GP and community 2 Flashcards
what are the two ways of inducing immunity ?
active immunity - induced using inactivated or attenuated live organisms or their products, acts by inducing cell-mediated immunity and serum antibodies.
Passive immunity - results from injection of immunoglobulin - immediate protection but only last a few weeks
what is herd immunity?
Describes how a population is protected from a disease after
vaccination by stopping the pathogen responsible for the infection
being transmitted between people - in this way even people who
cannot be vaccinated (immunocompromised) can be protected
By being vaccinated an individual is not only protected from being
infected themselves but then then also cannot pass this infection
onto other people where it may cause severe disease
For herd immunity to be effective in a large proportion (80-95%) of
the population needs to be vaccinated
what are some reasons for vaccination uptake and drivers?
Wakefield MMR controversy seriously impacted uptake
access to healthcare has an impact on uptake
emerging group of affluent parents who are opting out of vaccination programs for various reasons - they don’t believe in them, they think they may harm children, they believe they can protect their children
what system can you use to assess a child with a fever?
traffic light system
green = low risk
amber = intermediate risk
red=high risk
when would you put a child into the green section of the traffic light system and how would you manage?
- they have normal skin colour
- they respond normally to social cues
- they are content/smiles
- stays awake or awakens quickly
- strong normal cry/not crying
- normal skin and eyes
- moist mucus membranes
LOW RISK of serious illness - manage child at home with advice and a safety net
advice such as regular fluids and keep an eye out for signs of dehydration
when would you put a child into the amber section of the traffic light system and how would you manage?
- pallor
- not responding normally to social cues
- no smiles
- wake only with prolonged stimulation
- decreased activity
RESP signs - nasal flaring Tachypnoea (6-12 months >50 RR, >12 months RR> 40) - O2 sats less than 95% on air - crackles in the chest
Circulation and hydration
- tachycardia (<12 months - >160bpm, 12-24 months - >150 bpm, 2-5 years- >140 bpm)
- cap refil > 3 seconds
- dry mucous membranes
- poor feeding in infants
- reduced urine output
3-6 months - temp >39 fever for more than 5 days rigors swelling of a limb or joint non-weight baring limb
*intermediate risk of serious illness - seek further help
treat cause
when would you put a child into the red section of the traffic light system and how would you manage?
- pale/mottles/ashen/blue • No response to social cues • Appears ill to a healthcare professional • Does not wake or if roused does not stay awake • Weak, high-pitched or continuous cry
Resp
- grunting
- tachypnoea - RR>60
- moderate/severe chest indrawing
- reduced skin turgor
- <3 months temp greater than 38
- non-blanching rash
- budging fontanelle
- neck stiffness
- focal neurological signs/seizures/status epilepticus
**high risk of serious illness - urgent assessment within 2 hours
what are some common causes of pyrexia?
childhood infections such as chickenpox, croup, measles, tonsillitis
consider UTI if no localising symptoms/ signs
think of TB and endocarditis - especially in high risk (immunocompromised patients)
think tropical diseases e.g. malaria in those returning from holiday
other causes: malignancy such as lymphoma or leukaemia, immunological cause such as Kawasaki disease
what are the pros and cons of barrier contraception?
benefits: used only during intercourse, reduces STI transmission and rarely any side effects
CONs: can break, split or tear, may interrupt intercourse, require some degree of technique, allergies e.g. latex
how does the combined pill act as a contraceptive?
acts to inhibit ovulation
why should you not prescribe COCP?
if one risk factor present with caution, if greater than one then you should avoid
Smoking > 15/day
Controlled hypertension
mmobility e.g. wheel chair use
Family history of venous thromboembolis
elative < 45yrs
BMI > 30kg/m2 (caution), if >35 avoid
Age ≥ 35yrs (caution), if ≥ 50 yrs avoid
Avoid if prothrombotic coagulation abnor
Leiden, antiphospholipid antibodies
Avoid if valvular/congenital heart disease with history of
complications e.g. pulmonary hypertension or AF
History of CVD including stroke/TIA, migraine, IHD, peripheral
vascular disease
Avoid if current breast cancer or carrier of BRCA1 or BRCA2
Avoid in liver disease e.g. active/flare of viral hepatitis, liver tumour or
severe cirrhosis
what are the benefits of the COCP?
