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Community + Public Health Flashcards

1
Q

What is the definition of Public Health?

A

The science and art of preventing disease, prolonging life, and promoting health through organised efforts of society

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2
Q

What are the 4 tiers of social determinants of health?

A
  1. Non-modifiable individual factors
  2. Individual lifestyle factors
  3. Social and community networks
  4. General socioeconomic, cultural and environmental conditions
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3
Q

Give the non-modifiable individual factors within the social determinants of health model

A
  1. Age
  2. Sex
  3. Ethnicity
  4. Genes
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4
Q

Give some factors within the general socioeconomic, cultural and environmental conditions under the social determinants of health model

A 
Working conditions - employment
Living conditions - housing
Education
Healthcare services
Water and sanitation
Agriculture and food production
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5
Q

What is the difference between equality and equity?

A

Equality - giving everyone equal shares

Equity - giving what is fair and just dependent upon individual needs

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6
Q

What is horizontal and vertical equity?

A

Horizontal equity = equal treatment for equal need

Vertical equity = unequal treatment for unequal need

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7
Q

What are 4 factors to measure when looking at health equity?

A 
Supply of healthcare
Access to healthcare
Utilisation of healthcare
Healthcare outcomes
Health status
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8
Q

What are the 3 domains of public health practice?

A

Health Improvement
Health Protection
Improving Services

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9
Q

What is primary prevention?

A

Aims to prevent a disease from occcurring - reduce or eliminate exposures that increase risk of a disease

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10
Q

What is secondary prevention?

A

Aims to detect early disease and slow it down or halt progress of disease to maximise the chance of complete recovery

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11
Q

What is tertiary prevention?

A

Aims to reduce the complications of severity of disease that has already been diagnosed and is symptomatic

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12
Q

What is the prevention paradox?

A

A larger number at small risk of disease may contribute more cases than a small number of people individually at a greater risk
OR
A preventive measure which brings much benefit to the population often offers little to each participating individual

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13
Q

What are 2 prevention approaches?

A

HIgh risk approach - targets high risk individuals to reduce risk (tends to favour affluent)
Population approach - targets all individuals aiming to reduce risk for every individual

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14
Q

What is health psychology?

A

Emphasising the role that psychological factors have in progress and consequences of disease - promote healthy life choices and prevent disease

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15
Q

What is a health behaviour?

A

Behaviour aimed at preventing disease (eg eating healthy)

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16
Q

What is an illness behaviour?

A

A behaviour aimed at seeking remedy (eg going to doctor)

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17
Q

What is sick role behaviour?

A

A behaviour aimed at getting well (eg taking medications)

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18
Q

What proportion of cancer cases are preventable due to modifiable risk factors?

A

1/3

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19
Q

What are 3 levels of health intervention?

A

Individual
Local community
Population

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20
Q

What is unrealistic optimism?

A

Individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility

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21
Q

What health behaviour has the largest impact on illness and premature death in the UK? What are the common diseases related to this behaviour?

A

Smoking!

COPD, cancer, cardiovascular disease

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22
Q

What are the 3As in aiding smoking cessation?

A

Ask
Advise
Assist

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23
Q

Give the stages in the Needs Assessment cycle

A

Needs Assessment
Planning
Implementation
Evaluation

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24
Q

What are the 3 factors to assess in a needs assessment?

A

Need - ability to benefit from intervention
Demand - what people ask for
Supply - what is provided

