learning Flashcards
CHADS2 score
MMSE score
GAD-7
(7)
Feeling nervous, anxious or on edge?
Not being able to stop or control worrying?
Worrying too much about different things?
Trouble relaxing?
Being so restless that it is hard to sit still?
Becoming easily annoyed or irritable?
Feeling afraid as if something awful might happen?
Fraser Guidelines (5)
With regards to the provision of contraceptives to patients under 16 years of age the Fraser Guidelines state that all the following requirements should be fulfilled:
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
Depression: switching antidepressants
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
Switching from fluoxetine to another SSRI
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
Switching from fluoxetine to venlafaxine
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
- the first SSRI should be withdrawn* before the alternative SSRI is started
Switching from fluoxetine to another SSRI
- withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
Switching from a SSRI to a tricyclic antidepressant (TCA)
- cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- an exception is fluoxetine which should be withdrawn prior to TCAs being started
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
- cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly
Switching from fluoxetine to venlafaxine
- withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly
he Royal College of Obstetricians and Gynaecologists (RCOG) recommend that the following triad is present before diagnosis hyperemesis gravidarum:
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
NIPE exam vital signs
Respiratory rate = 30-60
Heart rate = 90-160
Blood pressure - not recorded unless unwell
Pulse Ox - n/a
Disadvantages of combined oral contraceptive pill
(6)
people may forget to take it
offers no protection against sexually transmitted infections
increased risk of venous thromboembolic disease
increased risk of breast and cervical cancer
increased risk of stroke and ischaemic heart disease (especially in smokers)
temporary side-effects such as headache, nausea, breast tenderness may be seen
Advantages of combined oral contraceptive pill
(8)
highly effective (failure rate < 1 per 100 woman years)
doesn’t interfere with sex
contraceptive effects reversible upon stopping
usually makes periods regular, lighter and less painful
reduced risk of ovarian, endometrial - this effect may last for several decades after cessation
reduced risk of colorectal cancer
may protect against pelvic inflammatory disease
may reduce ovarian cysts, benign breast disease, acne vulgaris
Management of Alcohol withdrawal
(4)
patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
carbamazepine also effective in treatment of alcohol withdrawal
phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
Types of nappy rash
Nappy rash counselling
disposable nappies are preferable to towel nappies
expose napkin area to air when possible
apply barrier cream (e.g. Zinc and castor oil)
mild steroid cream (e.g. 1% hydrocortisone) in severe cases
management of suspected candidal nappy rash is with a topical imidazole. Cease the use of a barrier cream until the candida has settled
Management of PPH
ABC including two peripheral cannulae, 14 gauge
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
if medical options failure to control the bleeding then surgical options will need to be urgently considered
the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Which score assesses severity of anxiety and depression symptoms in hospital?
Hospital Anxiety and Depression (HAD) scale - assesses severity of anxiety and depression symptoms
Which score is used to determine the need to anticoagulate a patient in atrial fibrillation?
CHADS2
Heart failure severity scale score
NYHA
A scoring system used to assess the severity of liver cirrhosis
Child-Pugh classification
Score which helps estimate the risk of a patient having a deep vein thrombosis
Wells score
Score used to assess cognitive impairment
Mini-mental state examination
Patient Health Questionnaire - assesses severity of depression symptoms
PHQ-9
Used as a screening tool and severity measure for generalised anxiety disorder
GAD-7
Used to screen for postnatal depression
Edinburgh Postnatal Depression Score
Questionnaire used to detect eating disorders and aid treatment
SCOFF
Alcohol screening tools
AUDIT
CAGE
FAST
Score used to assess the prognosis of a patient with pneumonia
CURB-65
Used in the assessment of suspected obstructive sleep apnoea
Epworth Sleepiness Scale
International prostate symptom score
IPSS
Indicates prognosis in prostate cancer
Gleason score
Assesses the health of a newborn immediately after birth
APGAR
Used to help assess the whether induction of labour will be required
Bishop score
Assesses the risk of a patient developing a pressure sore
Waterlow score
Risk assessment tool developed by WHO which calculates a patients 10-year risk of developing an osteoporosis related fracture
FRAX
Acute pancreatitis score
Ranson criteria
Malnutrition score
MUST
Score which stratifies upper GI bleeding patients who are ‘low-risk’ and candidates for outpatient management.
