Specific Directive) is
required.
There is no set format for PSDs written into the legislation, however a PSD must: * state the name of the patient * state the name and dose of the prescription only medicine to be administered* show evidence to confirm that the patient has been considered as an individual * include frequency/duration/start and end dates of treatment * be signed by a prescriber
Vaccine storage
- 2 – 8°c from manufacturer to administration
- Never frozen
- Protected from light
- Direct from fridge where possible
- Transported in a validated cool box with max-min thermometer if
necessary - Can be returned if cold chain maintained
A good report…
- Has informed patient consent (with exceptions)
- Stands alone
- Is written for a lay person of reasonable intelligence
- Is factual (unless an opinion is sough that falls within your sphere of
competence) - Is thorough and complete to the best of your reasonable ability (with
certain exceptions) - Is not misleading
What to withhold in insurance reports
- Adverse genetic test results
- Negative tests for blood-borne viruses, e.g. HIV
- STIs which are resolved and from which there is no long-term health
implication - Information relating to family history not obtained from the patient
Patient requests to amend reports…
Patients are entitled to see any medical report about them
* They can request modification
* If refused – the patient can attach a note disputing the views expressed
* They can withdraw consent for the report to be sent
* You can inform the person who commissioned the report
The GMC’s Good Medical Practice (2006) points out that you must be
honest when writing reports and that you must not deliberately leave out relevant information.
The Data Protection Act
Practices must:
* Have a data protection officer
* Provide patients with access to their notes when asked (within one
month) and without charge
- Request does not have to be in writing
- Assume the age of consent for access to be 13 years
GP practices hold
* Personal data (e.g. name, address)
* Sensitive personal data (e.g. medical information, religion, sexuality)
* This must be retained for ten years (or until the patient is 21 years old if
longer)
Subject Access Requests
- Can be made by the patient or a third party with consent
- Can be for all or part of the record
- Can be ‘reason blind’
- Should be answered in 28 days
Withholding data
Data may be withheld in the following circumstances
* Its release would reasonably be expected to cause significant harm to
the patient’s physical or mental health
* Any reference to a named third party
Access to deceased records
GDPR regulations only apply to the living.
* Deceased records governed by Access to Health Records Act (1990)
Access to deceased records:
* Via NHS England or local equivalent (as data controller)
* Personal representative – e.g. executor of will
* Person with possible claim arising from the death
* Limited to relevant information
* Overridden by wishes documented in life
Correcting data
- If the patient and GP are in agreement that a record is factually incorrect, it should be amended.
- This should be done in such a way that the correction is audit traceable.
- If the patient believes the record to be incorrect but the GP does not, an
addendum must be added to the record to this effect but the original notes should remain.
NHS complaints
- Initial response within 2 working days
- Full response within reasonable period as defined in policy
- Extended if exceptional circumstances
- Records kept for 10y (longer in children)
- Can be verbal or written
- Investigated and responded to by an independent person
- Procedure can be discontinued if informal resolution
- Must identify patient’s right to escalate to Parliamentary and Health
Service Ombudsman - Could also complain to GMC
- Should be made within a year of the incident or finding out about the
adverse outcome
Responsibilities under the Health and Safety at Work Act (1974):
- Provide a safe system of work
- Provide a safe place of work
- Provide safe equipment
- Employ safe and competent people: employers are also liable for the actions of their staff and managers
- To carry out risk assessments as set out in regulations, and taking steps to
eliminate or control these risks; - To inform workers fully about all potential hazards associated with any work
process, including providing instruction, training and supervision; * To appoint a ‘competent person’ responsible for health and safety - Provide adequate facilities for staff welfare at work.
