GP Flashcards
define domestic abuse
any incidence or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16+ who are, or have been, intimate partners or family members, regardless of gender or sexuality.
can encompass, but not limited to:
psychological, physical, sexual, financial, emotional.
list the different types of domestic abuse
psychological physical sexual financial emotional
- not limited to these, can be more than one type
give some ways domestic abuse impacts on health
- traumatic injuries following an assault e.g. fractures, miscarriage
- somatic problems or chronic illness consequent on living with abuse e.g. headaches, GI problems, chronic pain
- psychological or psychosocial problems secondary to abuse e.g. PTSD, attempted suicide, substance misuse, depression etc
in triaging a woman in A&E with injuries, what are some flags that could suggest domestic violence?
'reported as unwitnessed by anyone else' repeat attendance delay in seeking help multiple minor injuries not requiring treatment presenting 7pm-7am
what must you always consider if you identify a woman as being a victim of domestic abuse?
are there any children in the household - child safeguarding is utmost priority!!
what is the role of doctors in responding to domestic/sexual abuse?
- display helpline posters and contact cards, helps create an environment where people feel able to talk
- focus on patient’s safety (and safety of children)
- acknowledge and be clear that behaviour is not ok
- give information and refer on where appropriate
- be part of their process of recognising and escaping abuse
- be open to working with other agencies
what are the components of Maslow’s hierarchy of needs, from base to top?
physiological - breathing, food, water, sex, sleep etc
safety - security of body, of employment, of resources, of the family, of health, of property
love/belonging - friendship, family, sexual intimacy
esteem - self-esteem, confidence, achievement, respect of others
self-actualization - morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
what is the main stated cause of homelessness?
“relationship breakdown”
caused by - mental illness, domestic abuse, disputes with parents, bereavement
list some health problems faced by homeless adults
- IDs incl TB and hepatitis
- poor condition of feet and teeth
- respiratory problems
- injuries following violence/rape
- sexual health, smears, contraception
- serious mental illnesses
- poor nutrition
- addictions/substance misuse
what are some of the barriers to healthcare faced by homeless people?
- difficulties with access - opening times, getting appointments, perceived discrimination
- lack of integration between primary care services and other agencies (housing, social sector, criminal justice system, third sector)
- other things on their mind - focussed on pure survival, not getting a smear
- don’t know where to find help
what are some barriers to healthcare faced by Gypsies and Travellers?
- reluctance of GPs to register these groups, and to visit sites
- poor reading and writing skills (many are illiterate)
- communication difficulties
- too few permanent and transient sites
- mistrust of professionals
- lack of choice
define refugee
an adult/child that ‘owing to a well founded fear of being persecuted for reasons of race, religion, nationality, social group/political opinion is outside the country of his nationality, and is unable, or owing to such fear, unwilling to avail himself of the protection of that country’
define asylum seeker
someone who has submitted an application to be recognised as a refugee and is waiting for their claim to be decided by the home office
define internally misplaced person
someone who’s had to leave their home for similar reasons to refugees/asylum seekers, but has not crossed international borders.
what is indefinite leave to remain?
when a person is granted full refugee status and given permanent residence in the UK.
they have all the rights of a UK citizen.
eligible for family reunion - one spouse and any child of that marriage under age of 18
what are asylum seekers entitled to?
money (£35 per week)
housing - no choice dispersal
NHS care
if under 18, have a social services key worker and able to attend school
NOT allowed to - work or claim any other benefits.
FAILED asylum seekers - not entitled to money/housing/NHS care
what are some barriers to accessing healthcare faced by asylum seekers?
- lack of knowledge of where to get help
- lack of understanding of how NHS works
- language/culture/communication
- hyper-mobility
- not homogenous group
- health not a priority
what physical health problems might an asylum seeker/refugee face?
- common illnesses
- illness specific to country of origin
- injuries from war/travelling
- no prev health surveillance/screening/imms
- malnutrition
- torture, sexual abuse
- infestations
- communicable disease / blood borne diseases
- untreated chronic disease / congenital problems
what mental health problems might an asylum seeker/refugee face?
