GP Flashcards
What is gender identity
A sense of one’s own gender. Typically aligned with the sex assigned to them at birth.
What is transgender
A wide range of identities: transsexual, cross-gender, people who identify as a third gender and people with atypical gender appearances. A trans woman identifies as a woman but was born classified as a man and vice versa.
Some transgender people take hormones to align their body with their gender identity.
What is cisgender
Someone who’s gender identity is aligned with their sex at birth (no changes).
Define ‘intersex’
People born with physical or biological characteristics that do not fit the typical definition of male or female.
(Includes sexual anatomy, reproductive organs, hormonal and chromosomal patterns).
What is sexual orientation
The person’s physical, romantic and/or emotional attraction towards another person.
Heterosexuals are attracted to the opposite sex, Homosexuals are attracted to the same sex, Bisexual’s are attracted to people of both sexes.
What are the 4 GMC core duties of a doctor
Knowledge skills and performance
Safety and quality
Communication, partnership and teamwork
Maintaining trust
Duties of a doctor: what comes under ‘knowledge skills and performance’?
Provide good standard of practice and care
Keep knowledge up to date
Recognise and work within the limits of your competence
Duties of a doctor: what comes under ‘safety and quality’?
Take prompt action if patient safety, dignity or comfort is compromised
Protect and promote health in patients and the public
Duties of a doctor: what comes under ‘communication, partnership and teamwork’?
Treat patients as individuals and respect their dignity, and treat them politely and considerately.
Respect their confidentiality
Work in partnership with patients
Listen to and respond to their concerns
Give them the information they want in a way they can understand
Support patients in caring for themselves
Work with colleagues in the best interests of patients
Duties of a doctor: what comes under ‘maintaining trust’?
Be honest and open and act with integrity
Never discriminate
Never abuse patient’s trust in you or the public’s trust in the profession
You must always be able to justify your decisions and actions
What is primary care?
Managing illness and clinical relationships over time.
Role includes: Preventing illness, promoting health, managing clinical uncertainty.
Involves shared decision making with patients.
What are the 5 levels to Maslow’s hierarchy?
Physiological - breathing, food, water, sex, sleep
Safety - security of body, employment, family, health, morality
Love/belonging - friendship, family, sexual intimacy
Esteem - self-confidence, achievement, respect of and by others
Self-actualisation - creativity, spontaneity, problem solving, acceptance of facts, lack of prejudice
What is it when the expression of a genome depends on the environment?
Epigenetics
- lived experience affects human biology and contribute to health and disease.
What is allostasis?
stability through change
- our physiological systems are adapted to react rapidly to environmental stressors.
What is allostatic load?
Long-term overtaxation of our physiological systems leading to impaired health
- The price we pay for allostasis
Give an example of allostasis and allostatic load on an organ system:
Cardiovascular System
Allostasis: works to maintain our erect posture, and enable physical exertion
Allostatic load:
Over-activation leads to hypertension, stroke MI
Metabolic Systems
Allostasis: Activating and maintaining energy reserves, including energy supply to the brain
Allostatic Load: obesity, diabetes, atherosclerosis
Immune System
Allostasis: Response to pathogens,
Tumour surveillance
Allostatic load: Inflammatory and auto-immune disorders
Central Nervous System
Allostasis: Learning, memory, neuroendocrine and autonomic regulation
Allostatic Load: Neuronal atrophy, death of nerve cells, impairment of memory and executive function
What does salutogenesis mean?
Favourable physiological changes which promote health and healing
What are the dangers of overprescribing antibiotics?
- unnecessary side effects
- medicalise self living conditions
- antibiotic resistance
Respiratory tract infections.
What are the self limiting conditions to not to prescribe antibiotics for?
- Otitis media
- Acute sore throat/pharyngitis/tonsillitis
- Common cold
- Rhinosinusitis
- Acute cough/bronchitis
(natural history of self limiting infections above: 1 4 days 2 1 week 3 10 days 4 2 1/2 weeks 5 3 weeks
Respiratory tract infections.
When to prescribe antibiotics in self limiting conditions?
