GP Flashcards
What is primary prevention and example?
disease hasn’t started yet (immunisations and lifestyle measures to prevent risk factors [smoking])
8 determinants of public health?
o Finance, ideology, education, wealth, clean water and hygiene, nutrition, self help o Controlling climate change and reducing health inequalities o Less tobacco o Better health services and treatments o More GPs in deprived areas o Education of risk factors o Better housing and environment o Patient-centred care
What is the inverse care law and distributive justice?
those who need health services less use it more than those who need it more (higher mortality and chronic illness associated with deprivation); resources need to be distributed fairly to all
What is the definition of health?
complete physical, mental and social wellbeing
What is secondary prevention and its benefits?
disease started but caught early enough to slow progression or recurrence (had a stroke and reducing risk by altering lifestyle/on statins; reducing risk factors when diagnosed with hypertension); cost-effective and most effective at reducing health inequalities
What is tertiary prevention and example?
preventing consequences of the disease (reduce the disability/handicap of the stroke – rehab for walking and speech therapy etc)
What are the 7 barriers to prevention and explanation of each?
genes that predispose; cognitive so that they don’t understand how the risk factor could impact them or just don’t care; psych = if like the risk of it; logistical = IT systems cannot predict all the RFs etc or cannot afford some interventions for some lower income peoples; political = if government makes cuts on certain tech; ethical = can’t vaccinate everyone without consent; financial; motivation
What is equity?
what is fair and just
What is equality?
Making stuff equal
What is horizontal equity?
equal treatment for equal need
What is vertical equity?
unequal treatment for unequal need
What 2 factors do inequity consider?
spatial (geographical) and social (other types of determinants) [deprivation, gender, ethnicity]
3 core values of equity in healthcare?
supply, access and availability to populations
Health improvement definition?
societal interventions for preventing disease, promoting health and reducing inequalities
What is GOBI-FFF for improving health?
growth monitoring, oral rehydration for diarrhoea, breast-feeding, immunisation, family planning, female education, food supplementation
What is health promotion and how is it achieved?
developing skills and understanding of health prevention (some education requires a bit of fear of the consequences of not getting help = effective), immunisation, nutrition, sanitation, maternal health and child health and control of endemic diseases
How to educate patients in healthcare?
knowledge, attitudes, intentions, behaviour
What is health protection?
limit infectious diseases and environmental hazards
What is intermediate care?
– care between primary and secondary (usually in the community); health and social services; care close to home, new tech, cost-effective, less rigid professional roles, integration of different practices
What is community participation?
allowing and planning with the community to participate in their own healthcare
3 levels of improvement?
individual, community and ecological level
What is a health needs assessment?
systematic way of looking at population and reviewing their health needs for resource allocation and prioritisation
What is accessibility?
equitable distribution of healthcare
What is health need?
general term for having good lifestyle
What is health care need?
more specific in need for interventions and prevention provided by healthcare (for population, condition or an intervention can be applied)
What is felt need?
individual perceptions of variation from normal health
What is expressed need?
individual seeks help to overcome variation in normal health (demand)
What is normative need?
professional defines intervention appropriate for the expressed need
What is comparative need?
comparison between severity, range of interventions and cost
How to approach a need epidemiologically?
define problem; size of problem; services available; evidence base; models of care; existing services and recommendations
What is a comparative approach?
compares services received in different populations (inequities)
What is multimorbidity?
multiple conditions leading to complexity in care (think about cons)
What is polypharmacy and its pros and cons?
5 or more drugs at once (think about cons); appropriate = where medicines use is optimised and good research into what the best ones are and the least drugs used with the least interactions and most benefit (inappropriate = opposite of this and don’t necessarily know why patient is taking some of them)
What is a health behaviour?
behaviour aimed to prevent disease (can be split up into health damaging and promoting)
What is illness behaviour?
behaviour to seek remedy
What is sick role behaviour?
any activity aimed at getting well
What is depersonalisation?
turning a person into a statistic
What is a systematic review?
use literature to study something
What is a meta-analysis?
use literature and use statistics to analyse it
What is a cohort study?
follow group of people over time and look at their exposure to stuff and see if they develop a disease
What are co-concurrent behaviours?
one behaviour may make chance of having another one more likely (smoking and alcohol abuse)
What are population and individual interventions?
o Population = health promotion
o Individual = patient-centred approach
Why do people to health damaging behaviours?
inaccurate perceptions of risk and susceptibility
4 aspects of barriers to self care and breakdown?
pt factors = rebel, lack of motivation, socioeconomic; healthcare factors = time to educate, motivating pt and money to promote; society = responsibility with GP and advertising of risk factors (smoking/alcohol)
6 steps of disease prevention behaviour?
precontemplation (uninterested/unaware to make a change), contemplation (assess barriers and benefits of giving up), preparation (pt prepares to make the change), action (desire to change lifestyle but not going through prev steps my be less effective), maintenance and relapse prevention
What is motivational interviewing?
asking questions “Have you ever thought about giving up?” “what’s stopping you?”
