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Finals > OSCE communication skills > Flashcards

OSCE communication skills Flashcards

1
Q

Drugs requiring counselling

SSRIs

A

A: Alter the balance of some of the chemicals in the brain. Mainly affect a neurotransmitter called serotonin. An altered balance of serotonin and other neurotransmitters if thought to play a part in causing depression.

T: Once daily

H: Tablet

L: 3-6 months after feeling better

E: 4-6 weeks

T: N/A

I: GI (diarrhoea, nausea, vomiting, appetite changes, weight changes), headaches, drowsiness, worsening of symptoms at first, withdrawal

C: CIs: suicide risk (-> refer)

S: www.mind.org

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2
Q

Drugs requiring counselling

Methotrexate

A

A: Disease-modifying drug which has both reduced inflammation and suppresses the immune system. Early use improves outcomes and symptoms.

T: Once weekly with folic acid at another time. Build the dose up slowly.

H: Usually tablet. Injection is available.

L: Long-term

E: 4-6 months

T: FBCs, LFTs, U&Es. Before starting, then every 2 weeks until stable, then every 2-3 months.

I: Alopecia, headaches, GI disturbance. MYELOSUPPRESSION - attend A&E if infection, unexpected bleeding or bruising, anaemia

C: Myelosuppression, liver toxicity, pulmonary toxicity (let know if SOB)
CIs: Pregnancy (including male), hepatic impairment, breast-feeding, active infection, immunodeficiency

S: No NSAIDs/aspirin, get the annual flu jab, arthritisresearch.org.uk

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3
Q

Drugs requiring counselling

Lithium

A

A: Mood stabiliser. Exact mechanism unknown. Thought to enter cells and interfere with neurotransmitters release and second messenger systems.

T: Once or twice daily, depends on brand

H: Tablet, capsule or syrup

L: Lifelong usually, if works. Regular psych reviews.

E: 1-2 weeks

T: Before starting: FBC, U&Es, TFTs, betaHCG, ECG.
Check lithium levels after 5 days, then every week until stable for 4 weeks, then every 3 months. Check TFTs, U&Es, calcium every 6 months.

I: GI (abdo pain, nausea), fine tremor, metallic taste, thirsy, polyuria, weight gain, oedema

Toxicity: anorexia, dizziness, vomiting, dysarthria, diarrhoea, ataxia, muscle twitching, coarse tremor

C: Toxicity, diabetes insipidus, hypothyroidism
C: 1st trimester, breast-feeding, cardiac disease, significant renal failure, addisons, low sodium diets, untreated hypothyroidism

S: www.bipolar.org.uk

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4
Q

Drugs requiring counselling

Atypical anti-psychotics

A

A: Schizophrenia is caused by over-activity of the chemicals in transmission of messages in the brain. Olanzapine works by blocking receptors in brain that are involved with transmitting these messages between nerve cells.

T: Tablet daily or depot injection every 2-4 weeks (upper arm, buttocks, upper thigh)

H: Tablet or depot, start at small dose and build up over week or 2. Dose adjusted depending on persons response.

L: Long-term. Tell a doctor if planning a pregnancy.

E: Days-weeks

T: Occasional LFTs

I: Anti-dopaminergic (tardive dyskinesia, tremor etc), anti-cholinergic (constipation, dry mouth), Anti-histaminergic (weight gain, dizziness, drowsiness), Anti-adrenergic (hypotension)

C: Neuroleptic malignant syndrome (high fever and muscle rigidity), agranulocytosis (swelling of mouth, throat or rash), withdrawal
CIs: liver failure, phaeochromocytoma, caution in epilepsy, parkinsons, DM, glaucoma, heart, prostate, kidney problems, pregnancy

S: www.rethink.org

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5
Q

Drugs requiring counselling

Levodopa

A

A: Levodopa works to replace some of the dopamine in your brain that it is no longer able to make. Will help reduce symptoms, in particular the rigidity and slow movements. Given with carbidopa (inhibits peripheral levodopa degeneration)

T: 3-4 times daily with food (reduces nausea)

H: Tablet, with carbidopa

L: For as long as it works effectively. After 5 years most people suffer from end dose deterioration (works for shorter time) and on-off effect (fluctuate between severe parkinsonism and repetitive involuntary movements)

E: Fast-acting

T: N/A

I: Psychosis, N+V, dyskinesia, postural hypotension
BUT other drugs help these, e.g. domperidone and selegiline (MAO inhibitor)

C: End-dose deterioration, on-off effects
CIs: Glaucoma

S: Parkinsons.org.uk

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6
Q

Drugs requiring counselling

Bipshosphonates

A

A: Prevents bones from being broken down and helps to rebuild new bone. Remember lifestyle factors can also help with this - exercise, stop smoking, eat well.

T: Once weekly or smaller dose daily

H: Swallow tablet with full glass of water, take at least 30 mins before food/anything other than water, be upright for 30 mins after swallowing

L: Long-term

E: N/A

T: Dental check-up before starting then regularly (risk of jaw osteonecrosis)

I: Headache, heartburn, bloating, indigestion, GI (diarrhoea, constipation, black stools, abdo pain),

C: Osteonecrosis of the jaw
CIs: Pregnancy, dysphagia, stomach ulcers, severe renal impairment

S: www.Nos.org.uk

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7
Q

Drugs requiring counselling

Warfarin

A

A: Thins the blood. Blocks Vitamin K - the vitamin used by the body to make proteins that cause the blood to clot.