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25
What is a health needs assessment?
Systematic approach for reviewing health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities
26
What is the difference between health need and health care need?
Health need - much more general, morbidity, mortality, sociodemographics Health care need - much more specific, ability to benefit from healthcare
27
What may a health needs assessment be carried out about?
Population/sub-group Condition Intervention
28
What is felt need?
Individual perceptions of variation from normal health
29
What is expressed need?
Individual seeks help to overcome variation from normal health
30
What is normative need?
Professional defines intervention appropriate for expressed need
31
What is comparative need?
Comparison between severity, range of interventions and cost
32
What are 3 approaches to a health needs assessment?
Epidemiological Approach Comparative Approach Corporate Approach
33
What is a comparative approach for health needs assessment?
Comparing the services received by one population with those received by others - spatial and social
34
What is a corporate approach for health needs assessment?
Focus on actors involved in services
35
What is the health belief model?
Individuals will change their behaviour if they: 1. Believe they are susceptible to disease 2. Believe that it has serious consequences 3. Believe that taking action reduces susceptibility 4. Believe that benefits of taking action outweight the costs
36
What is the theory of planned behaviour?
Proposes that best indicator of behaviour is intention to carry it out - attitude to behaviour - perceived social pressure - subjective norm - perceived behavioural control
37
What factors need to be considered in bridging gap between intention and behaviour?
``` Perceived control Anticipated regret Preparatory actions Implementation intentions Relevance to self ```
38
What are the 5 stages of the transtheoretical model?
``` Pre-contemplation Contemplation Preparation Action Maintenance ```
39
What is motivational interviewing?
Counselling approach for initiating behaviour change by resolving ambivalence
40
What is nudge theory?
Nudge the environment to make the best option the easiest e.g. opt-out schemes, reducing fast food restaurants
41
What is a succinct definition of evaluation?
Assessing to what extent a service achieves its objectives
42
Give Donbedian's 3 components core to evaluation of health services
Structure Process (including outputs) Outcomes
43
What are Maxwell's Dimensions of Quality?
``` Effectiveness Efficiency Equity Acceptability Accessibility Appropriateness ```
44
What is malnutrition?
Deficiencies, excesses or imbalances in a person's intake of energy and/or nutrients
45
Give some examples of early influence on food behaviour
Maternal diet and preferences Role of breastfeeding, age of introduction to solid food Parenting practices
46
Give some examples of Non-Organic Feeding Disorders (NOFEDs)
Common in children under 6 yrs old Food aversion, food refusal, food selectivity, failure to advance to age-appropriate foods, negative mealtime interactions
47
What are the 3 distinct eating disorders and the 4th separate category?
Anorexia nervosa Bulimia nervosa Binge Eating Disorder Other Specified Feeding or Eating Disorder (OFSED)
48
What is multimorbidity?
Simultaneous presence of (3) or more chronic conditions in the same subject
49
What are the 3 types of opioid receptor in the body?
MOR, KOR, DOR
50
Where are opioid receptors in the body
``` Central nervous system, less in peripheral Vas Deferens Knee joint GI tract Heart Immune system ```
51
What is the major effect of opioid receptors in the nervous system?
Pre-synaptic action inhibiting neurotransmitter release
52
What are the side effects of opioids?
``` GI tract - constipation K, M Respiratory depression - sleep apnoea (CVS risks - if used for arthritis) CNS - dizziness, sedation, falls, fractures MSK - increased falls risk/fracture risk Endo - decreased pituitary hormones - hypogonadism, fertility problems, menstruation Immune - decreases Addiction and misuse ```
53
Give some non-pharmacological interventions for managing chronic pain
Physical - yoga, pilates, stretch, exercise, weight loss Psychological - counselling, CBT, mindfulness, relaxation, meditation Complementary - massaging, reflexology Occupational - work-based review
54
Give some non-opioid analgesics
Paracetamol NSAIDs Cox-2 inhibitors
55
Give some examples of adjuvant analgesics
Anti-convulsants Anti-depressants Lidocaine patches
56
Give 6 signs of abuse or dependency on opioids
1. Use of pain medications other than for pain treatment 2. Impaired control/compulsive use of medication 3. Continued use of medication despite harm 4. Craving or escalation of medication use 5. Selling/altering/stealing medications/prescriptions 6. Reluctance to try non-pharmacological interventions
57
What individual and lifestyle factors are associated with increased risk of opioid dependency?
Younger, cohabiting but not married, unemployed, non-White, poor physical health, internet pharmacy
58
What are the 3 core principles of the NHS?
1. meets needs of everyone 2. free at the point of delivery 3. based on clinical need, not ability to pay
59
What is the inverse care law?
The principle that the availability of good medical or social care tends to vary inversely with the need of the population served
60
Give Maslow's Hierarchy of Needs in order from the bottom of the pyramid to the top
Physiological - breathing, food, water, sleep Safety - security of body, materials, family Love/Belonging - friends, family, sex Esteem - self-esteem, confidence, achievements Self-Actualisation - morality, creativity, problem solving
61
Give some barriers to healthcare for homeless people
Lack of access - difficulty registering at GP, appointment procedures, perceived/actual discrimination Lack of integration with other agencies - housing, criminal justice, voluntary Other needs - immediate survival outweighs health
62
What are some health inequalities faced by the traveller/gypsy community?
``` Overall poorer physical health Higher child mortality rate Worse mental health Pregnancy complications Bronchitis and asthma ```
63
What are some barriers to healthcare for gypsy/traveller community?
Registering for GP services - no permanent address Perceived/actual discrimination Reluctance to seek treatment until becomes severe Low income Low education Cultural health beliefs - gender, stoicism, mental health stigma
64
What are some health inequalities faced by the LGBTQ+ community?
Depression Suicide and self-harm Drugs and addiction problems STIs (especially HIV)
65
What is minority stress theory?
Poorer health outcomes stem from negative social climate they can experience