PTSD depression sleep disturbance psychosis self harm
also, any mental health conditions anybody else could get!
what are some flags that might make you consider loneliness in a patient?
- body language, appearance, talkative, clinging
- denial, boredom
- living alone
- male 50+
- bereavement, recent transition
- mobility
- sensory impairment
- close family nearby?
- quality not quantity of social contact
define social exclusion
dynamic process of being shut out, fully or partially, from any of the social, economic, political or cultural systems which determine the social integration of a person in society
what are the 5 domains of social exclusion?
material resources civic activities basic services neighbourhood social relationships
give some causes of social exclusion
poor health, sensory impairment, poverty, housing issues, fear of crime, transport issues, discrimination, poor coordination, fragility of networks
define disability
relates to anyone who has a physical, sensory or mental impairment which seriously affects their daily activities
what is age related macular degeneration?
central part of retina that’s used for detailed work is called the macular - macular disease is the collective term for conditions causing damage
no cure but can sometimes be slowed or halted in some cases with medical treatment, drug therapy or laser treatment.
most common eye condition in the UK.
what is retinitis pigmentosa?
inherited diseases of retina - leads to gradual reduction in vision, initially night and peripheral vision then difficulties in reading and colour vision
what is glaucoma?
condition affecting optic nerve.
once affected, can’t be reverse.
often the nerve is damaged before vision loss is noticed
what is diabetic retinopathy?
blood supply to retina is impaired.
if caught early can be treated by laser - stops progression but doesn’t restore loss.
what are cataracts?
very common - lens changes with ageing, becoming less transparent - turns misty or cloudy.
how do you calculate a unit of alcohol?
% ABV * ml / 1000
give some social/psychological risk factors for problem drinking
- drinking within the family
- childhood problem behaviour relating to impulse control
- early use of alcohol, nicotine and drugs
- poor coping responses to life events
- depression as a cause (not a result!) of problem drinking
what are the most common causes of death related to alcohol?
- accidents and violence
- malignancies
- cerebrovascular disease
- coronary heart disease
what is foetal alcohol syndrome?
occurs if persistent drinking throughout pregnancy
small underweight babies, slack muscle tone
mental retardation, behavioural and speech problems. characteristic facial appearance.
cardiac, renal and ocular abnormalities.
list some screening tools for alcohol problems
AUDIT
CAGE
also - PAT, FAST, abbreviated AUDIT
DON’T use blood tests
what is the role of brief structured advice in managing potential alcohol abuse in the GP setting?
well-researched technique - use 5-15 mins to cover potential harm caused, reasons for changing incl health and well-being benefits, cover obstacles to change, strategies to combat and goals.
briefly explain the NYHA staging of heart failure
Stage I - No limitation on ordinary physical activity
Stage II - Normal at rest. Ordinary physical activity causes breathlessness.
Stage III - Normal at rest. Less-than-ordinary activity causes breathlessness.
Stage IV - Symptoms at rest.
what is ‘heart failure’?
when output of the heart is inadequate to meet the needs of the body - end stage of all cardiac diseases
give some high output causes of chronic heart failure (and explain what that means!)
high output heart failure occurs when heart is working at normal/increased rate, but needs of the body are increased.
causes - hyperthyroidism, anaemia, Paget’s disease, AV malformation
what are some low output causes of heart failure?
low output = due to reduced heart function, due to either increased preload, pump failure or chronically excessive afterload.
causes - mitral regurg, fluid overload, ischaemic heart disease, cardiomyopathy, MI, AF, aortic stenosis, restrictive cardiomyopathy, constrictive pericarditis, tamponade, chronic HTN
drug causes - beta blockers (if making them really bradycardic), verapamil, diltiazem
what investigations would you order in suspected heart failure?
BNP (serum B type natriuretic peptides) and NTproBNP (N-terminal-pro-BNP) - if raised, refer to cardiology for review.
