GP + general med Flashcards
CVD and public health
What is first-line treatment for hypertension in people over 55?
Calcium channel blockers eg amlodipine (1st line) or nifedipine (2nd line).
What is the difference between dihydropyridines and non-dihydropyridines?
They are both CCBs. Dihydropyridines such as amlodipine and nifedipine are potent vasodilators. They are used more for hypertension. Non-dihydropyridines (verapamil, diltiazem) reduce cardiac conduction and contractility. They are used more for chronic stable angina.
Give two contraindications to using ACE inhibitors and why.
Do not use if RAS or AKI because they reduce the effectiveness of the kidney by inhibiting angiotensin II. (Patients with renal artery stenosis cannot constrict the efferent glomerular arteriole and rely on it being dilated. When ACE reduced AT2 activity, the glomerulus loses its capacity to dilate the efferent arteriole. The resistance and GFR fall due to decreased blood flow.)
In patients with severe RAS, ACEIs reduce glomerular filtration and are likely to cause severe and progressive renal failure.
Give two contraindications to using a thiazide-like diuretic and why.
Do not use in gout or hypokalaemia because they cause increased excretion of water and therefore potassium.
What is the first-line treatment for heart failure with preserved ejection fraction?
Manage comorbidities such as HTN, AF, IHD and diabetes in line with NICE guidance. Then offer cardiac rehabilitation.
What vaccinations should an 8-week-old have?
6-in-1: Diphtheria, tetanus, pertussis, polio, Hib, hep b.
Pneumococcal/ PCV
Rotavirus
Meningococcal B
What vaccinations should a 12-week-old have?
2nd 6-in-1
2nd Rotavirus
What vaccinations should a 16-week-old have?
3rd 6-in-1
2nd pneumococcal
2nd Men B
What vaccinations should a 12-13 month old have?
Hib/Men C
MMR (measles, mumps and rubella)
Pneumococcal booster
Men B booster
What does the 4-in-1 booster contain and when should children get it?
3 years 4 months, as it is the ‘pre school booster’.
Diphtheria, tetanus, pertussis, polio.
Name 5 notifiable diseases.
Encephalitis Meningitis Poliomyelitis Diphtheria Food poisoning Measles Mumps Rubella TB Pertussis Full list available at PHE.
What is the FeverPAIN score?
Score which helps determine how unwell an infant is. Fever during the previous 24 hours Purulence Attend rapidly (Symptom onset <=3 days) Very inflamed tonsils No cough/coryza.
What is safety netting and when should you do it?
If the infant is at a low risk on the traffic light score: responds normally to social cues, no resp/other problems, good circulation and hydration. Safety netting: Tell patient to come back if infant not improving, decrease wet nappies or fever every day for more than 5 days.
Call 999 if they become difficult to rouse, floppy, or develop a non-blanching rash.
Give 5 signs which would indicate intermediate risk of serious illness in a child with fever according to the traffic light tool.
Colour: Pallor reported by carer.
Activity: Not responding normally to social cues, not smiling, hard to wake, decreased activity.
Resp: Nasal flaring, tachypnoea (RR >50 if 6-12 months old or >40 is >12 months old); O2 sats <95% OA, chest crackles.
Circulation: Tachycardia (>160bpm <12 months, >150bpm <24 months, >140bpm <5 yrs), CRT >=3s, dry mucous membranes, poor feeding, decreased urine output.
Other: T >=39 in 3-6 month old rigors, fever >=5 days, swelling of limb or joint, non-weight bearing of a joint.
Give 5 signs from the traffic light tool which would indicate a need to refer an infant on for treatment.
Colour: Pale/mottled/ashen/blue
Activity: No response to social cues, appears ill to a healthcare professional, unrousable or only stays awake for a short time, weak/high-pitched/continuous cry.
Resp: Grunting, tachypnoea (RR >60), moderate/severe chest indrawing.
