EXPLAINING A DIAGNOSIS Flashcards
STRUCTURE
what is the structure for explaining a diagnosis?
BUCES
- B = brief history
- U = Understanding
- C = Concerns
- E = explanation
- S = summarise
STRUCTURE
what should you include in the brief history?
- what has brought them to see the doctor?
- any symptoms
- any risk factors (lifestyle, family history)
STRUCTURE
what should you include in understanding?
- Do you understand why I wanted to discuss ____ with you?
- Have you heard of ______ before?
- What do you know about _______?
STRUCTURE
what should you include in concerns?
ICE
- Ideas = what is your understanding?
- concerns = what are your concerns?
- expectations = what are you hoping to gain from the appointment?
STRUCTURE
what should you include in explanation?
Sign post
Im now going to explain how the ________ works, then move on to discuss what _______ is, why it is important to address and how we can manage it together
“Normally We Can Probably Manage”
- N = normal anatomy/physiology
- W = what is it? explain the disease
- C = causes, risk factors
- P = problems/complications
- M = management
STRUCTURE
what is the structure for the explanation component?
“normally we can probably manage”
- N = normal anatomy/physiology
- W = what is the disease?
- C = causes
- P = problems/complications
- M = management
STRUCTURE
what should you include in the summarise part?
- summarise key points
- ask the patient if they have any questions
- offer leaflets and direct to NHS website
HTN
how would you explain normal anatomy/physiology for HTN?
“The circulation system within your body is made up of your heart, a muscular pump, and blood vessels.”
“The pressure within the vessels is a combination of how hard the heart pumps and how stretchy the vessels are. This is measured both when the heart pumps – systole, the top number – and when the heart relaxes – diastole, the bottom number.”
HTN
how would you explain what HTN is?
“High blood pressure occurs when the vessels become less elastic and more narrow. This means that to pump blood around the body, the heart has to work harder, which increases the pressure in the vessels.”
“It is normal for your blood pressure to go up and down during the day, especially when you are active; however, it should not be consistently greater than 140 over 90.”
“Although your blood pressure is high today, this doesn’t necessarily mean you have hypertension. To formally diagnose, I would like for you to be fitted with a machine that takes readings over 24 hours and provides an average.”
HTN
how would you explain the causes of HTN?
“The most common cause of high blood pressure is getting older. However, many factors in your lifestyle can have a significant impact; these include smoking, not getting enough exercise, being overweight, drinking alcohol in excess and a diet high in salt, sugar and fats.”
HTN
how would you explain the problems/complications of HTN?
- IHD
“Fatty deposits can build up so much that the artery which supplies the heart muscle becomes partially or completely blocked; this is called angina or a heart attack. Both of which can lead to permanent damage to the heart and even death.” - stroke, TIA and vascular dementia
“Fatty deposits can also build up in vessels that supply your brain. If these become blocked, it can cut off the oxygen supply to parts of your brain, leading to a stroke or a type of memory impairment called vascular dementia.” - CKD
“If there is too much pressure in the kidneys, this leads to damage that reduces kidney blood flow. This damage means that the kidneys cannot filter the blood as effectively.” - PVD
“The narrowing of vessels due to high blood pressure can reduce the circulation to your hands and feet. If this progresses, you can get pain in your limbs when moving and, in the worst-case scenario, can lead to amputation.”
HTN
how would you explain the management?
- target is to reduce BP to below target
- unlikely to get symptoms of HTN so BP must be regularly monitored to ensure we maintain this target
- lifestyle changes = smoking cessation, weight loss, 150 minutes of moderate activity per week, limit salt, caffeine + alcohol. Encourage fruit, veg, grains, nut and oily fish
- antihypertensives if unable to lower BP with lifestyle changes alone. Will require frequent monitoring to ensure you dont get low blood pressure, which can cause dizziness.
- can calculate risk of having a heart attack or stroke in the next 10 years. If this is above 10% we can offer you a statin to reduce risk.
ANGINA
how would you explain the normal anatomy/physiology of angina?
“The heart is a muscular organ in the centre of your chest that acts as a pump, circulating blood throughout your body to deliver oxygen and nutrients to your organs and tissues.”
“The heart requires its own blood supply. The arteries which supply the heart are called the coronary arteries.”
ANGINA
how would you describe what angina is?
“Angina is chest pain or discomfort that happens when your heart isn’t getting enough blood, often because of narrowed arteries. It can be triggered by physical activity, stress, or cold weather.”
“There are two types: stable and unstable. Stable angina typically occurs during exercise and goes away with rest or medication. Unstable angina is more serious and poses a greater risk. It can happen at rest, be more intense and may not improve with medication.”
ANGINA
how would you explain the causes?
“The most common cause of angina is coronary artery disease, where the arteries that supply blood to your heart become narrowed due to a build-up of fatty deposits. This can happen due to factors like an unhealthy diet, lack of exercise, smoking, ageing, or a family history of heart disease.”
ANGINA
how would you explain the problems/complications?
MI
- fatty deposits can build up in arteries supplying the heart muscle.