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Spurious
an association that has arisen by chance and is not real
Spurious
an association that has arisen by chance and is not real
Indirect association
the association is due to the presence of another factor (a confounding variable)
Direct association
a true association not linked by a third (confounding) variable
Diabetes ranges
If the patient is symptomatic:
- fasting glucose greater than or equal to 7.0 mmol/l
- random glucose greater than or equal to 11.1 mmol/l
7/11
IF asymptomatic do test x 2
HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
direct switch is possible
Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low dose of the alternative SSRI
Switching from an SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommended
- an exception is fluoxetine which should be withdrawn, the leave a gap of 4-7 days prior to TCAs being started at a low dose
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
direct switch is possible
Switching from fluoxetine to venlafaxine
withdraw and then start venlafaxine at a low dose 4–7 days later
Meniere’s and driving
patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
DEXA Scan results
-0.6 ?
> 0 Reassure
0 to -1.5 Repeat bone density scan in 1-3 years
< -1.5 Offer bone protection
Normal distribution of data
1 standard deviation?
2 standard deviations ?
3 standard deviations ?
68.3% within 1SD of the mean
95.4% within 2 SD of the mean
99.7% within 3 SD of the mean
Side effects Procainamide
fatigue, dry cough, pleuritic chest pain, and a facial rash is suggestive of drug-induced lupus erythematosus (DILE)
Side effects Digoxin
gastrointestinal disturbances, visual disturbances, and arrhythmias;
Side effects sodium valproate
nausea and vomiting, as well as tremors, hair loss, and weight gain.
Drugs causing drug induced lupus
Most common causes
procainamide
hydralazine
Less common causes
isoniazid
minocycline
phenytoin
Cancer risk with COCP
increased risk of breast cancer and cervical cancer
Side effects of ACE I
cough
thought to be due to increased bradykinin levels
angioedema: may occur up to a year after starting treatment
hyperkalaemia
first-dose hypotension: more common in patients taking diuretics
Cautions and CI ACE I
pregnancy and breastfeeding - avoid
renovascular disease - may result in renal impairment
aortic stenosis - may result in hypotension
hereditary of idiopathic angioedema
specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L
Type 1 error
False positive
Falsely rejecting null hypothesis
Type 2 error
False negative
Falsely accepting null hypothesis
P value
The probability of getting these results by chance. The further away from 1 the stronger the data.
statistically significant if P-value <0.05
P = 0.0001 very unlikely (1 in 10,000 chance)
* P = 0.01 unlikely (1% or 1 in 100 chance)
* P = 0.05 fairly unlikely (5% or 1 in 20 chance)
* P = 0.1 not unlikely (10% or 1 in 10 chance)
* P = 0.8 very likely (80% chance)
Risk ratio
risk of an event in one group /
risk of an event in another group
Risk
1 boy is born for every 2 births, so the probability (risk) of giving birth to a boy is:
1/2 = 0.5
Odds
The number of times an event happens divided by the number of times it does not:
* 1 boy is born for every 2 births, so the odds of giving birth to a boy are:
1:1 (or 50:50) = 1/1 = 1
Odds ratio (OR)
odds of an event in one group/
odds of an event in another group
e.g. risk of pneumonia in patients taking statins:
* Statins odds 2231/1775 = 0.126;
no statins odds 8759/80484 = 0.109
Therefore OR for pneumonia with statins versus no statins
= 0.126/ 0.109 = 1.15
Hierarchy of evidence
- Systematic reviews and meta-analyses
- Randomised controlled trials with definitive results
- Cohort studies
- Case control studies
- Cross-sectional studies
- Case reports
Hazard ratio
HR = treatment hazard rate/placebo hazard rate
e.g.
Infection rate in ‘new Rx’ group = 10%
Infection rate in amoxicillin group = 40%
HR = 10/40 = 0.25
Absolute Risk Reduction
ARR = [Infection rate in ‘new Rx’ group] - [Infection rate in amoxi group]
e.g.
Infection rate in ‘new Rx’ group = 10%
Infection rate in amoxicillin group = 40%
40%-10% = 30%
Relative Risk Reduction
RRR = How much the risk is reduced in the new Rx group compared to the
control group
e.g.
Infection rate in ‘new Rx’ group = 10%
Infection rate in amoxicillin group = 40%
ARR/ control = 30/40 = 75%
Number Needed to Treat
NNT How many people need new Rx for one person to benefit.