- Does not interrupt intercourse
- Can be stopped at short notice
- May make periods more regular, lighter and less painful
- May reduce risk of ovarian, endometrial & bowel cancer
- May have therapeutic benefit in gynaecological disorders
what are the limitations of the COCP?
- Effectiveness is reduced if pill is forgotten - COMPLIANCE IS
MAJOR ISSUE & responsible for failure - S/E’s include headaches, nausea and breast tenderness
- Increases risk of venous thromboembolism and stroke - should
advise to keep legs moving and drink lots of fluids when
travelling more than 3 hrs to reduce DVT risk - Potentially increased risk of breast cancer
- Does not protect from STIs
what advice should be given on taking the COCP?
- If started within the first 5 days of the cycle then there is no
need for additional contraception - If it is started at any other point in the cycle then alternative
contraception should be used e.g. condoms for the first 7 days - Should be taken at the same time every day
what may reduce the efficacy of the COCP ?
- Vomiting within 2 hours of taking pill
- Taking medication that induce diarrhoea or vomiting e.g.
orlistat - Taking liver enzyme-inducing drugs e.g. rifampicin (antiinfective), ritonavir (anti-viral), St John’s wort, anticonvulsants
e.g. carbamazepine or modafinil
Note: sodium valproate does not affect pill efficacy
what happens if a pill is missed when taking the COCP?
- If 1 pill is missed (at any time in the cycle):
• Take the last pill even if it means taking two pills in one
day and then continue taking pills daily, one each day
• No additional contraceptive protection needed - If ≥ 2 pills are missed (i.e. pills are > 48 hrs late at any 1 time):
• Take the most recent pill missed even if it means taking
two pills in one day, leave any earlier missed pills and
then continue taking pills daily, one each day
• The woman should use condoms or abstain from sex until
she has taken pills for 7 days in a row - If pills are missed in week 1 (Days 1-7): EMERGENCY
CONTRACEPTION should be considered if she had unprotected
sex in the pill-free interval or in week 1 - If pills are missed in week 2 (Days 8-14): After seven
consecutive days of taking the COCP there is NO NEED for
emergency contraception - If pills are missed in week 3 (Days 15-21): She should finish the
pills in her current pack and start a new pack the next day; thus
omitting the pill free interval
how does the progesterone only pill work?
prevents ovulation, fertilisation and implantation
what are the benefits of the POP?
- Suitable for those who cannot take oestrogen
- Do not need to remember to start/stop since taken without
breaks - Does not interrupt intercourse
- Can be stopped at short notice
what are the limitations of the POP?
- Protection reduced if forgotten to take
- May cause irregular bleeding, amenorrhoea or more frequent
bleeding - Vomiting and diarrhoea may affect protection
- No protection from STIs
how does progesterone injection work?
prevents ovulation
benefits and limitations of injected progesterone for contraception?
benefits - do not need to remember to take daily, does not interrupt intercourse, can be stopped at short notice, reduces risk of ectopic pregnancy and endometrial cancer
Limitations - menstrual irregularity, injection, weight gain, unpredictable return of fertility, increased risk of osteoporosis
what are the different forms of long-acting reversible contraceptives?
- implant e.g. Nexplanon (inhibits ovulation)
- hormone intrauterine system - Mirena (prevents fertilisation and implantation)
- intrauterine contraceptive device e.g. copper coil (prevents fertilisation and implantation)
what are the pros and cons of the implant?
Benefits:
- Last for 3 years - thus no compliance issues
- Reversible
- Does not interrupt intercourse
Limitations: - May cause irregular bleeding, amenorrhoea or more frequent bleeding - Can cause or worsen acne - Requires training to insert and remove - Infection risk - No STI protection
what are the pros and cons of the IUS?
Benefits: - Lasts for 3-5 years - Reduces BLEEDING, ectopic pregnancy risk (compared to IUCD), dysmenorrhoea - Provides endometrial protection
Limitations:
- May cause erratic bleeding
- Can cause acne, headaches and breast tenderness
- Risk of infection and or pain during insertion and removal
- Increases infection risk -> pelvic inflammatory disease -
related to existing carriage of STIs (screen for STIs before
insertion)
what are the pros and cons of the IUD?