- when they are completely blocked it is a heart attack
- this can cause permanent damage to the heart and its function
Stroke
- fatty deposits can also build up in the blood vessels supplying the brain
- if these become blocked it can cause a stroke
Unstable angina
- if angina is lasting longer than usual, occurring at rest or more severe, it is a medical emergency and you should attend hospital immediately
sudden cardiac death
- in rare cases it can lead to sudden death
reduced quality of life
- can limit ability to engage in usual activities
can be challenging and we recognise that is can be stressful
- please know we are always there to support you
further support
- many websites offer support and information
- example = british heart foundation
ANGINA
how would you explain the management?
- goal = reduce how often you have symptoms, make them less painful and relieve discomfort quickly. also want to prevent worsening + lower risk of heart attack or stroke
- recommend combination of healthy lifestyle + long term medications
- lifestyle = smoking cessation, weight loss, physical exercise (150 mins per week), reduce alcohol, encourage fruit, vveg, whole grains, nuts and oily fish. Limit salt
- GTN spray = if experience chest pain, use GTN spray. If the pain has not gone after 5 mins, take a second dose. If pain still has not gone or got worse call 999
- long term meds = to reduce how often you have angina + can improve overall function of heart. If you experience episodes still use GTN
- surgery = if meds don’t work or are unsuitable
COPD
how would you explain the normal anatomy/physiology for COPD?
- lungs are responsible for breathing, supplying oxygen and removing CO2
- breathe in = air enters nose/mouth and goes down your windpipe. Trachea divides into bronchi and then into bronchioles
- alveoli are at end of bronchioles. They are stretchy air sacs
- blood enters blood through walls of alveoli + waste CO2 is removed
COPD
how would you explain what COPD is?
- COPD = common condition affecting lungs, making it harder to breathe
- includes emphysema and chronic bronchitis
- inflammation in lungs which narrows tubes in your lungs, making if harder to breathe
- lungs produce mucus which is coughed up as phlegm
- air sacs called alveoli are destroyed. This makes it harder to absorb oxygen
COPD
how would you explain the causes of COPD?
- caused by long term exposure to harmful irritants that damage the lungs
- most common = smoking. the risk increases the more you smoke and the longer you have been smoking for
- other things = breathing in chemical fumes, air pollution and rarely an inherited genetic condition
COPD
how would you explain the problems/complications?
- symptoms develop slowly over many years
- unfortunately symptoms like breathlessness and cough worsen over time, making daily activities more challenging
- treatment can slow progression but there is no cure
- narrowing of airways = feeling breathless
- damage, irritation and inflammation = mucus + cough
- more prone to chest infections, particularly in winter as it is harder for lungs to clear mucus + bacteria
- may get flare-up (exacerbation) = breathlessness, coughing, wheezing + more mucus. Can be triggered by infection, irritants or changes in weather
COPD
how would you explain the management?
STOP SMOKING
- most important = stop smoking. Most effective way to prevent it getting worse as it prevents further damage + improves breathing
VACCINATION
- entitled to free vaccinations = one-off pneumococcal vaccine + annual flu jab
PULMONARY REHAB
- pulmonary rehab = programme of exercise classes, info on looking after lungs, eating well + managing COPD. Helps understand COPD + reduce breathlessness
INHALERS
- SABA = delivers small amount of medicine directly to lungs. Relaxes muscles in airways + opens them up. Eases breathlessness
- LABA = provide sustained relief of breathlessness throughout the day. typically used twice daily
- ICS = reduces swelling + inflammation in airways. Should be used consistently even when feeling well to maintain airways + prevent flare ups
TREATMENT OF FLARES
- oral steroids = short course of steroid tablets, typically for 5 days
- antibiotics = if worsening breathlessness, cough or phlegm turning brown, green or yellow
OXYGEN
- if blood oxygen levels are low + meet specific criteria = qualify for long term oxygen therapy. Involves having oxygen delivered through tubes in nose or mask for at least 15hrs per day
ACNE
how would you describe the normal physiology?
- normal function = act as a barrier
- imagine skin as bricks stacked on top of each other
- there are glands which produce oily substance called sebum = helps maintain and protect skin
- acne = too much sebum produced
ACNE
how would you explain the condition?
- over production of sebum
very common in teenagers - commonly affects face, chest and back
- mild acne = comedones (whitehead = open comedone, blackhead = closed comedone)
- severe = papules and pustules
ACNE
how would you explain the cause of acne?
- problem with hair follicles and associated glands in skin
- a few different things cause increased sebum
- increased sex hormones during puberty
- menstruation causes varying symptoms
- bacteria on skin
- medications like steroids or glands being blocked by things like makeup
ACNE
how would you explain the problems/complications?
- once healed can be left with scarring or changes in skin colour. This is why it is important to treat acne well
- often makes people self-conscious or worried about appearance. Important to talk to someone about it.
ACNE
how would you explain management?