66
What is life course theory?
Accumulation of advantages and disadvantages over time
67
What is intersectionality?
Multiple identities contribute to a person's sense of self and how these different aspects are themselves potentially subject to forms of discrimination and marginalisation
68
What are the barriers to healthcare for the LGBTQ+ community?
Stigma/prejudice Fear of disclosing LGBTQ+ status Previous negative experiences
69
What is an asylum seeker?
A person that has applied for refugee status
70
What is a refugee?
A person granted asylum and refugee status. Usually allows remain for 5 years and then reapply
71
What is indefinite leave to remain?
Person granted full refugee status and given permanent residence in the UK
72
What are asylum seekers entitled to?
£37.75 per week Housing Free NHS care (if child, social services key worker and school)
73
What are asylum seekers not allowed to do?
Not allowed to work | Not entitled to any other form of benefit
74
What are refugees allowed to do/entitled to?
5 years leave of remain in UK Right to work and claim benefits Can apply for family union Can apply for a travel document
75
How can a refugee get British Citizenship?
After 5 years refugee status can apply for Indefinite Leave to Remain (ILR) After 1 year ILR, can apply for British Citizenship
76
What happens to failed asylum seekers?
Not entitled to money, NHS care, housing Reliant on charities Can appeal decision May be detained in immigrant removal centre
77
Give some barriers to healthcare for asylum seekers/refugees
``` Lack of knowledge of access Language barriers Discrimination, lack of understanding of culture Transport to appointments Frequent dispersal by Home Office Not homogeneous group ```
78
Give some red flags of human trafficking
TRAFFICKING Timid/terrified, Registered with GP/nursery/school (not), Accompanied by controlling person, Foreign language, Frequently moving location, Inconsistent history, Control passport/bank (not), Keep alert, Evidence of injuries left untreated, DNA appointments
79
What action do you take if imminent threat suspected for trafficked individual?
Call police
80
What action do you take if victim of trafficking appears or claims to be under 18?
Follow child safeguarding procedures | Report to NSPCC
81
What action do you take for trafficking victim if no imminent threat but consents to help?
Inform safeguarding | Organise NRM interview with first responder (Salvation Army, Modern Slavery helpline, Police Anti-Slavery unit)
82
What action do you take if trafficking victim has no imminent threat and does not consent to help?
Give information leaflet on modern slavery | Contact number if safe to do so
83
What is the definition of health?
State of complete physical, mental and social wellbeing, not merely the absence of disease or infirmity
84
Give 2 famous reports in response to health inequalities
``` Black Report (1980) Acheson Report (1998) ```
85
Give 3 theories of health inequalities
Psychosocial - stress means body can't meet its own demands Neo-material - hierarchial society means little investment in public goods Life-course - combination psychosocial and neo-material, with greater affects at critical points in life and accumulation over life
86
How is social class quantified?
Registrar General's Model (occupation-based) | NS-SEC model
87
What is incidence?
Number of new cases per unit time - expressed as % or per 100 000
88
What is prevalence?
Number of existing cases at a given point in time
89
What is sociology?
Study of social relations and processes
90
What is the medicalisation hypothesis?
Doctors tend to see everything medically when could be due to non-medical or social forces
91
What is sustainability?
Being able to meet the needs of today without compromising the ability of future generations to meet the needs of tomorrow
92
What is a true positive?
Test positive and have disease
93
What is a false positive?
Test positive but don't have disease
94
What is a true negative?
Test negative and don't have disease
95
What is a false negative?
Test negative but have the disease
96
What is sensitivity?
The proportion of people who have the disease and test positive
97
What is specificity?
The proportion of people without the disease who are correctly excluded by the test (test negative)
98
How would you calculate sensitivity?
True positives/no. people who were screened and have disease
99
How would you calculate specificity?
True negatives/no. people screened without disease
100
What is the positive predictive value?
The proportion of people with a positive result who have the disease Number true positives/total number positives
101
What is the negative predictive value?
The proportion of people with a negative result who do not have the disease Number of true negatives/total number negatives
102
What is selection bias?
The people who choose to participate may be different to those who do not
103
What is lead time bias?
Screening identifies disease earlier, giving impression that it lengthens survival but survival time may be unchanged
104
What is length-time bias?
Diseases with longer period of presentation are more likely to be picked up by screening than shorter, more aggressive diseases. Longer, less aggressive diseases likely to have better survival than shorter ones, giving impression screening improves survival rates.
105
What is satiation?
what brings an eating episode to an end
106
What is satiety?
Inter-meal period
107
What are the stages of the satiety cascade?
Sensory, cognitive, post-ingestive, post-absorptive
108
What are the 4 main STIs?
Chlamydia Gonorrhoea Syphilis Trichomoniasis
109
What are the different phases of a pandemic?
Phase 1-3 = animal infections, a few humans Phase 4 = sustained human-human transmission Phase 5-6 = widespread human infection
110
What is the exact measurement of a unit of alcohol?
10ml OR 8g of ethanol
111
How do you calculate number of units in alcohol?
(%alcohol x amount of liquid in ml) / 1000
112
What are the questions of the CAGE questionnaire?
Do you ever feel like Cutting down alcohol? Do you ever get Annoyed when people tell you to cut down? Do you ever feel Guilty about how much you drink? Do you ever use alcohol as an Eye-opener?
113
What is compliance vs adherence vs concordance?
Compliance - patient follows doctor's orders Adherence - acknowledges patient's beliefs Concordance - doctor and patient are equal
114
What is the problem with healthy life expectancy trajectories?
Healthy life expectancy is not increasing as fast as life expectancy so more people living with morbidities
115
What is polypharmacy?
Use of 4 or more medications by a patient, or administration of more medications than is clinically indicated
116
What is opportunity cost?
The sacrifice in terms of the benefits forgone by not allocating resources to the next best activity
