GP/ILA Flashcards
What s the NICE pathway for hypertension?
First interaction >140/90 mmhg
- Then offer ABPM to confirm diagnosis
What is stage 1 hypertension?
140/90 mmhg
ABPM= 135/85
What is the treatment of stage 1 hypertension?
Lifestyle modifications
What lifestyle modifications are used to treat hypertension?
- Diet + exercise
2.Low sodium intake
3.Low alcohol consumption
4.. Discourage excess consumption of caffeine
5.Stop smoking
Any patient with Stage 1 HTN plus comorbidities should be treated as Stage 2 HTN.
List some examples of these comorbidities.
- target organ damage
-established CVD
-renal disease
-diabetes
-Qrisk3 of >10%
What is stage 2 hypertension?
160/100 mmhg or ABPM 150/95
What is the 1st line treatment for Stage 2 HTN in a person under 55 years or diabetic?
ACE-I
- ramipril
OR
ARB - candesartan
What is the 2nd line treatment for Stage 2 HTN if a person is under 55y or diabetic and already on an ACEi?
Add calcium channel blocker - Amlodipine
What is the 3rd line treatment for Stage 2 HTN?
this is the same for under and over 55s and for Afro-Caribbeans
Add thiazide like diuretic
What is the 4th line treatment for Stage 2 HTN if a pt’s Potassium is below 4.5mmol/l?
Spironolactone
What is the 4th line treatment for Stage 2 HTN if a pt’s Potassium is above 4.5mmol/l?
Increase dose of thiazide like diuretic- indapemide
What is the first line treatment of stage 2 hypertension of >55 or Black African?
CCB - amlodipine
What are the causes of hypertension?
primary - idiopathic
Secondary causes - pregnancy, Cushing’s, conns, CKD
What are the risk factors of hypertension?
- increasing age
-obesity
-smoking
-Diabetes
-Black ethnicity
-FHx
What further investigations are needed in people with hypertension?
- urine sample for albumin:creatinine ratio and test for haematuria
- Measure HBA1C, eGFR, total cholesterol and HDL cholesterol
-Examine for retinopathy
-Arrange an ECG
What is drug induced impotence?
The influence of drugs on neurogenic, hormonal and vascular mechanisms may result in decreased libido and impotence
What are the side effects of ACE-I?
- vomiting
- chest pain
- dry cough - ramipril
- hypotension
- headache
- angina
- alopecia
What are the side effects of CCB?
- abdo pain
- leg swelling
3.drowsiness
4.headache - nausea
What are the side effects of ARB?
- abdo pain
- back pain
- diarrhoea
- headache
- hypotension
- hyperkalaemia
What are the side effects of diuretics?
- erectile dysfunction
- dizziness
- headaches
What are the side effects of beta blockers?
- ED
2.Bradycardia - confusion
- depression
- diarrhoea
What is heart failure?
Where the heart is unable to fill or eject blood
What is ejection fraction?
% of blood leaving heart during each contraction
What is heart failure with reduced ejection fraction?
Systolic HF - pump dysfunction
What are the causes of HF with reduced ejection fraction?
- Reduced contractility due to MI or myocarditis
- Reduced blood supply to the heart due to CAD
3.Increased afterload due to hypertension
4.Impaired mechanical function due to valve disease
What is HF with preserved ejection fraction?
Diastolic HF - filling dysfunction
What are the causes of HF with preserved ejection fraction?
- Restrictive cardiomyopathy due to sarcoidosis
- Valve disease
- Hypertension
- Ventricles noncompliant and unable to fill during diastole
What are the different types of HF?
- Biventricular heart failure
- Cor pulmonale- HF secondary to any cause of pulmonary arterial hypertension
3.Left-sided HF = impaired ability of left ventricle to maintain adequate cardiac output without an increase in left sided filling pressures - Right sided HF= Impaired ability of the right ventricle to deliver of blood flow to the pulmonary circulation and increased right atrial pressure
What are the RF of Heart Failure?
- cardiac disorders- IHD, valvular heart disease, HTN, LV hypertrophy
- Other chronic disease = diabetes, obesity, chronic lung disease
-Toxins- smoking, illicit drugs
What are the complications of heart failure ?