NNT = 100/ ARR
Round up to the nearest whole number
NNT = 1 / (adverse outcome rate with placebo - adverse outcome rate with treatment)
Kaplan-Maier approach
a technique for using “censored” observations: where not all patients have been followed up for the full duration of the study
“triangulation”
Using more than one qualitative research method to gather data
Likelihood ratio
The “positive likelihood ratio” (LR+) tells us how much the probability of disease increases if the test
is positive:
LR+
= probability of an individual with the condition having a positive test/ probability of an individual without the condition having a positive test
= sensitivity/
(1 - specificity)
The “negative likelihood ratio” (LR-) tells us how much it decreases if the test is negative
LR- =
probability of an individual with the condition having a negative test / probability of an individual without the condition having a negative test
= (1-sensitivity)
specificity
Likelihood ratio interpretation
- > 10: large increase in the likelihood of disease
- 2 – 5: small increase in the likelihood
- 1: no change in the likelihood
- 0.2 - 0.5: small decrease in the likelihood
- < 0.1 large decrease in the likelihood
Bayesian statistics
- Starts with current belief (a “prior”) in whether a treatment works; updates this belief with the data;
this new belief is called the “posterior”. - Reflects the way that we actually think.
Sampling bias
not covering all of the population of interest (also called omission bias) or only covering some parts because it’s more convenient (also called inclusion bias).
Procedural bias:
exists when participants are put under some kind of pressure to provide information.
Respondent bias
survey participants unable or unwilling to provide accurate or honest answers.
Measurement bias:
measurement methods (instrument, or observer of instrument) are consistently different between the study groups.
Attrition bias
patients may drop out because the treatment made them worse - or,
patients may drop out when the treatment works.
Publication bias
study results less likely to be published when they are not
statistically significant or less “interesting”.
Chi-squared test
It is a measure of the difference between actual and expected frequencies (the frequency we would
see if the null hypothesis were true).
If the observed and the expected frequencies are the same, the C2 (=chi squared) value is zero
DALY (disability-adjusted life year)
A measure of health loss: the impact of a disease or injury in terms of healthy years lost.
Categorical data
a variable whose values represent different categories of the same feature; examples
include different blood groups, different eye colours, and different ethnic groups;
Continuous data
variables which can take any value within a given range, for instance blood pressure.
Ordinal data
data that can be allocated to categories that can be “ordered”, e.g. from least to strongest;
an example is the staging of malignancy;
Delphi study
A survey of experts in two or more ‘rounds’, in which, in the second and later rounds of the survey, the results of the previous round are given as feedback. Therefore, the experts answer from the second round on under the influence of their colleagues’ opinions. So, respondents can learn from the views of others, without being unduly influenced by the people who talk loudest at meetings, or who have most prestige etc.
Standardised mortality rate
How many people, per thousand of the population, died in a given year.
Standardised mortality ratio (SMR)
The ratio of observed deaths in the study group to expected deaths in the general population; it can
be given as a percentage.
If the SMR is quoted as a ratio:
o < 1 indicates fewer than expected deaths in the study group (compared with the expected deaths in the general population)
o = 1 indicates observed deaths equals expected deaths
o >1 indicates there were excess deaths
Sometimes the SMR is expressed as a percentage, after multiplying by 100. In this case:
o < 100 indicates fewer than expected deaths (compared with the expected deaths in the
general population)
Statistical process control (SPC) charts
Where something is being measured regularly (e.g. number of complaints a month in an
organisation), these help to distinguish between normal abnormal variation.
* Points outside the ‘control limits’ (the acceptable variation range) need investigation.
Case-control studies
Retrospective, they start with the event of interest and then look back for associated events.