Circulation: decreased skin turgor
Other: T >=38 in <3 month old, non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurological signs/focal seizure.
These all indicate high risk.
What is child health surveillance?
Child health surveillance is the monitoring of the health of children, especially those in at-risk families, between birth and age five.
Give five key opportunities for assessment of children under five years.
Neonatal exam New baby review (around 14 days) 6-8 week examination 1 year health review Health review at 2-2.5 years
What happens at the 6-8 week baby check?
Check for: Congenital heart disease, developmental dysplasia of hip (DDH), congenital cataract, undescended testes
Record: Weight, head circumference, tone, spine examination, palpation of femoral pulses, assess for hernias, whether they are breast-fed.
Also an opportunity for parents to raise any concerns they may have.
What is the ‘red book’ and what does it contain?
The ‘red book’ is the PCHR - personal child health record - which is a national standard health and development record given to parents and carers at a child’s birth. It contains info about immunisations, reducing risk of certain diseases such as SIDS, hearing, eyesight, DDH and milestones.
Give five factors that would indicate an ‘at-risk’ family.
Both parents unemployed
Poor-quality/ overcrowded housing/ homeless
Low income
Neither parent has an educational qualification
Either parents has long-standing limiting illness, disability or infirmity/ addiction/ mental health problem
Give three disadvantages of teenage pregnancy compared to pregnancy over the age of 20.
Increased (3x) risk of postnatal depression
Increased (60%) infant mortality rate
Less likely to finish education
Increased risk of poverty, poor housing
Lower rates of economic activity
Cost to the economy in abortions, delivery and social security payments.
What is Gillick competency?
The capacity of under 16s to consent to treatment without the parents knowledge. A child is Gillick competent if they have sufficient understanding and intelligence to fully understand what is involved in a proposed treatment including the purpose, nature, likely effects and risks, success rate, and availability of other options. This is a decision-by-decision assessment.
What are the Fraser guidelines?
Guidelines which determine a child’s ability to consent to contraceptive or sexual health advice and treatment. Advice can be given if (UPSSI)
- Child has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment
- Cannot be persuaded to tell parents or allow you to tell them
- Very likely to begin or continue having sex with or without the treatment/advice
- Physical or mental health is likely to suffer without advice/treatment.
- The advice or treatment is in the patient’s best interests.
At what age is a child legally capable of consent to sexual activity?
- Intercourse with any under 13 is always rape. It is still an offence to have sex with an under 16 even if they consent.
At what age is a patient able to take medical decisions independently of their parents?
Between 16-18, depending on if they are considered competent - age is not the only determinant of competence.
What is the definition of health?
Not just absence of disease:
State of complete physical, mental and social wellbeing.
What is the Gini co-efficient?
Statistical representation of the nation’s income distribution among its residents - lower efficient means greater equality amongst people
What are the determinants of health? Give 2 for each category.
Biological: genetics, age, sex, ethnicity, birth weight/premature
Individual lifestyle: smoking, drinking, stress, development (early years), exercise, recreational drugs
Socioeconomic: peer pressure, education, employment, culture, wage, religion, existing disease exposure, access to health care
Environment: air quality, housing, housing stability, water and sanitation, travel, climate
What is epigenetics?
‘the study of how your behaviors and environment can cause changes that affect the way your genes work’ (CDC)
Ie - nurture part and how it affects nature.
The expression of the genome depends on the environment; Lived experience affects human biology.
What is allostasis?
Stability through change. The body’s ability to rise to a challenge.
What is allostatic load?
The price we pay for allostasis - long term overtaxation of our physiological systems leads to impaired health.
Eg, allostasis works to maintain posture and enable physical exertion, overactivation leads to htn, stroke and MI.; allostasis works to respond to pathogens, allostatic load leads to inflammatory disorders.
What is salutogenesis?
Favourable physiological changes secondary to experiences which promote healing and health.
What is primary prevention?