The Glasgow-Blatchford Bleeding Score (GBS) stratifies upper GI bleeding patients who are ‘low-risk’ and candidates for outpatient management.
Indications foir induction of labour
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
pre-eclampsia
rhesus incompatibility
Management of cord prolapse
cord prolapse is an obstetric emergency
the presenting part of the fetus may be pushed back into the uterus to avoid compression
if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
the patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out
the left lateral position is an alternative
tocolytics may be used to reduce uterine contractions
retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part
although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.
mMSE
A - appearance and behaviour
S - speech (how they are speaking, rather than what they are saying, which comes under thought content)
E - emotion (mood and affect; how the patient says they feel compared with how they appear to you)
P - perceptions (any unusual experiences/ hallucinations etc)
T - thought (form and content)
Thought form - this is where you describe if the patient shows any evidence of formal thought disorder
Thought content - this is where you describe if the patient is very fixated on one particular idea, or if there is a general tone or theme to their thoughts
I - insight
C - cognition
dehydration red flags
tachypnoea
tachycardia
sunken eyes
reduced skin turgor
Systems review
(7)
Ask about respiratory symptoms (breathlessness, cough, chest tightness)
Ask about cardiovascular symptoms (chest pain, palpitations, leg swelling)
Ask about gastrointestinal symptoms (nausea, vomiting, diarrhoea, constipation, anorexia)
Ask about urogenital symptoms (urinary frequency, dysuria, genital itch, genital pain, dyspareunia)
Ask about dermatological symptoms (rash, pruritus)
Ask about neurological symptoms (headache, visual disturbance, weakness, paraesthesia, dizziness, syncope)
Ask about systemic symptoms (fever, weight loss)
Obstetric history
Ascertain gravidity and parity
- Gravidity is the number of times a person has been pregnant, regardless of outcome, so in this case she is gravida 3
- Parity is the number of times a person has delivered a foetus/baby of at least 24 weeks gestation, regardless of mode of delivery or live/stillborn, in this case she is para 0
Ask gestation
- A question such as “Do you know how far along you are in the pregnancy?” may prompt the patient to tell you
Ask specifically about the last menstrual cycle (LMP)
Calculate approximate gestation
Ask about any problems in pregnancy
- May be useful to ask if she has attended any extra appointments or clinics, and if she’s attended the GP for anything else
Ask about ultrasound scans
- Remember a normal schedule for ultrasound scans is a “dating” scan at 10-14 weeks and a foetal anomaly scan at 20 weeks. Additional scans are dictated by clinical picture
Ask if any other investigations during pregnancy
Ask about foetal movements
- Foetal movements are usually not felt until 16-20 weeks gestation, so if she’s feeling movements, this suggests she is a later gestation than we think!
It’s important to tell the patient it’s NORMAL not to feel movements at this gestation!
