Counselling summaries Flashcards
Initiating SSRI’s (6)
- Take a number of weeks to work (upto 8 wks)
- Can worsen mood/ increase suicide risk first 4 weeks
- GI side effects often settle
- Sexual dysfuction SE
- Don’t stop suddenly and withdrawal risks
- Follow up 1/2 weeks if for mood
Name 3 common SSRI withdrawal symptoms?
Flu like/ GI symtoms
Anxiety/ worse mood
Dizzy
Roscea management options?
Cx - Trigger avoidance, sun protection, skin care
- Skin camoflage/ make up
Mx- Topical brimonidine (if red), topical ivermectin (papules) or oral doxycycline if severe papules or pustules
Acne - self care advice (3)
Don’t overwash or scrub - use neutral or acid cleaning product twice daily
Don’t pick or scratch
Avoid oil based make up, but can go no oil based, remove make up at end of the day (labelled non acnegenic or non-comodogenic) - TAKE OFF AT NIGHT
Asthma - medical treatment stepwise?
MART now prefered!
1) PRN ICS/ LABA
- 1 puff
2) 1 puff BD of ICS/ LABA
3) + trial montelukast
4) Increase ICS/ LABA dose
5) Triple therapy with ICS/ LABA/ LAMA
Asthma aspects to counsel for new diagnosis?
D- Explain diagnosis
F- Feno/ spiro
Ca - Triggers
Lifestyle (smoking, exercise, vaccines)
M- Inhalers (video send for technique)
+ Personalised asthma management plan
- incl Safetynetting of when to escalate and seek help
COPD aspects to counsel for new diagnosis?
1) Explain diagnosis + symptoms
2) Triggers - smoking
3) Lifestyle (smoking, exercise, vaccines)
4) Inhalers (video send for technique)
5) Safetynetting of when to escalate and seek help including exacerbations
New diagnosis of angina - next steps:
1) Explain diagnosis and triggers (exertion, stress, eating, cold)
2) Ix (ECG, bloods)
3) Manage diet, smoking, exercise, weight
4) GTN (take 2nd dose after 5min, if not stopped 999)
5) Aspirin, BB or CCB 1st line, statin)
6) Driving (can drive as long as no symptoms at rest, emotion or when driving) - don’t notify DVLA
3 reasons to consider hospital admission and unstable angina? (In context of pt with known angina)
Pain at rest
Pain on minmal exertion
Rapidly progressing symptoms
Advise for angina and treating ED?
Don’t use at least 24 hours of sildenafil/ GTN
If angina during sex and used sildenafil - don’t use GTN and if pain doesn’t stop in 5 mins call ambulance
Give 3 examples of places you can signpost women with breastfeeding problems to?
Midwife
Health visitor
The breast feeding network - free helpline
Lactational mastitis, tx options?
1) Paracetamol and NSAIDS
2) Continue breastfeeding - if can’t do this then express or use pump
3) oral fluclox for 10 days QDS if not better or worsening after 12-24hrs
If not settling, send breast mild for culture, consider co-amoxiclav or referral to breast for more concerning pathology
How should you interpret and manage a raised calcium?
Severe > 3.5 = Immediate admission
Mod 3-3.5 = Consider same day (SDEC if unknown cause, home team if malignancy)
<3mmol/ L and asymptomatic:
- Consider stopping thiazide diuretic/ suppliments
- Screen for malignancy
New NAFLD - management plan?
If Fib4/ ELF or NFS low risk then managing in primary care
Lifestyle
- 5/10% weight loss in 6m target
- Diet and exercise
Control co-morbidities
Hypertension treatment pathway
<55/ diabetes - ACEI (Lisinopril)
Over 55/ black - CCB (Amlodipine)
2nd: ACEI + CCB
3rd: Increase ACEI or CCB depending which 1st
4th: Indapamide 2.5mg
5th: Max dose of all
6th: Consider doxazocin or bisoprolol
Raynauds - 3 management steps
1) Bloods to assess other autoimmune
2) If secondary (over 30 onset, painful, asymetrical likely then refer)
3) Nifidipine (5-20mg TDS) prophylaxis if interfering with daily life
Name 3 considerations of when to and when not to calculate fracture risk?