ECG (if ECG and BNP normal, NICE says it’s probs not heart failure)
might do an echo - can identify cause.
also - CXR, lung function tests if trying to exclude respiratory cause, bloods (FBC, U&E, creatinine, eGFR, TFTs, BM/HbA1c) - these are to test for exacerbating factors and things you can treat!
what are the Farmingham criteria for congestive cardiac failure?
diagnosis of CCF needs 2 major or 1 major + 2 minor criteria:
MAJOR - paroxysmal nocturnal dyspnoea, neck vein distension, crepitations, acute pulmonary oedema, S3 gallop, hepatojugular reflux, cardiomegaly, increased central venous pressure, weight loss >4.5kg in 5 days in response to treatment
MINOR - bilateral ankle oedema, nocturnal cough, dyspnoea on ordinary exertion, tachycardia >120, pleural effusion, hepatomegaly, reduced vital capacity
describe the non-drug aspects of managing a patient with chronic heart failure in GP land
6 monthly review - check functional capacity, fluid status, screen for depression, medication review etc
educate - about disease and prognosis
lifestyle measures - stop smoking, low salt diet, weight loss, healthy diet, regular exercise. discuss needs for benefits, disabled badge etc.
give annual flu and pneumococcal vaccines.
describe the use of diuretics in management of a patient with chronic heart failure
diuretics - used to relieve congestion/fluid retention - use a loop diuretic (e.g. furosemide 20-40mg or bumetanide 1-2mg). add thiazide if problems with oedema/HTN continue.
monitor for hypokalaemia - treat with amiloride or K+ supplements if needed.
list some classes of drug used in management of heart failure, and name the drugs commonly used
diuretics - usually loop (furosemide), might add thiazide
ACE inhibitors - ramipril, start low and titrate up
beta-blockers - bisoprolol - ‘start low, go slow’
might substitute an ARB in if the ACEi gives a cough (e.g. candesartan)
how does management of heart failure differ if the patient has a preserve ejection fraction?
this is less common - basically can’t do anything beyond give diuretics and treat co-morbidities
when might you consider referring a heart failure patient to cardiology?
- making initial diagnosis (should have a routine referral)
- unable to manage at home
- severe
- not controlled by first line medication
- angina, AF, other symptomatic arrhythmia
- heart failure due to valve disease
- comorbidity that might impact heart failure e.g. COPD, renal failure, anaemia, thyroid disease, PVD, urinary frequency, gout
- woman with heart failure planning pregnancy
give some examples of drugs that might be used by a cardiologist in the management of heart failure
aldosterone antagonists e.g. spironolactone
hydralazine + nitrate in combo
ARB - in combo with ACEi and beta blocker
digoxin - anti-arrhythmic and positive inotrope
amiodarone - used for arrhytmias
what is the prognosis of chronic heart failure?
progressive deterioration to death, high BNP is poor prognostic factor
50% dead at 5 years - this is improving though
what symptoms are seen if a patient has left ventricular heart failure?
dyspnoea, poor exercise tolerance, fatigue, orthopnoea, PND, nocturnal cough, wheeze, nocturia, cold peripheries, weight loss
what symptoms are seen if a patient has right ventricular heart failure? what causes right ventricular heart failure?
peripheral oedema, ascites, nausea, anorexia, facial engorgement.
causes - left ventricular failure, pulmonary stenosis, lung disease
what signs would you expect to see on a CXR of a patient with chronic heart failure?
ABCDE! Alveolar oedema Kerley B lines Cardiomegaly Dilated upper lobe vessels pleaural Effusion
how does furosemide work? side effects?
laymans terms = works on kidneys to help you get rid of excess fluid, which can make symptoms better
acts on ascending limb of loop of Henle to inhibit the Na/K/2Cl co transporter
SEs - hypokalaemia, renal impairment.
monitor U&Es!
how do ACE inhibitors work in heart failure? side effects?
angiotensin-converting enzyme inhibitors - ramipril, lisinopril.
first line for chronic heart failure - improves symptoms and prognosis
laymans - reduces the strain on your heart by lowering your blood pressure, makes it easier for heart to work.
block action of ACE, preventing conversion of angiotensin I to angiotensin II - reduces peripheral vascular resistance, so lowers BP (and afterload!)