Ask about uterine activity
E.g. hardening of stomach or cramping
Ask about vaginal losses
E.g. discharge, fluid, mucous plug, tissue, ??foetus
Ask about symptoms of pre-eclampsia if you haven’t already (headache, visual disturbance, epigastric pain, oedema)
Ask about history of sexually transmitted/pelvic infections
Urge incontinence
Cause (2)
Investigations (4)
Management (4)
Cause
- overactive bladder (OAB)/urge incontinence
- due to detrusor overactivity
Investigations
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
Management
- bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinics are first-line - NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
- Immediate release oxybutynin should, however, be avoided in ‘frail older women’
- mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
Pharmacological management of nocturesis
Desmopressin-sublingual/tablet form
- 1-2hrs before Bed time
- Warn about excessive drinking and illness
- Not used when there is only day time symptoms
Anticholinergic(oxybutynin)
- overactive bladder(detrusor instability)
- used with desmopressin used in bedwetting + day time symptom
Tricyclics(imipramine)
- second line
- Used in enuresis clinics
- More side effects Toxicity in overdose a concern
Stress incontinence
Cause (1)
Investigations (4)
Management (4)
Cause (1)
- leaking small amounts when coughing or laughing
Investigations (4)
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
Management (4)
- pelvic floor muscle training - NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
- surgical procedures: e.g. retropubic mid-urethral tape procedures
- duloxetine may be offered to women if they decline surgical procedures
- a combined noradrenaline and serotonin reuptake inhibitor
- mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
Nocturesis treatment pathway
Management
- look for possible underlying causes/triggers
- constipation
- diabetes mellitus
- UTI if recent onset
- emotional trauma
general advice
- fluid intake
- toileting patterns: encourage to empty bladder regularly during the day and before sleep
- lifting and waking
reward systems (e.g. Star charts)
- NICE recommend these ‘should be given for agreed behaviour rather than dry nights’ e.g. Using the toilet to pass urine before sleep
enuresis alarm
- generally first-line for children
- have sensor pads that sense wetness
- high success rate
desmopressin
- particularly if short-term control is needed (e.g. for sleepovers) or an enuresis alarm has been ineffective/is not acceptable to the family
AKI Scoring
Explaining Statins
Briefly explains about hypercholesterolaemia
Explains the potential complications
Explains how statins work
Explains that statins are a daily medication
Advises the patient to take the medication in the evening
Explains that the treatment is lifelong
Explains that statins decrease a patient’s risk profile over many years
Statin prescriptions require regular monitoring. Lipids and LFTs should be performed prior to starting treatment. LFTs should be repeated after three months. Further monitoring is then done yearly.
Talks about common side effects
Important side effects include rhabdomyolysis, hepatic disorders, and pancreatitisAdvises the patient to let their clinician know about any side effects that they experience
Asks the patient to consult with their clinician if they are about to start any new medications
Explains to the patient that some types of statin can interact with grapefruit juice
Checks for any allergies
Asks about current drug history
Explain lithium
Explains the mechanism of action of lithium
- Mood stabiliser - balances the patient’s mood in between depression and mania, exact mechanism is unknown. Thought to interfere with neurotransmitter release in the brain.
Explains how the patient should take the medication
- Tablet, to be taken once daily
Explains the duration of treatment
- Usually lifelong, with regular reviews by a psychiatrist
Explains how long it takes for the medication to work
- Takes 1-2 weeks to work
Explains appropriate monitoring tests before initiation:
- FBC
- U&Es
- TFTs
- b-HCG (pregnancy test)
- ECG
During treatment:
- Li levels after 5 days, then every week until stable for 4 weeks, them 3-monthly
- TFTs, U&Es, Ca should be monitored 6-monthly
Explains some of the important side effects
- Water symptoms: thirst, polyuria, impaired urinary concentration, weight gain, oedema
GI side effects:
- abdominal pain, nausea
- Metallic taste
- Fine tremor
Explains some of the symptoms of lithium toxicity
- anorexia
- diarrhoea
- vomiting
- dysarthria
- dizziness
- muscle twitching
- tremor
- Drowsiness
- Apathy
- Restlessness
Provides supplementary advice to the patient for further help (e.g. Bipolar UK charity)
Checks the patient understanding, using “chunk and check” method
Asks if the patient has any remaining questions
Explaining steroids
Explains what Addison’s disease is to the patient
Explains that without treatment he could become seriously ill
Explains the need for him to wear a medical emergency identification bracelet
Explains that he will also need a steroid card
Explains that these are different steroids to anabolic steroids, and he will not gain muscle mass
Explains that he will not experience testicular shrinking
Reassures the patient that although steroids do have many potential side effects fertility issues are not considered to be likely
Talks briefly through how steroids work with the patient
Explains how often he needs to take the steroids
Explains that steroids are taken orally as a tablet
Discusses the length of treatment
Discusses ongoing monitoring requirements
Tells the candidate the potential common side effects of steroids
Tells the candidate the potential serious side effects of steroids
Emphasises the importance of not missing steroid doses
Explains to the patient that he should not stop taking the steroids abruptly
Talks to the patient about sick day rules for steroids (Patient should take double the dose of steroids if they feel unwell)
Explains to the patient that they will need to double their dose of medication if they feel unwell
Emphasises that the patient should seek medical help if they are so unwell they cannot take medication orally
Gives the patient advice for travelling, for example, they should carry extra medication and an emergency intramuscular injection
Advises the patient to let their clinician know about any side effects they experience
Ask the patient to consult with their clinician if they are about to start any new medication whilst taking steroids
Explains the need for concurrent prescription of alendronate to prevent steroid-induced osteoporosis
Checks for any allergies
Asks about current drug history
Normal electrolyte ranges
TDP management
magnesium sulfate 4g
DKA Main principles of management
fluid replacement
- most patients with DKA are deplete around 5-8 litres
- isotonic saline is used initially, even if the patient is severely acidotic
- please see an example fluid regime below.