- Cardiogenic shock
-Arrhythmias -AF - Biventricular failure
-End of organ damage -CKD
What are the Signs & symptoms of HF?
- orthopnoea
-Paroxysmal nocturnal dyspnoea
-Breathless
-Ankle swelling
-Fatigue
-Tachycardic
-Raised JVP
-Ascites
What is the NICE pathway for Heart Failure?
Has the patient had a previous MI?
Yes -> Urgent Transthoracic Echo (TTE)
No -> measure serum BNP
> Above 4000pg/ml -> urgent TTE
> 100 - 4000pg/ml -> TTE within 6 weeks
You suspect a patient is in heart failure. What investigations should you do?
12 lead ECG
CXR
Bloods
Urinalysis
Peak flow / spirometry
What would you see on a CXR if a patient had heart failure?
Alveolar oedema (Bat’s wings)
Kerley B lines
Cardiomegaly
Pleural effusion
Which bloods should you order if you suspect Heart Failure?
FBC
U+Es
LFTs
TFTs
eGFR
Lipid profile
Glucose
Describe Stage 1 of the NYHA classification of Heart Failure
No symptoms or limitation to daily activities
Describe Stage 2 of the NYHA classification of Heart Failure.
Mild symptoms and slight limitation of daily activities
Describe Stage 3 of the NYHA classification of Heart Failure.
Marked symptoms, limitation on daily activities, only comfortable at rest
Describe Stage 4 of the NYHA classification of Heart Failure.
Severe symptoms, uncomfortable at rest
What is the 1st line management for Heart Failure?
ACEi + Beta blocker
> When starting ACEi, measure U+Es, eGFR
What treatment is given for symptomatic relief of HF?
Loop diuretic- furosemide
= for breathgless/oedema
What further treatment can be given for Heart failure?
- spironolactone - if symptoms persist
-Digoxin
-Hydralazine with Nitrate may be of particular use in Afro-Caribbean patients
Who is involved in the management of a patient with Heart failure in the community?
GP
ANPs
District Nurses
Third sector (BHF)
Family
Counselling
Palliative services
Community Mental Health Teams
What is the prognosis of Heart failure?
50% die within 5 years of diagnosis
40% die or are re-admitted in 1 year
What are poor prognostic indicators of HF?
- Reduced EF
-Comorbidities
-Smoker - Previous MI
- Obesity
What is the difference between palliative and terminal care ?
Palliative = can be provided at any stage of serious illness that is impacting their daily life- focuses on improving their quality of life. Relieving pain for the patient.
Terminal care = Care us more about giving support to those who have 6 months or less to live due to a terminal illness
What are seronegative spondyloarthropathies?
- Family of joint disorders that classically include Ankylosing spondylitis, psoriatic arthritis, IBD and reactive arthritis. - They typically include:
- axial skeleton, peripheral asymmetric joint involvement, enthesitis, extra articular features and HLA B27 antigen
What is psoriatic arthritis?
- An inflammatory arthropathy affecting both large and small joints.
- Belongs to a group of seronegative inflammatory spondyloarthropathies
- HLA- B27
- Immune mediated inflammatory response that affects the skin, joints and periarticular structures
What are the risk factors of psoriatic arthritis?
- Personal history of psoriasis
- First degree relative with psoriasis or PsA
- History of joint trauma
What are the symptoms of psoriatic arthritis?
- Joint pain
- Morning stiffness and improves through the day.
- Fatigue, malaise, low grade fevers
What is the clinical examination findings of someone with psoriatic arthritis?
- Swelling and tenderness of affected joints
- Reduced range of motion
- Dactylitis
- Skin psoriasis
- Nail changing
What are the extra articular manifestations of psoriatic arthritis?
- Uveitis
- Urethritis
- Aortic regurgitation
- Mitral valve prolapse
- IBD
- Achilles tendonitis
What are the investigations ordered for psoriatic arthritis?
- Absence of Rheumatoid factor and anti-ccp
- ESR and CRP normal or elevated
- X-ray of affected joints – may show erosion of the small joints (erosion in DIP) or soft tissue swelling
- MRI of sacroiliac joints
What is the diagnosis for psoriatic arthritis?