Anyone with RF
- Any men over 75 and women over 65
Don’t if fragility fracture - straight to DEXA
Who should be treated with bisphosphonates for osteoporosis?
Anyone with T score -2.5 or lower
Certain groups taking steroids - refer if major RF’s
Management advice for osteoporosis?
Cx: Stop smoking, exercise, diet, alcohol
Mx: Calcium, vit D suppliments
Bisphosphonates for those who meet criteria
List 4 management/ support options for cancer related fatigue?
1) Light exercise
2) Diet and weight mx
3) Sleep (apps like sleepio may be available)
4) Complimentary therapies (massage etc )
5) Talking therapy
Macmillian signpost
Mennorhagia - non IUS/ COCP or temporary management options?
Norethisterone (5mg TDS for 10 days)
Transexamic acid 1g TDS for up to 4 days
NSAIDS (mefanamic acid)
What criteria to start fertility investigations?
Trying for 1 year
OR
6 months if F over 36, known cause or risk factors
OR
Over 40 - immediate
ADHD likely on primary care assessment - mx options?
Referral to group based parent/ carer ADHD support
W+W for 10 weeks, or referral to CAMHS if they want this
Lyme disease - management?
Erythema migrans - start tx
No rash but suspicious - ELISA bloods (discuss with local ID/ micro)
ABx: Doxycycline 100mg BD 21 days (off licence but in guidance)
What are the classic features of erythema migrans rash? (3)
Spreads over days to weeks
Usually larger than 5cm
At site of tick bite - 1/2 weeks after
Not usually hot, itchy or painful
Hyponatremia - primary care cut offs?
<125 = Severe and urgent admission
125-129 = Moderate - consider if medical team discussion needed
130-135 = Mild, manage in primary care
Causes of hyponatremia. Name 3 common:
a) Drugs
b) Conditions
a) Thiazide diuretic, loop diuretics, SSRI, PPI
b) Acute illness/ D+V/ heart failure/ CKD/ ascities
3 symptoms of hyponatremia?
Unsteady/ falls
Cognitive/ memory
Vomiting
Drowsyness/ headache
Hyponatraemia assessment? (3)
Volume status
Symptoms
Causes (drugs, conditions)
Serum and urine osmalarity and osmolality
Which SSRI for post-natal depression and breastfeeding if needed?
Sertraline safest
Chlamydia - needing to treat there and then without GUM - what advice/ management?
Partner notification and treatment
- Encourage swabs if possible
- Check safe and safe sex practices
- Consider other STI’s - HIV etc
- Consider pregnancy
No intercourse for 7 days
1st: Doxycycline 100mg BD for 7/7 or Azithromycin 1g oral single dose then 500mg OD for 2/7
Chlamydia management in pregnancy?
Azithromycin, 1 g orally for 1 day, then 500 mg orally once daily for 2 days
Discuss with obstetrics and midwife
3 things to check before PSA test?
No UTI in 6 weeks
No ejactulation or vigerous exercise in 48hrs
No biopsy etc in 6 weeks before
3 key self management advice steps for eczema?
- Triggers- powder, pets, smoking
- How to moisturise (downward motion, 30mins before/ after steroid)
- Nails/ scratching
- Moisturise even when better (protects skin barrier)
Safetynet: Weeping/ fever/ spreading red
Shingles mx counselling (4)
Avoid contact at risk people (young, pregnant, older, not had chicken pox)
Keep clean, dry, don’t share towels etc, wash hands
Aciclovir (if in first 3 days or stretch first week)
Painkillers (Para/ NSAID/ weak op upto amitrypt, dulox, gabapentin)
- Can consider capsaicin cream
- Can consider steroid in severe pain
Chickenpox mx (3)
Infective before rash appears then until all lesions crusted over (5 days)
Avoid contact pregnant/ vulnerable and keep away school or nursery til crusted
Paracetamol/ NSAIDS
Topical calamine lotion for itch
Piriton (chlorphenamine) over age 1
Safetynet: Dehydration and bacterial infection (redness and high fever after getting better)
Exposure to chicken pox in pregnancy/ immunocompromise?
If definitely had CP/ shingles before or two doses vaccine then immunity assumed
if no hx or uncertain
- Test for VZ IgG (if can get result in 24hrs, if not hospital)
If neonate or immunocompromised seek specialist advice
Choice of emergency contraception?
