GP Flashcards
obesity in children
Way to report adverse drug reactions to meds?
Yellow Card scheme
It is run by the Medicines and Healthcare products Regulatory Agency (MHRA).
The following should be reported (taken from the MHRA website) to the yellow card scheme?
- all suspected adverse drug reactions for new medicines (identified by the black triangle symbol) should be reported
- all suspected adverse drug reactions occurring in children, even if a medicine
has been used off-label - all serious* suspected adverse drug reactions for established vaccines and
medicines, including unlicensed medicines, herbal remedies, and medicines used off-label
*reactions which are fatal, life-threatening, disabling or incapacitating, result in or
prolong hospitalisation, or medically significant are considered serious.
Info about the yellow card scheme?
Yellow Cards are found at the back of the BNF or reports can be completed online (www.yellowcard.gov.uk)
any suspected reactions (not just confirmed) should be reported
patients can report adverse events
Yellow Cards are sent to the MHRA who in collate and assess the information. In turn the MHRA may consult with the Commission on Human Medicines (CHM), an independent scientific advisory body on medicines safety
A large number of criteria must apply before a national screening programme is considered. For example:
There must be a test available which picks up a disease or condition before symptoms develop.
This test must be reasonably accurate. It should not be positive for too many people who do NOT have the condition and it must not miss many people who DO have the condition.
The test must be reasonably simple to perform and acceptable to the people having the test.
The benefits of the screening test must be greater than any potential harm or risks it could cause.
The cost of the test, across the whole population, must not be more than the benefits it gives.
There must be a treatment at the early stage of the condition or disease which will make a difference to the outcome. There is no point in screening for something if it cannot be successfully treated.
The condition being screened for must have a significant impact on health and well-being.
There must be an organised, efficient plan for what happens if the test is positive.
Screening programmes in UK?
Abdominal Aortic Aneurysm Screening Programme for men the year they turn 65.
Bowel Cancer Screening Programme every 2 years for people between the ages of 54 and 74 (shortly to become aged 50 to 74); people can choose to continue past the age of 74 by requesting the test every 2 years.
Breast Screening Programme every 3 years for women between the ages of 50 and 70; women can choose to continue past the age of 70 by requesting the test every 3 years.
Cervical Screening Programme every 3 years for women between the ages of 24.5 and 50 and then every 5 years for women between the ages of 51 and 64.
Diabetic Eye Screening Programme every year for people with diabetes.
Fetal Anomaly Screening Programme offered in the first trimester of pregnancy to all pregnant women.
Infectious Diseases in Pregnancy Screening Programme to all pregnant women.
Newborn and Infant Physical Examination Screening Programme to all newborn babies.
Newborn Blood Spot Screening Programme to all newborn babies.
Newborn Hearing Screening Programme to all newborn babies.
Sickle Cell and Thalassaemia Screening Programme to all pregnant women.
AAA screening?
single abdo USS too all men 65yrs and over
Bowel ca screening?
FIT= every 2 years for people between the ages of 54 and 74 (shortly to become aged 50 to 74); people can choose to continue past the age of 74 by requesting the test every 2 years.
Breast ca screening?
every 3 years for women between the ages of 50 and 70; women can choose to continue past the age of 70 by requesting the test every 3 years.
Cervical ca screening?
every 3 years for women between the ages of 25 and 50 and then every 5 years for women between the ages of 51 and 64
Diabetic eye screening?
every yr for pt with diabetes
Fetal anomaly screening?
Screening for 11 physical conditions as part of the 20-week scan is offered to all pregnant women and takes place between 18⁺⁰ and 20⁺⁶ weeks of pregnancy.
Infectious Diseases in Pregnancy Screening Programme?
A blood test should be offered as early as possible in pregnancy to ensure timely referral and management of care.
HIV
hepatitis B
syphilis
Newborn and Infant Physical Examination Screening Programme?
within 72hrs of birth and 6 to 8 weeks
Newborn Blood Spot Screening Programme?
normally when 5d old
sickle cell disease (SCD)
cystic fibrosis (CF)
congenital hypothyroidism (CHT)
phenylketonuria (PKU)
medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
maple syrup urine disease (MSUD)
isovaleric acidaemia (IVA)
glutaric aciduria type 1 (GA1)
homocystinuria (HCU)
Newborn Hearing Screening Programme?
ideally within the first 4 to 5 weeks after they are born, up until 3m of age
automated otoacoustic emission (AOAE) test. Some babies also need a second test, the automated auditory brainstem response (AABR) test.
Sickle Cell and Thalassaemia Screening Programme?
All pregnant women are offered screening for thalassaemia.
All biological fathers are offered screening if the pregnant woman is a genetic carrier for sickle cell disease or thalassaemia.
Primary prevention?
(Before Disease Occurs)
Goal: Prevent the onset of disease or injury.
Methods: Health education, vaccination, lifestyle modifications (e.g., exercise, healthy diet, avoiding smoking), environmental safety measures.
Example: Vaccination against measles, wearing seat belts, promoting hand hygiene.
Secondary prevention?
(Early Detection and Intervention)
Goal: Detect and treat diseases in their early stages to prevent progression.
