GP Flashcards
frailty
Frailty is a medical term regarding a state of physical or mental health of an individual.
It describes an individual’s ability to recover / respond to adverse health events.
features of frailty
slowness
exhaustion
wt loss
weakness
low PA
what is old age
Old age is the general slight slowing down physically and mentally of an individual.
This can be the accumulation of earlier life health decisions and overall wear and tear and general luck of genetics
An elderly individual is more likely to have comorbidities
generall >65/70
non medical mx non acute AF
address Risk Factors and Treat Underlying Cause
Reduce excessive alcohol and/or caffeine intake
Effective blood pressure management
Treat any underlying thyroid disease
Refer for echo and cardiology assessment if valvular heart disease and/or heart failure are suspected causes
mx paroxysmal AF
Infrequent or well tolerated paroxysmal AF or Known precipitants (e.g caffeine)
Consider no drug treatment or “pill in the pocket” strategy (B-blocker PRN)
Give patients information and reassurance
Frequent, symptomatic paroxysmal AF
Treat with regular B-blocker (e.g. atenolol) 50-100 mg OD
If not controlled refer for specialist management (e.g. amiodarone)
mx chronic AF
1st=rate control: Consider controlling ventricular rate with a B-blocker (e.g. Atenolol) or rate limiting calcium channel blockers (e.g. Diltiazem).
Aim for ventricular rate of 60-80 bpm at rest and 90-115 bpm for moderate exercise. If monotherapy does not control symptoms consider combination therapy with any 2 of: B-blocker, Diltiazem or Digoxin
2nd=rhythm control using cardioversion
when to refer for rhythm control in AF
Associated heart failure
Atrial flutter suitable for ablation
New onset AF
AF secondary to treated/corrected precipitant
If rate control unsuccessful/still symptomatic after rate is normalised
anticoagulation in AF
CHADVASC VS HASBLED
chadvasc
CHF
HTN
AGe >75
DM
stroke/TIA/VTE
vascular disease
age 65-74
female
1=condider antcoag
2=anticoag
HASBLED
HTN
abnormal renal or liver function
stroke
bleeding
labile INRs
>65
drugs or alcohol
score of 3+ = significnat risk bleed
RF falls
Increasing age
Multiple previous falls
Disorders of gait or balance
Visual impairment ->correct if possible, advise to get eyes tested
Cognitive impairment
Low morale/depression -> tx as necessary, support network
High level of dependence
Decreased mobility
Foot problems
Lower limb weakness or arthritis -> physio for strengthening
Hx stroke or PD
Use of psychotropic drugs, sedatives, diuretics, BB
Alcohol
Environment: loose rugs, poor lighting, ice, high winds ->OT visit
Infection e.g. pneumonia, UTI
medications increasing risk of falls
Digoxin toxicity – Blurry or yellow vision
Amitriptyline – Anticholinergic side-effects
Indapamide- Can precipitate gout
Medications causing postural hypotension: nitrates, diuretics, anticholinergic medications, AD, BB, L-dopa, ACEi ->alter medication, compression stockings
Medications associated with falls for other reasons: benzos, antipsychotics, opiates, anticonvulsants, codeine, digoxin, other sedative agents
falls assessment
identification of falls history
assessment of gait, balance and mobility, and muscle weakness
assessment of osteoporosis risk
assessment of the older person’s perceived functional ability and fear relating to falling
assessment of visual impairment
assessment of cognitive impairment and neurological examination
assessment of urinary incontinence
assessment of home hazards
cardiovascular examination (BP, HR and rhythm) and medication review.
mx falls
strength and balance training
home hazard assessment and intervention
vision assessment and referral
medication review with modification/withdrawal
Also need to tx conditions causing falls
EDUCATION COVERING:
what measures they can take to prevent further falls
how to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components
the preventable nature of some falls
the physical and psychological benefits of modifying falls risk
where they can seek further advice and assistance
how to cope if they have a fall, including how to summon help and how to avoid a long lie.
benefits of patient centrered care
Improves satisfaction
Reduces perception of hierarchy
Improved resource allocation
Better outcomes for patients = prevention of future issues = reduced economic impact of illness
shared decision making
In essence – Involve family members and the patient in a discussion about how to proceed. Usually in complex cases when the safety of discharge/treatments are in question
problematic polyphamarcy
The prescribing of medicines that are no longer clinically indicated or appropriate or optimised for that person
Where the benefit of a medicine does not outweigh the harm
Where the combination of multiple medicines has the potential to, or is causing harm to the person
Where the practicalities of using the medicines prescribed to a person have become unmanageable or are causing harm or distress, for example where some medicines should be taken before food, others after food, some in the morning, some in the evening and others at multiple times during the day.
medication review
Seeking the person’s (and/or their carer’s) perspective of their medicines and how they will take them
Explaining what the medicine does
Assessment of whether the medicines are essential or not
Assessment of the person’s level of adherence to the medicines
Assessment of the effectiveness (both clinical and cost effectiveness) of the medicines
Assessment of the safety of the medicines, and consideration of whether a safer alternative may be available given the persons medicines record
Decision and actions regarding stopping or continuing the medicines
milia
Tiny pearly white papules
Nose, face and sometimes palate
Due to blocked sebaceous ducts
Up to 50% of babies
Reassure; they go away spontaneously
Erythema Toxicum Neonatorum
Red blotches with a central white vesicle
Each spot lasts around 24 hours
Unknown cause
Up to half of newborns in first week of life
The spots are sterile! This is a well baby - reassure again!
harlequin Colour Change
One side of the body flushes red; the other remains pale
Unknown mechanism, thought to be immature hypothalamic control of vasomotor system
10% of babies; between 2nd and 5th day of life
Generally considered harmless - reassure!