Otitis media - bilateral OM under 2 years old; with otorrhoea
Acute sore throat with 3 or more cantor criteria: exudate, fever, tender cervical lymphadenopathy, absence of cough
Systemically unwell / high risk (e.g. co morbidities, ex prem-baby, immunosuppression)
Age >65 and 2 or more, or >80 and 1 or more: hospital admission within the last year, diabetes, congestive cardiac failure, current glucocorticoid use
Complications: pneumonia, mastoiditis, peritonsillar abscess.cellulitis
Respiratory infections. Which antibiotics for: 1. Otitis media 2. Sinusitis 3. Tonsillitis 4 LRTI 5 UTI
- Amoxicillin
- Amoxicillin, or doxycycline
- Penicillin
- Amoxicillin
- Trimethoprim or nitrofurantoin
What are the 4 stages of wound healing?
Vascular response
Inflammatory response
Proliferation
Maturation
In would healing, the vascular response occurs to which layer of the skin? What processes does this set off?
Wounds penetrate to the dermis.
Vasoconstriction occurs immediately to reduce blood loss. (5-10 mins)
Clotting process is initiated by exposure to air.
A fibrin mesh or clot forms causing temporary closure of the wound - this is replaced by a scab when it dries out.
Blood and serous fluid cleanse the wound of surface contaminants.
In wound healing, the inflammatory response is defined by what 5 things?
Calor - Heat Tumor - localised swelling Rubor - erythema/redness Dolor - pain Functiono laesa - some loss of function
In wound healing, what happens during the inflammatory response? When does it peak and how long does it last?
Platelets trapped in the fibrin mesh release inflammatory mediators (prostaglandin/ histamine) -> vasodilation.
Neutrophils and macrophages are recruited into the wound by growth factors.
Neutrophils release free radicals and proteases and are bactericidal.
Macrophages ingest dead tissue and release cytokines that recruit lymphocytes and fibroblasts.
Lymphocytes enter the wound after 72 hours and secrete chemotactic factors for fibroblasts
Vasodilation peaks 20mins after injury.
This phase can last up to seven days in a clean wound.
During which phase is slough formation common? + what is slough?
Slough is the accumulation of dead cellular debris and is common in the inflammatory phase.
Can prevent a wound from healing properly.
In wound healing, what happens in the proliferative stage? And when does this stage start?
Begins at 2-3days after the wound, can last up to 4 weeks.
Fibroblasts secrete collagen and glycosaminoglycans.
New connective tissue (collagen) fills the wound.
Granulation (angiogenesis, epithelialisation and contraction of wound size occur.
In wound healing, what happens during maturation?
Starts when collagen production stops (usually 20 days after injury).
Wound strength progresses.
What can happen if wound healing does not occur properly?
Can develop into a chronic wound, or formation of a keloid scar.
In wound healing, what are primary, secondary and tertiary intentions?
P = only if little or no tissue loss, wound edges apposed - in surgical wounds closed with sutures -> linear scar.
S= wound edges not apposed (e.g. ulcer) -> wound allowed to granulate -> broader scar.
(epithelialisation occurs from edges of wound/or from base)
T= wound purposely left open - with an infection/foreign body, initially cleaned and derided -> later surgically closed by suture/skin graft.
What are the main barriers to wound healing? General and local factors.
General: Elderly Diabetes - microvascular disease, neuropathy, raised glucose Malnutrition Malignancy Renal/hepatic failure Drugs Immunosuppressive disease Vitamin deficiency
Local factors: Site Infection Oedema Vascular insufficiency Previous radiotherapy
What are the 5 stages of Grief?
Denial - defence mechanism, refusing to accept facts
Anger - with themselves/others
Bargaining - seek compromise (e.g. ‘can we still be friends’ when facing a breakup)
Depression - sadness, regret, fear, uncertainty
Acceptance - some emotional detachment and objectivity
When experiencing grief, some people have an adjustment disorder. What does this mean?
A MALADAPTIVE emotional or behavioural reaction to an identifiable stressful event / change. Not a healthy, expected response.
