Gp Lectures Flashcards
What is allostasis?
Stability through change - systems react rapidly to environmental stressors
What is allostatic load
Long term overtaxation of physiological systems leads to impaired health - stress
E.g. Of allostasis and allostatic load of CV system
Allostasis - maintain erect posture, and enable physical exertion
A Load - over activation -> hypertension, stroke, MI
Natural history of self limiting conditions that DO NOT need Abx
Otitis media - 4 days Acute sore throat/pharyngitis - 1 week Common cold - 10 days Acute rhinosinusitits - 2-3weeks Acute cough - 3 weeks
When should ABx in otitis media
Bilateral <2yr
Or if otorrhoea
When abx in sore throat?
With 3 or more of:
Exudate, fever, tender cervical lymphadenopathy, a sense of cough
Other examples of when to give ABX
Systemically unwell
High risk co-morbidity (immunosuppressive, prem bab)
Old with recent hospital admission / diabetes /Ccf/ glucocorticoid use
Complications - pneumonia, mastoiditis, abscess
Common Abx for Otitis media? Sinusitis? Tonsilitis? LRTI? Uti?
Amoxicillin 500mg tds 5 days Amoxicillin 500mg tds 5 days / doxycycline 5 days Penicillin 10 days Amoxicillin 5 days Trimethoprim / nitrofurantoin 3 days
Vascular response to wound
Vasoconstriction
Clotting when blood exposed to air
Blood and serous fluid clean wound
Vasodilation and permeability in vessels adjacent
Fibrin mesh temporality closes wound -> turns into scab
Signs of inflammation
Heat - calor Swelling - Tumor Erythema - rub or Pain - dole Loss of function
Egs of inflammatory mediators released by platelets trapped in fibrin mesh
PDGF, Prostaglandins, histamine
What locally causes vasodilation by wound?
Histamine
When does vasodilation peak after injury
20 mins - don’t confuse with infection
Role of neutrophils and macrophages
N- release free radicals and pro teases - bactericidal
M - invest dead tissue, release cytokines that recruit lymphocytes and fibroblasts
Lymphocyte role
Enter wound after 72hr and secrete chemotactic factors for fibroblasts
Primary secondary tertiary intention?
1- little tissue loss - wound edges can be directly apposed -> linear scar
2 - wound edges not apposed - eg ulcer / skin loss ->granulation and broader scar
3 - Would purposely left open - later surgically closed eg graft / suture
General barriers to healing?
Local barriers?
Elderly, diabetes, malnutrition, malignancy, immunosuppressive
Infection, oedema, vascular insufficiency, prev radiotherapy
5 stages of grief
Denial Anger Bargaining Depression Acceptance
Not always in order and not everyone experiences them all
What is an adjustment disorder
Emotional or behavioural reaction which is maladaptive
When do adjustment disorders often develop
Recovery taking too long (>6/12 usually have acceptance)
The coping mechanisms are extreme or harmful
Continuing impact on relationships / social functioning
Self harm
Types of domestic abuse
Psychological Physical Sexual Financial Emotional
3 ways domestic abuse can impact on health
Trauma
Somatic problems due to living with abuse (headaches, gi, chronic pain, LBW, premature babie)
Psychological (PTSD, self harm, substance misuse, depression, anxiety…)
What to consider safeguarding in domestic abuse
If there is child abuse / child witnessing
Tool to assess risk in domestic abuse
DASH
What to do in standard / medium risk domestic abuse
Give contact for domestic abuse services
What to do in high risk domestic abuse
Refer for MARAC / IDVAS
You can break confidentiality
What is MARAC
Multi agency risk assessment conference
Egs of models / theories of behaviour change
Health belief model Health belief model Theory of planned behaviour Stages of change / trans theoretical model Social norms Motivational interviewing Nudging Social marketing
When do people change in the health belief model ?
They believe: they are susceptible There is serious consequences action reduces susceptibility Benefits of action outweigh costs
What factors influence HBM
Demographic - SES, gender, age..
Psychological - personality, peer group …
Cirque of HBM
Other factors influence - eg self efficacy
Does not consider the influence of emotions on behaviour
Does not differentiate between first time and repeat behaviour
Cues to action help HBM, E.g. Of an internal and external cue ?
Internal - feeling unwell
External - reminder letters
What is the most important factor for addressing behaviour change in patients?
Perceived barriers
Biggest predictor of behaviour in TPB
Intentions
What 3 things determine a persons intention in TPB
Attitude to the behaviour
The perceived pressure to undertake the behaviour - Social norm
Perceived ability to perform behaviour - perceived behavioural control
Ways to help people act on their intentions
Perceived control - They CAN do it
Anticipated regret - how do you feel after behaviour
Predatory actions - break into small steps
Implementation intentions - eg when make tea, take meds
Critique of TPB
Lack of temporal element
Doesn’t take into account emotions
Doesn’t explain habitual behaviour
Relies of self reported behaviour
Stages of transtheoretical model
Pre-contemplation, contemplation, preparation, action, Maintenance
Advantages of stages of chance
Accounts for relapse
Temporal element
Accounts individual stages of readiness (Tailored interventions)
Critique of stages of change
Not everyone goes through all the stages
Change might be a continuum rather than discreet
Doesn’t take into account - values, habits, culture, social and economic factors
There are 3 main behaviours related to health. What are they and EG?