117
What is cost-effective analysis?
Incremental cost per life year gained
118
What is cost-utility analysis?
Incremental cost per quality-adjusted life year gained
119
What is cost-benefit analysis?
Outcomes measured in monetary units - net monetary benefit
120
What is a top-down deductive ethical argument?
Using an ethical theory and consistently applying it to each problem
121
What is a bottom-up deductive ethical argument?
Using past cases to create guides for practice
122
What criteria allows disclosure of confidentiality?
Required by law Patient consent Public interest
123
What are the principles when breaching confidentiality?
Anonymous if practicable/possible Patient consent if possible Kept to a necessary minimum
124
What is virtue ethics?
Based upon character of person, integrating reason and mind - if intentions and state of mind are right then action can be virtuous
125
Give 3 types of human error and what they are
Error of omission - correct action delayed/not done Error of comission - incorrect action taken Error of negligence - action/omissions taken did not meet standards required
126
What is a skill-based error?
When performing a well-learned/routine action but error occurs e.g. distraction, little attention, memory lapse
127
What is a Rule/Knowledge-based error?
Incorrect plan or course of action taken due to lack of experience/awareness/knowledge
128
What is distress?
Negative stress that is damaging or harmful
129
What is eustress?
Positive stress that is beneficial and motivating
130
What does FEADE for evidence-based medicine stand for?
``` Focused questions Evidence base Appraisal Decision Evaluation ```
131
What does PICO for focused questions stand for?
Population Intervention Comparator Outcome
132
What is hierarchy 1a and 1b in the hierarchy of evidence?
``` 1a = systematic review or meta-analysis of RCTs 1b = at least one RCT ```
133
What is hierarchy 2a and 2b in the hierarchy of evidence?
``` 2a = at least one controlled trial without randomisation 2b = at least one other type of quasi-experimental study ```
134
What is validity?
How close to the truth something is
135
What is reliability?
How consistent the results are (repeatability/reproducibility)
136
What is applicability?
How relevant a study is to clinical medicine
137
What are the different study designs falling under observational studies?
``` - no intervention, show association but no causation Case reports Ecological Cross-sectional Case-control Cohort ```
138
Give features of ecological studies
Descriptive observational study | Uses routinely collected data to observe trends in data to generate hypotheses
139
Give features of cross-sectional studies
Descriptive and analytical observational study Divides population into those with disease/without disease at a defined time to find associations at THAT POINT IN TIME - generates hypotheses
140
Give features of case-control studies
Analytical observational study Divides into those with disease and without disease RETROSPECTIVE - looks at previous exposures Only shows association, not cause
141
Give features of cohort studies
Analytical observational study Starts with population without disease and follows up over time = PROSPECTIVE Identifies association between exposures and disease over time - more able to show causation than retrospective
142
What is a randomised controlled trial?
Experimental/Intervention Study Randomised into groups - one given intervention, one in control and outcomes measured Randomisation allows confounding factors to be equally distributed to reduce confounding biases
143
What is a quasi-experimental study?
Intervention study but without randomisation of groups
144
What is a systematic review?
Clearly formulated question that uses symptomatic and explicit methods to identify, select and critically appraise relevant research, to collect and analyse data from the studies included
145
What is a meta-analysis?
Statistical methods to analyse and summarise the results of included studies
146
How do you calculate absolute risk?
Incidence/population
147
How do you calculate relative risk?
Risk in exposed group / risk in non-exposed group
148
What signifies no increased risk for between exposure and non-exposure groups regarding relative risk?
Null value for relative risk RR = 1 Confidence interval includes 1
149
What is absolute risk difference?
AR in exposed group - AR in non-exposed group
150
What is the number needed to treat?
The number of people you would need to treat in order to cure one person/prevent one bad outcome NNT = 1/ARR (absolute risk reduction)
151
What is the number needed to harm?
The number of individuals exposed to harm needed for one person to develop disease NNH = 1/ARD (absolute risk difference)
152
How do you calculate odds?
Probability / (1 - probability) | AR / (1-AR)
153
How do you calculate odds ratio?
Odds of exposed group (P/1-P exposed) divided by Odds of non-exposed group (P/1-P non-exposed)
154
What studies cannot use relative risk and should use odds ratio instead?
Case-control studies
155
When might OR be used over RR in cross-sectional or cohort studies?
If independent or dependent variable are not clear
156
What might mean that association between variables is not causality?
1. Confounding factors 2. Reverse Causality 3. Bias 4. Chance
157
What screening questionnaires are there for alcohol misuse?
1. CAGE 2. AUDIT (Alcohol Use Disorders Identification Test) 3. FAST
158
What is the max AUDIT score and what score is the cut off for hazardous or harmful drinking?
Total score = 40 Cut off = 8 or more Score of 3 or more should involve more detailed assessment of drinking
159
What is FAST and what is the total max score and cut off scores?
Subset of AUDIT for emergency settings Total max score = 16 Score of 3 or more is FAST positive for harmful drinking If FAST positive, complete the full AUDIT questionnaire
160
Describe briefly how Disulfiram helps reduce alcohol intake
Makes patient feel nauseous upon drinking alcohol
161
How many units constitutes binge drinking in men and in women?
8 units or more in single session = men | 6 units or more in single session = women
162
If a patient presents to GP with a blood pressure of 140/90 or more, what should you do?
Repeat, if different, repeat again. Record lower of last 2 measures as blood pressure If between 140/90-180/120 - ABPM or HBPM if not tolerated
163
How do you calculate blood pressure from ABPM?
Should be 2 readings per hour during waking hours | Take average of at least 14 measurements during patient's waking hours
164
When would you do same-day specialist referral for hypertension?
If BP over 180/120 AND Retinal haemorrhages or papilloedema New onset confusion, chest pain, heart failure signs, AKI
165