May develop when:
- the recovery is taking too long (>6 months and no acceptance)
- extreme/harmful coping mechanisms
- continuing life impact (can’t attend school/work)
- self harm/suicidal thoughts
- persistent anxiety/depression
Define domestic abuse
Any incident or pattern of incidents of controlling, or coercive, threatening behaviour, violence or abuse between those of aged 16 or over who are/have been intimate partners/family members.
Can encompass:
physical; psychological; sexual; financial; emotional abuse.
How does domestic abuse impact on a person’s health? Give three ways with example conditions for each.
- Traumatic injuries following assault
- fractures, miscarriage, bruises - Somatic problems/chronic illness consequent of living with abuse
- headache, GI problems, premature delivery - Psychological or psychosocial problems secondary to abuse
- PTSD, attempted suicide, substance misuse, depression, anxiety, eating disorders
What is the best indicator of domestic violence in someone presenting with non-accidental?
Trauma ‘unwitnessed by anyone else’.
Repeat attendance, delay in seeking help, multiple minor injuries not requiring medical treatment.
What to do in a suspected case of domestic abuse?
Standard/medium risk - give contact details for domestic abuse services.
High risk - refer to MARAC (multi-agency risk assessment conference).
-> links up to date info about victim’s needs and risks directly to provision of services and appropriate responses for services involved.
When can you break confidentiality in domestic abuse cases?
In a high risk case if consent cannot be/isn’t given
What is the difference between incidence and prevalence?
Incidence = new cases, denominator (disease free people at start of study), time
Prevalence = existing cases, point in time
What does disease epidemiology look at?
Time, place, and person: age, gender, class, ethnicity
What is person-time and when is it used?
A measure of time at risk (time from entry to study to 1 disease onset, 2 loss to follow-up or 3 end of study.
Used to calculate incidence rates.
Useful when participants are involved in the study for varying lengths of time.
Define absolute risk
Odds of it taking place. Actual numbers involved - has units (e.g. 50/10000 deaths in a population)
Define relative risk
One category relative to another - no units (e.g. x% more likely to develop disease because of FH (comparative to no FH) )
Tells you about the relationship between a risk factor and the disease.
Define attributable risk
A type of absolute risk.
Rate of disease in the exposed that may be attributed to the exposure.
(incidence in exposed - incidence in non exposed).
Gives size of effect - ideal for establishing public health outcome.
Relative risk here would be the ratio between the two: incidence in exposed divided by incidence in unexposed.
Calculate attributable risk and relative risk:
Incidence of Disease A in smokers, 1/1000 person-years Incidence of Disease A in non-smokers, 0.05/1000 person-years
Incidence of Disease B in smokers, 8/1000 person-years Incidence of Disease B in non-smokers, 4/1000 person-years
Why is the attributable risk smaller for Disease A compared with Disease B even though the relative risk is much larger?
Disease A
Attributable = 1 - 0.05 = 0.95/1000 person-years
Relative = 1 / 0.05 = 20
Disease B
Attributable = 4/1000 person-years
Relative risk = 2
A smaller and R larger -> Disease B is more common.
What is number needed to treat?
The number of people you need to treat to prevent one bad outcome.
What is bias?
A systematic deviation from the true estimation of the association between exposure and outcome.
-> distortion of true underlying association
What are the two main groups of bias?
Selection bias - systematic error in selection of study participants, and allocation of participants to different study groups
Information (measurement( bias - systematic error in measurement or classification of exposure and outcome.
What are sources of information bias?
Observer (observer bias)
Participant (recall bias)
Instrument (wrongly calibrated)
Define confounding
Where a factor is associated with the exposure of interest and independently influences the outcome but does not lie on the causal pathway.
When assessing causality, what factors are important to consider?
1) Strength of association - magnitude of relative risk
2) Dose response - higher exposure, higher risk of disease
3) Consistency - similar results in other studies using different designs
4) Temporality - does exposure priced outcome?
5) Reversibility - removal of exposure reduces risk
6) Biological plausibility - biological mechanisms explaining the link
If an association is not causal, what could it be?
Bias, Chance, Confounding, Reverse causality
Epidemiological study design - what is a cohort study?
Population -> people without disease -> exposed/not exposed -> exposed either have the disease or not, and not exposed either have the disease or not.
Direction of enquiry equals time course of study.
Epidemiological study design - what is a case control study?
