Community and Public Health Flashcards
What is the BP target for a person under 80 years old?
BP <140/90 mmHg - same as CKD
ABPM/HBPM <135/85 mmHg
What are the BP targets for somebody over 80 years old?
BP <150/90 mmHg
ABPM/HBPM <145/85 mmHg
What are some causes of primary/essential hypertension?
Overweight + Obesity
Sodium intake
Potassium
Physical fitness
Alcohol
What are some causes of secondary hypertension?
Renal disease
CKD
Endocrine disease
Conn’s
Cushings
Diabetes mellitus
Pregnancy
Miscellaneous causes, including drugs
What should you investigate with hypertensive patients?
-
Test urine
Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip -
Measure
Plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol -
Examine the fundi
For the presence of hypertensive retinopathy - ECG should be undertaken
What is the pharmocological management of hypertension?
Step 1
<55 years old and not afro-carribean - ACEi or ARB
>55 years old or afro-carribean - CCB
Step 2
Add the other from step 1 OR thiazide-like duirectic
Step 3
ACEi or ARB + CCB + thiazide-like diuretic
Step 4
Low-dose spironolactone if K+ <4.5 mmol/l
Alpha-blocker or beta blocker if K+ >4.5 mmol/l
How often is follow up required on a stable hypertensive patient?
6 months
What is heart failure?
Heart failure is a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired
What are the symptom of heart failure?
Breathlessness
Exertional
At rest - can be orthopnoea and paroxysmal nocturnal dyspnoea (PND)
Fatigue
Exercise intolerance
Fluid retention - ankle swelling
Tachycardia
Displaced apex beat
Third heart sound
Gallop rhythm
Reduced pulse volume
Pulsus alternans
Raised JVP
What are the investigations of heart failure?
Chest radiology
ECG
Echocardiography identifies:
Focal or diffuse myocardial dysfunction
Valvular disease
Pericardial disease
Left ventricular systolic dysfunction
BNP
What is the management for actue heart failure?
-
Lung function optimisation:
- Sit the patient up
- Administer maximal oxygen concentrations
-
Intravenous diuretic:
- 40-80 mg frusemide
-
Intravenous opiate analgesia:
- 5 mg diamorphine over 5 min
-
Treatment of arrhythmias:
- May require DC cardioversion or intravenous anti- arrhythmic therapy
- Vasodilator therapy
-
Digoxin:
- Cautious intravenous administration if the above fail
-
Venesection:
- A pint may be removed from a moribund patient who fails to respond to the above
-
Inotropes:
- Dobutamine infusion
- Dopamine infusion
What does each type of drug helpful for in chronic heart failure?
Three types of treatment have been shown to reduce morbidity and mortality in patients with heart failure:
Angiotensin converting enzyme (ACE) inhibitors
Beta-blockers
Miineralocorticoid receptor antagonists
Sacubitril valsartan
Ivabradine
Treatments aimed at relieving symptomes include:
Diuretics
Digoxin - not only for patients in atrial fibrillation
Hydralazine plus nitrate
What is the management for chronic heart failure?
- *First-line treatments are:**
- ACE inhibitors
- Beta-blockers
- Mineralocorticoid receptor antagonists (aldosterone antagonists) e.g. spironolactone
- *Specialist initiated treatments**
- Sacubitril valsartan
- Ivabradine
- Yydralazine in combination with a nitrate
Managing all types of heart failure
- Diuretics
- Calcium-channel blockers - avoid verapamil, diltiazem w reduced ejection
- Anticoagulants
If heart failure and atrial fibrillation
- Antiplatelet drugs
Indiated in HF patients with atherosclerotic arterial disease (including coronary heart disease)
What does each class represent on the New York Heart Association?
I
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
II
Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
III
Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
IV
Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
What are the live attenuated vaccines?
- Oral typhoid
- Yellow fever
- Measles, mumps, rubella (MMR)
- Oral rotavirus
- Oral polio
- BCG
- Influenza (intranasal)
What are the inactived preperation vaccines?
Rabies
Hepatitis A
Influenza (intramuscular)
What are the toxoid vaccines?
Diphtheria
Tetanus
Pertussis
What is herd immunity?
Herd immunity is a form of indirect protection from infectious disease
This occurs with some diseases when a sufficient percentage of a population has become immune to an infection,
This reduces the likelihood of infection for individuals who lack immunity.