What are the pressures of primary care?
time in consultation, pressure of isolation in consultation, dealing with uncertainty in presentation, managing long-term relationships with pts, switching emotions to suit the pt presentation, pt demand vs budget, constant reorganisation
What is a pt centred approach and how to do it?
put pt first; explore disease and illness experience, understand whole person (psychosocial), find common ground for management, have prevention and health promotion, build on pt relationship and rapport, be realistic with time and resources
What is the IATROGENIC criteria for screening (Wilson-Junger)?
o Important condition o Acceptable treatment o Treatment and diagnostics available o Recognisable stage o Opinions on who to treat as a pt o Guaranteed safety, highly discriminatory, valid and reproducible o Exam must be acceptable by pt o Natural hx of disease known o Inexpensive test o Continuous screening and not one-off
What is involved in informed consent?
may disadvantage from it by having false positive etc
What are partially effective screening tests?
pap smear, mammography, finding smokers, faecal occult, abdo aortic aneurysm, chlamydia
What are ineffective/unproven screening tests?
mental test, urine dip, antenatal procedures, PSA
What are the cons of screening tests?
most at risk don’t present for screening; ‘worried well’ overload the service; services for invest +ve inadequate; -ve result may mean keep taking risks
What are the 6 consultation models and a brief explanation for each?
- Biomedical – history-taking, exam, invest, diagnosis, treatment, review (takes time)
- Balint
- Byrne and long – establish a relationship, finds reason for attendance, verbal/physical exam, consider condition, treatment/invest, end
- Pendleton – reason for attending, other problems considered, choose action for each problem with pt, pt involved in management, relationship maintained
- Neighbour – connect with pt, summarise (pts expectations and presenting complaint), handing over, safety netting, house keeping
- The Calgary-cambridge model – initiating session, gather information, build relationship, explanation and planning, closing session
How to deal with uncertainty in consultations?
consider differentials, time as a tool, evidence-based medicine, share uncertainty with pt, safety netting if things don’t go to plan, gamble safety so ‘most luck’, clinical governance
What is clinical governance and how to do it?
reflect on mistakes to maintain and improve excellence; risk avoidance, infrastructure, clinical effectiveness, audit, education training, staff; record: description of event, learning outcomes and action plan
What is an audit?
systematic critical analysis of quality of health care; looks at current practice, measures against pre-selected standards, identifies and implements areas for change; continuous; improves: care for pts, aid to administration, enhanced staff professionalism, efficient use of resources, continues education, accountability held
What is an audit cycle?
identify issue, agree criteria, set standards, plan and prepare (what data etc), first data collection, implement changes, second data collection, summary of findings
What is the CQC and its function?
must register for any regulated activities they perform; treatment of disease/disorder/injury, diagnostic and screening, surgeries, family planning
How to handle complaints?
should be heard and investigated properly; genuine apology received and assured steps taken; <1yr after event or when event came to light
What is an appraisal and its components?
annual; general info, keep up to date, review of practice, feedback on practice, continuing professional development, quality improvement activity (audit), significant events, feedback from colleagues/pts, review of complaints/compliments
What is revalidation?
happens every 5 yrs and must pass this each time so can continue to practice and be a registered doctor
How to increase compliance with prescribing and pt taking medication?
identify with doctor, pt’s satisfaction with dr, simple regimens, written info, longer consultations, educate, continuity of care, shorter waiting times, self-monitoring by pt; can monitor plasma drug levels; aim for most cost-effective treatment
Values of good doctoring?
place diagnosis in context of pt’s life; listen; examine pt thoroughly; cost-effective treatment; differentials in biopsychosocial terms; explain diagnosis simply; additional problems and risks; list treatments and guidelines; balance your pros and cons with pt’s; follow-up and communication arranged; arrange for treatment purchase, cost implications, accountability, justify treatment choice using 4 pillars of ethics; try to be professional and authentic
Why is continuity of care important?
multiple and complex health problems; more difficult now as need quicker accessibility so not always same GP; better for rapport and communication
Who is more likely to have a chronic condition?