Aims to prevent a disease from becoming established
Aims to reduce or eliminate exposures and behaviours that increase risk of a disease
Can be aimed at individuals or population approach, e.g. immunisations
What is secondary prevention?
Aims to detect early disease and slow down or halt the progress of disease and maximise the chance of a complete recovery
What is tertiary prevention?
Aims to reduce the complications or severity of disease that has already been diagnosed and is symptomatic, by offering appropriate treatments or interventions
What is equality?
Treating everyone the same
What is equity?
Equal opportunity/support proportional to each persons need.
What is horizontal equity?
Equal treatment for equal need. Eg giving 2 people with mild hypertension the same medication that will help them both.
What is vertical equity?
Unequal treatment for unequal need. Eg giving more funding to poorer areas.
What is health improvement? Give an example.
Concerned with societal interventions (not primarily delivered through health services) aimed at preventing disease, promoting health, and reducing inequalities.
What is health protection? Give an example.
Concerned with measures to control infectious disease risks and environmental hazards
What is improving services concerned with? Give an example.
Concerned with the organisation and delivery of safe, high quality services for prevention, treatment, and care. Eg, GP consultations
Give 3 ways domestic abuse impact on health.
Traumatic injury following assault eg miscarriage, fracture
Somatic problems or chronic illness eg headaches, premature delivery
Psychological or psychosocial problems secondary to the abuse eg PTSD, anxiety
Affects child living with domestic abuse - self esteem, education
What is MARAC?
Multi-agency risk assessment conference - meeting with links up to date information about victims needs and risks directly to the provision of appropriate services and responses for the victim, child/ren and perpetrator.
What is the IVDA?
Service which works primary with women who are at the highest risk from domestic abuse in the city, helps them increase their safety by providing advocacy and advice around domestic abuse, safety planning, support through court proceedings and a voice in the MARAC process.
What is health psychology?
Health psychology emphasises the role of psychological factors in the cause, progression and consequences of health and illness.
Aims to put theory into practice by promoting health behaviours and preventing illness.
What are the 3 main categories of health behaviour?
Health behaviour: Behaviour aimed to prevent disease (eg eating healthily)
Illness behaviour: Behaviour aimed to seek remedy (eg going to the doctor)
Sick role behaviour: activity aimed at getting well (eg taking prescribed medications; resting)
What are health damaging behaviours?
Smoking, alcohol abuse, risky sexual behaviour, sun exposure, driving without a seatbelt
What are health promoting behaviours?
Taking exercise, healthy eating, attending health checks, medication compliance, vaccinations.
What is a population level intervention?
Health promotion - the process of enabling people to exert control over the determinants of health, thereby improving health. (PHE)
What is an individual level intervention?
Patient centred approach: care responsive to individual needs.
Give an example of health promotion.
Health promotion/awareness campaigns: change 4 life, 5 a day, stoptober, movember.
Promoting screening and immunisations - cervical smear screening, MMR vaccine
What would be the impacts of primary care intervention to reduce alcohol consumption on the individual, community and population?
Individuals behaviour - less alcohol consumption, individual health outcomes, domestic violence
Local community - local alcohol sales, alcohol-related crime and A+E events
Population level - national alcohol sales and consumption, statistics on alcohol related crime and A+E events, demographic patterns of liver cirrhosis.
[lecture]
What is it called when someone has inaccurate lower perception of risk?
Unrealistic optimism: individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility.
(Weinstein 1983)
Give 5 things that influence an individual’s perception of their risk.
Perceptions of risk influenced by:
-Lack of personal experience with the problem
-Belief that preventable by personal action
-Belief that if not happened by now, its not likely to
-Belief that problem infrequent
+health beliefs, situational rationality, culture variability, socioeconomic factors, stress, age.
Perception of risk impacts on medication adherence, keeping appointments etc.
How would you go about helping individuals to change their health behaviours?
Work with your patients priorities Aim for easy changes over time Set and record goals Plan explicit coping strategies Review progress regularly!!