- acne can be unpleasant to live with so we try to get it under control
TOPICAL CREAMS
- first try OTC creams = salicylic acid (unblocks glands), benzoyl peroxide (helps with any bacteria on skin)
- cleanse and wash skin everyday with these
TOPICAL RETINOID
- if moderate = topical retinoid (reduces amount of sebum produced but can be drying)
- use every other day and see how you get on with it
OTHER TREATMENTS
- if those don’t work, come back and there are some tablets that we can try that often help or if we are really struggling I can refer you to dermatologist
PSORIASIS
how would you explain normal physiology/anatomy?
normal function = act as barrier
- imagine skin as layers of bricks stacked on top of each other
- normal skin = mortar between bricks, preventing irritants getting in and prevents water getting out (stops skin drying)
PSORIASIS
how would you explain what psoriasis is?
- chronic inflammatory skin condition
- most frequently affecting scalp, elbows and knees
- develop itchy red scales
PSORIASIS
how would you explain the cause of the disease?
- development is very complicated + lots of different factors contribute
- thought to be a problem with parts of immune fish becoming overactive, leading to inflammation of the skin
- don’t know the exact cause but thought to be combination of genetic, immune + environmental factors
- genetic component = often runs in families
- often no clear trigger
- some things precipitate it = infection, hormone changes + medications e.g. lithium
- some things make it worse = skin trauma, smoking, alcohol + stress
PSORIASIS
how would you explain the problems/complications?
rare complication = severe flare known as pustular or erythrodermic psoriasis. It is serious + requires emergency medical treatment
if you notice pus filled blisters on body or develop painful itchy rashes al over = seek urgent medical advice
OTHER PROBLEMS
- persistent disease
- anxiety + depression from psychosocial burden
- reduced QoL
- development of psoriatic arthritis
PSORIASIS
how would you explain the management?
- important to get under control
- topical cream = mainstay of treatment
EMOLLIENTS
- emollient = fills cracks between dry bricks to stop irritants getting in + prevents water escaping.
- Also reduces flares.
- lots of different types of emollient e.g. cream, gel, ointment. Can work together to find one that works.
- ask a specialist nurse to speak to you about them today if you like?
TOPICAL STEROID
- used alongside emollient to help manage symptoms
- can change to alternative if first one does not work
- should not be used on face as it can cause skin thinning and other serious side effects
- always wash hands after applying steroid cream
OTHER TREATMENT
- in most people, treatments discussed help
- do have other treatments if these are not successful and we can discuss those if it becomes appropriate
ASTHMA
how do you explain the normal physiology/anatomy?
- breathe in = air enters mouth down windpipe. Air then goes into bronchi, bronchioles and into air sacs called alveoli. Here oxygen is absorbed into the blood
ASTHMA
how would you explain what asthma is?
- one of the most common lung conditions
- have inflamed and sensitive airways than can become narrower than normal
- common symptoms = cough, wheeze, chest tightness + SOB
- symptoms come and go, often in response to specific things
- important to take medication everyday even if feeling well as it reduces the chance of you being unwell
ASTHMA
how would you explain the causes?
- don’t know the exact cause
- some people are more likely to get asthma such as having allergies + family history
- common triggers = allergies, infections, stress, smoking + sudden temperature changes
ASTHMA
how would you explain the problems/complications?
ACUTE ASTHMA
- worsening symptoms not relieved by inhalers = asthma attack (exacerbation)
- important to manage as it can be life-threatening
- signs = wheezing a lot, tight chest, coughing, difficulty talking due to breathlessness, breathing quickly
- if experience this = call 999
PERSISTENT SYMPTOMS
- important to take medication everyday as it builds up protection in airways to prevent attacks
- if experience symptoms frequently = review with GP who may alter medications
- seek review if affecting activities, waking up at night or peak flow readings are lower than normal
ASTHMA
how would you explain management?
- aim = to minimise impact on day to day life
- if managed effectively would expect no symptoms during day or night + no limitation on exercise
INHALERS
- will be given a inhaler with the type dependent on severity of asthma
- used to relieve asthma symptoms + help reduce long term inflammation in airways
- should use inhaler twice per day
- important to not miss doses
- take extra doses if you feel short of breath, up to maximum
OTHER TREATMENT
- may require stronger medication + referral to specialist
PEAK FLOW
- will give peak flow meter
- tube that you blow into + emasures how fast you can blow air out of lungs
- important to do twice daily when starting medication + if symptoms get worse
PERSONALISED ASTHMA MANAGEMENT PLAN
GLAUCOMA
how would you explain the normal anatomy/physiology?
- eyes produce watery fluid called aqueous humour
- required to provide nutrients and oxygen to tissues in the eye
- maintains eyes normal pressure and shape
- fluid is produced at the back of the eye, travels to the front and leaves via a sieve-like drainage system
GLAUCOMA
how would you describe what glaucoma is?
- an eye condition where the optic nerve which connects the eye to the brain becomes damaged
- caused by build up of fluid in the front of the eye which increases pressure
- if not diagnosed and treated it can lead to blindness
- there are multiple types, most common = primary open-angle glaucoma. It develops slowly over many years + is caused by drainage channels gradually being clogged up
- like a kitchen sink, if you leave a tap on for a long time, the sink will block
- in the eye there is nowhere for the extra fluid to go so pressure increases and damages the nerves
GLAUCOMA
how would you explain the risk factors and symptoms?