SEs - hypotension (esp first dose), dry cough (due to excess bradykinin), hyperkalaemia, renal impairment
be aware of first-dose hypotension, especially if starting on loop diuretic at the same time!
how do ACE inhibitors work in hypertension? side effects?
angiotensin-converting enzyme inhibitors - ramipril, lisinopril.
first line if <55yrs and not afro-carribbean
laymans - improves blood pressure by encouraging veins and arteries around your body to relax a bit, reduces strain on your heart.
block action of ACE, preventing conversion of angiotensin I to angiotensin II - reduces peripheral vascular resistance, so lowers BP.
SEs - hypotension (esp first dose), dry cough (due to excess bradykinin), hyperkalaemia, renal impairment
be aware of first-dose hypotension, especially if starting on loop diuretic at the same time!
how do beta blockers work in heart failure? side effects?
e.g. bisoprolol, atenolol
first line option - improves prognosis
via beta1-adrenoreceptors (in heart, beta2 ones are in vessels and airways) these drugs reduce force of contraction and speed of conduction in heart - ‘protects’ heart from effects of chronic sympathetic stimulation.
start low, go slow - might initially impair cardiac function, so don’t just whack the dose straight up - titrate up every 2+ weeks.
SEs - fatigue, cold extremities, headache, GI upset, erectile dysfunction.
CONTRA-INDICATED IN ASTHMA
how does spironolactone work in heart failure? what kind of drug is it? side effects?
used if at least moderate severity, or heart failure arising within 1 month of an MI, generally as addition to beta blocker and ACEi/ARB.
it’s an aldosterone antagonist.
inhibits action of aldosterone by competitively binding to the aldosterone receptor - increases sodium and water excretion, and potassium retention (risk of hyperkalaemia when combined with ACEi).
SEs - hyperkalaemia, gynaecomastia, erectile dysfunction
define polypharmacy. when does it become “inappropriate polypharmacy”?
5+ medications.
inappropriate as soon as 1 drug prescribed that shouldn’t be there:
- no evidence based indication, expired indication, dose too high
- medicines that aren’t working
- combination of, or any one, drug(s) causing adverse reaction
patient doesn’t want/isn’t able to take as intended
list some potential consequences of polypharmacy
increasing costs of healthcare increasing adverse drug events drug interactions medicines non-adhesive cognitive impairment, functional impairment, falls, urinary incontinence, nutrition
what community support is available for patients with heart failure?
cardiac rehab (psuchological support, education, structured exercise programme, RF modification)
regular reviews - heart failure nurses
support groups
list some causes of hypertension
unknown/'essential' (95%) renal disease endocrine - Cushing's, Conns, phaeochromocytoma, acromegaly, hyperparathyroidism Pregnancy Coarctation of the aorta
what is the treatment threshold for hypertension?
> 160/100 if otherwise healthy.
If >140/90 might treat if other risk factors/co-morbidities.
how is hypertension staged/classified?
stage 1 = clinic BP >140/90 and subsequent daytime average ABPM/HBPM >135/85
stage 2 = clinic BP >160/100, average ABPM/HBPM >150/95
severe = clinica systolic >180 or diastolic >110
what is the difference between ABPM and HBPM?
