GP Notes Flashcards
How should a question on medical complexity be discussed?
Medical Complexity is conceptually regarded as a combination of multiorgan system involvement from chronic health condition(s), functional limitations,
ongoing use of medical technology, and high resource need/use.
Medical complexity can largely be broken down into medical, mental illness, patient behaviour, socio-economic and resources.
What are the componants of the FeverPAIN score
F – Fever in past 24 hours
P – Purulent tonsils
A – Attend rapidly (under 3 days)
I – Inflamed tonsils
N – No cough or coyza
Score:
0-1 = no antibiotics
2-3 = 3 day back up antibiotic prescription
3 = Immediate antibiotic or 48 hour delay
What are the components of the Centor Score?
- Exudate or swelling
- Tender/swollen anterior cervical nodes
- Temperature over 38
- No cough
Score:
0-1 = No antibiotics
2-3 = Culture
4 = Antibiotics
What drug should be given for anaphylaxis?
As soon as anaphylaxis is recognised 0.5mg IM Adrenaline must be given.
Define anaphylaxis
Anaphylaxis is a severe, life threating, systemic hypersensitive reaction (type 1). It involves respiratory difficulty and/or hypotension (which may present as fainting, collapse, or loss of consciousness). Patients do not have to have both to be in anaphylaxis.
There is always a rapid onset of symptoms. Skin changes can include urticaria, erythema or angioedema. 80% will have skin changes. There will be a history of exposure to an allergen.
What are the causes of anaphylaxis?
Causes of anaphylaxis can include nuts, wasp stings and drugs. These are the three most common causes. There are many potential causes.
How should anaphylaxis be managed?
Every patient should be assessed with the ABCDE approach. Diagnosis is dependent on finding the acute onset of illness, life-threatening airway or circulation problems, and potential skin changes. Call for help, raise the patient’s legs, and give 0.5mg IM Adrenaline. Then establish an airway, high flow oxygen, IV fluid challenge (500-1000 crystalloid stat), Chlorphenamine (10mg IM or slow IV), Hydrocortisone (200mg IM or slow IV) and monitor SATs, ECG, and BP.
Patients should then be admitted and observed for 6-12 hours. Biphasic reaction can occur in 20%. Mast cell tryptase at baseline and 2 hours later can be used for monitoring. In the community, patients should be given 2x Epi-Pens and organise an immunology follow up. Patients should call an ambulance even if they use their epi-pen and it works.
What is the inverse care law?
The inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served. – Tudor Hart
This means that those who need it most are least likely to receive it. He believed nullifying market trends in healthcare would reduce this burden.
How should complex conversations in GP be approached?
Doctor factors: Tiredness/burnout, lack of empathy, not listening, poor job satisfaction, poor communication skills, rushed, personality, feelings, personal problems and illness
Patient factors: No diagnosis, no treatment, health beliefs, impaired quality of life, emotions, personality, expectations, cultural and language barriers, PMH, psychosocial history and inequalities.
System factors: Lack of resources, long waiting times, overstretched system, lack of time, overbooking, inadequate IT and cancelled clinics.
Health beliefs can be cultural, generational, socioeconomic factors, trends, media, religion and spiritual beliefs. These are involved in every patient encounter.
Safety netting was introduced by Roger Neighbour. The aim is for the doctor to answer these three questions:
- ‘If I am right, what do I expect to happen?’
- ‘How will I know if I am wrong?’
- ‘What would I do then?’
What is Palliative care?
Palliative care is defined as ‘the active, holistic care of patients with advanced progressive illness.’ This commonly means managing symptoms such as pain, SOB, anxiety, agitation, constipation, nausea, vomiting, hiccups, depression, psychological distress, spiritual distress and financial problems.
Who is involved in palliative care in the community?
- GP role: Co-ordinate care, DNACPR and prescribing palliative care medication
- Community Nurse: Often main co-ordinator and provider of palliative care, administer palliative care medication, wound dressings and holistic support to the family and social care.
- Macmillan nurse: Work embedded within the NHS teams but funded by Macmillan charity. They are subspecialised into chemotherapy, paediatrics, breast ect… They provide practical and emotional support as well as clinical advice for the MDT.
- Community Palliative Care Team: Provide advice and support to patients, family and GPS and sometimes will take over management. They facilitate patients visiting hospice, support or end of life care. They also have access to physio, OT and alternative therapy services.