- often picked up at regular eye appointments
- usually no early warning symptoms and they develop over a long time so often go un-noticed
- unclear why drainage system clogs but there are multiple risk factors
- increasing age
- short sighted (myopia)
- afro-caribbean ethnicity
- smokinf
- family history of glaucoma
GLAUCOMA
how would you explain the management?
- involves eye drops
- important you are comfortable with when and how to put these in effectively
- important you are aware of side effects
- if drops don’t work, surgery can be offered
REGULAR CHECK-UP
- will be invited for regular check-ups with an optometrist
- they will measure pressure in the eye + have a look at the back of the eye
- they will do regular visual field tests as well
GLAUCOMA
how would you explain the problems/complications?
ACUTE ANGLE CLOSURE GLAUCOMA
- sudden pain, red eye or reduced vision = seek medical attention immediately
- often accompanied with N+V and seeing haloes around lights
PROGRESSION OF GLAUCOMA
- risk of worsening sight
- can become severe enough to effect QoL
- important to use eye drops as instructed to reduce risk of damage
DRIVING
- important to make sure you meet DVLA sight requirements
- as eyesight gets worse the brain tries to adapt + fill in blanks so it is hard to tell blind areas
EPILEPSY
how do you explain the normal anatomy/physiology?
- brain controls how we move, say and do, memories and emotions and how we interpret the world around us via different senses
- different areas with different roles talk to each other
- signals go in both directions, both recognising thing sin world around us and making us move
EPILEPSY
how would you explain epilepsy?
- a condition that affects the brain
- causes a person to have an increased tendency to have seizures
- different types
EPILEPSY
how would you explain a seizure?
- an event where there is a chaotic burst of signalling that interferes with the brains normal function
- most last 30 seconds to 1 minute
- some people have warning signs= aura
- can stay awake or lose consciousness
- may feel very tired, confused and need sleep to recover
EPILEPSY
how would you explain the cause?
- does not have one specific cause
- some people are born with it and some develop it later in life
- can be caused by events before you were born or during birth
- can develop later in life from head injury, stroke or brain tumour
- in many cases it remains unknown
- some circumstances can trigger a seizure such as flashing lights, fevers, drugs + missing epilepsy medications
EPILEPSY
how would you explain the complications?
IMPACT ON LIFE
- avoid taking baths or swimming alone
- avoid climbing or skiing
- avoid driving until no seizures for one year
- if having frequent seizures, may be encouraged to wear a helmet
STATUS EPILEPTICUS
- prolonged seizure activity without recovery
- is a medical emergency that can result in brain damage if not recognised + treated promptly
- inform family + friends if you carry rescue meds so they can help in an emergency
SUDDEN UNEXPLAINED DEATH IN EPILEPSY
- rare, often during sleep
- may occur during or just after seizure
- happens in 1 in 1000 people with epilepsy each year
- can decrease risk by taking medications
SIDE EFFECTS
- may experience side effects
- will vary based on medication taken
- can affect development of babies if you were to become pregnant
- important to be on effective contraception
- should speak to doctor if you want to start a family so medications can be reviewed whilst still controlling seizures
DIABETES
how would you explore the patient’s understanding?
“What do you think is causing your symptoms?”
“What do you know about diabetes?”
“What has been explained to you about diabetes so far?”
DIABETES
how would you explore the patient’s concerns?
ICE
Ideas:
- What does the patient think is causing their symptoms?
- What is their understanding of the diagnosis?
Concerns:
- What are the patient’s concerns regarding their symptoms and diagnosis?
Expectations:
- What is the patient hoping to get out of the consultation today?
DIABETES
how would you explain the normal anatomy/physiology?
- after eating, food is broken into sugar which is released in blood
- sugar is fuel for all cells in the body + need to get from blood into cells
- a hormone called insulin is key to getting sugar into cells
DIABETES
how would you explain what the disease is?
- sugar cannot get into cells as insulin is not working properly
- sugar builds up in blood
- this can cause damage to cells if it remains high for too long (heart, eyes, kidneys, liver, etc)
DIABETES
what are the causes?
TYPE 1
- combination of genetics + environment
- triggers immune system to destroy insulin producing cells in pancreas
- reliant on insulin
TYPE 2
- combination of genetics + diet and lifestyle
- combination of inadequate insulin production + increased insulin resistance
DIABETES
what are the problems/complications?
build up of sugar in blood leads to damage to cells
- kidney failure
- increased risk of heart attacks
- increased risk of stroke
- loss of vision
- peripheral neuropathy
can cause slow healing of wounds + ulcers on feet
DIABETES
what is the management?
WHAT PT CAN DO
- lifestyle changes = avoid high sugar, lose weight, regular exercise
- stop smoking
- tight glycaemic control
- attend diabetic checks
- encourage good foot care + regular podiatrist appts
WHAT DR WILL DO
- regular check ups to screen for diabetic complications
- regular blood tests to check blood sugar levels
- start metformin
- manage complications as they arise
AF
how would you explain what AF is?