Look at cases of patients already diagnosed, and see if they were exposed or not. Additionally look at controls without the disease, and see if they were exposed or not.
Direction of enquiry is the reverse of the time course of study (looking back).
Epidemiological study design - what is a randomised control trial?
Population -> selected defined by criteria -> potential participants invited to participate -> randomised into treatment groups and control
What is the most robust interventional study design?
Randomised control trial
Epidemiological study design - what is a cross-sectional study?
Descriptive = prevalence - people with disease/population studied
Analytical = table of people with disease/not against if they were exposed to the agent or not
Epidemiological study design - what is an ecological study?
Geographical - prevalence of disease plotted against exposure level
Time trends - prevalence of disease against time
What type of study design is this:
Investigators find a high level of correlation between levels of socioeconomic deprivation and cardiovascular mortality across electoral wards in the UK
Ecological
What type of study design is this:
Researchers set out to examine the association between alcohol consumption and stroke. They identify all new patients admitted with stroke and compare their alcohol consumption with patients admitted for elective surgery
Case control
What type of study design is this:
General practitioners set up a study to estimate the prevalence of depression within their registered population. They decide to start with a random sample of adults aged 45-74 years.
Cross-sectional
Give a few types of epidemiological study design
A. Cohort study B. Case-control study C. Case series D. Case report E. Meta-analysis F. Randomised controlled trial G. Cross-sectional study H. Ecological study I. Systematic review J. Migration study K. Intervention study
What are different types of epidemiological measurement?
A. Attributable risk B. Case-fatality rate C. Cumulative incidence D. Incidence rate E. Odds ratio F. Person-years G. Prevalence H. Absolute risk reduction I. Relative risk J. Number needed to treat
What is an odds ratio?
Odds of exposure in cases/odds of exposure in controls.
What type of epidemiological measurement is this:
In a randomised controlled trial, the time at risk was determined from entry to the study to various end points.
A. Attributable risk B. Case-fatality rate C. Cumulative incidence D. Incidence rate E. Odds ratio F. Person-years G. Prevalence H. Absolute risk reduction I. Relative risk J. Number needed to treat
Person-years
What type of epidemiological measurement is this:
For patients with meningococcal meningitis, the risk of dying has been estimated to vary from 5-10%.
A. Attributable risk B. Case-fatality rate C. Cumulative incidence D. Incidence rate E. Odds ratio F. Person-years G. Prevalence H. Absolute risk reduction I. Relative risk J. Number needed to treat
Case-fatality rate
What type of epidemiological measurement is this:
In a case-control study of recent alcohol consumption and road traffic accidents, the measure of association was substantially greater than 1 and indicates that there is a positive association between exposure and outcome.
A. Attributable risk B. Case-fatality rate C. Cumulative incidence D. Incidence rate E. Odds ratio F. Person-years G. Prevalence H. Absolute risk reduction I. Relative risk J. Number needed to treat
Odds ratio
Different types of association and causation: A. Bias B. Chance C. Confounding D. Specificity E. Reverse causality F. Dose-response G. Strength of association H. Reversibility I. Biological plausibility J. Consistency
Which is this:
Researchers set out to examine the hypothesis that stress causes hypertension using hypertensive and normotensive individuals in a case- control study. The study design is however criticised because of concerns regarding the temporal sequence of events.
Reverse causality
Different types of association and causation: A. Bias B. Chance C. Confounding D. Specificity E. Reverse causality F. Dose-response G. Strength of association H. Reversibility I. Biological plausibility J. Consistency
Which is this:
A study reports an association between coffee consumption and cancer. However, subsequent studies find that there is a clear association between smoking and coffee consumption.
Confounding
Different types of association and causation: A. Bias B. Chance C. Confounding D. Specificity E. Reverse causality F. Dose-response G. Strength of association H. Reversibility I. Biological plausibility J. Consistency
Which is this:
An association between postmenopausal oestrogen use and endometrial cancer was reported in some studies. However, it was subsequently argued that this might be due to increased diagnostic attention received by women with uterine bleeding after oestrogen exposure.
Bias
Prevention is classified into primary, secondary and tertiary prevention. Explain the difference between the three categories, giving examples of each.