ABPM = ambulatory BP monitoring - continuous BP monitoring usually for 24 hours. HBPM = home BP monitoring - BP taken at home, not a continuous machine.
when would you initiate antihypertensive treatment, if patient has stage 1 hypertension?
if <80y age and 1+ of:
- target organ damage
- established CVD
- diabetes
- renal disease
- 10y CVD risk 20+% (Q risk)
when would you initiate antihypertensive treatment, if patient has stage 2 hypertension?
all stage 2 hypertension needs drug treatment!
sneaky trick qu
what are some non-drug measures that can be taken in managing hypternsion?
education - to make sure pts understand why it’s important they take drugs etc
lifestyle - smoking cessation, regular exercise, reduce alcohol intake, reduce dietary salt, increase fruit and veg intake, reduce caffeine, encourage relaxation/stree management
when would you prescribe a statin in a hypertensive patient?
if existing CVD - give statin regardless of baseline cholesterole/LDL levels
OR - for primary prevention in patients >40y with HTN and 10y CVD risk 20+%
describe the flowchart of antihypertensive drugs
first line = ACEi (or ARB) if <55yrs.
if >55 or african/caribbean = CCB (e.g. amlodipine)
Step 2 = ACEi + CCB
Step 3 = ACEi + CCB + thiazide-like diuretic
Step 4 = add spironolactone or higher dose thiazide-like diuretic. consider alpha/beta blocker.
what are the treatment targets used in hypertension management?
non-diabetic, no CKD = <140/80 diabetic, T2DM = <140/90 T1DM = <135/85 if any renal, foot, eye or cardiovascular complications in a diabetic patient - need tighter control, aim for <130/80 CKD = <130/80
what would be included in an annual hypertension review appointment?
- check BP (obvs) and look for signs of end-organ failure (incl urine dip for proteinuria)
- discuss symptoms and medication
- assess and treat other modifiable RFs
- reinforce lifestyle advice
what features in a hypertension patient would prompt you to consider referring to secondary care?
- accelerated hypertension
- renal impairment
- suspected secondary hypertension
- patients <40yr
- BP difficult to treat (got to step 4)
- pregnancy
what is the first line treatment for a white patient <55yrs old requiring antihypertensives?
ACE inhibitor - ramipril or lisinopril
how do ACE inhibitors work as antihypertensives? important side effects?
reduce risk of stroke, MI and death from CVD.
block action of ACE to prevent conversion of angiotensin I to angiotensin II. angiotensin II would normally be causing vasoconstriction, so blocking it means peripheral vascular resistance drops.
SEs - dry cough!! due to increased levels of bradykinin, which is usually inactivated by ACE. also first dose hypotension, hyperkalaemia, renal failure.
what is the first line treatment for a Afro-Carribbean patient, or a patient >55yrs old requiring antihypertensives?
calcium channel blockers e.g. amlodipine, nifedipine
how do CCBs work as antihypertensives? important side effects?
reduce calcium entry into vascular and cardiac cells - causing relaxation and vasodilation in arterial smooth muscle - lowers BP
amlodipine/nifedipine (dihydropyridines) are selective-ish for vessels, while diltiazem/verapamil (non-dihydropyradines) are more cardio-selective.
SEs (of dihydropyridines) = ankle swelling, flushing, headache and palpitations.
what is the second line / step 2 of antihypertensives?
ACEi / ARB + CCB
what is the third line / step 3 of antihypertensives?
ACEi + CCB + thiazide-like diuretic
what is the fourth line / step 4 of antihypertensives?
add spironolactone or higher dose thiazide-like diuretic. consider alpha/beta blocker.
probs refer to cardiology - this is resistant hypertension
how do thiazides/thiazide-like diuretics work as antihypertensives? important side effects?
e.g. bendroflumethiazide (no longer NICE recommended though), indapamide
inhibit Na/Cl co-transporter in distal convoluted tubule of nephron - prevents reabsorption of sodium and so more water excreted.
tell patient - offering you a ‘water tablet’ for your high BP, will also help with leg swelling if they have it - ask about difficulty getting to toilet on time!
SEs - erectile dysfunction, hyponatraemia, hypokalaemia
give an example of an alpha-blocker. what common chronic condition are they used fourth line?
doxazosin, tamsulosin, alfuzosin
used in resistant hypertension
(also first line option for BPH)
act on alpha1 adrenoceptors, which are mostly found in smooth muscle and urinary tract. so block those to induce relaxation, can drop BP.