- Mainly clinical based of history and clinical examination – aided by CASPAR criteria
What is the management of psoriatic arthritis?
The aim is to control the symptoms and prevent damage and complications.
- NSAIDS
- DMARDs
- Intraarticular glucocorticoid injection
- Biologics – TNF alpha inhibitors, interleukin inhibitors
- Physiotherapy
What are the complications of psoriatic arthritis?
- CVD
- Joint erosion
What is psoriasis?
- Chronic inflammatory skin condition
- Demarcated red, scaly plaques
- Can be precipitated by infections or hormonal changes
- Smoking and alcohol worsen symptoms
- Sun light is a relieveing factor
What are the clinical features of psoriasis?
- Pruritic lesions
- Pain or burning sensation around lesions
- Joint pain and stiffness
- Family history of psoriasis
What is found on a clinical examination with someone who has psoriasis?
Psoriatic lesions are:
- Well demarcated, erythematous plaques
- Generally, symmetrically distributed – scalp/ elbows/ knees
Nail changes:
- Pitting
- Onycholysis
- Yellowing and ridging
What are the types of psoriasis?
- Chronic plaque psoriasis – most common
- Guttate psoriasis- multiple, small scaly plaques across trunk. Onset often acute following an infection.
- Erythrodermic psoriasis – rare but severe- hospital admission
What are the investigations for psoriasis?
- Diagnosed clinically – clinical test: gentle scraping and removal of scale causes pinpoint capillary bleeding.
What is the management of psoriasis?
- Topical corticosteroids - hydrocortisone, eumovate
- Tar preparations.
- Calcipotriol
- Methotrexate
- Acitretin
- Cyclosporin
Define ‘refugee’.
a person who has been forced to leave their country in order to escape war, persecution, or natural disaster.
Define ‘asylum seeker’.
Someone who has submitted an application to be recognised as a refugee + is waiting for their claim to be decided by the Home Office.
Who has the right to apply for asylum in the UK?
Anyone has the right to apply for asylum in the UK + remain until a final decision on their application has been made.
When a refugee is granted ‘indefinite leave to remain’, what does this mean
When a person is granted full refugee status + given permanent residence in the UK.
they have all the rights of a UK citizen.
they are eligible for family reunion (one spouse, and any child of that marriage under the age of 18) .
What are asylum seekers entitled to?
Entitled to Money: £35 / week
Entitled to housing: no choice dispersal
Entitled to NHS care
> if under 18, are allocated a social services key worker + can go to school
Asylum seekers are not allowed to work; are not entitled to any other form of benefit.
failed asylum seekers are not entitled to any of the above.
Why might asylum seekers find it difficult to access health care services?
Language / culture / communication barriers
Lack of knowledge re: where to get help
Health is not a priority.
Give short definitions for:
i) Asylum seeker
ii) Refugee
iii) Humanitarian protection
A person who has made an application for refugee status
ii) A person granted asylum + refugee status. Usually means leave to remain for 5 years, then reapply.
iii) Failed to demonstrate claim for asylum but face serious threat to life if returned. Usually 3 years, then reapply.
What is consent?
To give permission or an agreement
What is the age of consent?
16- This is the age when young people of any sex, gender or sexual orientation can legally consent to taking part in sexual activity.
When deciding whether to prosecute someone who takes part in sexual activity with a person under the age of 16, what should be considered?
oHow close in age and maturity levels those involved are.
oThe relationship of those involved.
oWhether the person under 16 consented
oWhether the person under 16 was aged 12 or under (under the age of 13 children are seen as being less capable of consenting than those aged 13 or over)
How do you consult with a sexually active child?
1.Establish whether the child is already sexually active, in what circumstance is the sexual activity occurring and with who.
2. Exclude rape
3.If there is a potential sexual crime = referral to police is obligated
4.Fraser guidance if contraception is needed
What questions do you ask a patient to exclude rape through exploitation?
oHave you ever stayed out overnight or longer without permission from your parent or guardian?
oHow old is your partner or the person you have sex with? (is the age gap 4 or more years?)
oDoes your partner stop you from doing things you want to do?
oThinking about where you go to hang out, or to have sex. Do you feel unsafe there or are your parents or guardian worried about your safety?