What are the different traffic lights for colour for spotting a sick child?
Green
Normal colour
Amber
Pallor reported by parent/carer
Red
Pale/mottled/blue
What are the different traffic lights for activity for spotting a sick child?
Green
Responds normally to social cues
Amber
Not responding to social cues
No smiling
Red
No response to social cues
Appears ill to healthcare professional
Does not wake
What are the different traffic lights for respiratory for spotting a sick child?
Green
Amber
Nasal flaring
Tachyponea
RR>50 breaths, age 6-12 months
RR>40 breaths, age >12 months
O2 sats <96 on air
Red
Grunting
Tachyponea >60 beaths
Chest indrawing
What are the different traffic lights for circulation and hydration for spotting a sick child?
Green
Normal eyes and skin
Amber
Tachycardia
>160 beats/min, age <12 months
>150 beats/min, age 12-14 months
>140 beats/min, age 2-5 years
CRT >3 seconds
Red
Reduced skin turgor
What are the different traffic lights for other for spotting a sick child?
Green
Amber
Age 3-6 months, temp >39 degrees
Fever >5 days
Rigors
Red
Age< 3 months, temp >38 degrees
Non-blanching rash
Bulging fontanelle
Neck stiffness
What are the current notifiable disease?
- Acute encephalitis
- Acute infectious hepatitis
- Acute meningitis
- Acute poliomyelitis
- Anthrax
- Botulism
- Brucellosis
- Cholera
- COVID-19
- Diphtheria
- Enteric fever (typhoid or paratyphoid fever)
- Food poisoning
- Haemolytic uraemic syndrome (HUS)
- Infectious bloody diarrhoea
- Invasive group A streptococcal disease
- Legionnaires Disease
- Leprosy
- Malaria
- Measles
- Meningococcal septicaemia
- Mumps
- Plague
- Rabies
- Rubella
- Severe Acute Respiratory Syndrome (SARS)
- Scarlet fever
- Smallpox
- Tetanus
- Tuberculosis
- Typhus
- Viral haemorrhagic fever (VHF)
- Whooping cough
- Yellow fever
What could the disease be if a fever lasts >5 days?
Kawasaki disease
What antenatal surveillance is done?
- Ensure intrauterine growth
- Check for maternal infections e.g. HIV
- Ultrasound scan for fetal abnormalities
- Blood tests for Neural Tube Defects
What newborn survelliance is done?
- Clinical examination of newborn
- Newborn Hearing Screening Programme e.g. Oto-acoustic emissions test
- Give mother Personal Child Health Record
What first month survelliance is done?
Heel-prick test day 5-9
- Hypothyroidism
- Phenylketonuria (PKU)
- Metabolic diseases
- Cystic fibrosis
- Medium-chain acyl Co-A dehydrogenase deficiency (MCADD)
Midwife visit up to 4 weeks*
When happen in months between the first month and pre school?
Health visitor input
GP examination at 6-8 weeks
Routine immunisations
What pre-school surviellance is done?
National orthoptist-led programme for pre-school vision screening to be introduced
What ongoing surveillance is there?
- Monitoring of growth, vision, hearing
- Health professionals advice on immunisations, diet, accident prevention
What investigations would you undertake in infants younger than 3 months?
- Full blood count
- Blood culture
- C-reactive protein
- Urine testing for urinary tract infection
- Chest radiograph only if respiratory signs are present
- Stool culture, if diarrhoea is present
What are the different types of consent?
- Informed
- Expressed
- Implied
What are the different types of consent forms in the UK NHS?
Consent Form 1
For competent adults who are able to consent for themselves where consciousness may be impaired (e.g. GA)
Consent Form 2
For an adult consenting on behalf of a child where consciousness is impaired
Consent Form 3
For an adult or child where consciousness is not impaired
Consent Form 4
For adults who lack capacity to provide informed consent
Which of a child’s parents can consent for them?
In British law the patient’s biological mother can always provide consent.
The childs father can consent if the parents are married (and the father is the biological father), or if the father is named on the birth certificate (irrespective of marital status).
If parents are not married and the father is not named on the birth certificate then the father cannot consent.
What ages can child consent to treatment?
- <16 years old may consent to treatment if they are deemed to be competent (Fraser guidelines) but cannot refuse treatment.