SE - hypotension! esp. postural. dizziness and syncope.
what tip can you give patients when playing with their BP meds to avoid them having a fall?
if risk of first dose hypotension - take at bed time!
what drugs should a patient be offered as part of secondary prevention post-MI?
all patients should be offered the following drugs:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent, typically clopidogrel)
ACE inhibitor
beta-blocker
statin
what lifestyle advice might be given for secondary prevention post-MI?
diet: advise a Mediterranean style diet, don’t recommend omega-3 supplements or eating oily fish
exercise: advise 20-30 mins a day until patients are ‘slightly breathless’ (cardiac rehab programmes helpful)
sexual activity may resume 4 weeks after an uncomplicated MI. Reassure patients that sex does not increase their likelihood of a further MI.
advise weight loss, reduce alcohol.
if a patient is diabetic, how does that change first line hypertension management, and why?
first line always an ACE inhibitor in diabetes, as they’re renoprotective
what non-drug, non-lifestyle advice treatment should be given to all post-MI patients as part of secondary prevention?
cardiac rehabilitation!
including an exercise programme of some kind
what are ‘red’ features on the traffic light system for assessing a febrile child?
- pale/mottled/ashen/blue skin, lips or tongue
- no response to social cues
- appearing ill to a healthcare professional
- doesn’t wake/stay awake if roused
- weak, high pitched or continuous cry
- grunting
- RR >60
- moderate/severe chest indrawing
- reduced skin turgor
- bulging fontanelle
what are the ‘amber’ features on the traffic light system for assessing a febrile child?
- pale skin/lips/tongue reported by carer
- not responding normally to social cues
- no smile
- wakes only with prolonged stimulation
- reduced activity
- nasal flaring
- dry mucous membranes
- poor feeding in infants
- reduced urine output
- rigors
what are the ‘green’ features on traffic light system for assessing a febrile child?
green if they have all of the below, and no amber/red signs:
- normal colour of skin/lips/tongue
- responds normally to social cues
- content/smiles
- stays awake/wakens quickly
- strong, normal cry/not crying
- normal skin and eyes
- moist mucous membranes
what are the steps involved in assessing a febrile child?
1) check your ABCDEs
2) assess against red/amber/green criteria
3) measure and record - HR (tachycardia = at least amber), RR, CRT (3+ is amber sign), temp (if < 3 months, 38+ C = red risk, if 3-9 months and 39+ C = at least amber)
4) assess for dehydration (prolonged CRT, abnormal skin turgor, abnormal resp pattern, weak pulse, cool extremities)
explain Gillick competence
a competent child is one who can understand the nature, purpose and possible competence of a proposed procedure + the consequences of not undergoing the procedure.
competent child (<16) can consent to treatment, but if they refuse they can be overruled by parents/court.
if not competent - only someone with parental responsibility can authorise/refuse
UNLESS it’s an emergency - can provide any medical treatment, limited to what is necessary for saving life
what 4 criteria need to be met for a patient to be deemed capacitous? what needs to be done before we can declare a patient incapacitated?
Patient needs to be able to:
1) understand the information
2) retain the information
3) weight it up
4) communicate decision back
You have a duty to take all reasonable steps to attempt to make them capacitous e.g. Braille/sign language, giving lots of time to explain and weigh it up etc.
if a patient is deemed incapacitated, what should you as the GP do before giving at treatment?
- take all factors affecting the decision into consideration
- involve the patient with decision making as far as possible
- take the patient’s previously known wishes into consideration
- consult everyone else involved in patient’s care/welfare (but remember, up to you to make best interests decision, not giving relative power to decide)
how would you manage an unwell child falling into the ‘red’ category?
refer for immediate/same day review by a paediatrician
how would you manage an unwell child falling into the ‘amber’ category?
treat cause if found
if no cause located, decide based on concerns of you and family:
- advise parent’s to ring up if any deterioration/failure to improve
- arrange to review within a few hours
- refer for paediatric review
SAFETY NET - advise on warning symptoms (amber/red) and how to access further healthcare e.g. walk in/OOOH
what are some common causes of pyrexia in a child <5yrs?