- type of heart arrhythmia meaning heart is beating irregularly
- atria and ventricles beat out of rhythm so blood isn’t pumped as efficiently
- heart beats faster to compensate
- causes feelings of palpitations, dizziness and light-headed
AF
how would you explain what the risk factors are?
high blood pressure
obesity
alcohol consumption
heart attacks
age
more common in men
smoking
AF
how would you explain the management?
- either manage rate or rhythm
- cardiologist will run through options
- will treat with anticoagulant
- when heart is not beating efficiently, blood flow becomes turbulent
- this increases the risk of blood clots
- can cause strokes
- can be treated with DOACs or warfarin
- DOACs are preferred as they have fewer complications + require less monitoring
BACTERIAL VAGINOSIS
how do you explain what it is?
- vagina naturally has bacteria called flora
- BV = when flora is disrupted + large proportion of bacteria take over
- not an STI
BACTERIAL VAGINOSIS
what are the risk factors?
- washing inside of vagina (can change acidity)
- existing STIs
- new sexual partners (cannot be passed via sex but pH can change)
- copper/mirena coil
BACTERIAL VAGINOSIS
what are protective factors?
- condoms
- only washing external genitalia with water (not inside)
- combined oral contraceptive
BACTERIAL VAGINOSIS
what is the management?
- often goes away by itself if not troublesome
- if bothering you can give antibiotic (METRONIDAZOLE) for 5-7 days
- should not drink alcohol whilst taking metronidazole
- can cause nasty reaction (vomiting, palpitations + flushing)
BACTERIAL VAGINOSIS
what are the complications?
- most people do not experience complications
- can cause wider infection of pelvis (pain, fever, abnormal bleeding)
- more likely to catch STIs
- can increase risk of miscarriage, preterm labour, LBW + womb infection
CKD
how would you explain what it is?
- kidneys do not function properly
- chronic = for more than 3 months
- healthy kidney = filter out waste from blood
- many conditions put strain on kidneys + over time cause them to fail
- classified into stages according to results of blood tests (eGFR)
CKD
what are the risk factors?
age >50
male
black/hispanic
diabetes
cardiovascular disease
gout
previous kidney problems
one kidney
obesity
smoking
medications
CKD
what is the medical management?
- no cure
- manage symptoms and prevent progression
- ACE inhibitor
- statin (protects against heart disease)
- specialist treatments for anaemia
- dialysis (waste filtered from blood by machine)
CKD
what is the lifestyle management?
- cut down smoking
- reduce sodium and phosphate
- reduce alcohol
- good control of any medical conditions
ENDOMETRIOSIS
how would you explain what it is?
tissue similar to lining of the womb grows outside the womb
can cause lots of different symptoms such as:
- pelvic pain
pain during sex
- difficulty getting pregnant
- urinary symptoms
ENDOMETRIOSIS
what are the risk factors?
- no definitive cause
- early menarche
- family history
- white ethnicity
- smoking
- nulliparous
ENDOMETRIOSIS
what is the management?
- no cure
- can be treated with painkillers, hormone treatments of surgery
- painkillers = paracetamol or NSAIDs
- hormonal = COCP
- surgery = laparoscopy to remove tissue
FIBROADENOMA
how would you explain what it is?
benign breast lump
not cancerous
common in young women
are smooth and moves around easily
are usually painless but can have pain just before periods
FIBROADENOMA
what is the management?
- no treatment or follow up required
- only surgically removed if particularly large
- continue self examining
- if any changes to size, texture, nipple discharge seek medical attention
FIBROADENOMA
what is the prognosis?
fall into 3 categories
- 1/3 = get smaller
- 1/3 = stay the same size
- 1/3 = gets bigger
FEBRILE SEIZURES
how would you explain what it is?
- common (3% get one)
- triggered by fever rather than lifelong
- fits are not dangerous
- more dangerous if lasting for more than 5 minutes (would give medications)
FEBRILE SEIZURES
what should be done at home if it happens again?
- recovery position (give leaflet)
- time seizure
- if it lasts longer than 5 minutes call for an ambulance
FEBRILE SEIZURES
what is the management?
- if lasts longer than 5 minutes, will be given medications called a benzodiazepine
- otherwise may observe to make sure no further seizures occur or treat illness/fever
- if this happens again we can give you a medication to squirt into cheeks of mouth if seizure lasts more than 5 minutes
FEBRILE SEIZURES
what is the likelihood of further seizures?
1 in 3 children experience further seizures
INSOMNIA
what is it?
- where person cannot fall asleep or keep asleep during the night
- to the extent that they are affected the following day
INSOMNIA
what are the causes?
stress
life events
sometimes no identifiable trigger
INSOMNIA
how common is it?
10% experience it at some point
more common in women
increasing age
MH problems
chronic pain
medications (steroids, dopamine agonists)
INSOMNIA
what is the non-medical management?