Coil always preferable
If <5 days of D14 (assumed ovulation) and doesn’t want coil:
Ulipristal (<120hrs) as long as:
- No progesterone in last 7/7
- No Enzyme medications
- No severe asthma
- Can avoid breastfeeding 7/7
Otherwise levonogestrel (<72hrs):
- Double dose if BMI is over 26 or weight over 70kg or enzyme inducer medication
New domestic violence - counselling on options?
Place of safety/ safety plan
Charities (National domestic abuse helpline)
- Safeguarding MARAC (if wants or if children/ others involved)
Sexual health/ substance misuse as appropriate
Non specific cancer pathway referral - what bits to be done first?
Bloods, X-ray, FIT, urine dip
(i.e. weight loss, fatigue, generalised abdominal pain, loss of appetite)
Sciatica - new - counselling?
Cx - Usually wks to months
Stay active, return to work, not prolonged rest, use heat, speak to occupational health
Leaflet for exercises/ advice
Mx: Physio, paracetamol, NSAIDS - consider dulox or amitryp if needed
SNx: CES, severe pain at 6 weeks if not improving
What contraceptive options over age 40 and why?
IUS/ IUD
POP
Implant
(don’t affect stroke/ MI/ OP risks)
COCP/ patch - specific doses and progesterone can be 40-50 but not after 50 - discuss risks
Depot injection - higher osteoporosis risk
Suspected miscarriage mx points?
If any then refer to EPAU:
- Pain
- > 6weeks gestation OR uncertain gestation
- Risk factors (prev ectopic)
If <6 weeks and no pain, manage expectantly
- Rpt pregnany test in 7-10days
- Return if new bleeding or pain
How to counsel a woman after miscarriage? (4)
Rpt pregnancy test 7-10days if not already done
Periods normally return 1-2 months
Start trying again when feeling ready, usually wait 2 weeks for infection risk/ or contraception
Reassure, 1 in 5 pregnancies miscarry (1 in 2 over age 40). Miscarriage association have good support
Check in emotional support
Request baby loss certificate on government website
Name 3 causes low B12?
Medicines (metformin, PPI’s)
Diet (vegan)
Pernicious anaemia (IF antibodies)
Gastrectomy
Nitrous oxide
Remember if combined B12 + folate, always start B12 24 hours before (B before F)
How is pagets disease managed?
Bone pain + raised ALP think Pagets (usually over 50)
Supportive devices/ aids
Paracetamol/ NSAIDS
Bisphosphonates
All need secondary care referral and monitoring (ortho)
What is the number 1 NHS sexual health signposting website?
Brook
Contraception/ pregnancy/ gender/ abuse/ relationships - has lots of good stuff for gender and sexual health
HRT counselling - 4 main risks? What’s protective?
Breast ca - Slight increase, much less than lifestyle
CVA/ VTE - Raised, less with patch
CVD/ Osteoporosis - Protective, especially in younger
Ovarian ca - Slight increased risk
DVLA rules in dementia/ cognitive impairement?
Mild cog impairment/ doesn’t affect driving - G1 and G2 can drive w/o notifying DVLA
Dementia - Must notify DVLA and do not drive (G1 and G2)
New dementia diagnosis - key management?
Social/ group or stimulating therapies (use resources like ageuk
Medicines (donepezil, memantine ususally alzeihmers only) - should only be started by secondary care, not primary care
Driving advice - must inform DVLA, stop driving when not safe (judgement call)
Discuss planning ahead, LpoA, advance care
Discuss social support, care needs etc
What website could carers be signposted to which includes all advice to support carers from finances to practical and wellbeing support?
https://www.carersuk.org/
2 main types of hair loss and how to manage?
Telogen effluvium - Common, usually 3 months post trigger (stress, illness, childbirth, surgery, drug treatment)
- Usually self limiting and lasts 6 months (bloods for iron, thyroid etc)
- Known as Anagen effluvium if due to drugs like chemo
Mx: Topical mionxidil foam can be brought OTC - if no response after 1 year refer to dermatology, cosemetic options for wig or alopecia UK website
Alopecia areata - Pathcy hair loss, usually over 40’s
- Unusal to see total hair loss
- If wanting tx and no hair regrowth/ it’s patchy can use potent steroid for 3 months (off-licence)
- Offer derm referral
New diagnosis COPD - points to counsel?