infection most common cause - consider UTI if no localizing symptoms/signs.
non-infective causes - malignancy (leukaemia, lymphoma), immunological (Still’s, Kawasaki’s disease), drugs, liver or renal disease
what symptoms/signs in a febrile <5yo would make you consider meningococcal disease?
non-blanching rash - particularly with 1+ of:
- ill-looking child
- lesions >2mm in diameter (purpura)
- CRT 3+
- neck stiffness
what symptoms/signs in a febrile <5yo would make you consider a pneumonia?
tachypnoea (>60 if 0-5m, >50 if 6-12m, >40 if >12m) crackles in chest nasal flaring chest indrawing cyanosis O2 sats <95%
what symptoms/signs in a febrile <5yo child would make you consider bacterial meningitis?
neck stiffness
bulging fontanelle
decreased level of consciousness
convulsive status epilepticus.
what symptoms/signs in a febrile <5yo child would make you consider herpes simplex encephalitis?
focal neurological signs
focal seizures
decreased level of consciousness
what symptoms/signs in a febrile <5yo child would make you consider UTI?
vomiting poor feeding lethargy irritability abdominal pain or tenderness urinary frequency or dysuria
what symptoms/signs in a febrile <5yo child would make you consider septic arthritis/osteomyelitis?
swelling of a limb or joint
not using an extremity
non-weight bearing
what symptoms/signs in a febrile <5yo child would make you consider Kawasaki disease?
bilateral conjunctival injection
change in mucous membranes in the upper respiratory tract (for example, injected pharynx, dry cracked lips or strawberry tongue)
change in the extremities (for example, oedema, erythema or desquamation)
polymorphous rash
cervical lymphadenopathy
what home care advice would you give a parent/carer who you’re sending home with a febrile child (no red/amber features)?
- to look out for red/amber signs, how to access healthcare if deteriorate e.g. OOOH
- temperature management - DON’T use tepid sponging/underdressing/over-wrapping - can use alternating paracetamol and ibuprofen if child distressed
- regular fluids (breastmilk if breast fed) - any fluid fine, watch for signs of dehydration - if present, encourage fluids, seek advice if worried (111, walk i centre)
- how to identify non-blanching rash
- check child during night
- keep off school - notify them of febrile illness
you’ve just seen a febrile 2 year old in your GP surgery - you assessed him against the traffic light criteria and he’s currently green. there’s no identifiable cause, but you aren’t particularly concerned at present, you give safety-netting and explain how to call OOOH or find the walk in if they need more help later this evening.
Mum asks - “when should I seek further advice?” (or something that sounds more like what a Mum would actually say)
- if child has a fit
- develops non-blanching rash
- if parent/carer feels child is getting worse
- if parent/carer becomes more worried
- fever lasts >5 days
- carer is distressed or worried they can’t look after their child
what signs of dehydration would you advise a parent caring for a febrile <5 yo looks out for?
sunken fontanelle (if young enough) dry mouth sunken eyes absence of tears poor overall appearance
how would you explain the importance of vaccination to a mother concerned about their safety and considering not allowing her child to be vaccinated? include an explanation of herd immunity
- immunisations have caused massive improvements in health since they were introduced
- their quick, safe and effective
- child’s body will then be able to fight off diseases better - there’s a greater risk of them being exposed to harm if they aren’t vaccinated (due to risk of catching, a being very ill from, the illness)
herd immunity = when a large portion of population have been vaccinated, everyone benefits from herd immmunity - important that all healthy children are vaccinated, as there’s a proportion who can’t due to immune problems - herd immunity helps to protect them. it also prevents large outbreaks, and can lead to virus eradication.
what common side effects of childhood immunisations would you inform the parents about?
- redness or swelling around the injection site
- might be irritable/unwell/slight fever for a couple of days (esp common with MenB - advised to give 3 doses paracetamol after to prevent/treat fever)
- after MMR - can get a rash about a week later, may also get fever/swollen glands
what % of population need to be vaccinated to achieve herd immunity?