SLEEP HYGIENE
- avoid napping in the day
- avoid alcohol in evening
- avoid caffeine after midday
- keep same timing of going to sleep and waking up
- avoid eating + exercising late at night
- regulate temperature of bedroom
INSOMNIA
what is the medical management?
short term medications
- ZOPICLONE (can develop tolerance + addiction)
- MELATONIN (hormone produced by body, taken at night)
BACK PAIN
how would you explain what it is?
- very common
- most episodes resolve on their own
- commonly caused by pulled muscle or strain
- sometimes can happen over a long period of time or during sleep
- rarely a sign of underlying problem but it would present with other symptoms
BACK PAIN
what are the reassuring negatives?
- no weight loss
- no fevers
- no stiffness
- no changes to bowel movements
- no urinary incontinence
- no changes to sensation
BACK PAIN
what is the management?
staying active
ibuprofen +/- paracetamol
(take ibuprofen with food + not for too long as it can cause reflux + stomach ulcers)
hot/cold packs
if it does not get better
- reassess
- physiotherapy
- different medications
- CBT
NEEDLESTICK INJURY
what are the main infections spread from needlestick injuries?
- Hep B (30%)
- Hep C (2-3%)
- HIV (0.3%)
NEEDLESTICK INJURY
what is the management of any infections?
- HIV = PEP (reduces chance of getting disease)
- Hep B = will naturally pass most of the time or can be treated with medications
- Hep C = treated with medications and is very effective
- will check for vaccination history for hep B
NEEDLESTICK INJURY
what first aid should you do?
- squeeze any sites to encourage bleeding, ideally under running water
- wash with plenty of soap and water
- avoid scrubbing or sucking at the wound
- get medical attention for testing
NEEDLESTICK INJURY
what sexual health advice should be given?
use barrier contraception even if using hormonal contraception during testing period
this is so if you have any of the infections, you will not pass it on to anyone else
PAEDIATRIC CONSTIPATION
what is paediatric constipation?
- hard and infrequent poo
- very common in children (often learned behaviour)
- often starts after one poo causes pain so child holds in poo to prevent it happening again
- this results in harder stool and a vicious cycle
PAEDIATRIC CONSTIPATION
what are the management options?
- try to encourage behaviour change (make going to the toilet a positive experience e.g. poo reward chart)
- encourage oral intake + increasing fibre
- aim for one soft poo per day
- laxatives to make poo softer (may be required for months)
- sometimes constipation stretched bowel and stops feeling urge to poo (can result in soiling)
- laxatives allow child to poo regularly so bowel returns to normal size and feeling urge will return
PAEDIATRIC CONSTIPATION
what are the complications of constipation?
- faecal impaction (can result in obstruction = very unwell)
- small tears in rectum (cause pain and bleeding)
- rectal prolapse (caused by straining)
PAEDIATRIC GORD
what is GORD?
- very common, not dangerous or serious
- most children grow out of it
- at bottom of food pipe is a muscle that opens and closes to allow food into stomach and prevent stomach contents going back up
- in young babies the muscle is not fully developed yet so sometimes it may not fully close
- this means milk can come back up into the mouth
- lying down a lot can make it worse
PAEDIATRIC GORD
what are the management options?
NON MEDICAL
- 30 degree tilt when feeding to allow milk to go down
- smaller more frequent feeds 6-8 times daily
MEDICAL
- gaviscon (neutralises stomach acid)
- PPI (reduces the amount of stomach acid)
PAEDIATRIC GORD
what are the complications?
- stools turning black or blood in vomit
- if growth starts tailing off
PRE-CONCEPTION COUNSELLING
what should you check in history?
SEXUAL HISTORY
- how often
- any STIs (current or past)
GYNAE/OBSTETRIC HISTORY
- last period
- period pattern (any pain, heavy or light)
- current contraception
- any gynae conditions
- any previous pregnancies
SOCIAL HISTORY
- smoking
- alcohol
- diet
- vaccinations
OTHER
- medical conditions
- medications or supplements
- family history of genetic conditions or difficulties conceiving
PRE-CONCEPTION COUNSELLING
how can chances for conception be optimised?
- important that partner ejaculates inside vagina
- focus on vaginal sex as much as possible
- understanding your cycle as having sex around ovulation can increase chances
- need to have sex 2-3 time per week (85% get pregnant within 1 year)
- need to reverse any contraception (e.g. get coil removed)
PRE-CONCEPTION COUNSELLING
what is the lifestyle advice?
- stop smoking (can impact fertility and amount baby grows + develops)
- stop drinking alcohol during pregnancy
- aim for BMI <25 (increases chance of conception + reduces chance of complications during pregnancy)
- avoid people who have chickenpox + rubella (can affect baby)
PRE-CONCEPTION COUNSELLING
what supplements should be taken?
- folic acid for at least first 3 months (reduces chance of spina bifida, dose so weight dependant)
- vitamin D
PRE-CONCEPTION COUNSELLING
what is the dietary advice?
- avoid certain cheeses and meats
- will give leaflet
OSTEOPOROSIS
how would you explain what it is?
- condition where bones get weaker + more likely to break
- not usually painful unless broken a bone
OSTEOPOROSIS
what are the risk factors?