Cases: The group of people who have the condition or disease being studied
Controls: A similar group of people who do not have the condition or disease.
risk of ‘selection bias’: cases or controls may not be representative; risk of ‘recall bias’; can’t
establish ‘cause & effect’
Study for uncommon outcomes/diseases; illnesses with a long delay between exposure and disease, e.g. asbestos and mesothelioma
Case-control
Cohort studies
Prospective; they start with a well-defined group of people and observe for future events
Can be costly and time-consuming; loss to follow-up (‘attrition’) may lead to bias
Study for uncommon exposures; some ability to establish causation
Can study a range of outcomes/diseases caused by one exposure
e.g. heart disease, lung cancer, stroke caused by smoking
Cohort studies
Methotrexate
The most widely used DMARD.
Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis.
Other important side-effects include pneumonitis
Chi-squared test
used to compare proportions or percentages e.g. compares the percentage of patients who improved following two different interventions
Mann-Whitney U
This statistical test is used to measure ordinal, interval or ratio scales of unpaired data. An example of an ordinal variable is Likert items e.g. a 5 point scale. This is not the correct test to compare percentages.
Students t test paired / unpaired
for when data is normally distributed
Antibiotic choice for acne vulgaris
Clindamycin
Doxycycline / lymecycline
Antibiotic choice for cough if indicated
Doxycycline - adults
Amoxicillin - children
Also clarithromycin, erythromycin
Antibiotic choice for otitis media
Amoxicillin
Clarithromycin if pen allergic
Otitis externa + cellulitis abx?
Flucloxacillin
Antibiotic for bacterial vaginosis
Metronidazole
Antibiotic for sinusitis
pen v
doxy if pen allergic
Oral candidiasis
Azoles > nystatin
Miconazole = azole
Vaginal candidiasis
Topical azoles (pessary)
If recurrent (>3 year) then oral fluconazole course 6 months
Antibiotics for Impetigo
Fusidic acid topically
Mupirocin if MRSA
More severe then oral flucloxacillin
Antibiotics for leg ulcers
Always colonized, abx only needed if infection.
Flucloxacillin
Cipro + clind
Oxygen gel non healing ulcers.
Abx for bites
Cats always give
Dogs if hand foot tendon immunocompromised
Co amoxiclav
Metro and clarith (human), metro and doxy (animal) if pen allergic
Fungal skin infections
Topical terbinafine
Or Imidazole if ?candida
Can go to orals if not clearing
Fungal nail infections
Oral terbinafine
Must confirm with scrapings
Check LFTs
Apply weekly antifungal cream to prevent recurrence
Treatment for chickenpox
Seek specialist advice in pregnancy, neonate and immunocompromised
Consider acyclovir if <24 hours from onset AND one of : <14, severe pain, dense/ oral rash, smoker, on steroids
Otherwise conservative
Treatment for shingles
Acyclovir if >50 years old and within 72 hours of rash
Or ophthalmic / ramsay hunt / eczema / non truncal involvement / pain / mod severe rash
If ongoing >1week consider acyclovir
800mg 5x day 7 days
Diagnosis of asthma in 5-16
1) spirometry and bronchodilator reversibility
2) FeNO with uncertainty then peak flow
Diagnosis of asthma >17
1) FeNO
2) spirometry and bronchodilator reversibility
3) peak flow variability
What is FeNO
Marker of inflammation in the airways
NO produced by body to vasodilate
<25 ppb: Normal, and usually indicates asthma is unlikely
25–50 ppb: Intermediate, and suggests some airway inflammation and asthma may be a possibility
>50 ppb: High, and strongly indicative of asthma
Spirometry and asthma
FEV1 <80% predicted
FEV1 /FVC <0.7
Written asthma management plan to include :
- Describe how to recognise and respond to worsening asthma
- Individualize the plan for the patient based on understanding
- Provide advice about change in ICS and how/when to add OCS
- If using peak flow use personal best rather than predicted. Step up on 25% reduction
- Quadruple dose ICS as long as within range (consider stepping down after 3 months if stable)
AF increases stoke risk by …
5 x
1 in 5 strokes caused by AF
Rate control for AF (4)
- beta blockers eg bisoprolol
- rate limiting calcium channel blocker eg diltiazem
- digoxin (if sedentary lifestyle or failure of above)
- combination of any of the above
NB do no offer amiodarone for long term rate control
Rhythm control for AF (5)
- DC cardioversion acute or planned
- Left atrial catheter ablation
- Left atrial surgical ablation
- Class 1c antiarrhythmics - flecainide
- Pill in the pocket for PAF
NB flecainide or dronedarone first line unless structural disease / HF. -use amiodarone instead
Monitoring for amiodarone
Liver function tests required before treatment and then every 6 months.