How would you manage a patient with 180/120 BP or more with no signs requiring same day referral?
Do investigations for target organ damage Consider starting anti-hypertensives immediately If no target organ damage, repeat BP within 7 days
166
What are the limits for Stage 1 hypertension?
140/90-159/99 in clinic AND ABPM or HBPM 135/85-149/94
167
What are the limits for Stage 2 hypertension?
160/100 - 180/120 in clinic AND ABPM or HBPM > 150/95
168
What counts as Stage 3 or severe hypertension?
>180 systolic or >120 diastolic
169
What investigations do you do to check for target organ damage for hypertension?
``` Urinalysis - haematuria, Albumin:creatinine ratio U+E HbA1c Fundoscopy ECG ```
170
How would you assess cardiovascular risk for someone with hypertension?
Lipid profile | QRISK score
171
What lifestyle advice would you give for someone with hypertension?
``` Smoking cessation Alcohol limitation Reduce caffeine Healthier diet and more exercise Limit dietary sodium ```
172
How would you manage someone presenting with hypertension under 40 years old?
Refer for specialist assessment to assess possible secondary causes of hypertension
173
What investigations might you do to diagnose heart failure?
ECG (LVH), cardiac examination, blood tests (BNP and NBP) If BNP<100ng/L or NBP<300ng/L EXCLUDE HF If raised BNP, do transthoracic Doppler Echo to detect cardiac abnormalities
174
Why is BNP released in heart failure?
Released by ventricles when cardiomyocytes are overworked - increases sodium excretion to increase water loss
175
What treatment might you give in acute heart failure?
Reversible or need transplantation? LMWH IV diuretic therapy, monitor renal function + heart rate, + U+Es, blood pressure Ventilation + oxygen Consider ultrafiltration, beta blocker, ACE-I, ARB, aldosterone antagonist Follow up 2 wks later, consider valvular surgery
176
What investigations might you do to rule out other differentials or secondary causes of chronic heart failure?
``` ECG CXR FBC, LFTs, U+Es, TFTs, lipid, HbA1c Peakflow/spirometry Urinalysis Measure NT-proBNP. If >2000, need specialist assessment and echo within 2 wks If 400-2000, need echo in 6 weeks ```
177
How would you manage a patient with chronic heart failure and reduced ejection fraction?
Medication review Loop diuretic - furosemide, bumetanide ACE-I and Beta Blocker (start separately). Add MRA if not managed, hydrazaline nitrate + digoxin. Titrate up slowly and monitor BP and renal function Consider anti-platelets, statins, lifestyle advice, mental health support, Exercise-based group rehabilitation, cardiac rehabilitation Offer annual influenza vaccine + GTN spray Surgery - cardioverter debrillator, cardiac resyncrhonisation therapy, bypass operation, transplant Palliative care
178
How would you monitor a patient with chronic heart failure?
Medication reviews U+Es - especially K+ (digoxin and MRA use) Fluid status, cardiac rhythm, nutrition, cognition, functional capacity Recent medication - days-weeks Stable - every 6 months
179
Which calcium channel blockers are you not allowed to use in heart failure?
Non-dihydropyridines - can cause heart block | Can use dihydropyridines e.g. amlodipine
180
What ethnicities might change your hypertension medication? Why?
African/Carribbean - have low renin-angiotensin-aldosterone system so ACE-I, ARB and MRAs don't work as effectively as CCBs
181
Which organ causes the most conflict in management of heart failure and why?
Kidneys! Can be a cause of heart failure, but also damaged by heart failure Diabetic nephropathy may make more susceptible to damage, but Metformin and poor renal function can lead to lactic acidosis Diuretics can damage kidneys
182
When might beta blockers be avoided?
Asthma! - use cardioselective if have to Bradycardia Not tolerated - tired, slow
183
What is the NoTears Tool?
``` To aid medication reviews Need/indication Open questions Tests Evidence Adverse effects Risk Reduction Simplification/switches ```
184
Give another tool used to support medication reviews
STOPP-START tool
185
What is the prognosis of heart failure?
50% die suddenly | usually 5-10yrs from diagnosis
186
What is the primary prevention for heart failure?
Reduce salt, caffeine, alcohol, smoking, cholesterol 5 a day and plenty of fibre Start statin if QRISK2 score higher than 10% Low sugar diet Exercise and weight loss - Orlistat (lipase inhibitor)
187
What is the secondary prevention for heart failure?
Excercise - at least 150 mins moderate intensity/wk Weight loss Low salt, fat, alcohol, caffeine, sugar Smoking cessation 5 a day, 2 portions fish/wk, wholegrains Cardiac rehabilitation programme ACE-I, BB, statin, aspirin and anti-platelet (dual therapy up to 12 months if post-MI)
188
What is the tertiary prevention of heart failure?
Cardiac rehabilitation programme Diabetes control - hyoglycaemic control CABG, PCI
189
What are the CXR signs of heart failure?
``` Cardiomegaly Kerly B lines Upper lung venous congestion Interstitial oedema Alveolar oedema (bat wings) Dilated vessels Pleural effusions ```
190
How is HBPM done?
Measured twice a day. Each measurement consists of 2 measurements at least 1 min apart, seated. Continues for 4-7 days
191
What is the most common STI in the UK? | What is its incubation period?
Chlamydia | 7-21 days
192
How does chlamydia present?
Many are asymptomatic (50-70%) Women - cervitis (PCB, IMB, dyspareunia), dysuria Men - urethritis - discharge, dysuria
193
What are some potential complications of chlamydia?
PID, increased ectopic pregnancy risk, infertility, endometritis, reactive arthritis, epididymitis
194
What investigations would you do to test for chlamydia in men and women?
Women - NAAT vulvovaginal/cervix swab | Men - first void urine sample
195
How is chlamydia treated?
Doxycycline 7 days | 2nd line - Azithromycin 3 days
196
What is the commonest bacterial cause of Bacterial Vaginosis? How does this affect vaginal pH?
Gardnerella vaginalis Overgrowth or aerobic lactobacilli - reduced lactic acid production Vaginal pH >4.5
197
What are the common presenting features of bacterial vaginosis?
Fishy smelly discharge Potential white-grey or green discharge Thin discharge No soreness or irritation usually
198
What investigations would give you a diagnosis of bacterial vaginosis?
Clue cells on microscopy Positive whiff test (add KOH, smell fishy) Raised vaginal pH
199
What treatment do you give for bacterial vaginosis?
Metronidazole either stat OR 5-7 days TDS
200
What type of organism causes trichomoniasis?
Parasite - Trichomonas Vaginalis | Not STI and raises pH
201
What are the common presenting features of trichomoniasis?
Yellow-green frothy discharge Vulvovaginitis - itching and irritation Strawberry cervix on examination Men often asymptomatic or urethritis
202
What investigation would show trichomonas vaginalis?