- can be normal part of ageing
- women = increased risk
- steroids
- omeprazole
- malabsorption of vitamins
- family history
- alcohol
- smoking
OSTEOPOROSIS
what are the protective factors?
- regular exercise
- healthy diet with calcium + vitamin D
- reducing alcohol intake
- stop smoking
OSTEOPOROSIS
what is the management?
- make sure you have enough calcium + vit D
- bisphosphonates (need to be taken in a certain way)
- there other options as well but this is the first step
OSTEOPOROSIS
how can risk of falls be reduced?
- no trip hazards
- make sure eye sight is optimised
- check hearing
- handrails on stairs
OSTEOARTHRITIS
how would you explain what it is?
- damage to joints and cartilage
- wear and tear progresses over time
- causes pain and stiffness, swelling + clicking sounds
- most commonly affects knees, hips and hands but can affect any joint
OSTEOARTHRITIS
what are the causes?
no single cause but there are several risk factors:
- increasing age
- women
- obesity (more stress and strain)
- repeated injuries to joints
- overuse (occupational)
- other medical conditions (gout, + other arthritis)
OSTEOARTHRITIS
what is the management?
CONSERVATIVE
- exercise
- weight loss
MEDICAL
- ibuprofen/paracetamol
- deep heat to distract from pain
- corticosteroid injection into joint
SURGICAL
- usually last line after other methods not worked
- joint replacement
OSTEOARTHRITIS
how is it diagnosed?
- ususally clinical diagnosis (based on symptoms)
- may to x-rays or blood tests
CHLAMYDIA
how would you explain what it is?
- most common type of STI in UK
- caused by bacteria spread via sex + genital fluids
- many do not get symptoms
- symptoms include pain when weeing, discharge, pain after sex, painful testicles
CHLAMYDIA
what are the risk factors?
- spread through unprotected sex
- includes vaginal, anal + oral sex
- contact with genitals can cause infection even without penetration
- shared sex toys can spread
- can get chlamydia in eyes
CHLAMYDIA
what are the protective factors?
barrier contraception e.g. dental dams and condoms
CHLAMYDIA
what is the management?
- antibiotics (DOXYCYCLINE 100mg for 7 days)
- do not have sex for 7 days
- all sexual contacts within last 60 days should receive testing (either patient or GUM clinic can trace)
- recommend getting tested again in 3-6 months
CHLAMYDIA
what are the side effects of doxycycline treatment?
- indigestion + nausea (take with full glass of water)
- sun sensitivity (avoid sunbathing)
- headaches
CHLAMYDIA
what safety netting advice should you give?
- if symptoms do not clear up
- if symptoms feel worse e.g. bleeding, pelvic pain or worsening discharge
- get in touch
CHLAMYDIA
what are the consequences of not getting treated?
IN WOMEN
- can cause PID
- increased risk of ectopics
- can cause infertility
IN MEN
- epididymitis
BOTH
- reactive arthritis (painful joints, pain when weeing and eye infection)
OBESITY
how would you explain what it is?
- excessive fat accumulation
- affects 1 in 4 adults
- calculated from BMI (looks at height and weight)
- BMI over 25 = overweight
- BMI over 30 = obese
- BMI is not a perfect indicator, if does not take into account age, sex, muscle mass
OBESITY
what are the causes?
- combination of eating too much + exercising too little
- eating processed or fast foods
- liquid calories e.g. in alcohol
- recommended intake = 2000 calories for women and 2500 calories for men
- not exercising enough can lead to excess calories to be stored as fat
recommended to do 150 minutes exercise per week - some medical conditions e.g. underactive thyroid + cushings syndrome
- some medications e.g steroids
OBESITY
what is the lifestyle managment?
- healthy diet with lots of fruit + veg
- good portion of protein from meat, fish and eggs, pulses
- reduce calorie intake by 600 calories per day
- aim to lose 0.5-1kg per week to be safe
- avoid radical diets
- go to weight loss groups
- exercising (couch to 5k)
OBESITY
what is the medical management?
ORLISTAT
- reduces fat absorbed by the body
- can cause unpleasant side effects e.g. urgency to pass stools
- prevent gaining weight but does not directly cause weight loss
SEMAGLUTIDE
- makes you feel full so eat less
- given as an injection
OBESITY
what are the surgical management options?
- need to meet strict criteria + attempted other methods previously
- gastric sleeve
- balloons
- bypass
- reduce volume of stomach so less food can be absorbed
OBESITY
what are the complications of obesity?
- HTN
- coronary heart disease and strokes
- T2DM
- osteoarthritis
- CKD
- liver disease
- increases risk of cancers
- reduced fertility (reversed upon weight loss)
VIRAL INFECTION
what is a viral infection?
- virus = a bug that can cause infection
- examples include COVID-19, flu, the common cold
- some viruses can be prevented with vaccinations
- most viral infections resolve themselves but you may feel unwell for a week or longer
- supportive measures such as rest, fluids and painkillers can help
VIRAL INFECTION
what are antibiotics?