Health behaviour - prevent disease - eating healthy
Illness behaviour - seek remedy - visit doctor
Sick role behaviour - aimed at getting well - taking prescribed medication
Identify 3 transition points where interventions are likely to be more effective
Leaving school, entering workforce, becoming a parent, becoming unemployed, bereavement
Planning cycle in health needs assessment ?
Needs assessment -> planning -> implementation -> evaluation -> repeat
3 parts of health needs assessment
Need - ability to benefit from intervention
Demand - what people ask for
Supply - what is provided
3 approaches fro health needs framework
Epidemiological
Comparative
Corporate
Aspects of epidemiological approach to health needs
Define problem Size of problem - prevalence Services available - prevention, treatment, care Evidence base - effectiveness Models of care - quality / outcomes Existing services
Problems with epidemiological approach
Data availability
Variable data quality
Evidence base inadequate
Doesn’t consider felt needs of people afffected
What is the comparative approach to health needs
Compares services between subgroups E.g. Spatial / age
Issues with comparative approach
Data availability
Data quality
Difficulty finding a comparable population
Issues with corporate approach to health needs assessment
Hard to distinguish demand from need
Groups may have vested interest
Influenced by politics
Dominant personalities -> influence
Alcohol recommended limits
Men 21 units/week
women 14 units/week
Pregnant women alcohol intake
none in first trimester then no more than 2 units per week
Factors that influence drinking levels
Social - occupation, availability, advertising, peer group
Family - religion, tradition, culture
Personality, genetics, health
Why are women drinking more
Socially acceptable, more disposable income, marketing target women
Risk factors for problem drinking
Drinking within family Childhood problem behaviours early use of nicotine and drugs poor coping responses to life events depression as a cause not a result of drinking
Alcohol intake per day -> liver damage?
Min 30g
Usually around 160g
Alcohol and liver problems ? Which are reversible ?
50% heavy have fatty liver - reversible
13-30% develop cirrhosis
Why does heavy alcohol intake increase risk of heart disease?
Hyperlipidaemia
Hypertension
Can precipitate arrhythmia (usually AF)
Alcohol and cancer types?
25-50% of head and neck cancers due to alcohol
Liver, stomach, Colon, rectum, pancreas
Breast
Risks with alcohol consumption in pregnancy
Risk of miscarriage / LBW
Foetal alcohol syndrome
Signs of fetal alcohol syndrome
Small underweight babies, slack muscle tone
Mental retardation, behaviour and speech problems
Facial abnormalities
Cardiac, renal and ocular abnormalities
Facial abnormalities in foetal alcohol syndrome?
Microcephalic, hypoplastic jaw
Thin upper lip, smooth philtrum, upturned nose
Short Palpebral fissure (upper eyelid fold)
What general support for alcohol in primary care?
Vitamin supplementation Assess risk of - IHD -Osteoperosis Screening questions Structured advice (Potential harm, benefits of stopping, obstacles to change, goals)
Examples of alcohol screening questionnaire
CAGE / AUDIT
Medication for relapse prevention?
Disufiram (antabuse)
Acamprosate, GABA blocker
Criteria for alcohol dependence syndrome
3 in a 12 month period
Tolerance increase in for same effect
Physiological withdrawal
Difficulty controlling amount and termination of use
Neglect social / other areas of life
Increasing time spent obtaining and using alcohol
Continued use despite negative physical and psychological effects
What causes wernicke encephalopathy
Bit b1 deficiency - often after withdrawal of alcohol
Triad of Sx in wenicke
Acute mental confusion
Ataxia
Opthalmoplegia (paralysis of muscles around eye)
Is Wernickes chronic? Treatment? What can it lead to?
Reversible
IV / oral vit b1 (thiamine vitamin b1)
Korsakoff’s
What can be given in hospital setting to booze patients
Pabrinex (b1)
Main Sx of Korsakoffs ? Others?
Memory loss - esp short term
Loss of spontaneity, initiative and confabulation
How is korsakoffs diagnosed
CT scanning
What is delirium Tremens? Sx? Treatment?
3-5day toxic confusional state follows withdrawal of alcohol with long Hx of use
Clouding of consciousness, confusion, seizures, hallucinations
Marked tremor
Supportive fluids / benzodiazepines prevent fitting
Why are ‘nudging’ and financial incentives rarely used in behaviour change?
Nudging - ethical issues
Financial insensitive - ineffective (people care more about what they have to lose)
Societal risk behaviour is usually over or underestimated by people?
Over estimated
Main idea in social norms ?
Find out the real social norm and disseminate
Critique of social norms
What if the norm is an unhealthy behaviour
What are the three parts of the framework for health service evaluation?
Structure - what it there Eg number of ICU beds
Process - what is done Eg number of patients seen
Outcome - health Eg Mortality, morbidity, QOL, patient satisfaction
Issues with using health outcomes in evaluation
Cause and effect hard to establish (esp if other factors)
Lag time may be long
Large sample sizes needed
Data availability / quality
What are the dimensions of quality (maxwell’s dimensions)
3 Es and 3 As
Effectiveness, efficiency, equity
Acceptability, accessibility, appropriateness