Microscopy - shows mobile trophozoites
203
What treatment do you give for Trichomoniasis?
Metronidazole 5-7 days or stat
204
What is another name for thrush?
Vaginal candidiasis
205
What are the common presenting features of vaginal candidiasis?
``` Vulvovaginal itchiness, irritation - dyspareunia, dysuria Cottage cheese white discharge, non-smelly Vulval erythema (sometimes) ```
206
What investigation would you do if unclear whether clinical picture confirms thrush?
High vaginal swab
207
How would you treat vaginal candidiasis?
Local clotrimazole pessary OR | Oral fluconazole
208
What is the causative organism in gonorrhoea?
Gram negative diplococcus - Neisseria gonorrhoea or gonococcus
209
What are the common presenting features of gonorrhoea?
Men - urethral discharge, dysuria Women - Cervicitis - discharge (yellow), dyspareunia Rectal and pharyngeal infections may occur but can be asymptomatic Disseminated gonococcal infection - tenosynovitis, polyarthritis, dermatitis (trunk, palms, soles, extremities)
210
What are some potential complications of gonorrhoea?
Septic arthritis Endocarditis Perihepatitis (Fitz-Hugh-Curtis syndrome)
211
How do you treat gonorrhoea?
IM Ceftriaxone | If refuse needles - oral cefixime and azithromycin
212
What are the causative organisms of painful genital sores/ulcers?
HSV-1 or HSV-2 | Primary infection asymptomatic, but can recur causing painful sores and ulcers
213
How would you treat genital herpes?
Oral acyclovir | if cold sores too, topical acyclovir
214
What organism causes syphilis?
Treponema Pallidum
215
What are the presenting features of primary syphilis infection?
Painless ulcer/chancre at point of sexual contact | Heals after 4-6 weeks, non-tender local lymphadenopathy
216
How does secondadry syphilis present?
6-10weeks after primary infection Rash - trunk, palms, soles Painless genital warts OR asymptomatic if in latent phase (still asymptomatic after 2 yrs - not infectious)
217
How does tertiary syphilis present?
Granulomas on skin and bones Aortic aneurysm Neurosyphilis (dementia, psychosis, strokes)
218
How would you treat syphilis?
Penicillin
219
What are the different causes of painless genital warts?
Syphilis - primary or secondary | HPV 6-11 - STI
220
What are the presenting features of HPV 6-11 infection?
Painless, fleshy genital warts - may be itchy
221
How would you treat HPV infection?
Topical podophyllum or cryotherapy 1st line 2nd line - imiquimod cream May clear without intervention
222
Give some common presenting features of acute primary HIV infection
``` 2 weeks to 10 months post-exposure Lethargy, depression Fever Rash Weight loss ```
223
How long is the clinical latency period of HIV and what features might be present?
7-10 years | Asymptomatic, may have enlarged lymph nodes
224
What are the features of early symptomatic HIV? (CD4>200)
``` Oral/vaginal candida Shigella >2 episodes/dermatomes Cervical dysplasia Peripheral neuropathy Unexplained fever Diarrhoea >1 month ```
225
What might be some features of AIDS (CD4<200)?
Candidiasis TB Recurrent bacterial pneumonia Invasive cervical carcinoma, Kaposi sarcoma Primary CNS lymphoma, non-Hodgkin's lymphoma Other opportunistic infections
226
What investigations might you do for HIV?
Offer to all suspicious clinical pictures Offer to ALL pregnant women Venous blood sample - positive at 4-10wks, repeat 2 weeks later if negative
227
What preventive measures may be taken for HIV?
Primary - condoms, reduce partners, needle exchange programmes, sex education, pre-exposure prophylaxis Secondary - post-exposure prophylaxis, vaginal Tenofivir, screen blood products Tertiary - Caesarean section, circumcision, bottle feeding
228
What treatment is given to those who test HIV positive?
Highly Active Anti-Retroviral Therapy (HAART)
229
What treatment would you give when a mother is HIV positive?
Maternal viral load <50 - oral zidovudine to infant Maternal viral load >50 - triple ART to infant Breastfeeding - oral nevirapine to infant, encourage bottle feed
230
How does the cap/diaphragm work?
Silicone cap placed in vagina prior to sex with spermicide - prevents sperm entering uterus Keep in for 6 hrs after sex Needs fitting
231
How does the combined pill work as a contraceptive?
Combined synthetic oestrogen and progesterone - prevents ovulation, thins lining of uterus and thickens cervical mucus. Monophasic keeps hormones at constant level throughout cycle = 1st line
232
How should the COCP be taken?
Same time every day. Start on day 1 of cycle Some pills for 21 days, with 7 day break But some can be taken back-to-back until breakthrough bleed. Then should stop for 4 days
233
What should be done if 1 or 2 COCP doses are missed?
Take the last pill you missed, even if it means taking 2 in one day Carry on the rest of pack as normal If missed 2 or more doses, risk of pregnancy
234
How should condoms be used?
Use or place condoms before penis comes into contact with vagina Use water-based lubricants Use during oral sex as well as penetrative sex
235
How does the implant work?
Plastic tube inserted under skill of upper arm Release progestogen - stops ovulation, thickens cervical mucus and thins lining of womb Replace every 3 years Fit in first 5 days of cycle. If not, use condoms for first 7 days Can stop periods or make the irregular, lighter, heavier
236
What are the risks associated with the COCP?
SE: breast tenderness, mood swings, nausea, abdo pain, headaches, menstrual irregularities Risks: breast cancer, cervical cancer, VTE risk, HTN, CVD, liver disease, hemangioma
237
What conditions is the COCP protective against?
Menorrhagia - periods usually regular, lighter, less painful Reduces risk ovarian and endometrial cancers Reduced risk colorectal cancer Reduced risk ovarian cysts Reduced acne in some women Possible reduction benign breast disease and osteoporosis
238
What are the 2 most common contraceptive injections and how are they used?
Depo-Provera - 12 week intervals - IM | Sayana - 13 week intervals - SC (self-administered)
239
What are the risks with the contraceptive injections?
Highest dose of hormones out of hormonal contraceptives Can cause weight gain and thin bones (reduces oestrogen as is progestogen only) Takes around 1 yr to regain fertility
240
How is the contraceptive patch used?
Sticky transdermal patch (Evra) on thigh or stomach Change every week for 3 weeks, then one week off Contains oestrogen and progesterone
241
How are female condoms used?
Inserted into female vagina before intercourse No lubricant needed Can be uncomfortable and noisy
242
How is female sterilisation done?
GA operation - clamp or block fallopian tubes with implants | If unsuccessful, remove fallopian tubes with salpingectomy
243
How does the IUD work?