Stop smoking
Pulmoanry rehab
Improving exercise/ function
Vaccines
Start SABA inhaler
- Review 1 week to discuss further step up tx
New RA - counselling (5)
D- Explain diagnosis
I - Link to ICE
F - Bloods and urgent (3wk) rheum referral for DMARD and steroids
- Within 3 days if small joints or more than one joint
Ca- Stop smoking, stay active
M - NSAID + PPI, talk about osteoporosis, vaccines etc another appt
S- Signs septic arthritis, follow up appointment to discuss further
New COPD - 5 non pharmacological management steps?
Stop smoking
Pulmonary rehab
Increase activity
Flu/ pneumococcal vaccines
Self-management plan (exacerbations etc)
Address co-morbities
Inhaler technique etc
What is the diagnostic criteria of COPD?
FEV1/FVC < 0.7
Over 35, with risk factor (smoking/ occupation) and one of:
Breathless/ wheeze/ cough/ frequent LRTI/ sputum
How is severity of COPD graded?
FEV1
- >80% = Mild
50-79% = Moderate
30-49% = Severe
<30% = Very severe
PCKD counselling (5)
Genetic (AD)
- No contact sports
Managing HTN (130/80), ACEI
Death is from CVD risk, smoking, weight, exercise
Referral to reno (vasopressin etc)
Monitoring renal function and at least annual ultrasound - eventually will need dialysis (50% by age 60)
PCKD genetic counselling - what considerations?
Generally screening of children a no, removes their choice
Adults all need counselling RE risks and benefits of screening and make own choice
Benefit - Early diagnosis + treatment, family planning
Risks - Effects for insurance and psychological effects of disease with no effective treatment
Acne - DIFCaMS?
D- Explain treatable but does take lots of time
I - ICE (confidence/ mood?)
F- PCOS ix? If scaring/ low mood - refer
Ca- Washing BD, non oil based makesup
M- Multiple options, single agent BP or combination tx’s or COCP or refer
S- Not better at 3 months come back
14year old with chlamydia - considerations in management plan?
STI clinic - all children management by specialist service
Mx- Doxy 100mg BD 7/7
Pregnancy test!
Age of partner, coercision, risk of exploitation/ conset?
Any other partners? Future risk, sexual health counselling - Brook Website
Follow up in a week (phone) to check symptoms resolved. Re-test at 3-6 months as <25’s high risk of catching again
Head lice management counselling?
Confirm by combing, need live lice to confirm, not egss
Treat all family at same time
- Hedrin lotion
- Bug buster comb (wet hair combing)
(Retest a few days after treatment)
Children can still attend school, no way to avoid, just use comb detector
Management of self harm disclosure
Immediate safety
- Managing injury/ ingestions etc (ED)
- Can they keep themselves safe (crisis team)
Address underlying MH condition (referral, therapies, medication)
Social safety plan (support at home)
- Follow up at 48hrs
MH act allows compulsory admission if mental disorder warrants hospital tx AND need to be admitted in interests of own or others safety
Management of migraines in 17yrs.
Most from conservative (8wk headache diary and trigger avoidance)
Paracetamol/ NSAID
- NASAL triptan (oral not licenced under 18yrs)
- Antiemeric like stematil (unlicenced)
Follow up after 4 weeks - after this refer as limited options
DON’T DO PREVENATIVE TREATMENT IN GP
New PCOS - management counselling
D - Explain (risk T2DM, CVD)
I - Link ICE (periods, fertility, hirsuitism)
F- QRisk/ lipids/ HTN/ sugar monitoring
Ca - Lifestyle (weight, exercise, diet, smoking)
M-
COCP for clinical features periods + acne (off-label),
Acne mx
Cyclical progesterone/ COCP for irregular periods
Metformin (off label) usually specialist but can use in primary care if BMI over 25 for metabolic benefit
PCOS and planning pregnancy - what advice?
Optimise PCOS (CVD - all lifestyle, weight etc)
Offer OGTT in preconception periods
Huntingtons - inheritance, age of onset and presentation + management?
Autosomal dominant
Age onset 30-50yrs
Mild pyschotic and behaviour symptoms and then chorea (invol rapid movements)
(Affects movement, thinking and behaviour)
Management currently makes no difference to disease progression - usually up to 20 yrs
Name 5 contraindications to HRT?