- 16-18 years it is presumed patients are competent to give consent to treatment.
- 18 years or older may consent to treatment or refuse treatment.
What are the requirements for capacity?
They must be able to understand the information surrounding a decision and its consequences
They must be able to retain the information long enough to make a decision
They must be able to use the information, by weighing up the pros and the cons of the decision
They must be able to communicate the decision
What is a Lasting Power of Attorney (LPA)?
Lasting Powers of Attorney (LPA) are appointed by patients under the Mental Capacity Act before they lose their capacity, and can make decisions on their behalf.
The LPA cannot make treatment decisions if the patient still has capacity.
When can you breach confidentiality?
- Following an order made by a judge or presiding officer of a court.
- In certain cases of communicable disease, when you must inform the local authority.
- To prevent an act of terrorism.
- To comply with a statutory request made by a regulatory body such as the GMC.
Is it mandatory for a patient to have a chaperone?
It is not mandatory to have a chaperone and many patients may wish to be examined without another individual present. In these cases, the offer and refusal should be documented in the medical records
A doctor should not feel pressured to perform an examination without a chaperone if they do not wish. However, they should ensure the patient is referred to a colleague who is comfortable doing so and that they would not wait unnecessarily for treatment because of this
What are the different treatment options for alcohol withdrawal (acute and chronic)?
Oral Thiamine
if their ‘diet may be deficient’
Benzodiazepines
For acute withdrawal
Disulfram
Promotes abstinence
Acamprosate
Reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials
What medication can you give to alcoholics to produce unpleasent side effects of drinking?
Disulfiram
What drug is used for acute alcohol detoxification?
Chlordiazepoxide
What drug can be used long term for alcohol management?
Acamprosate
What is TIMI score?
Estimates mortality for patients with UA or NSTEMI
What are the stages of chronic kidney disease?
Stage 1: > 90 mL/min/ 1.73m2
Stage 2: 60-89 mL/min/ 1.73m2
Stage 3A: 45-59 mL/min/ 1.73m2 Stage
3B: 30-44 mL/min/ 1.73m2Stage
4: 15-29 mL/min/ 1.73m2
What condition is heparin contraindicated?
Bacterial endocarditis
What are the Fraser Guidelines?
The House of Lords concluded that advice can be given on ONLY contraception and sexual health if:
- He/she has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
- He/she cannot be persuaded to tell her parents or to allow the doctor to tell them
- He/she is very likely to begin or continue having sexual intercourse with or without contraceptive treatment
- His/her physical or mental health is likely to suffer unless he/she received the advice or treatment
- The advice or treatment is in the young person’s best interests.
What is Gillick Competency?
Children under the age of 16 can consent to medical treatment if they have sufficient maturity and judgement to enable them fully to understand what is proposed.
What are the risk factors of TB?
- Being born in high prevalence areas
- Children less than 5 years of age
- Close contacts
- History of untreated or inadequately treated active TB infection
- Co-morbid conditions
- Immunosuppressive drugs
What health issues can a patient bring the UK from abroad?
TB
HIV infection and viral hepatitis
Malaria
What is the purpose of screening?
Screening may be described as the process of looking at a population perceived to be at risk from a condition in an attempt to identify those at higher risk, in whom some intervention may be made
What is the WHO criteria for screening?
- The condition screened for should be an important one
- There should be an acceptable treatment for patients with the disease
- The facilities for diagnosis and treatment should be available
- There should be a recognised latent or early symptomatic stage
- There should be a suitable test or examination which has few false positives - specifity - and few false negatives - sensitivity
- The test or examination should be acceptable to the population
- The cost, including diagnosis and subsequent treatment, should be economically balanced in relation to expenditure on medical care as a whole
What are the characteristics of a screening test?
- Acceptable
- Repeatable
- Sensitive
- Specific
- Simple - quick and easy to interpret
What are examples of screening tests?
What are Wilson’s Criteria for screening tests?
- The condition should be an important health problem
- The natural history of the condition should be understood
- There should be a recognisable latent or early symptomatic stage
- There should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific
- There should be an accepted treatment recognised for the disease
- Treatment should be more effective if started early
- There should be a policy on who should be treated
- Diagnosis and treatment should be cost-effective
- Case-finding should be a continuous process