WHO targets >95%, PHE targets >94% (we don’t normally meet that in England!)
higher unemployment and lower household income significantly associated with low uptake.
list the notifiable diseases
- acute encephalitis
- acute infectious hepatitis
- acute meningitis
- acute poliomyelitis
- anthrax
- botulism
- brucellosis
- cholera
- diphtheria
- enteric fever (typhoid/parathyroid)
- food poisoning
- haemolytic uraemic syndrome
- infectious bloody diarrhoea
- invasive group A strep disease and scarlet fever
- Leggionnarie’s
- leprosy
- malaria
- measles
- meningococcal septicaemia
- mumps
- plague
- rabies
- rubella
- SARS
- smallpox
- tetanus
- TB
- typhus
- viral haemorrhagic fever
- whooping cough
- yellow fever
who do you notify of a notifiable disease?
public health england / local health protection team
what immunisations are given at 8 weeks old?
diphtheria, tetanus, pertussis, polio, Hib, hep B - (DTaP/IPV/Hib/HepB)
pneumococcal conjugate vaccine (PCV)
MenB
Rotavirus
what immunisations are given at 12 weeks old?
diphtheria, tetanus, pertussis, polio, Hib, hepB
rotavirus
what immunisations are given at 16 weeks old?
Diphtheria, tetanus, pertussis, polio, Hib and HepB
pneumococcal (PCV)
MenB
what immunisations are given at one year old?
Hib and MenC
pneumococcal (PCV)
MMR
MenB
which children are eligible to receive the live attenuated flu vaccine?
children aged 2 and 3 on August 31st of that year children in reception class and school years 1, 2, 3, 4 and 5 piloting all primary school-aged children in some parts of country children aged 2 to 17 with long-term health conditions
delivered via nasal spray
what immunisations are given ‘pre-school’ (3y 4m old or soon after)?
diphtheria, tetanus, pertussis and polio
MMR (confirm first dose given)
what immunisations are given to girls age 12-13?
HPV types 6, 11, 16, 18 - protects against genital warts and cervical cancer.
two doses given 6-24 months apart.
what immunisations are given at 14 years old (school year 9)?
tetanus, diphtheria and polio (confirm MMR status)
MenACWY
how is the rotavirus vaccine delivered?
orally - drops
do you adjust the immunisation schedule for prematurity i.e. if gestational age 30 weeks when delivered, would you give first imms at 18 weeks (+10 weeks)?
NO - prematurity means the babies are at greater risk of infection, so important to give them as normal from 2 months after birth.
when is the DTap/IPV/Hib/HepB vaccine given? what does it protect against?
8 weeks
12 weeks
16 weeks
protects against diphtheria, tetanus, pertussis, polio, Hib, hepB
further DTap/IPV at 3y 4m.
also tetanus/diphtheria and polio given at 14yrs
when is the PCV (pneumococcal) vaccine given?
8 weeks
16 weeks
1 year old
When is the MenB vaccine given?
8 weeks
16 weeks
1 year
when is the rotavirus vaccine given?
8 weeks
12 weeks
when is a MenC vaccine given?
combined with Hib at one year.
as part of MenACWY for 14 year olds.
when is the MMR vaccine given?
one year
3y 4m
when is Hib vaccinated against?
8/12/16 weeks as part of DTap/IPV/Hib/HepB
one year as part of Hib/MenC
what are the most common conditions presenting with abnormal vaginal discharge in GP land?
bacterial vaginosis
candidiasis
also - normal changes!
consider STIs and other non-infective causes
describe normal vaginal discharge
white/clear, non-offensive, varies with menstrual cycle
give some symptoms that might indicate abnormal vaginal discharge
- heavier than usual
- thicker than usual
- pus-like discharge
- white and clumpy discharge
- greyish/greenish/yellowish/blood-tinged
- foul-smelling discharge
- discharge accompanied by bloodiness, itching, burning, rash, soreness