Serum potassium concentration should be measured before treatment.
Chest x-ray required before treatment
Thyroid function tests should be performed before treatment, then at 6-monthly intervals, and for several months after stopping treatment
Regular eye checks - corneal deposits possible
Antidote for dabigatran
Idarucizmab
Novel oral anticoagulants (NOACs)
Dabigatran: A direct thrombin inhibitor
Rivaroxaban: A factor Xa inhibitor
Apixaban: A factor Xa inhibitor
Edoxaban: A factor Xa inhibitor
Post ablation for AF how long should antiarrhythmics be used ?
3 months
5 year survival of breast ca
85%
Cases of breast ca a year
50 000
BRCA facts
- Tumour suppressor genes
- Autosomal dominant
- Can be inherited from either parent
- Mutations greatly increase risk of breast and ovarian ca
- Frequency ~1/400
(1/50 in ashkenazi jews) - Screening offered from age 30
TP53 gene
Risk of sarcoma, adrenal, brain and breast
Cancer risk 100% in women, 73% in men
Referral criteria to secondary care for genealogy - family history of breast cancer
ONE first-degree female relative diagnosed with breast cancer <40
ONE first-degree male relative diagnosed with breast cancer at any age
ONE first-degree relative with bilateral breast cancer where the first primary was diagnosed <50
TWO first-degree relatives, or 1 first-degree and 1 second-degree relative, diagnosed with breast cancer at any age
1 first-degree or second-degree relative diagnosed with breast cancer at any age AND 1 first-degree or second-degree relative diagnosed with ovarian cancer at any age (1 of these should be a first-degree relative) or
THREE first-degree or second-degree relatives diagnosed with breast cancer at any age.
Monitoring requirements for sodium valproate
Monitor liver function before therapy and during first 6 months especially in patients most at risk.
Measure full blood count and ensure no undue potential for bleeding before starting and before surgery.
Down’s syndrome risk
1/1,000 at 30 years then divide by 3 for every 5 years
1/50 at 45 years
Medical management for ladies with genetic risk breast ca
Pre menopause - Tamoxifen
Poset monopasue - Anastrazole/ tamoxifen/ raloxifene
All increase risk of VTE
People who need statins . No need to calculate risk (7)
- Age >84
- Established cardiovascular disease
- eGFR <60 / albuminuria
- Peripheral vascular disease
- Familial hypercholesterolemia
- T1DM
- Polycythemia vera
Modifiable risk factors for CVD (7)
- T2DM
- Smoking
- Blood lipids
- Level of physical activity
- Diet
- Salt intake
- Blood pressure
Non modifiable risk factors for CVD
- Age
- Sex
- Ethnicity
- Socioeconomic status
- Familial hypercholesterolemia
QRISK calculator
Age
Sex
Ethnicity
Postcode
Smoking
Diabetes
Angina / MI in relative <60
CKD
AF
On blood pressure treatment
Rheumatoid arthritis
Cholesterol
BP
New for Qrisk 3
SLE
Severe mental illness
Erectile dysfunction
Migraines
On steroids
Antipsychotics
Estimates risk of a stroke or myocardial infarction in the next 10 years. >10% start statin.
Atorvastatin 20mg first line.
Strongest to weakest statins
rosuvastatin 5mg , atorvastatin 20mg, simvastatin 50mg , lovastatin, pravastatin, and fluvastatin.