Benefits:
- Lasts for 10 years
- No systemic side effects
- Effectiveness unaffected by other medications
Limitations:
- Heavy periods
- Problems with insertion and removal
- Ectopic pregnancy risk
- Increases infection risk -> pelvic inflammatory disease -
related to existing carriage of STIs (screen for STIs before
insertion)
what are the different types of emergency contraception?
- levonorgestrel (levonelle)
- Ulipristal acetate (ella one)
- copper coil
when can levonorgestrel be used? and what are its side effects?
- Can be given up to ≤ 72 hours (3 days) after unprotected intercourse, but
is effective for 96 hours (4 days) - Can be used more than once if >1 episode of unprotected intercourse in
a single cycle - Inhibits ovulation, contains progesterone
- S/E’s; headache, nausea and menstrual disturbance (a short withdrawal
bleed is common
when can ulipristal acetate be used? and what are its side effects?
- Can be used ≤ 120 hours (5 days) after unprotected intercourse
- Can only be used more than once per cycle
- Progesterone receptor modulator
- Inhibits ovulation
- May reduce the effectiveness of hormonal contraception - COCP/patch/ring should be started/restarted 5 days after having ulipristal & barrier
methods should be used during this period - Breastfeeding should be delayed for one week after taking
- Contraindicated in those with severe asthma that’s insufficiently controlled by oral glucocorticoids
- S/E’s; headache, nausea (if vomits within 3 hours then should return to
take another tablet + anti-emetic) , abdominal pain & menstrual disturbance (next bleed can be early or late)
how does the copper coil act as emergency contraception?
- Can be used ≤ 120 hours (5 days) after unprotected intercourse at any
time of the cycle - MOST EFFECTIVE of the three (< 99%)
- Prevents fertilisation
- CANNOT be offered to women presenting more than 5 days after the earliest expected day of ovulation (day 19 of a 27 day cycle) who have had unprotected intercourse more than 5 days previously
- Can be left in as long term method of contraception, or removed at next menstrual period
what are the Fraser guidelines?
specific to consent to contraception
* children under the age of 13 are unable to consent for sexual intercourse so consultation in this age group should trigger child protection issues
The following requirements should be fulfilled for them to be given contraception
- The young person understands the professional’s advice
- The young person cannot be persuaded to inform their parents
- The young person is likely to begin, or to continue having, sexual
intercourse with or without contraceptive treatment
- Unless the young person receives contraceptive treatment, their physical
or mental health, or both are likely to suffer
- The young person’s best interests require them to receive contraceptive
advice or treatment with or without parental consent
what are the two types of consent?
expressed (by signing a consent form)
Implied (i.e. complies with procedure without ever specifically agreeing to it)
for consent to be valid patients need to:
- be competent to make the decision
- have received sufficient information to take it
- not be acting under stress
what does the four part capacity test involve?
- Do they UNDERSTAND the information relevant to decision
- Can they RETAIN that information long enough to decide
- Can they use of WEIGH UP the information to decide
- Can they COMMUNICATE their decision?
what is the Gillick competence?
consent in children <16 years
- at 16 years or older a young person can be treated as an adult and can be presumed to have capacity
- children under 16 can consent if they are able to understand the nature, purpose and likely effects and risks of a proposed treatment as well as its chances of success and the availability of other options
- if a child passes the Gillick test - they are considered Gillick competent to consent to that medical treatment or intervention
- it is only valid if given voluntarily and not under the influence or pressure by anyone else
- each individual decision requires assessment of a gillick competence
- When a competent child refuses treatment, a person with parental responsibility or the court may authorise investigation or treatment
which is the child’s best interests
what principles can be used to disclose patient information ?
Caldicott principle for disclosure of patient information:
- justify the purpose - patients may agree to it, implied consent applies when patients are aware that personal information may be shared but they make no objection, patients must have a realistic opportunity to refuse.
- you should not use patient identifiable information unless it is absolutely necessary
- use minimum amount of patient identifiable information
- access to patient identifiable information should be on a strict need-to-know basis
what situations can confidentially be breached?
- emergencies - to prevent or lessen a serious and imminent threat to life or health of the individual concerned or another person
- statutory requirement
- public interest
- reporting notifiable diseases
- required by court or tribunal
- adverse drug reactions
- complaints
when should you offer a chaperone?
• When carrying out an intimate examination you should offer the patient the
option of having a CHAPERONE (impartial observer) wherever possible
• This applied whether or not you are the same gender as the patient
what should a chaperone do ?