Current, past or suspected breast Ca
Undiagnosed vaginal bleeding/ endometrial hyperplasia
Current or previous idopathic VTE (unless on anticoag)
Active or recent CVD (angina, MI)
Pregnancy
Active liver disease
(Breast cancer, blood clots, heart, liver)
Older (62) patient with Fhx of non braca breast cancer wants to continue HRT, what are the key considerations?
Risks vs. benefits
Risk - Combined much higher breast ca risk than oestrogen only
- Mitigate with transdermal oestrogen and micronised progesterone orally
Risk higher with advancing age and over 5 years HRT use
- Manage CVD risks - obestiy biggest risk factor
IBS - management options? (4)
Rule out (calprotectin, FBC, CRP, coeliac)
Constipation - laxatives
Diarrhoea - loperamide
Spasm - buscapan, meberverine
Refractory pain - Low dose amitryptiline or SSRI 2nd line
Refer gastro if uncertain diagnosis, atypical symptoms or not manageable in primary care
Managing globus? (3)
Diagnosis of exclusion - exclude serious/ red flag
GORD possible cause - PPI’s
- Consider SALT for exercises and relaxation
- Consider SSRI if concominent pysch features
Gential warts explain and manage?
Virus - causes painful blisters
Often commonly reoccurs, but tends to settle more over time
Mx- Refer STI clinic, test other STI’s
- Imiquod cream
Achillies tendinopathy - presentation and management?
Assess rupture etc - same day refer
Pain, stiffness, worse on activity
- Lasting over 7 days then refer to physio
Restless legs management?
Common in pregnancy
- Gentle exercise, stretch and massage
- Sleep hygeine
- Caffeine, alcohol, diet etc
Check iron levels (commonly associated, commonly low in pregnancy)
Acitinic keratosis - management?
If single lesion and low risk (no immunotherapy etc)
- Diclofenac gel (3months)
Avoid sun, use suncream, safetynet if changing
If high risk features, diagnostic uncertainty or multiple lesions refer to derm
- If features of SCC (concern RE transformation, refer 2ww)
Urticaria management and counselling (3)?
Identify triggers (allergen, heat, stress, idopathic etc)
1st - Non sedating antihistamine 6 weeks, if works do 6 months
(If very severe consider up to 7 days oral steroid)
Long term - antihistamines up to 4x normal dose (off licence)
- Camomile lotion
- Chlorphenamine (Sedating) at night time to help sleep
Management of alopecia areata? (Patchy skin loss)
Common, lifetime 1 in 50, about half remission within 1yr - can reoccur again
Can trial potent or very potent steroid 3months (if no hair regrowth)
- Derm referral
- Cosmetic options
- Support group (Alopecia UK)
How do you manage andorogenic alopecia in women (thinning)? (2)
Reassure rarely results in total hair loss
- Hair pieces and wigs
- Topical minoxidil (OTC only) or surgical hair transplant
When to suspect aortic stensosis (5) and how to ix?
Classic triad - heart failure, chest pain and syncope
- Systolic murmur, narrow pulse pressure
- Urgent ECG and Echo, along with CXR
If symptomatic that may mean SDEC same day referral as high risk
Plantar fascitis mx? (3)
Can take up to 1yr
- Refer if ongoing at 3-6months post primary care mx
- Rest and avoid prolonged standing/ walking
- Comfortable shoes/ consider insoles
Paracetamol/ NSAIDS
Plantar/ calf stretching for 4-6 weeks
Physio
FAP - what inheritance, how manage someone with FHx?
Autosomal dominant (50% if parent or sibling)
- Take FHx
If syx - FIT and bowel 2ww
Otherwise:
Refer to genetics for counselling, ix and colonscopy
(Most need colectomy before age 20 if confirmed)
Fibromyalgia mx options (5)
Exercises programme
Talking (CBT, ACT)
Accupuncture
Duloxetine/ amitriptyline
- Nil other pain meds
Review existing and stop where possible
Counselling for new hepatitis C - what to include? (5)
Refer - ID +/- gastro (80% chronic)
Symptoms liver (pain, N+V, jaundice, weight loss)
Further screening - other infections, HIV etc
- Sex/ IVDU - risk of transmission
- How did they get it? Others at risk
- Don’t drink alcohol
New NAFLD - counselling?