Amount needed to achieve 40% reduction
Marburg score
Risk of ACS
Age F>65 M >55 1
Vascular disease 1
Patient thinks its cardiac 1
Worse on exercise 1
Not reproducible by palpation 1
<2 low risk
3 medium
>4 high
Assessing chronic stable chest pain
Typical / atypical
- Crushing retro sternal chest pain, radiating to jaw, arms, neck
- Precipitated by exertion
- Relieved by GTN spray after 5 mins
3 = typical chest pain
2 = atypical chest pain
1/0 = non cardiac chest pain
Angina management
1) Beta blocker
2) Calcium channel blocker (non rate limiting eg nifedipine , amlodipine, felodipine)
Diltiazem - use caution
Verapamil - contraindicated
3) Long acting nitrate
4) Nicorandil, ivabradine, ranolazine
Only offer >2 if awaiting revascularization or unable to have it
Secondary prevention for Angina
- Aspirin 75mg
- ACE inhibitor
- Statin (atorvastatin 80mg)
- Well controlled BP
- Screen for depression
CGA description ?
Describes CKD
C - Aause
G - GFR
A - Albuminuria
Alport syndrome
Alport syndrome is a genetic disease causing kidney damage, hearing loss, and eye problems. Learn about its symptoms, diagnosis, and treatments for kidney health.
Blood pressure target in CKD
CKD alone <140/90
CKD + diabetes/ pcr >70 = <130/80
Diabetes and CKD drugs
ACE I / ARB
SGLT-2 inhibitor
When to refer CKD to renal team
- All patients with eGFR <30
- None diabetics with ACR >70
- Haematuria with ACR >30
- 3 readings over 90 days showing deterioration in eGFR >25%
- Treatment resistant hypertension (4 agents)
- Genetic cause
-?Renal artery stenosis - Heavy proteinuria
CKD G3A1 confirm diagnosis ? If uncertain
Cystatin c blood test
CKD grading system
CGA
What contains gluten ?
BROW
Barley
Rye
Oats
Wheat
Highest incidence of coeliac
50-67
Bleeding on OCP
No need for 7 day break
If you have breakthrough bleeding then stop taking for 4 days
UK MEC 3 COCP (7)
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension (on antihypertensives)
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
UK MEC 4 COCP (9)
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies (e.g. in SLE)
Gestational diabetes oral glucose tolerance test (OGTT) levels
Gestational diabetes can be diagnosed by either a:
fasting glucose is >= 5.6 mmol/L, or
2-hour glucose level of >= 7.8 mmol/L
‘5678’
When should Q Risk not be used?
> 84
T1DM
CKD 3 (eGFR <60) / proteinuria
Familial hyperlipidaemia
QRISK2 may underestimate CVD risk in:
- HIV
- serious mental health problems
- medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids or immunosuppressant drugs
- autoimmune disorders/systemic inflammatory disorders such as systemic lupus erythematosus
When to investigate familial hypercholesterolaemia
- total cholesterol level > 7.5 mmol/L
- there is a personal or family history of premature coronary heart disease (an event before 60 years in an index person or first-degree relative [parents, siblings, children])
Statins in T1DM
Atorvastatin 20 mg should be offered if type 1 diabetics who are:
older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors
Statins in CKD
atorvastatin 20mg should be offered to patients with CKD
increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved and the eGFR > 30 ml/min. If the eGFR is < 30 ml/min a renal specialist should be consulted before increasing the dose
Treatment for croup
0.15mg/kg dexamethasone single dose
Incubation of gastroenteritis
Incubation period
1-6 hrs: Staphylococcus aureus, Bacillus cereus*
12-48 hrs: Salmonella, Escherichia coli
48-72 hrs: Shigella, Campylobacter
> 7 days: Giardiasis, Amoebiasis
After starting ACE I for HTN + DM , acceptable change in creatinine and eGFR
NICE suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, although any rise should prompt careful monitoring and exclusion of other causes (e.g. NSAIDs). A rise greater than this may indicate underlying renovascular disease
How long after MI can you have sex ?
4 weeks
How long after MI can you have sex ?
4 weeks
Drugs after an MI ?
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
Drugs after an MI ?
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
Drugs after an MI ?
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
How long after MI can heavy workers go back?