T-shaped copper and plastic device inserted into uterus Can stay 5-10 yrs Copper alters fluids in womb so sperm can't survive Stops fertilised eggs from implanting Patient should check in place after 1st month and after every period - if threads present
244
What are the risks with the IUD?
Perforation Pelvic infection (should do pelvic exam before inserting to check for local infection/STI) in first 20 days May be unethical for some as prevents implantation of embryo - abortion?
245
How does the IUS work?
T-shaped plastic device inserted into uterus | Releases progestogen
246
What are the risks of the IUS?
Risk of perforation Pelvic infection (should do pelvic exam before inserting to check for local infection/STI) in first 20 days Rejection Ectopic pregnancy
247
How should the progesterone-only pill be taken?
Every day with no break | AT SAME TIME EVERYDAY - some 3 hr window, some 12 hr window (don't ovulate with 12hr pills)
248
What are the risks with the mini pill?
Increased risk of breast cancer and ovarian cyst formation
249
How does the vaginal ring work?
Small plastic ring placed inside vagina Releases oestrogen and progestegen Leave in for 21 days, then remove and take 7d off
250
How is male sterilisation done?
Vasectomy - vas deferens cut or blocked in LA operation Use contraception for at least 8wks after operation Not-reversible on NHS, but can be done privately
251
What are some risks associated with teenage pregnancy?
More likely to leave education | Increased risk still birth, low birth weight, poor breastfeeding, poor maternal mental health
252
What is Gillick competency?
Allows children under the age of 16 to consent to healthcare interventions if they are deemed to have capacity. Based upon maturity, understanding and assessment of situation.
253
What is the purpose of the Fraser Guidelines?
Allows children under 16 to consent to sexual health interventions if certain criteria are met
254
What are the criteria under the Fraser Guidelines?
1. Patient can understand advice + what's involved 2. Patient cannot be persuaded to inform parents or agree for doctor to inform parents 3. Patient will continue to have sexual intercourse with or without contraception 4. Patient's mental or physical health may suffer if not given contraceptive advice/treatment 5. Patient's best interests involve giving contraceptive advice/treatment without parental consent
255
What are the guidelines on age of sexual consent in England and Wales?
1. Illegal to have sex with anyone under age 16 2. Will not prosecute teenagers under 16 where both mutually agree and are of similar age 3. Illegal for someone over 18 to have sex with someone under age of 18 if person is in a position of trust 4. People under 12 cannot legally give consent to any sexual activity
256
Give some cognitive assessment that might be done to screen for dementia in primary care. Can these rule out dementia?
``` AMTS 6-CIT GPCOG or Mini-Cog MOCA Can't rule out dementia if normal! ```
257
What questionnaires can you do to screen for dementia with carers/informants?
Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE) Functional Activities Questionnaire (FAQ)
258
What investigations might you do as a confusion screen?
``` FBC - Hb, WCC LFTs B12, thymine TFTs HbA1c U+Es Calcium Urinalysis - (but often have asymptomatic bacturia) CT head - CJD, bleeds, tumours ```
259
Where would you refer if suspect dementia and organic causes of confusion been excluded in a patient?
Memory Clinic or Community Old Age Psychiatry If rapid decline in cognition - Neurology (CJD) If suspect AD, test verbal episodic memory
260
What medications should you avoid or take caution with in LBD?
Anti-cholinergics - dampen effects of Achesterase inhibitors (rivastigmine) - worsen cognition Dopamine agonists - increase hallucinations (but may improve PD symptoms)
261
What might you see on hisopathology of Alzheimer's Disease?
Neurofibrillary tangles Senile plaques Neuronal loss
262
What is PRIME-MD?
Aka PHQ-2 (screening tool for depression) 1. Little interest or pleasure in doing things? 2. Feeling down, depressed or hopeless in last month)
263
What is the screening tool for dependent alcohol users?
Severity of Alcohol Dependence Questionnaire
264
What is the cut off score on the SADQ for chlordiazepoxide detoxification regime?
16 or over
265
What are the classes of score for the SADQ?
<16 = mild physical dependency 16-30 = moderate dependency 31 or over = severe dependency
266
In depression when would you refer to specialist services?
If urgent risk to self or others | If combined antidepressants and CBT are not working (tried 2 SSRIs, SNRI...)
267
What are the risk factors for TB?
Close contact with TB, travel to TB-endemic country, homesless people, IVDUs, HIV positive, crowded living conditions, poor sanitation, diabetes, immunosuppressants, severe kidney disease, low body weight, silicosis, head and neck cancer
268
Describe the course of TB transmission and infection
Mycobacterium tuberculosis, respiratory droplet spread Initial infection clears quickly Bacteria can become dormant - latent phase Or progress to active TB instead or after latent phase over following weeks or months
269
What is the standard treatment for people with active TB?
2 months: Rifampicin, Ethambutol Hydrochloride, Pyrazinamide, Isoniazid then 4 months: Rifampicin and Isoniazid if no CNS If CNS - do 10 months continuation instead of 4
270
What is the main health concern with the medications given for active TB treatment?
ALL hepatotoxic - check liver function
271
How should contacts of someone with TB be managed?
Quantiferon testing (or Mantoux in children) If under 65, consider BCG vaccination Treat for latent TB?
272
How would you treat latent TB?
3 months isoniazid and rifampicin (preferred liver problems) | OR 6 months isoniazid
273
How would you diagnose active lung TB?
Chest XR | 3 sputum samples 8-24hrs apart, at least one early morning sample
274
Give the common presentation of gout
Acute, red, hot swollen joint (often at metatarsophalangeal joint of big toe)
275
What is the pathophysiology of gout?
Deposition of monosodium urate crystals in and near joints, associated with raised plasma urate
276
What are some triggers of gout?
``` Trauma Surgery Starvation Infection Diuretics ```
277
What are some potential long-term consequences of gout?
Tophi | Renal disease - stones, interstitial nephritis
278
What are some differentials for gout?
``` SEPTIC ARTHRITIS - exclude! Reactive arthritis Haemarthrosis Calcium pyrophosphate desposition Palindromic RA ```
279
What are some risk factors for gout?
Elderly, impaired renal function, HTN, metabolic syndrome, diuretics, anti-hypertensives, aspirin Dietary (alcohol, sweeteners, red meat, seafood) Genetic disorders Tumour-lysis syndrome Cytotoxics Warfarin
280
What should you screen for in someone with gout?