- Be sensitive and respect the patients dignity and confidentiality
- Reassure the patient if they show signs of distress or discomfort
- Be familiar with the procedures involved in a routine intimate
examination - Stay for the whole examination and be able to see what the doctor is
doing, if practical - Be prepared to raise concerns if they are concerned about the doctor’s
behaviour or actions
what is the antenatal child health surveillance?
- Ensure intrauterine growth
- Check for maternal infections e.g. HIV
- Ultrasound scan for fetal abnormalities
- Blood tests for Neural Tube Defects
what is the newborn child health surveillance?
- Clinical examination of new born
- New born Hearing Screening Programme e.g. ooo-acoustic emissions test
- Give mother Personal Child Health Record
what should be done in the first month of life for the health surveillance of the child?
Heel prick test (tests for 9 serious conditions) - usually around day 5-9
- congenital hypothyroidism
- phenylketonuria
- CF
- sickle cell
- other metabolic disease
in the first few months of life what health surveillance should children have
- Health visitor input
- GP examination at 6-8 weeks
- Routine immunisations
at pre-school age what health surveillance should children have?
- national orthoptist-led programme for pre-school vision screening
what ongoing health surveillance should children have?
- Monitoring of growth, vision & hearing
- Health processionals advice on immunisations, diet & accident
prevention
Appendicitis - pathophys pres differentials ix management complications
Patho - gut organisms invade the appendix wall after lumen obstuction. 10-20 year olds.
pres - umbilical pain to MCBURNEYS point, pain is worse on coughing/palpating. constipation, vomiting, loss of appetite, tachycardic, shallow breaths, lying still.
differentials - UTI, crohns, meckles diverticulum, gastritis, pregnancy, terminal ileitis.
Ix - exam ROSVIG sign (palpation in the LIF causes pain in the RIF). Bloods - ESR/CRP, neutrophil leukocytosis, USS
Mx - apendicectomy, abx - IV cefuroxime, metrondidazole.
Comps - perf, peritonitis, sepsis
Crohns
mouth to anus.
commonly seen in terminal ileum and colon.
Transmural - this is why prone to strictures, fistulas, adhesions
Skip lesions (non-continuous). Goblet cells and granulomas.
Pres - weight loss, lethargy, diarrhoea (bloody), abdo pain, skin tags/ulcers.
Ix - raised CRP/ESR, raised faecal calprotectin, anaemia, low B12/vit D.
Management - surgery?
Ulcerative Colitis
Always starts at rectum, never spreads beyond ileocaecal valve and is continuous.
Peak incidence = 15-25 and 55-65.
pres - bloody diarrhoea, urgency, tenesmus, abdo pain (LLQ).
Patho - submucosa, crypt abscesses, uveitis.
IX - barium enema - loss of haustrations, pseudopolyps, drainpipe colon.
Mx - remove colon?
features shared by UC and Crohns
diarrhoea, arthritis, erythema nodosum, pyoderma gangrenosum.
Hypothyroidism
aetiology
aetiology - maldescent of thyroid, autoimmune (Hashimotos thyroiditis), dyshormonogenesis, TSH deficiency, iodine deficiency.
pres -
CONGENTIAL - faltering growth, feeding problems, prolonged jaundice, constipation, pale, cold, mottled, goitre, hoarse cry, umbicial hernia, delayed development.
ACQUIRED - bradycardic, cold intolerance, loss of apetite, weight gain, constipation, menorrhagia, infertile, early menarche, dry skin, brittle hair, short, myopathy, depression, low conc.
Diagnosis - Guthrie, TFT (TSH, T3/4), high CK, high cholesterol, anaemia
Mx - levothyroxine
Hyperthyroid
Aetiology - graves disease (autoimmune have autoantibodies - MOST COMMON), toxic multinodular goiter, toxic adenoma, drugs - iodine supplements, amiodarone.
Pres - increased appetite, weight loss, diarrhoea, steatorrhoea, anxious, irritable, low conc, insomnia, tachy, palps, AF, oligomenorrhoea, infert, lid lag + retraction, exophthalmos, opthalmoplegia, pretibial myoxedema, muscular myopathy, tremor, alopecia, fine hair, heat intolerance, sweating.
Diagnosis - TFT - TSH/T3/4. Autoantibodies for thyroid gland.