BUT: if persistent, consider AVM
single Palmar Crease
A common abnormality
Associated with various genetic disorders (not just Down’s!)
usually benign unless other features present
Thorough examination
Likely reassure
Heat Rash (Milaria)
Itchy red rash
More common when hot and humid
Keep baby cool
Maybe dress in fewer clothes
Keep fluids up
Ophthalmia Neonatorum (Neonatal Conjunctivitis)
Triad of purulent discharge, eyelid oedema and normothermia
Commonly caused by E. Coli exposure during delivery
Presents within the first month
Swab to confirm
Oral erythromycin
umbilical Granuloma
The umbilicus should dry, blacken and separate about 1 week after birth
Granuloma often described as a persistently wet umbilicus
check for infection (antibiotics needed)
Exclude patent urachus
Use silver nitrate cautery stick
colic
Very common
Usually ages up to 3 months
Repeated, unstoppable crying with rigid body and red face
Knees drawn up - no real association with abdo pain
More often in evening
No known cause, usually resolves spontaneously
Parents can try colic drops (break down excess GI gas)
Not evidence for Cow’s milk allergy or need to change feeds
neonatal sleeping
Issues around inconsistent sleep pattern, night feeding
Parental exhaustion
All babies have different sleep patterns
“Sleep when your baby sleeps”
Baby should sleep in the same room as parent for 6 months (night and day)
Newborn can be as high as 18 hours
By 4 months, twice as long asleep at night as during the day
From 6 months night feeds may not be necessary (12 hours sleep)
cows milk protein intolerance
ymptoms usually develop within a week of cow’s milk introduction, although they may be delayed for several weeks.
Reactions may be triggered by food ingestion, inhalation, or skin contact (rare).
The trigger is usually cow’s milk, however, it may be cow’s milk protein in maternal breast milk in infants who are exclusively breastfed (rare in IgE-mediated allergy).
IgE-mediated reactions usually occur following a small amount of milk, whereas non-IgE-mediated reactions usually occur after ingestion of larger volumes of milk.
Most affected children present by six months of age; onset is rare after 12 months of age.
Skin reactions - such as an itchy rash or swelling of the lips, face and around the eyes
digestive problems – such as stomach ache, vomiting, colic, diarrhoea or constipation
hay fever-like symptoms – such as a runny or blocked nose
eczema that does not improve with treatment
In severe cases can cause anaphylaxis
mx cows milk protein intolerance
Removing all cows’ milk from the child’s diet for a period of time.
If baby is formula-fed, can prescribe special infant formula.
If baby is exclusively breastfed, the mother will be advised to avoid all cows’ milk products.
Child should be assessed around every 6 to 18 months to see if they have grown out of their allergy.
failure to thrive
FAILURE TO GROW AT THE EXPECTED RATE
Mild?
fall across two centile lines
Severe?
fall across three centile lines.
indicators failure to thrive
Most sensitive indicator in infants and young children?
weight
In older children?
height
causes failure to thrive
most common=Not enough food (95%) This can be due to poverty, socioeconomic difficulties, emotional deprivation, unskilled feeding,
Organic causes
* Decreased appetite, e.g. psychological or secondary to chronic illness.
* Inability to ingest, e.g. GI structural or neurological problems.
* Excessive food loss, e.g. severe vomiting (gastro-oesophageal refl ux
disease (GORD), pyloric stenosis, dysmotility), diabetes mellitus
(urine).
* Malabsorption (see b p.334).
* Increased energy requirements, e.g. congenital heart disease, cystic
fi brosis, malignancy, sepsis.
* Impaired utilization, e.g. various syndromes, IEM, endocrinopathies.
ix failure to thrive
History
age of onset of FTT, and timing of weaning, food diary, meal times description, previous IUGR, other sx (D&V, fatigue), health of other children
dietary history from dietician
Examination:
Growth and systems
Signs of organic disease: distended abdo, chronic resp disease, heart failure,
If organic disease possible
FBC, ESR/CRP, U&E, creatinine, total protein and albumin, Ca2+,PO4 3 – , LFT, immunoglobulins, coeliac antibody screen
Urinalysis - ncluding M, C&S.
Further investigations: are indicated if there are suggestive symptoms or the faltering growth is severe,
IEM screen, karyotype, serum lead (pica), sweat test, upper endoscopy and small intestinal biopsy, CXR, bone age, skeletal survey (NAI), abdominal US, head CT/MRI, oesophageal pH monitoring, ECG, faecal occult blood.
mx non-organic failure to thrive
Provide dietetic input, whatever the cause, to support nutritional correction and education.
Identify and correct associated comorbidities, e.g. developmental delay
Input from a psychologist and social services may be useful
Important to manage effectively as severe FTT may be associated with developmental and behavioural impairment
when is hospital admission required in failure to thrive
<6m and severe FTT
normal infant crying
Increases in the early weeks of life and peaks around 6-8 weeks of age and usually improves by 3-4 months of age.