Diet, execise, alcohol, smoking - lifestyle + weight loss key
Calculate Fib4 score - if higher thank 2.67/ signs liver disease or uncertain diagnosis then refer
Annual reviews (blood pressure, BMI, diabetes. lipids) - optimise all areas
Can consider pioglitazone off-licence for NASH
Post MI - medications to aim for? (5)
1) Dual antiplatet (12 months then aspirin only)
2) ACEI - titrate to max tolerated
3) Beta blocker - titrate to max tolerated
4) Atorvastatin 80mg
Post MI - what 5 things to counsel?
Meds - 5x (DAPT, statin, ACEI/ BB - titrate to mx)
Cardiac rehab
Sex - 4 weeks
Driving - 4 weeks, 7days if PCI.
> Manage all cardiovascular risk (diet, exercise, smoking, alcohol)
Management of chronic fatigue syndrome?
Refer to specialist CFS service if >3mths and debilitating + post-exertion malaise + sleep disturbance
Manage stress/ anxiety/ sleep hygeine
- CFS fluctuating, varies long term recovery
Consider CBT
Specialist physio
Diet etc advice
How do you diagnose CKD?
eGFR <60ml/min for 3 months or more
OR
ACR>3 for 3 months or more
CKD1- eGFR >90 (i.e. if only ACR affected)
CKD2- 60-89
CKD3a- 45-59
CKD3b- 30-44
CKD4- 15-29
CKD5 <15mls/min
How do you manage CKD (new)?
Arrange monitoring bloods and ACR at minimum annually
- If accelerated (25% drop or 15mls/min in 12 months) refer
Offer ACEI if ACR is over 70mg/mmol (or 30 with HTN, or 3 with T2DM)
Manage CVD risk - especially BP (target 130/80)
- Add statin
- Add aspirin
- Add dapaglifozin if T2DM or ACR is over 22.6mg/mmol
AVOID NSAIDS - advise about AKI
Hypertension - diagnostic criteria?
Clinic 140/90 or over AND ABPM average over 135/85
Stage 2 - Clinic >160/100
ABPM > 150/90
Stage 3 - Clinic > 180/120
New stage 1 hypertension - management?
Check organ damage - ECG/ urine dipstick/ eye screening
Lifestyle- diet, exercise, caffeine, salt
1st - ACEI if T2DM or under 55 and white
- CCB if over 55/ black etc.
Arrange annual reviews for bloods and monitoring
Afro carribean pt who is 56 with T2DM. ABPM 154/95 - what treatment to start?
ARB (Candesartan)
All T2DM should have ACEI, except afro-carribean where ARB preferred
- Not CCB if diabetes
Hypertension management steps - up to step 4?
1) ACEI/ ARB or CCB
2) ACEI/ ARB + CCB
3) + indapamide
4) If K<4.5 then spironolactone, if K > 4.5 give doxazocin
Then refer
How to manage alcohol issues? (3)
Withdrawal - attend ED
Support quiting - turning point (avoid sudden reduction)
Px oral thiamine (if malnourished, liver disease etc)
Consider driving/ safety
- Mental health
- Other substances
PTSD - how to counsel management?
Assess/ treat co-morbid depression
If event in last month - specialist referral
Over 1 month - Refer pyschological therapy (EMDR) or drugs (venlafazine or SSRI)
- Can consider short term hypnotic
Reassure PTSD treatable, vetrans get fast-tracked
(Combat stress for vetrans and rape crisis good charities)
Managing a suspected new anorexia?
Urgent medical risk (low BMI, refeeding) > A+E
Urgent MH risk > Crisis team
Otherwise eating disorders team referral
- Arrange regular reviews whilst waiting
Concerns about safety for a patient with MH diagnosis (suicidal/ eating disorder etc). Refusing admission - which area of MHA needed?
Section 4
(Detain for emergency 72 hours whilst awaiting second assessment needed for S2)
How to manage suspected CMPA in GP?
Refer if IgE syx or consider if non-IgE and severe
Eliminate cows milk 2-4 weeks from mum diet or EHF (hydrolysed formula)
- Keep off until 9-12months old
Amino acid formula only for severe IgE or anaphylaxis/ ongoing syx with eHF
How to counsel a parent regarding infantile colic?