Primary = no disease - prevent it occurring
e.g. immunisation
Secondary = Pre-clinical disease - reduce impact of disease that is already present (e.g. treat as soon as possible/slow down progression)
e.g. screening programme
Tertiary = clinical disease - soften impact of disease with lasting effects/chronic disease - improving their ability to function
e.g. stroke rehabilitation programmes
What is the population approach to disease prevention?
A preventative measure delivered on a population wide basis - seeks to shift risk factor distribution curve.
e.g. dietary salt reduction through legislation and general public dietary advice -> shifts BP curve to left
What is the high risk approach to disease prevention?
Identify individuals above a chosen cut off and treat them.
e.g. screening people for high BP and treating them.
What is this phenomena known as:
A preventative measure that brings benefit to the population often offers little to each participating individual
Prevention paradox
What is screening
A process which sorts out apparently well people who probably have a disease (or susceptibility/precursors to a disease) from those who probably do not.
What is a screening test not/
Not diagnostic
Give two examples of screening types
1) Population based screening programmes
2) Opportunistic screening
3) Screening for communicable disease
4) Pre-employment and occupational medicals
5) Commercially provided screening
What are the 4 main criteria for screening and what do they entail?
1) The condition
- important health problem
- latent/preclinical phase
- natural history known
2) The screening test
- is it suitable (sensitive, specific, inexpensive)
- acceptable
3) The treatment
- effective
- agreed policy of whom to treat
4) Organisation and cost
- facilities
- cost and benefit
- ongoing process
What is sensitivity?
The proportion of people with the disease who are correctly identified by the screening test
True positive/all disease (true positive result+ false negative result)
remember by -> being sensitive = a positive
What is specificity?
The proportion of people without the disease who are correctly excluded by the test
True negative /all absent disease (false positive result + true negatives result)
What is positive predictive value?
The proportion of people with a positive test result who actually have the disease
True positive/ all positives tests (true positive result + false positive result)
What is negative predictive value?
The proportion of people with a negative test result who do not have the disease
True negative/ all negative test results (false negative result and true negative result)
Which screening results are dependent on underlying prevalence?
Predictive values or sensitivity and specificity
Predictive values
What type of bias is this - lead time or length time?
Disease starts, Pt A diagnosed after screening, earlier than pt B who is diagnosed when symptoms develop, both die at the same time.
A seems to have longer time after diagnosis until death.
Lead time
What type of bias is this - lead time or length time?
- Cancers may be slowly or rapidly progressive
- less aggressive cancers are more likely to be detected by screening rounds
- a comparison of survival in screen-detected patients with non screen-detected patients may be biased due to a tendency to compare more aggressive with less aggressive cancers.
Length time
Name a few determinants of health
Genes Environment Lifestyle Health care Social and community networks - education, work, living conditions, housing, sanitation
What is the difference between inequality and inequity?
Equality is concerned with equal share
Equity is about what is fair and just
Explain the difference between horizontal and vertical equity in relation to healthcare?
Horizontal = equal treatment for equal need
(e.g individuals with pneumonia (with everything else being equal) should be treated equally)
Vertical = unequal treatment for unequal need
(e.g. areas with poorer health may need higher expenditure on health services, individuals with a cold vs pneumonia need unequal treatment)
How would you examine health equity?
Supply of health care, Access to health care, Utilisation of services, Health care outcomes, Health status, Resource allocation
Wider determinants of health (smoking, socioeconomic environment)
In health care systems, how is equity usually defined?
Equal access for equal need
What are the three domains of Public Health?
Health improvement, health protection and improving services
What is the domain health improvement concerned with?
Social intervention aimed at preventing disease, promoting health and reducing inequalities.
e.g. housing, education, employment, lifestyle, family/community
What is the domain health protection concerned with?
Measures to control infectious disease risk and environmental hazards.
e.g. infectious disease, chemicals and poisons, radiation, environmental hazards, emergency response
What is the domain improving services (health care) concerned with?
Organisation and delivery of safe, high quality services for prevention, treatment and care.
e.g. clinical effectiveness, efficiency, service planning, audit and evaluation, clinical governance, equity