Mx - carbimazole, propylthiouracil, atenolol (BB), radioiodine, thyroidectomy.
what is thyrotoxic storm??? (and im not talking about the weather ROTFL)
hyperthyroid crisis caused by exacerbation. Characterised by decompensation of >/=1 organ system in poorly/untreated hyperthyroid.
Most commonly seen in graves.
Precipitants - infection, recent trauma/surg/childbirth, vascular (MI/stroke/PE), DKA, hypoglycaemia, withdrawal/non-compliance with meds.
Pres- hyperpyrexia >41 degrees!!!!! ITS GETTING HOT JHEEZ, dehydration, HR - >140bpm, arrhythmia, hypotension, congestive HF, N+V+D, juandice, abdo pain, confusion, agitation, seizures, delirium, psychosis, coma… DEATH…..
Ix - TFT - T3+T4 = high, TSH = low, bloods - LFT, renal, U&E, CK, Ca, BM, ABG, Infection screen, ECG, CXR.
Management - paracetamol (for that fever!!), resus- Oxygen, fluids, antithyroid shit - carbimazole, propylthiouracil (fuck am I spelling that right in the exam lolll). BB - propanolol, corticosteroids as blocks T4 -T3.
After 4 hrs - Lugol’s solution - aqueous iodine oral solution.
No improvement in 2 days? exchange transfusion, haemodialysis. Treat cause.
AKI
a reduction in renal function following an insult to the kidneys.
Aetiology - prerenal - hypovolaemia secondary to diarrhoea/vomiting, renal artery stenosis. Intrinsic - glomerulonephritis, acute tubular necrosis (ATN), rhabdomyolysis. post renal - kidney stone in ureter or bladder, benign prostatic hyperplasia.
RF- CKD, other organ failure, history, drugs - NSAIDs, aminoglycosides, ACEi, ARBs, diuretics, >65yrs
pres - reduced urine output, pulm + peripheral oedema, arryhthmias, uraemia (pericarditis, encephalopathy).
IX - U+E’s - na, K, urea, creatinine increase, urinalysis, renal USS.
Mx - largely supportive, careful fluid balance. review meds, refer to specialist, stop causative agent.
VTE risk factors
age obesity fhx pregnancy (esp in puerperium) immobility hospitalisation anaesthesia thrombophilia HF antiphospholipid syndrome polycythaemia nephrotic syndrome sickle cell MEDS - COCP, HRT, tamoxifen, olanzapine
Iron deficient anaemia
highest cause in school children of anaemia
aetiology - excessive blood loss, inadequate intake, poor intestinal absorption),, increased iron supplements.
pres - fatigue, SOB, palps, pallor, koilonychia (spoon shaped nails), hair loss, atrophic glossitis, angular stomatitis.
IX - history, FBC (hypochromic microcytic anaemia), serum ferritin (low), total iron binding capacity (high), blood film - anisopoikilocytosis.
Management - treat cause, oral ferrous sulphate, iron rich diet (dark leafy green veg, meat, iron-fortified bread).
side effects of steroids
- cardiovascular - htn, cardiomyopathy
- endocrine - diabetes
ocular - cataracts and glaucoma
msk - osteporosis, growth stunting, proximal myopathies
psych - depression and mania
bruising, pancreatitis and cushings
extra-intestinal features of IBD
- skin - pyoderma gangrenosum, erythema nodosum
- joints - arthritis, ankylosing spondylitis
- ulcers
- eyes - scleritis, uvetitis
- osteoporosis
- kidney stones
- gall stones and primary sclerosis cholangitis
- Blood - clots/DVT
- iron deficient anaemia
what are the different types of resp failure?
Type I respiratory failure involves low oxygen, and normal or low carbon dioxide levels.
Type II respiratory failure involves low oxygen, with high carbon dioxide.
amiodarone s/e
Arrhythmias; hepatic disorders; hyperthyroidism; nausea; respiratory disorders; skin reactions
pneumonia assessment scale in community and admission
CRB 65 (updated NICE) C = confusion (= 8/10 AMT) R = resp rate >30/min B = BP <90/60 65 = age >65
(in hospital + the U = urea >7mmol/l)
management - 2 = hospital otherwise stay at home
3 = ITU
management of mild CAP
mod CAP
high CAP
amox
amox + macrolide (clarythromycin/erythromycin)
co-amox + macrolide