What is Fraser guidance?
oApplies specifically to advice and treatment about contraception and sexual health.
You can prescribe contraception if:
oThe girls will understand the advice.
oThey cannot persuade her to inform her parents or to allow the Dr to inform the parents that she is seeking contraceptive advice.
oShe is very likely to continue having sexual intercourse with or without contraception.
oHer best interest requires the Dr to give her contraceptive advice, treatment or both without parental consent.
What is Gillick competency?
- Assesses whether the child has the maturity to make their own decisions
-Factors that need to be considered:o The child’s age, maturity, and mental capacity
oTheir understanding of the issue and what it involves.
oTheir understanding of the risks
oHow well they understand the advice been given.
oTheir understanding of alternative options
oTheir ability to explain a rationale around their reasoning
How is capacity assessed?
- Understand information given to them
- Retain that information long enough to be able to make the decision
- Weigh up the information available to make the decision
Communicate their decision – this could be by talking, using sign language or even simple muscle movements such as blinking an eye or squeezing a hand.
If a child isn’t competent, what should the medical professional do?
- seek consent from their parents or carers
-Can seek opinion from a colleague
-child protection concerns can be shared to CPS or police or safeguarding
What are the methods of contraception?
- copper-bearing intrauterine device (Cu-IUD)
- levonorgestrel-releasing intrauterine system (LNG-IUS)
- progestogen-only:
o implant (IMP)
o injectable (DMPA)
o pill (POP) - combined hormonal contraception (CHC)
- Vaginal ring
- Patch
- Pill
- Barrier methods (external/internal condoms)
What are the screening questions for combined contraceptive pill?
oAny new medications or health supplements?
oDiagnosed with new health conditions?
oAny headaches or migraines?
oEver had a blood clot – DVT/PE?
oImmediate family ever had a blood clot?
oHas any immediate family ever had breast cancer?
oSmoking status?
oBMI?
Can women under the age of 26 have an abortion?
- All women under the age of 16 are encouraged to involve their parents
-Doctors can offer an abortion if they are confident that you can give valid consent and that it is in their best interest
-If staff suspect risk of sexual abuse they are obliged to involve social services
What is abnormal vaginal discharge?
oChange of colour
oConsistency
oVolume
oOdour
oAssociated Sx like itch, sores
What are the most common cause of abnormal vaginal discharge?
BV and vaginal candidiasis. Other causes can be STD, contraceptive use, age, polyps etc.
Which STD can people be screened for?
- HIV
-Chlamydia
-Gonorrhoea
-Trichomonas
-Syphilis
What amount of time needs to elapse for each STI test to be accurate?
- 2 weeks for chlamydia and Gonorrhoea
-4 weeks for HIV and syphilis - 3-7 days for trichomoniasis
What is scarlet fever?
An infectious disease caused by streptococcus progenies also known as group A streptococcus.
How is scarlet fever transmitted?
- Highly contagious
- Transmitted when a person’s mouth, throat or nose comes into contact with infected saliva or mucus by aerosol transmission or by direct contact
Who is at increased risk of Scarlet fever?
- very young or very old
- immuni compromised
- IVDU
What is the presentation of scarlet fever?
- initial sore throat
- Fever
- Headache
- Fatigue
- Nausea
-Vomiting
-Sandpaper like blanching rash that develops on the trunk 12-48 hours after initial symptoms
-strawberry tongue
What is the diagnosis of scarlet fever?
Throat swabs and blood tests are not routinely indicated for the diagnosis
What is the Management for scarlet fever?
- If severe hospital admission
- 10 day course of phenoxymethylpenicillin
- If allergic to penicillin - azithromycin for 5 days for children aged 6months to 17
- or birth to 6 months is clarithromycin
What additional advice would you give to a patient and a family that has been diagnosed with scarlet fever?
- Exclusion from nursery, school for 24 hours after treatment
- Frequent handwashing, don’t share utensils
What vaccinations do a 8 week year old baby have?