Methods: Screening programs, regular check-ups, early medical interventions.
Example: Mammograms for breast cancer, blood pressure screenings, Pap smears for cervical cancer.
Tertiary prevention?
(Managing and Reducing Impact of Disease)
Goal: Reduce complications and improve quality of life for those with existing diseases.
Methods: Rehabilitation, medical treatment, support groups, chronic disease management.
Example: Physical therapy for stroke patients, insulin therapy for diabetes, cardiac rehabilitation after a heart attack.
Hyperthermia/Hyperpyrexia?
describes an excessive elevation of body temperature above the average normal temperature.
Hyperthermia/Hyperpyrexia causes?
It may be caused by the vast majority of agents which precipitate a pyrexia of unknown origin, however, relatively common causes include:
excessive sun exposure
bacterial septicaemia
viral infection e.g. infectious mononucleosis
rarer= syndrome of malignant hyperpyrexia and thyrotoxic crisis.
Rare examples of hyperthermia causes?
syndrome of malignant hyperpyrexia and thyrotoxic crisis.
Hyperthermia temp?
37.5–38.3 °C
Chronic rhinosinusitis?
affects up to 1 in 10 people. It is generally defined as an inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.
Chronic rhinosinusitis predisposing factors?
atopy: hay fever, asthma
nasal obstruction e.g. Septal deviation or nasal polyps
recent local infection e.g. Rhinitis or dental extraction
swimming/diving
smoking
Chronic rhinosinusitis features?
facial pain: typically frontal
pressure pain which is worse on bending forward
nasal discharge: usually clear if allergic or vasomotor.
Thicker, purulent discharge suggests secondary infection
nasal obstruction: e.g. ‘mouth breathing’
post-nasal drip: may produce chronic cough
Management of recurrent or chronic sinusitis?
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution
Red flags in chronic rhinosinusitis?
unilateral symptoms
persistent symptoms despite compliance with 3 months of treatment
epistaxis
Chronic sinusitis vs chronic rhinosinusitis?
same thing
Mesenteric adenitis?
inflamed lymph nodes within the mesentery
Mesenteric adenitis features?
an cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
Mesenteric adenitis Tx?
needs no Tx, it is self-limiting
Mesenteric adenitis vs appendicitis?
Mesenteric adenitis is….
Pain starts in RIF
Coryzal symptoms due to viral infection before hand
no anorexia or vomiting like appendicitis
Higher fever
More normal CRP and WBC
Self limiting in 24-48 hours
idiopathic arthritis aka…
Juvenile idiopathic arthritis (JIA)
BMI =?
BMI = weight (kg) / height (m) squared
BMI ranges?
Underweight < 18.49
Normal 18.5 - 25
Overweight 25 - 30
Obese class 1 30 - 35
Obese class 2 35 - 40
Obese class 3 > 40
Normal BMI?
Normal 18.5 - 25
Underweight BMI?
Underweight < 18.49
Overweight BMI?
Overweight 25 - 30
The management of obesity consists of a step-wise approach, what is this?
conservative: diet, exercise
medical= orlistat, liraglutide
surgical
Obesity Mx= orilistat MOA?
pancreatic lipase inhibitor
Obesity Mx= orilistat adverse effects?
faecal urgency/incontinence and flatulence. A lower dose version is now available without prescription (‘Alli’)
Obesity Mx= orilistat - when should it be used?
It should only be prescribed as part of an overall plan for managing obesity in adults who have:
- BMI of 28 kg/m^2 or more with associated risk factors, or
- BMI of 30 kg/m^2 or more
- continued weight loss e.g. 5% at 3 months
- orlistat is normally used for < 1 year
Obesity Mx= Liraglutide MOA?
a glucagon-like peptide-1 (GLP-1) mimetic that is used in the management of type 2 diabetes mellitus (T2DM)
Obesity Mx= Liraglutide how is it given?
given as a once daily subcutaneous injection
when used in the management of T2DM it was noted to cause weight loss in a significant proportion leading to research interest in its use in obesity
Obesity Mx= Liraglutide - criteria for use?
person has a BMI of at least 35 kg/m²
prediabetic hyperglycaemia (e.g. HbA1c 42 - 47 mmol/mol)
Obesity in children definition?
Defining obesity is more difficult in children than adults as body mass index (BMI) varies with age. BMI percentile charts are therefore needed to make an accurate assessment.
Obesity in children- when to consider Mx?
consider tailored clinical intervention if BMI at 91st centile or above.
consider assessing for comorbidities if BMI at 98th centile or above
Obesity in children- most common cause?
most common cause of obesity in childhood is lifestyle factors. Other associations of obesity in children include:
Asian children: four times more likely to be obese than white children
female children
taller children: children with obesity are often above the 50th percentile in height
Cause of obesity in children?
growth hormone deficiency
hypothyroidism
Down’s syndrome
Cushing’s syndrome
Prader-Willi syndrome
Consequences of obesity in children?
orthopaedic problems: slipped upper femoral epiphyses, Blount’s disease (a development abnormality of the tibia resulting in bowing of the legs), musculoskeletal pains
psychological consequences: poor self-esteem, bullying
sleep apnoea
benign intracranial hypertension
long-term consequences: increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease
When may bariatric surgery be used for obesity?
for many obese patients who fail to lose weight with lifestyle and drug interventions the risks and expense of long-term obesity outweigh those of surgery.