insulin
- an intravenous infusion should be started at 0.1 unit/kg/hour
- once blood glucose is < 15 mmol/l an infusion of 5% dextrose should be started
correction of electrolyte disturbance
- serum potassium is often high on admission despite total body potassium being low
- this often falls quickly following treatment with insulin resulting in hypokalaemia
- potassium may therefore need to be added to the replacement fluids
- if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required
long-acting insulin should be continued, short-acting insulin should be stopped
Osteoporosis explanation to the patient
Establishes patient’s current understanding
Offers detailed explanation of osteoporosis as a condition
Explains possible causes of osteoporosis
Discusses lifestyle modifications that can be of benefit
Discusses weight bearing exercise
Discusses quitting smoking
Discusses limiting alcohol
Discusses reducing the risk of future falls by addressing high risk activities/ modifying high risk areas of the home e.g. by installing shower rails
Recommends calcium and vitamin D supplements for healthy bones
Bisphosphonates explanation
Asks specifically about any previous gastric/ duodenal ulcers
Asks about alcohol intake
Establishes current medication regime
Asks about patient functioning to establish ability to comply with administration requirements
Confirms suitability for bisphosphonate therapy
Explains action of drug
Explains how to take bisphosphonates
Explains that it is taken weekly, on the same day each week
Explains that it should be taken with a glass of water a minimum of 30 minutes before food
Explains that they will need to sit upright for a minimum of 30 minutes following administration
Explains that bisphosphonates are a long term medication but do not need to be taken lifelong
Explains they would be taken for a minimum 3 years to get the most benefit
Explains potential side effects and complications
Explains minor side effects of indigestion/ general gastro-intestinal irritation (oesophagitis, diarrhoea, abdominal pain)
Explains major potential side effect of osteonecrosis of jaw (rare but serious)
Explains need for dental check before starting therapy and to continue with regular dental checks throughout treatment
Explains that GI side effects are significantly reduced if administration instructions are followed carefully
Explains that if patient is experiencing side effects they should come back to see their GP
Explains that in cases where patient’s do not tolerate the drug orally there are alternative therapies that can be considered
DOAC explanation
Checks patient understanding at this stage
Explains the risks associated with atrial fibrillation - clot formaiton
Explains the indication for rivaroxaban - stroke prevention
Clarifies drug as rivaroxaban 20mg once daily
Explains that treatment will be life long, or until a decision is made to stop
Explains it should be taken at the same time each day
Explains that if a dose is missed this can be taken up to 12 hours late
Explains not to double dose or take a dose more than 12 hours late (wait until next dose due)
Explains if takes a double dose by mistake to speak to a pharmacist, contact his GP or call 111
Reiterates importance of good compliance
Explains risks of poor compliance in terms of thrombosis risk
Explains side effects and possible complications of therapy
Unexplained bruising
Bleeding - minor (nosebleeds, increased bruising, small cuts taking longer to stop bleeding) versus major bleeding (intracranial bleeds , intra-abdominal bleeds)
Explains appropriate management of self-terminating bleeding episode - advises patient to speak to pharmacist or GP
Explains appropriate management of ongoing bleeding, severe bleeding, recurrent episodes of bleeding, rectal bleeding, haematuria or head injury / other major injury - advises patient to go to the Emergency Department for assessment
Explains that rivaroxaban can be reversed in the event of significant bleeding or trauma
Explains the need to tell dentists/ doctors in the future that he is on this medication due to blood thinning effects
Explains that some medications can interact with rivaroxaban
Patient should avoid NSAIDs such as ibuprofen
Patient should always check with a doctor before starting a new medication
Chunks information and regularly checks patient understanding throughout
Indications for warfarin over DOACs
mechanical heart valves
- target INR depends on the valve type and location
- mitral valves generally require a higher INR than aortic valves.