Why is behaviour change important?
Changing behaviour can impact mortality and morbidity eg adherence to blood pressure medications, exercise -> reduced risk of CVD.
Relatively simple solution - cheaper and easier to change and with less side effects than secondary/tertiary interventions.
What are the main causes of death in smokers?
50% non smoking related
50% smoking related - cancer, COPD, heart disease
Single biggest cause of inequality in death rates between rich and poor in the UK.
Give 3 factors that increase the likelihood of smoking.
Poverty
Unemployment
Unmarried
Male
Give 4 economic impacts of smoking.
Economic - smoke breaks -> loss in productivity; absenteeism, cost of cigarettes, 5% of healthcare costs, cigarette butt cleaning, fires, loss of economic output from death of smokers and passive smokers.
What is the NCSCT and what does it do?
A social enterprise to support the delivery of effective evidence-based tobacco control programmes and smoking cessation interventions provided by local stop smoking services.
Delivers training and assessment programmes
Provides support services for local and national providers
Conducts research into behavioural support for smoking cessation.
In terms of a health needs assessment, what are the definitions of need, demand and supply?
Need = ability to benefit from an intervention
Demand = what people ask for
Supply = what is provided
Example of all overlapping = cancer treatment.
Example of need without demand = vaccination
Example of demand without need = abx for viral infection
What is the difference between a health need and a health care need?
Health need = general need for health, measured using mortality, morbidity, socio-demographic measures
Health care need = specific ability to benefit from an intervention/service.
Health needs assessment covers both
What is a health needs assessment, what is it done for and what are the 3 approaches?
Assessing the felt, expressed, normative and/or comparative need of a population or subgroup (eg manor practice population; a condition (eg COPD), or for an intervention (eg coronary angioplasty). Approaches: Epidemiological Comparative Corporate
What is the name for an individuals perception of variation from normal health?
Felt need
What is the term for an individual seeking help to overcome variation in normal health (demand)?
Expressed need
What is normative need?
Professional defines intervention appropriate for the expressed need.
What is comparative need?
Comparison between severity, range of interventions, and cost.
What is the epidemiological approach to health needs assessment? Give 3 potential limitations.
Epidemiological approach:
Define the problem and size of problem using existing data on incidence and prevalence, morbidity and mortality, life expectancy, services available.
Pros: existing data, can evaluate services by trends over time.
Problems -
Required data may not be available or of adequate quality.
Evidence base may be inadequate
Does not consider FELT NEED
Explain what is meant by the comparative approach to HNA. What is its limitations?
Compares services received by a population (or subgroup) with others - spatial, social (age, gender, class, ethnicity). May examine health status, service provision, service utilisation and health outcomes - mortality, morbidity, QoL, patient satisfaction.
Pros: quick and cheap is data available, indicates whether provision or health is better or worse than comparable areas.
Problems - may not yield what the most appropriate level of provision or utilisation should be, data may not be available, data may be of variable quality, may be difficult to find a comparable population.
What is the corporate approach to HNA and what are the issues with it?
Assessment by politicians, professionals, providers, press, patients - focus groups, public meetings etc. Many stakeholders, decided by ‘the people’
Advantages: based on felt and expressed need, recognises expertise of those ‘on the ground’, takes into account wide range of views
Problems - may be difficult to distinguish need from demand, groups may have VESTED INTERESTS, may be influenced by political agendas, dominant personalities may have undue influence.
What are the theories of causation of health inequalities?
- Psychosocial: stress results in inability to respond efficiently to body’s demands. Impact on blood pressure, cortisol levels and inflammatory and neuro-endocrine response.
- Neo-material: More hierarchal societies are less willing to invest in the provision of public goods. Poorer people - less material goods, lower quality.
- Life-course: combination of the above. Cr
Critical periods - factors possess greater impact at different points in the life course.
Accumulation - hazards and their impacts add up - hard work leads to injuries resulting in disability.