Older and poorer socioeconomic
Pt issues with chronic disease?
finding and using health resources; know how to recognise and mange changes in disease; deal with problems/emergencies; using treatments effectively; managing stress/depression with chronic diseases; managing fatigue/sleep/pain problems; exercising enough and good nutrition; managing ADLs and relationships
How to effectively manage chronic disease in pts?
involve fam; collaborate; personalised care plan; tailored education in self-management; planned follow-up; monitor outcome and treatment adherence; tools and protocols for stepping-up the care; using specialist services; monitor process using clinical governance
What is self-care and how to encourage it?
encourage belief in one’s own health; explain about minor illness; encourage self-medication where appropriate; larder technique (honey and lemon for sore throat); watch and wait; deferred prescribing; use pharmacists; pre-empting requests for abx
How to allow a chronic disease pt to cope with ADLS
cope with ADLs, understand illness and cope, able to keep healthy, confidence on handling issues and self-help
RFs for medically unexplained symptoms (MUS)?
physical illness; trauma; media highlighting illness (develop enhanced sense of bodily awareness or mis-attribution of symptoms); stressful life events
Main complaints for MUS?
specific pain location; functional disturbance somewhere (palpitation); fatigue/exhaustion
Definition of MUS?
> 3months, affects function but cannot be explained; check mental health and stressors and impact on ADLs; psychosocial
Treatment first line for MUS?
Amitriptyline
Types of time off work for health needs and fitness to practice defintion?
o MSK, minor illness and stress/depression/anxiety main causes
o Longer they are off, less likely to return
o Find ways to keep going to work if possible and understand underlying cause; involve occupational health
o Can be emergencies for dependants, for themselves or from post-ops (TABLE ON PG 490)
o Before doctor can do statement of fitness to work (either completely can’t work or only under certain circumstances) for pt they themselves must claim 7 days incapacity
Fitness to drive bans for different diseases?
o TIA/stroke = 1 month, diabetes if insulin controlled then assessed every 1/2/3yrs for control, epilepsy = 1 year after last attack, first fit then 6 months, sleep apnoea don’t drive, significant head injury stop for 6 months, psychosis = 3 months, alcohol/drugs = 6months-1yr, check about drugs and if can affect driving (benzos, methadone, morphine, other opiates cannot drive), old age
Fitness to fly bans for different diseases?
o Most with cardiac are ok
o Mainly haematological like severe sickle cell where reduced oxygen carrying capacity may need O2 or cannot
o Not after 36wks pregnant
o COPD may need extra O2, pneumothorax until 2wks after successful drainage, resp infection until is resolved
o Can’t if disturbed/unpredictable psychotic behaviour
o Otitis media/sinusitis advised against
o 10days wait for chest/abdo surgery, 24 hours for laparoscopy, 7 days for neurosurgeryo
Fx – 24 hours if less than 2 hours and 48 if more
o Most need to take necessary PRN meds
Function of a CVD risk assessment?
• Reduce risk of cvd like coronary HD, stroke, TIA, peripheral artery disease and improve QOL and life expectancy
Non-modifiable RFs of CVD?
high age, male, FH, ethnicity
Modifiable RFs of CVD?
smoking, low HDL cholesterol, sedentary lifestyle, unhealthy diet, alcohol excess, obesity
Comorbidities with CVD?
hypertension, diabetes, CKD, dyslipidaemia, AF, SLE/RA, severe mental health problems
Other RFs for CVD?
low income and social deprivation
Primary, secondary and population-based prevention for CVD?
o Primary – NHS health check programme for 40-74yrs every 5yrs
o Secondary – RF modification and cardiac rehab for those with disease
o Population-based – promote walking and cycling for recreation
QRISK2 factors it assesses for CVD and advice for outcomes?