GPs are ideally placed to manage palliation because they are likely to know the patient and their family, which allows them to have difficult conversations such as DNACPR and end of life care. GPs can make pragmatic decisions about medications, investigations and admission to hospital. They are also used to managing uncertainty and multi-morbidity.
What are the cultural factors involved in palliative care?
Cultural differences in death and dying can include rituals before/after death, what to do with the deceased body and how quickly (MRI scanners are owned by some religious institutions to allow for rapid post-mortem), who is allowed to be present at death and grieving behaviour.
What is the GOLD standard framework? (GSF)
Gold Standard Framework is a standardised method of describing where a patient is on their journey from illness to end-of-life care. This should be reproducible across different healthcare settings and professionals. The starting question is, ‘would you be surprised if this patient died in the next 6-12 months?’
Aims of GSF include:
1. Identify patients to enable proactive care
2. Assess their needs and those of their carer
3. Plan their care involving patient family and MDT where appropriate.
There is a palliative care register in every practice which is discussed at the GSF meeting every 12 weeks. GSF meetings involve community nurses, palliative care team and macmillan nurses. The aim is for a proactive rather than reactive approach to patients reaching end-of-life care.
Describe the GSF stages
GSF stages:
- Green: Death expected in the next months
- Amber: Death expected within weeks
- Red: Death expected in the next couple of days to week
- Green GSF are expected to die within 6-12 months. They are clinically stable but have advancing frailty or could deteriorate quickly.
These patients need to be referred for benefits, assessed for carer needs, discussion about the patients and family’s future plans, discuss worries, spiritual and psychological, DNAR, advanced care planning, living will/advanced directives, and lasting power of attorney.
- Amber GSF are expected to die within the next weeks and patient deterioration may be noticeable week by week. “Hope for the best and plan for the worst.”
This is an opportunity to revisit holistic and carers assessment to see if anything has changed such as reduced mobility, need for hospital or OT. The DS1500 form provides the higher rate of benefits straight away without the normal 6month delay. DNAR and LPOA should be doubled checked. Respite, symptomatic care, and anticipatory meds should be prescribed at this stage. There should be a medication review for medications that do not provide symptomatic relief or that cause adverse effects. Stopping drugs can be a difficult conversation as family may see it as giving up.
- Red patients are expected to die within the next couple of days to a week and will be deteriorating day by day.
Anticipatory medications should be in place and there should be provision of a syringe driver. All non-essential medications should be stopped and required medication should be given sub-cut if there is swallowing issues. Patient comfort and symptom control are paramount goals. Preferred place of death is an important discussion.
Advanced care planning is a form which structures the consultation around end of life care and should be filled out for all patients on the GSF pathway.
How should management plans for MSK disorders be structured?
Lifestyle
Self-management
Pharmacotherapy
Injection Therapy
Surgical interventions and rehabilitation
What general lifestyle management can be used for MSK conditions?
Promote physical activity, highlight the importance of diet and nutrition on MSK health (adequate vitamin D for bone health), advice about the effects on smoking, obesity, and inactivity. Promoting lifestyle advice can be helped with referral and social prescribing. Patients who are frail should be advised on adapting to their physical environment to promote independence.
What general self-management can be used for MSK conditions?
Optimise the patient’s activity, mobility, and independence. Explore the consequences of patients’ actions and inactions regarding their health and recognise that MSK conditions are often associated with mental health issues, frailty, and multimorbidity. Refer individuals to psychological therapies ad counselling services, advise on adaptation that will reduce the impact of their MSK injury, self-help guidance, and support.
What general pharmacotherapy can be used for MSK conditions?
Common analgesia includes paracetamol, NSAIDs, Opiates, neuropathic agents, corticosteroids, and specialised drugs such as allopurinol. Always discuss patient expectations including the expected benefits and limitations. Signpost patients to further information, review the response to medication by assessing the risk-benefit ratio, polypharmacy, frailty, and cognitive impairment. Refer to a pain specialist if there is problems managing pharmacotherapeutically.
What general injection therapy can be used for MSK conditions?
Indications for therapeutic injections include OA (knee and hands), inflammatory arthritides, adult and juvenile RA, gout and pseudogout, and spondyloarthropathies. Soft-tissue injections can be used for bursitis, carpal tunnel syndrome, epicondylitis, and tenosynovitis.
Corticosteroid injections relieve pain, reduce inflammation, improve mobility, can be diagnostically beneficial, and may be injected with local anesthetics to provide rapid pain relief.