Chronic kidney disease HTN Dyslipidaemia Diabetes
281
What investigations would you do for gout?
Polarised light microscopy of synovial fluid - Negatively birefringent needle crystals Possible raised serum urate
282
What is the treatment of acute gout?
High dose NSAID (Diclofenac) OR Colchicine Steroids may also be used, rest and elevate joint, ice packs and bed cages can be effective
283
What prophylactic treatment might you give for gout?
If >1 attack in a year, tophi/renal stones - ALLOPURINOL (may trigger attack so cover with NSAID up to 6wks or colchicine up to 6 mnths) Febuxostat if allopurinol contraindicated
284
What crystals form pseudogout? How do thsee appear on polarised light microscopy?
Calcium pyrophosphate | Positively birefringent rhomboid crystals, also soft tissue calcium deposits on XR
285
How would you treat pseudogout?
Acute: aspiration, intra-articular steroids NSAIDs (+PPI), colchicine may prevent acute attacks Chronic: Methotrexate and hydroxychloroquine may be considered
286
In LFTs, what enzymes are: a) hepatocellular? b) biliary? c) pancreatic?
a) AST + ALT b) ALP + GGT c) amylase + lipase
287
What does raised AST but normal ALT indicate and why?
``` Problem elsewhere (not liver) - think MUSCLE, check CK AST produced by bone, muscle, heart, brain, RBC, not just liver, whereas ALT is specific to liver ```
288
What does a raised ALP but normal GGT suggest?
Not biliary problem, think elsewhere e.g. BONE | ALP produced bone, kidney, GIT, placenta, but GGT is specific to biliary + ALCOHOL use
289
What does a raised amylase but normal lipase suggest?
Not pancreatic cause, as amylase produced in saliva too, whereas lipase only produced in pancreas
290
What are the classic AST and ALT proportions in: a) liver disease? b) alcoholic fatty liver disease?
a) ALT>AST | b) AST>ALT
291
What should you monitor when starting ACE-I?
Renal function and electrolytes Be aware of rises in K (if over 5.5, need ECG, but acceptable up to 5.5 with ACE-I) Creatinine - allowed up to 30% increase from baseline after starting ACE-I If either of these is too much, switch to amlodipine
292
What ECG changes might you see in hyperkalaemia?
Tall tented T waves Prolonged PR Wide QRS complexes Small or absent p waves
293
What vaccines are within the 6-in-1 vaccine?
``` Diphtheria Tetanus Polio Whooping cough Hib Hep B ```
294
What routine vaccines are given to children at 2 months?
6-in-1 vaccine Rotavirus MenB
295
What routine vaccines are given at 3 months?
6-in-1 (2nd) Rotavirus (2nd) Pneumococcal
296
What routine vaccines are given at 4 months?
6-in-1 | Booster MenB
297
What routine vaccinations are given at 12-13 months?
MMR combined MenC and Hib Pneumococcal MenB
298
What routine vaccinations are given at 3-4 years?
4-in-1: Tetanus, Diphtheria, Polio, Whooping cough | MMR (2nd)
299
What routine vaccines are given at 13-14 yrs?
Booster Diphtheria, tetanus and polio (3 in 1) Men ACWY HPV girls (now boys too?)
300
Which children can get annual flu vaccinations?
2-3yrs All primary school and year 7 children 2-17yrs with long-term health conditions
301
How should you report a notifiable disease?
Report to "proper officer" at local council or local Health Protection Team Urgent - Ring within 24 hrs, then written notification form within 3 days Routine - written notification form within 3 days Do immediately after diagnosis, do not await confirmation
302
How would you manage a child with RED life-threatening features?
Call 999, ambulance
303
How would you manage a child with RED non-life-threatening symptoms?
Arrange urgent face-to-face assessment (if on telephone). Consider hospital admission immediately
304
How would you manage a child with AMBER symptoms?
Arrange face-to-face assessment Admit to hospital if: suspected UTI, no obvious site of infection, longer than expected for self-limiting, parental anxiety/not coping Manage at home otherwise - SAFETY NETTING - follow-up appointment - liaise with other healthcare providers inicluding out-of-hours so child has direct access if needed later
305
How would you manage a child with GREEN symptoms?
Urinalysis if no other site found for fever Child can be managed at home with anti-pyretics and fluids - only prescribe Abx if bacterial infection Safety netting and provide Fevers in Children leaflet Explain that anti-pyretics do not stop recurrent febrile seizures
306
How would you advise parents to use anti-pyretics and fluids?
- Don't use paracetamol and ibuprofen simultaneously - Can use one or alternate between them if one is ineffective - Don't give ibuprofen if child hypovolaemic - risk of renal impairment Keep child hydrated where possible - encourage fluids
307
What tool might you use if a child presents with GREEN symptoms and a sore throat?
FeverPAIN score Scores 1-5 Lower score means less likely to be streptococcal Higher score may mean streptococcal and give antibiotics e.g. amoxicillin
308
What does the FeverPAIN score stand for?
``` Fever (during previous 24hrs) Purulence Attend rapidly (within 3 days onset) Inflamed (severe) tonsils No cough or coryza ```
309
What are the symptom categories of the NICE traffic light guidelines?
``` Colour Activity Respiratory Circulation and Hydration Other ```
310
What are colour symptoms for green, amber and red in traffic light guidelines?
Green - normal colour Amber - pallor reported by parent/career Red - Pale/mottled/ashen/blue
311
What are the activity symptoms for green, amber and red in traffic light guidelines?
Green - responds normally to cues, content/smiling, stays awake, strong normal cry or not crying Amber - not responding normally to social cues, not smiling, wakes only with prolonged stimulation, decreased activity Red - no response to cues, appears ill, does not wake or does not stay awake if roused, weak high-pitched continuous cry
312
What are the respiratory symptoms for green, amber, red in traffic light guidelines?
Green - no respiratory symptoms Amber - nasal flaring, RR>50 6-12mnths, >40 over 12 mnths, O2 sats <95%, crackles Red - Grunting, RR>60, moderate/severe chest recession/indrawing
313
What are the circulation/hydration symptoms for green, amber and red in traffic light guideliens?
Green - normal eyes, skin, moist mucous membranes Amber - HR>160 under 1yr, >150 <2yrs, >140 2-5yrs, CRT 3s or more, dry mucous membranes, poor feeding, reduced urine output Red - reduced skin turgor
314
What are the "other" symptoms for green, amber and red in traffic light guidelines?
Green - none of the amber/red symptoms Amber - age 3-6mnths fever>39, fever>5days, rigors, swelling limb/joint, non-weight bearing limb, not using extremity Red - age<3mnths temp>38, non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurological signs, focal seizures

Phase 3a (8 decks)

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