3 months
How long post partum can you have a smear ?
3 months
Contraindications for phosphodiesterase-5 inhibitors.
nitrate prescription; patients for whom sexual activity is not advisable; history of non-arthritic optic neuropathy; retinal degeneration; use of indinavir/ketoconazole/itraconazole in patients over age 75 years (vardenafil only); heart failure and uncontrolled arrhythmia/hypertension (tadalafil only).
How long is licencing for Mirena LNG-IUS, for contraception
8 years
However, women who are aged 45 years or over at the time of LNG-IUS insertion may retain the device until the age of 55 if used for contraception
How long can you keep the copper coil in?
ranges from 5–10 years, depending on the device. Women who are aged 40 years or more at the time of IUD insertion may retain the device until they no longer need contraception, even if this is beyond the duration of the UK marketing authorisation.
How often do doctors need to revalidate ?
All licensed doctors in the UK working in the NHS and the private sector and all branches of practice need to complete a revalidation cycle once every five years via GMC
Core symptoms of ADHD
hyperactivity, impulsivity and inattention.
Motor planning and co-ordination difficulties may be found in up to 50% of children with ADHD.
Scale for thyroid toxicosis
Burch-Wartofsky Point Scale (BWPS)
Check temp, pulse, BP
Contraindications for Alteplase
(Used for thrombolysis)
a stroke in the last three months or a convulsion-accompanying stroke.
The ankle brachial pressure index (ABPI) is…
the ratio of the highest recorded systolic pressure recorded in the affected leg over the highest recorded systolic pressure in either arm (whichever arm had the highest reading).
IQ scores and LD
IQ score of 50–70 = mild learning disability.
IQ score of 35–49 =moderate learning IQ score of 20–34= severe learning IQ score of < 20 =profound learning disability.
FIT criteria
Aged 50 and over with any of the following unexplained symptoms:
rectal bleeding
abdominal pain
weight loss
Drugs that can lower seizure threshold
alcohol, cocaine, amphetamines
ciprofloxacin, levofloxacin
aminophylline, theophylline
bupropion
methylphenidate (used in ADHD)
mefenamic acid
Indications for higher dose folic acid in pregnancy ?
5mg needed for:
- BMI of more than 30 kg/m²
- diabetes
- sickle cell disease (SCD)
- thalassaemia trait
- coeliac disease
- on anti-epileptic medication
-personal or family history of NTD
?Multiples
Otherwise 400mcg
+ all pregnant patients take vitamin D 10mcg
Significant statistical heterogeneity…
Using Higgins I2, a value of 0% indicates statistical homogeneity. Significant statistical heterogeneity is often considered to be present if I2 is 50% or more.
The heterogeneity is a measure of how different the studies included in the meta-analysis are. Ideally they would be similar.
Postpartum levonorgestrel-intrauterine device (LNG-IUD) can be inserted…
within 48h of delivery, or after four weeks post-partum
At what age do NICE recommend that we start to assess women regarding their risk suffering a fragility fracture?
all women aged >= 65 years and all men aged >= 75 years should be assessed.
Younger patients should be assessed in the presence of risk factors, such as:
previous fragility fracture
current use or frequent recent use of oral or systemic glucocorticoid
history of falls
family history of hip fracture
other causes of secondary osteoporosis, for example:
hypogonadism in either sex including low testosterone in men and premature menopause in women
endocrine conditions, including diabetes mellitus, Cushing’s disease, hyperthyroidism
conditions associated with malabsorption, including inflammatory bowel disease, coeliac disease, and chronic pancreatitis.
rheumatoid arthritis and other inflammatory arthropathies.
low body mass index (BMI) (less than 18.5 kg/m²)
smoking
alcohol intake of more than 14 units per week for women and more than 14 units per week for men.