- 6in1
- Rotavirus
- MenB
What vaccinations do 12 week year old baby have?
- 6in1 second dose
- Pneumococcal vaccine
- Rotavirus second dose
What vaccinations do a 16 week baby have?
- 6in1 vaccine 3rd dose
- MenB vaccine 2nd dose
What vaccination does a 1 year old have?
- Hib/MenC 1st dose
- MMR vaccine 1st dose
- Pneumococcal 2nd dose
- MenB 3rd dose
What continuous vaccinations does a 2-15 year old have?
children’s flu vaccine
What vaccination does a 3 years and 4 months old have?
- MMR 2nd dose
- 4in1 pre school booster
What vaccination does a 12-13 year old have?
HPV vaccine
What vaccines do a 14 year old have?
- 3in1 teenage booster
- MEnACWY
What are the differentials for rashes in paediatrics?
- roseola infantum,
- parvovirus B19
- Kawasaki disease
- measles
- rubella
- viral urticaria
- septicaemia and
meningitis
What is Generalised anxiety disorder?
- Generalised anxiety disorder is characterised by excessive worry about everyday issues that is disproportionate to any inherent risk.
- It is a chronic condition that may fluctuate in severity.
What are the risk factors of GAD?
- Female sex
- Comorbid anxiety disorders
- Family history of anxiety
- Childhood adversity
- History of sexual or emotional trauma
- Sociodemographic factors
What is the presentation go GAD?
- Restlessness/ nervousness
- Easily fatigues.
- Poor concentration
- Irritability
- Muscle tension
- Sleep disturbance
How do you diagnose GAD?
The criteria for GAD is:
- Excessive anxiety and worry occurring more days that not for 6months<
- Individual finds it difficult to control the worry
- Have 3 or more of the symptoms
- Causing impairment in social, occupational or other areas
What questions would you ask when taking a medical history with someone who has GAD?
- The nature, severity and duration of symptoms
- Current physical or emotional stress
- History of trauma
- History of mental health disorders including FH
- Comorbid conditions
- History of alcohol and substance abuse
- Use of OTC remedies
- Availability of social and emotional support
What assessment tools can be used for GAD?
Tools such as GAD-2 or GAD-7 questionnaires should be considered to determine the severity
What is the management for GAD?
- Treat the comorbidities if present.
- If the anxiety symptoms are mild – A periods of active monitoring.
- Therapy/ CBT
- Drug therapy – SSRI or SNRI
What is panic disorder?
- this means having regular or frequent panic attacks without a clear cause or trigger. Experiencing panic disorder can mean that you feel constantly afraid of having another panic attack, to the point that this fear itself can trigger your panic attacks.
What is social anxiety/ phobia?
this diagnosis means you experience extreme fear or anxiety triggered by social situations (such as parties, workplaces, or everyday situations where you have to talk to another person).
What is Obsessive compulsive disorder?
- you may be given this diagnosis if your anxiety problems involve having repetitive thoughts, behaviours or urges.
What is post traumatic stress disorder?
this is a diagnosis you may be given if you develop anxiety problems after going through something you found traumatic. PTSD can involve experiencing flashbacks or nightmares which can feel like you’re re-living all the fear and anxiety you experienced at the time of the traumatic events.
What is the link between alcohol and anxiety?
- Alcohol is a depressant. It slows down processes in your brain and CNS and can initially make you feel less inhibited. In the short term it may make you feel more relaxed but these effects wear off quickly.
What is depression?
- Depression is characterised by the absence of a positive affect, low mood and a range of associated emotional cognitive, physical and behaviour symptoms.
- There is less severe depression and more severe depression
What questions would you ask in a medical history to someone with depression?
- Discuss the onset, duration, pattern and severity of symptoms, including impact on daily functioning at work, and on relationships.
- Current lifestyle including diet, exercise, sleep , alcohol, substances
- Any current or past mental health conditions
- Any risk factors: Family history, suicide, self-harm, Physical health conditions
- Any supportive relationships
- Any current or previous trauma
- Ask bout thoughts of self harm and suicide
How do you assess the risk f suicide with a person with depression?