Recurrent crying/ irritability under 5 months - usually first 6 weeks
Reassurance, holding strategies, winding, leg movements, white noise
- Parents take time out if needed
www.cry-sis helpline
Who should recieve prophylactic antibiotics when coming into contact with meningitis?
Anyone with prolonged close contact in household type setting during 7 days before onset of illness
Start ABx within 24 hours
How to manage suspect sleep apnea?
Urgent referral (ideally within 4 weeks to sleep clinic) if severe/ affecting work
OR routine if otherwise mild/ mod
Don’t drive if sleepiness in daytime, if can’t control syx in 3 months inform DVLA - if confirmed/ mod/ severe inform immediately
Mx new polymyalgia rheumatica (PMR?)
Screen GCA etc - safetynet
- Bloods for CRP/ ESR etc
Need bloods like TSH/ RF etc BEFORE starting steroids - do urgently
Steroids: 15mg daily for 3 weeks - review at 1 week (expect 70% improvement)
- Explain often need reducing course lasting 1-2years
Steroid card
Refer if younger than 60, atypical symptoms, over 2 years, relapsing symptoms, can’t manage
Contraception choices - can’t remember pills, doesn’t want coil, doesn’t like injections or thought of implant? What option and how to take?
Contraceptive patch
- Weekly
Same as COCP, slightly lower VTE risk - 3 patches and week break or 9 patches and week break
Consultation regarding contraception and learning difficulties (or other capacity difficulties) - how to approach?
Anyone you want with you to help talk through?
Establish understanding of contraception, what it’s for and why needed
Assess risk of exploitation or pressure
Closed Q’s (periods, COCP/ patch contraindications)
Give opportunity for informed decision (LARC vs. pills vs. patches)
“If you are struggling to understand we can have consultation again with someone you trust to help make deicisons together in your best interests”
Wanting to quick start contraception after UPSI and emergency contraception - what options?
Levongestrol - immediately start POP
EllaOne (ullipristal) - Need to wait 5 days (abstain or use condoms)
If won’t abstain or use condoms needs levonogestrel option (but only works as EC if UPSI in last 72hrs)
Acute diverticulitis management?
Co-amoxiclav - 5 days
Admit if severely unwell/ not tolerating oral/ dehydration OR significant comorbid OR OVER 65’s
Pain relief - paracetamol - avoid opiates
How should a patient be counselled to manage diverticular disease? (3)
High fibre
Lots of fluids
Encourage physical exercise
Safetynet RE flare ups and when to come for help
Management advice for cold-sore?
Infectious - don’t share towels/ utensils/ cups/ kissing
- Don’t pick, wash hands
HSV-1 - can transmit when asymptomatic
Zovirax cream/ plasters or moisturer to cover OTC
How to manage Rubella exposure in pregnancy?
Notify public health (notifable disease)
Urgent obstetric opinion (risk most under 20 weeks)
- Must be tested
- Counselled based on test risk
Managing chronic prostatits? (5)
Pain
- Simple only +/- neuropathic
Physio for pelvic floor
LUTS = Tamulosin
If under 6mths syx - can trial 6 weeks of doxycycline
CBT/ SSRI’s if pyschological impact
Child (15y) acting out and attacking parent - mx options?
?Police + immediate safety
Focussed care worker
MARAC - Domestic abuse from minor - support for mum
Womens shelter
Social services - support/ placement for child
15year old requesting vaccines against parental consent - ethical priniciples?
Over 16 can consent to tx regardless
At 15yrs - can consent if Gilick competent
- Need to make every effort to discuss with parents
- Might want to seek legal advice
Frequent falls - management options?
F- Bloods/ ECG/ examine cadio/ L+S BP/ neuro etc
Cons– AgeUK, tai chi/ yoga etc
Medical- DAME - Medication, eye test, manage comorbid, Enviro - Consider falls team/ OT etc
Safety- A+E if injury
New intermittent claudication - management?
F- Urgent refer (same day if acute) or urgently if chronic features of acute/ chronic limb ischemia
Ca- Manage all cardiovascular risk
- Supervised exercise programme
M- If not improved with supervised exercise
- Referral for angioplasty
S- Safetynet Acute Limb syx
Parents concerned about fussy eater- mx?