- bacteria = other type of bug that can cause infection
- antibiotics kill bacteria causing the infection
- they do not work on viruses because the structure is different
- need to make sure antibiotics are not overprescribed + not prescribed for viral infections. This is because bacteria can develop resistance and won’t be killed
VIRAL INFECTION
how can you tell the difference between viral and bacterial tonsillitis
BACTERIAL
- pus on tonsils
- tonsils are inflamed
- tender lymph nodes
- no cough
VIRAL
- runny nose
- cough
- sore throat
CENTOR and feverPAIN can be used
VIRAL INFECTION
when are tonsils taken out?
- typically done for recurrent tonsilitis
- unless you are getting very severe or recurrent tonsillitis, the risks outweigh the benefits
VIRAL INFECTION
what are the differences in presentation of bacterial and viral otitis media?
BACTERIAL
- high fever
- tender lymph nodes
- discharge
- swelling of the ear
- lasts longer
VIRAL
- runny nose
- cough
- sore throat
- resolves within 3 days
VIRAL INFECTION
what is the safety netting advice for otitis media?
mastoiditis
- swelling behind ear
- forward protrusion of the outer ear
- tenderness of the mastoid
it is a medical emergency so if you notice these symptoms please attend A&E
TERMINATION OF PREGNANCY
what are the different methods?
- medical = misoprostol and mifepristone, medications cause bleeding and cramping + you should pass the pregnancy tissue
- surgical = under GA, given medication to prepare the cervix, instruments are inserted to remove tissue
TERMINATION OF PREGNANCY
what are the risks and benefits of medical termination?
BENEFITS
- can be performed at home depending on how many weeks pregnant
- avoid surgery
RISKS
- can cause vomiting, cramps, chills and fever
- will cause bleeding (need someone around who can get you to hospital if you become unwell)
- cramps + bleeding can last a few weeks
- unable to give exact timeframe
- will need to check toilet for tissue (can be distressing)
TERMINATION OF PREGNANCY
what are the risks and benefits of a surgical termination?
BENEFITS
- will be booked + performed on operating list
- can go home same day
- do not have to see pregnancy tissue
RISKS
- risk of bleeding, pain, infection, damage to organs
- have GA so need someone to look after you for first 24hrs
- GA = allergy, N&V, sore throat + damage to teeth
TERMINATION OF PREGNANCY
what is important to discuss?
- neither method has 100% success rate
- required to repeat a pregnancy test to ensure no remaining tissue
- can refer to counselling services
TERMINATION OF PREGNANCY
what is the effect on fertility in the future?
- no evidence of any impact on future fertility
TENSION HEADACHES
what are they?
- primary headache (nothing causes it)
- tight band sensation
- affects both sides of the head
- not associated with nausea, vomiting, photophobia or vision changes
TENSION HEADACHE
what are the causes/risk factors?
stress
lack of sleep
excessive caffeine
try to avoid triggers
NHS articles to reduce stress
TENSION HEADACHES
what is the management?
MEDICATIONS
- paracetamol/ibuprofen
- do not take them too often as they can cause medication-overuse headache
- if chronic = amitriptyline or acupuncture
LIFESTYLE
- avoid triggers
- reduce caffeine
- healthy sleeping habits
- keep a symptom diary
TENSION HEADACHES
are there any complications?
- no complications from headaches
- regular use of paracetamol and ibuprofen can cause medication overuse headache
- regular use of ibuprofen can cause stomach ulcers
SMOKING CESSATION
what is the STAR approach?
- Set a quit date (in 2-4 weeks)
- Tell family and friends
- Anticipate challenges (+ make plans to overcome)
- Remove all tobacco products
SMOKING CESSATION
what are the medication therapies?
NICOTINE REPLACEMENT
- 1st line
BUPROPION
- start 1 week before quit date
- complete 12 week course
VARENICLINE
- start 1 week before quit date
- complete 12 week course
SMOKING CESSATION
what are the non-medication therapies?
- behavioural counselling programs
- various options available
SMOKING CESSATION
what is the follow up?
- have appointment 1-2 weeks after quit date
- have appointment at 4 weeks
- have review in 3 months and in 1 year to see new side effects, smoking status and relapse
RHEUMATOID ARTHRITIS
what is it?
- long term progressive condition
- causes pain, swelling + stiffness in joints
- commonly affects hands, wrists and feet
- autoimmune (immune system attacks joints)
- can have periods that are worse
- flares can be triggered by infection, stress + overexertion
RHEUMATOID ARTHRITIS
what are the causes?
- don’t know the cause
- there are several risk factors:
= female
= family history
= other autoimmune conditions
= smoking
RHEUMATOID ARTHRITIS
what is the management?
DMARDS
- disease modifying anti-rheumatic drugs
- reduce severity of symptoms
- slow disease progression
- can take a few months to work (important to keep taking)
STEROIDS
- can use short courses
- help treat flares
BIOLOGICS
- given if DMARDs do not work
dampen down immune system
RHEUMATOID ARTHRITIS
what are the complications?
- lung fibrosis (cough, SOB)
- eyes (red, painful, dry eyes)
- vasculitis
- carpal tunnel
- increased risk of infection (from medications)
- osteoporosis (from meds)