Who should be referred for bariatric surgery?
it is complicated
very obese patients (e.g. BMI 40-50 kg/m^2 etc) are referred early for bariatric surgery, particularly if they have other conditions that may be caused by it (e.g. type 2 diabetes mellitus, hypertension), rather than it being a ‘last resort’
Types of bariatric surgery?
Primarily restrictive operations
Primarily malabsorptive operations
Mixed operations
Types of bariatric surgery= Primarily restrictive operations?
laparoscopic-adjustable gastric banding (LAGB)=
it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2;
produces less weight loss than malabsorptive or mixed procedures but as it has fewer complications
sleeve gastrectomy=
stomach is reduced to about 15% of its original size
intragastric balloon=
the balloon can be left in the stomach for a maximum of 6 months
Types of bariatric surgery= Primarily restrictive operations- laparoscopic-adjustable gastric banding (LAGB)?
it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2
produces less weight loss than malabsorptive or mixed procedures but as it has fewer complications
Types of bariatric surgery= Primarily restrictive operations- sleeve gastrectomy?
stomach is reduced to about 15% of its original size
Types of bariatric surgery= Primarily restrictive operations- intragastric balloon?
the balloon can be left in the stomach for a maximum of 6 months
Types of bariatric surgery= Primarily malabsorptive operations?
biliopancreatic diversion with duodenal switch
usually reserved for very obese patients (e.g. BMI > 60 kg/m^2)
Types of bariatric surgery= Mixed operations?
Roux-en-Y gastric bypass surgery
is both restrictive and malabsorptive in action
Absorption sites?
Duodenum = Metal ions + Folate (first)
Jejunum = all vitamins except
Ileum = B12
Large intestine = U&E (Na K water)
Dehydration?
common presentation in the elderly and can present with nonspecific symptoms
Dehydration- exam findings?
Examination findings have poor sensitivity and specificity.
They include dry mucous membranes, loss of skin turgor, sunken eyes, and in severe dehydration tachycardia, hypotension and delirium.
Varicose veins?
dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart
Whilst extremely common, the vast majority of patients do not require any intervention.
Varicose veins- why do they occur?
most commonly occur in the legs due to reflux in the great saphenous vein and small saphenous vein
Varicose veins= RFs?
increasing age
female gender
pregnancy
the uterus causes compression of the pelvic veins
obesity
Presentation of varicose veins?
For many patients, the cosmetic appearance may prompt presentation.
However other patients may complain of symptoms:
aching, throbbing
itching
some may present with Cx of varicose veins
Cx of varicose veins?
a variety of skin changes may be seen
bleeding
superficial thrombophlebitis
venous ulceration
deep vein thrombosis
Cx of varicose veins= skin changes?
varicose eczema (also known as venous stasis)
haemosiderin deposition → hyperpigmentation
lipodermatosclerosis → hard/tight skin
atrophie blanche → hypopigmentation
Cx of varicose veins= in Lipodermatosclerosis what is the hyperpigmentation due to?
secondary to haemosiderin deposition and the appearance of tight skin
Ix for varicose veins?
venous duplex ultrasound: this will demonstrate retrograde venous flow
Mx of varicose veins?
the majority of patients with varicose veins do not require surgery so just conservative treatments
endothermal ablation: using either radiofrequency ablation or endovenous
laser treatment
foam sclerotherapy: irritant foam → inflammatory response → closure of the vein
surgery: either ligation or stripping
Mx of varicose veins- conservative Mx?
leg elevation
weight loss
regular exercise
graduated compression stockings
Mx of varicose veins- reasons for referral to secondary care include?
significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
previous bleeding from varicose veins
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer
Assess hydration status of pt?
Hands=
- Inspect the hands for relevant clinical signs
- Assess and compare the temperature of the hands
- Assess peripheral CTT
- Assess skin turgor
Pulses and blood pressure=
- Palpate the patient’s radial pulse and assess rate/rhythm
- Palpate the patient’s brachial pulse and assess character
- Measure the patient’s blood pressure
Measure the patient’s jugular venous pressure
Face:
- Inspect the eyes for signs relevant to the patient’s fluid status
- Inspect the mouth for signs relevant to the patient’s fluid status
Chest:
- Calculate the patient’s respiratory rate
- Assess central capillary refill time
- Auscultate the patient’s heart sounds
- Auscultate the patient’s lungs
Abdomen:
- Position the patient lying flat on the bed, with their arms by their sides and legs uncrossed
for abdominal inspection.
- Inspect the patient’s abdomen for signs suggestive of hypervolaemia
- Assess for shifting dullness if ascites is suspected
Oedema:
- Assess for sacral oedema
- Assess for pedal oedema
Viral exanthem?
an eruptive skin rash that is often related to a viral infection.
Immunizations have decreased the number of cases of measles, mumps, rubella and chickenpox, but all viral skin infections require clinical care by a physician or other healthcare professional.