- Assess the person’s level of social support and awareness of sources of help
- Arrange help appropriate to their level of need
- Advise the person to seek further help if their situation deteriorates
What tools are used to assess depression?
- Use a depression questionnaire
- PHQ-9
- HADS – hospital anxiety and depression scale
- BDI-II – Beck depression Inventor-II
What is the management for depression?
- Provide advice on the nature and course of depression
- Provide advice on how to improve sense of wellbeing
- Offer social support
- If significant risk of suicide, or to harm others – refer to specialist mental health services
- Offer a SRRI or SNRI – Amitriptyline/ fluoxetine or duloxetine
- CBT
- Arrange a review 2-4 weeks after stating treatment
What is the protocol if you notice a colleague drinking alcohol on while working?
Refer to GMC and senior colleagues
What is a cohort study?
Longitudinal prospective study which takes a population of people recording their exposures and conditions they develop
List 3 advantages of a cohort study
can follow up rare exposure
allows identification of risk factors - can sow causation
Less chance of bias
List 4 disadvantages of a cohort study
Large sample size required
Impractical for rare diseases
Expensive
People drop out
What is a cross sectional study?
Snapshot data of those with and without disease to find associations at a single point in time
What are the advantages of cross sectional study?
- Quick and cheap
- Few ethical issues
What are the disadvantages of a cross sectional study?
- prone to bias
-No time reference
What is a case control study?
Retrospective observational study which looks at a certain exposure and compares similar participants with and without the disease
What are the advantages of a case control study?
- good for rare diseases
-Inexpensive
What are the disadvantages of a case control study?
- Can only show association not causation
- Unreliable due to recall bias
What is a RCT?
Similar participants randomly controlled to intervention or control groups to study the effect of the intervention
Gold standard
What are the advantages of a RCT ?
- can infer causality
-Less risk of bias/ confounders
What are the disadvantages of RCT?
- time consuming and expensive
- Ethical issues can interfere
What is bias?
A systematic error that results in a deviation from the true effect of an exposure on an outcome
What is chance?
The possibility there is a random error
What are the 3 types of bias?
Selection bias
Information bias
Publication bias
What is selection bias?
Discrepancy of who is involved
What is information bias?
- Measurement bias
- Observation bias
- Recall bias (doesn’t remember or recall correctly)
- Reporting bias (don’t report truth because they feel judged)
What is publication bias?
Some trials are more likely to be published than others
What is confounding?
When an apparent association between an exposure and an outcome is actually the result of another factor.
Define incidence
Number of new cases in a population during a specific time period.
Define prevalence
Number of existing cases at a specific point in time.
Define sensitivity
The percentage of people correctly identified with the disease
Define specificity
The percentage of people correctly excluded as ‘disease free’
What problem might arise if a test is 100% sensitive?
Correctly identifies everyone with the disease as having the disease, but may cause false positives.
What problem might arise if a test is 100% specific?
Correctly excludes everyone without the disease, but may miss people who do have the disease
What is the ‘Positive predictive value’?
%age of those with a positive test who actually have the disease
What is the ‘Negative Predictive Value’?
%age of those with a negative test who are actually disease free
What is the criteria for a screening test?
Important disease
Natural history of the disease must be understood (detectable risk factors, disease markers)
Simple, safe, precise and validated test
Acceptable to the population
Effective treatment from early detection with better outcomes than late detection
Policy of who should receive treatment.
What is a Never event?
a serious, largely preventable patient safety incident that should not occur if available, preventative measures have been implemented
What are examples of never events?
Medical: wrong route chemo
Surgical: wrong site or retained object
Mental health: escape of transfer patient
What is the Swiss cheese model?
The Swiss Cheese Model demonstrates how, generally, a failure cannot be traced back to a single root cause; accidents are often the result of a combination of factors
What are the 4 layers of the Swiss cheese model?
- organisational influences
- unsafe supervision
- preconditions for unsafe acts
- Unsafe acts
What is the three bucket model?
- self
-context
-task
What is a medical error?
medical error is a “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
What is an adverse event?
An adverse event is a type of injury that most frequently is due to an error in medical or surgical treatment rather than the underlying medical condition of the patient.