F- Hx to consider ASD etc.
Ca- Normalise, same food as rest of family, don’t force to eat, just try again another time
- Don’t snack between meals or use food as a reward (sweets, chocolate etc)
Pityriasis rosea - presentation (3) and mx (3)
Herald patch (few cm) then spreading plaques all over within days or weeks
- Can be itchy
Self resolves in about 6-10 weeks
- Moisturise and avoid sun
- Steroid/ antihistamine for itch
Atheletes foot/ tinea pedis - counel points (5)
Ca- Breathable shoes, cool and dry properly, don’t share towels, avoid scatching
M- Mild (OTC antifungal 2 weeks)
Mod- antifungal/ steroid combo 7 days then antifungal alone further 7/7
- If severe then oral terbinafine
Presentation and counselling for TMJ disorders?
Px - Pain (pre-auric), clicking, popping, crepitus
Mx (Ca) - Rest jaw, avoid grinding/ clenching/ yawning/ gum etc. ice and heat packs
Manage stress
M - Simple analgesia/ short course benzo’s - amitryp for chornic pain
Counselling for tinnitus (not requiring referral)? (5)
Conider causes (wax/ TMJ/ infection/ meds) and tx
Sound therapy
(use www.tinnitus.org.uk)
Pyschological (CBT), manage anx/ depression/ sleep
Hearing assessments + consider hearing aid.
Psoriasis - topical treatments? (4)
Moisturiser to remove scale and relieve itch
1) Potent steroid plus vitamin D (dovonex) - OD each but diff times
(steroid up to max 8 weeks)
- Enstillar (calcipitrol + betamethasone)
2) if struggling stop steroid and vitD only BD for 12weeks OR potent steroid BD for up to 4 weeks
3) Coal tar (exorex)
Salycyclic acid if scale is thick
Psoriasis - non drug management advice (3)
Manage not cure
- Smoking/ alcohol/ weight
- Manage stress
Topical tx take several weeks to work, often relapse if stopped suddenly
Phototherapy if not controlled topically
Scalp psoriasis management?
Potent steroid (betnovate)
+
Vitamin D (calcipotriol) scalp ointment
Coal tar shampoo if mild/ mod (Capasal shampoo - also has salycilic acid)
Treat for 4 weeks
Cystic fibrosis
- Background carrer rate
- Inheritance pattern
- Testing options
Carrier 1 in 25
Autosomal recessive (1 in 4 chance if both parents carriers/ if affected sibling)
- If 1st degree relative can genetic testic (and then partner testing if relevant)
- Can do pregnancy testing (amniocentesis or CVS)
New pre-diabetes counselling?
D- High risk developing diabetes
I- Bring in ICE
F- Diabetes prevention programme/ free gym
Ca- Exercise, weight, diet
M- Consider olistat if BMI over 28, do QRISK and assess other risk
- Referral to weight management, consider liraglutide etc
New glaucoma - points to counsel?
Gradual visual loss - mainly working in from peripheries
(as build up of pressure, need drops to reduce pressure or SLT procedure)
Discuss driving and DVLA - they assess before deciding on driving
- Legal requirement to inform
Consider support with taking of drops (devices that can help if frail or arthritis etc)
New AMD - Syx (3) and mx (2)
Loss of central vision, straight lines appear wavy, loss of details
Mx- Refer to be seen in a week, some can have injections etc
(most common cause sight loss)
Discuss DRIVING - may still be able to drive - don’t need to inform DVLA as long as still meet visual fields standard
Elderly patient who needs to stop driving - how to help negotiation?
Stress safety
Free bus pass over 60
Hirsuitism - mx options?
Ca - Waxing/ lasers/ bleaching
M- Eflornithine cream (Vaniqua)
- As all PCOS etc - COCP - i.e. Dianette
Managing flare up of UC in primary care?
Admission > 6 stools/ day, significant blood, fever, tachy, hypotension, signs obstruction
Contact IBD nurses for steroid/ cons connect
Stool culture, bloods (inflam markers, renal etc) and review
Tension headaches - how quick to withdrawal NSAIDS/ paracetamol etc?
Stop abrupbtly
- Explain worse for 2-10days
- Usually get better within a few weeks
Obvs co-codamol/ benzo slower