second-line after DOACs:
- venous thromboembolism: target INR = 2.5, if recurrent 3.5
- atrial fibrillation, target INR = 2.5
Before starting antipsychotics
Lithium: side effects
Counselling DOACs
Counselling DOACs specifically:
Rrivaroxaban is a “blood thinner” and helps reduce the risk of blood clot formation and by extension, the risk of stroke.
It is taken once daily as a tablet, the duration of which is lifelong.
It doesn’t require regular monitoring with blood tests, unlike older medications including warfarin.
It will require a one off test of kidney function before starting the medication.
It does carry a small risk of serious bleeding events.
There are no specific dietary or lifestyle alterations needed.
Seeking medical advice is recommended if any unexpected bleeding occurs.
Seeking medical advice is recommended if any injuries to the head are sustained, or following any significant falls, as scans will be required to evaluate for internal bleeds.
Explaining Atrial Fibrillation specifically:
The regular heartbeat we all have is regulated by a certain parts of your heart called the pacemakers. They also ensure that the heart beats in a co-ordinated manner and hence pumps out blood effectively.
In atrial fibrillation, one of the pacemakers has lost its ability to provide control and this results in an irregular heart beat which can affect the heart’s effectiveness in pumping blood. This can leave you with palpitations, feeling lightheaded, and dangerously low blood pressure if left unchecked.
Often the underlying trigger for this condition cannot be pinpointed.
The diagnosis is made by looking at your heart rhythm trace and the unsuccessful attempts at reverting your heart back to normal rhythm.
If left untreated, it carries a risk of blood clot formation which itself can lead to stroke.
It can also be worsened by alcohol, infections, caffeine.
A long term (lifetime) treatment will be required as attempts to reverse the heart rhythm to its normal state have failed.
Early initiation of treatment is highly recommended to minimise the long term risk of stroke.
NICE recommend a step-wise approach for chronic plaque psoriasis
regular emollients may help to reduce scale loss and reduce pruritus
first-line: NICE recommend:
- a potent corticosteroid applied once daily plus vitamin D analogue applied once daily
- should be applied separately, one in the morning and the other in the evening)
- for up to 4 weeks as initial treatment
second-line: if no improvement after 8 weeks then offer:
- a vitamin D analogue twice daily
third-line: if no improvement after 8-12 weeks then offer either:
- a potent corticosteroid applied twice daily for up to 4 weeks, or
- a coal tar preparation applied once or twice daily
- short-acting dithranol can also be used
Score used in adult patients with atrial fibrillation, to assess risk of major bleeding with anticoagulation.
ORBIT
Management of rosecea
Management
topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques)
topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia
more severe disease is treated with systemic antibiotics e.g. Oxytetracycline
recommend daily application of a high-factor sunscreen
camouflage creams may help conceal redness
laser therapy may be appropriate for patients with prominent telangiectasia
patients with a rhinophyma should be referred to dermatology
Management of eczema
- avoid irritants
- simple emollients
- large quantities should be prescribed (e.g. 250g / week), roughly in a ratio of with topical steroids of 10:1
- if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
- creams soak into the skin faster than ointments
- emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers)
- topical steroids
- wet wrapping
- large amounts of emollient (and sometimes topical steroids) applied under wet bandages
- in severe cases, oral ciclosporin may be used
COPD treatment pathway