FEV1/FVC suggestive of asthma:
FEV1/FVC <0.7
FeNO suggestive of asthma
40 ppb or more in adults, 35 ppb or more in children
Bronchodilator reversibility suggestive of asthma
12% or more improvement in FEV1 and 200 ml or more volume increase
Peak flow variability suggestive of asthma
over 20%
Direct bronchial challenge test with histamine or methacholine suggestive of asthma
PC20 of 8 mg/ml or less
Drugs causing haemolysis in G6PD deficiency
anti-malarials: primaquine
ciprofloxacin
sulph- group drugs: sulphonamides, sulphasalazine, sulfonylureas
First line treatment for vitiligo
potent or very potent topical steroid
eg Mometasone furoate 0.1% ointment
Expected length of illness for common childhood conditions
Croup 2
Sore throat 2–7
Earache 7–8
Common cold 15
Non-specific RTI 16
Bronchiolitis 21
Acute cough 25
School nursery exclusion for rubella
5 days from onset of rash
School /nursery exclusion for measles
4 days from onset of rash
School / nursery exclusion for whooping cough
2 days after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
School / nursery exclusion for scarlet fever
24 hours after commencing antibiotics
School / nursery exclusion for Conjunctivitis
Fifth disease (slapped cheek)
Roseola
Infectious mononucleosis
Head lice
Threadworms
Hand, foot and mouth
None needed
School / nursery exclusion for chickenpox
Until all crusted over
School / nursery exclusion for mumps
5 days from onset of swollen glands
School / nursery exclusion for Diarrhoea & vomiting
Until symptoms have settled for 48 hours
School / nursery exclusion for Impetigo
Until lesions are crusted and healed, or 48 hours
after commencing antibiotic treatment
School / nursery exclusion for scabies
Until treated
School / nursery exclusion for influenza
Until recovered
Driving and sleep apnoea
Group 1 licences should have a review every 3 years
Group 2 licence holders should be reviewed annually.
To reapply for a driving licence, the driving and vehicle licensing agency (DVLA) needs medical confirmation of improvement in sleepiness, control of breathing and adherence to treatment.
Standardised mortality ratio (SMR)
An SMR of 100 means that the number of deaths is the same as would be expected for the general population. A number higher than 100 implies an excess mortality rate and an SMR of 1000 is ten times that of the general population.
Sometimes the SMR is not multiplied by 100, in which case SMR <1.0 indicates fewer than expected deaths and SMR >1.0 indicates more than expected deaths.
NUMBER NEEDED TO HARM (NNH)
The event rate in the exposed group is a/(a + b) = 3000/27000 = 0.111
The event rate in the unexposed group is c/(c + d) = 100/20100 = 0.005
Therefore, the absolute risk increase is 0.11-0.005 = 0.106
Number needed to harm = 1/0.105 = 9.4
This means that, for roughly every 9 men that smoke, one is likely to die from lung cancer.
Driving after severe head injury
The DVLA states that driving should cease for a period of 6–12 months following a significant head injury.
Severity of COPD (GOLD)
- Mild, with an FEV1 of > 80%
- Moderate, with an FEV1 of 50–79%
- Severe, with an FEV1 of 30–49%
- Very severe, with an FEV1 <30%
Eligibility for LTOT in COPD
SpO2 <92%
FEV1 <30%
Rx management of IE COPD
5 days:
30mg preg
Amox
Doxy
or clarithromycin
Most common dementia types
Alzheimer’s 50%
Vascular 25%
Lewy bodies 15%
Frontotemporal <5%
Mixed
Autosomal dominant alzheimers
Treatable causes <5%
Mini mental state exam
21 - 26 mild cognitive impairment
10-20 moderate
<10 severe
First line medication for dementia
Anticholinesterase inhibitors
- Donepezil
- Rivastigmine
- Galantamine
Antipsychotics in dementia
Risperidone (first choice)
Quetiapine and haloperidol
Never in lewy body
Cardiac risk assessment
Start low and titrate
Only when causing significant distress
Review and stop when indicated
Breast screening ages
women aged 47-73 years 50-70??
Above this age, women can continue to have screening by self-referring themselves.
What is measured in haemochromatosis
‘transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l’
Dexamthasone in croup
0.15mg / kg