QRISK 2 = age, sex, ethnicity, postcode, smoking, FH, PMH, bp, BMI, HDL-cholesterol ratio as percentage likelihood to get CVD in next 10 yrs
o <10% - reduce RFs
o >10% - advice on lifestyle and recommend statin
Pros of smoking cessation on population level?
less lung cancer; less chronic lung disease; less CVD; fewer pregnancy problems (pre-eclampsia, IUGR, preterm delivery, neonatal and late foetal death); less risk of passive smoking (cot deaths, lung disease and lung cancers); return of taste, smell and relative wealth
Steps for smoking cessation?
ask about it in consultations and greet any success with enthusiasm; advise according to needs; motivate by getting pt to list advantages; assist in practical ways (get quit date, get rid of all smoking equipment, inform friends of change); arrange follow-up and give messages of encouragement
Nicotine replacement therapy overview?
increases quit chance by 1.5x; higher doses for heavier; 3 months and taper for 2wks; don’t give for cardiac problems
Varenicline/Champix overview?
over 18s and take 1wk before quit date and taper up each day before quite date; cessation rate 2x increase; stop if agitated, depressed or suicidal
Bupropion/Zyban overview?
over 18s 1-2wks before quit date; cessation increased 2x; don’t give if eating disorders, bipolar or epilepsy
More at risk for alcohol and substance misuse?
lower socioeconomic and mental health
What is 1 unit of alcohol?
10ml or 8g of ethanol
Daily and weekly recommended limits for alcohol?
14 units per week = recommended; binge = more than 8 units
What is hazardous/harmful drinking?
excess intake causing potential/actual harm without dependence
What is alcohol dependence?
alcohol reduced then experience withdrawal symptoms
Questionnaires for alcohol?
CAGE and FAST questionnaire and also AUDIT
Ways to help cut down?
more non-alcoholic drinks; sip; don’t drink alone; limit opening hours; don’t buy yourself a drink when it is your turn to buy the round; go out to pub later; take rest days
Goals for reaching sobriety?
alcohol diary; teach how to estimate weekly intake; feedback; enlist family support; rewards for sobriety; community alcohol and treatment teams
Management of drug misuse?
reduce drug-related mortality and infections; decrease criminal activity; identify IVDUs; assess health and willingness to modify behaviour
Education for drug misuse?
safer routes of administration (smoking or rectal for heroine not injected); risks of psychosis and contamination; safe injecting, OD practice and first aid; safe sex practice; driving discuss; check for blood bourne diseases and hep B immunise
Treating the dependent?
set realistic goals; set conditions for acceptable treatment and behaviour; review regularly; refer to community substance misuse team; report to relevant authorities
When can orlistat be given?
BMI over 34
Risks from high BMI?
mortality, T2DM, gallbladder disease, dyslipidaemia, insulin resistance, breathlessness, sleep apnoea; less = CHD, hypertension, OA, gout, cancer, reproductive hormone abnormal, impaired fertility, PCOS, low back pain, stress incontinence, surgical risks, suicide, bullying
Causes of obesity?
physical inactive, cultural, low education, genes, smoking cessation, childbirth, drugs (steroids), endocrine
Management of obesity?
best in childhood prevention; assess willingness to change, eating, physical exercise, psych distress, social and family; aim for 0.5-1kg per week loss; group therapy (Weight Watchers); surgery if everything else failed and over 40 BMI
Measuring obesity?
BMI or waist circ
Diets recommended?
Mediterranean and 5/2
Treatment methods of obesity?
- Hba1c over 80 maybe think definitely metformin straight away; if under probs should but can think about it and not imminent but maybe in next week or so
- Self-management is very effective for treating diabetes and bp – lifestyle changes and adhering to meds
- If lots of polypharmacy and pt has high bp and diabetes with hypotension then probs stop the CCB first
- Don’t jump the gun if something like eGFR has decreased with bp meds if hf well controlled as if is stable then should be ok and eGFR decreases anyways with age; if affecting the kidney function then decrease ACEi first and maybe diuretic
- If eGFR is less then 30 then must stop metformin as can go into acidotic state from lactic acidosis
What is sleep insomnia and its cons?
disturbed or inadequate sleep; increases with age; cons = affects conc, memory, ADLs, relationship problems
Causes of insomnia?
travel, stress, shifts, small children, mental health problems, drugs (steroids), pain, pruritus, tinnitus, nocturia, OSA
Definition of good sleep?
<30 min fall asleep, 6-8hours, <3 awakenings, feeling well and refreshed waking up
Management of insomnia?
evaluate if unrealistic sleep expectations; eliminate physical problems (treat asthma etc and painkillers to last night); treat psych problems; relaxation techniques; consider drugs (hypnotics)