T: OD (usually evening)

H: Tablets - different colours for different strengths

L: 3 months for DVT, 6 months for PE, Lifelong for AF

E: 2-3 days

T: Start 5 mg for 4 days then test INR on days 5 and 8, adjusting dose accordingly. Start concomitantly with LMWH if immediate effect is required. Regular INR checks by anti-coag clinic.

I: Bleeding - tell doc is any unusual bleeding - dark stools, cuts taking longer to heal, bruising

CIs: Pregnancy! Hemorrhagic stroke, significant bleeding. Caution in high risk of falls.

S: Avoid liver, spinach, cranberry juice, alcohol binges, NSAIDs, aspirin, given anticoagulation book.

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8
Q

Drugs requiring counselling

Levothyroxine

A

A: Synthetic version of the normal hormone produced by the thyroid - thyroxine. Brings thyroxine levels back up to normal.

T: OD before breakfast

H: Tablet

L: Lifelong

E: Few weeks

T: Start test dose then review in 2-3 weeks. TSH every 2-3 months. When TSH stable, check annually.

I: Rare when thyroxin dose stable. May be hyperthyroid symptoms (vom, diarrhoea, headache, palps, heat intolerance)

C: N/A

S: Free prescriptions for everything if taking levothyroxine.

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9
Q

Drugs requiring counselling

Statin

A

A: Stops the lvier from making cholesterol. Cholesterol is one of the things that predisposes to artery problems and can cause heart disease, stroke or kidney disease. Also important to address other RFs.

T: OD in evening

H: Tablet

L: Lifelong

E: Decreases risk over many years

T: Review in 4 weeks. Then every 6 months. LFTs before starting, at 3 months and at 12 months.

I: Muscle pain, hair loss, itching

C: Rhabdomyolysis
CIs: Pregnancy

S: Avoid grapefruit. www.bhf.org.uk. Also important to address other CVS RFs.

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10
Q

Drugs requiring counselling

Metformin

A

A: Increases sensitivity of cells to insulin, so the body makes better use of the lower insulin levels.

T: OD with breakfast (may be BD)

H: Tablet with or immediately after a meal, same time each day.

L: Lifelong if works

E: -

T: U&Es before starting

I: Nausea, diarrhoea, abdo pain, weight loss

C: Lactic acidosis
CIs: renal impariment, ketoacidosis, low BMI, must not be taken on day of and 2 days after GA or XR contrast media (increased lack acidosis risk)

S: If miss a dose, take as soon as remember unless it is very close to next dose

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11
Q

Drugs requiring counselling

Iron tablets

A

A: Replaces the body stores of iron. Important because it is needed to make RBCs.

T: 1-3 times daily depending on brand

H: Works best if taken on an empty stomach but most take with food as iron can irritate the stomach. Tablet.

L: 4 months (3-4 weeks for Hb to normalise and 3 additional months to replenish stores)

E: 3-4 weeks

T: Hb in 3-4 weeks

I: GI irritation, coloured stools, tastes bad

C: N/A

S: N/A

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12
Q

Inhaler technique

Gathering info

A
  • how much do they know about condition

- how much do they know about the different inhalers

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13
Q

Inhaler technique

Types of inhalers and uses
BLUE

A

BLUE

  • Salbutamol
  • E.g. evohaler, reliever
  • Used during an attack to relieve symptoms
  • May be used with a spacer
  • SEs: tachycardia, tremor
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14
Q

Inhaler technique

Types of inhalers and uses
BROWN

A

BROWN

  • Steroid inhaler
  • Morning and night every day to prevent an attack
  • Rinse mouth afterward
  • May be used with a spacer
  • SEs: dry mouth, hoarse voice, thrush
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15
Q

Inhaler technique

Types of inhalers and uses
Dry powder inhalers

A
  • Used as a reliever of preventer as indicated
  • Different uses depending on the type
  • Typically click to activate then breathe in quickly and deeply, hold for 10 seconds
  • Not used in < 6 yrs (need quick breath)
  • Easier to use
  • Better for environment
  • SEs depends on drug inside
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16
Q

Inhaler technique

Initial explanation

A
  • Explain type of inhaler, it’s purpose and when to use
  • Inhaler contains a set dose of mediciation
  • Aim is to get it all the way down into the lungs
  • Drug released by pressing canister or twisting/clicking device - demonstrate!
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17
Q

Inhaler technique

Steps

A
  1. Check date of expiration
  2. Shake vigorously
  3. Remove cap and check inside is clean
  4. Stand or sit up straight
  5. Hold inhaler upright with index finger on top and thumb on bottom
  6. Breathe out completely
  7. Seal mouth around mouthpiece
  8. Simultaneously press firmly on canister and breath in slowly and deeply (aim for back of throat, not tongue)
  9. Hold breath for 10 seconds or as long as possible
  10. Breathe out slowly
  11. Replace cap
  12. Repeat after 1 min if required
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18
Q

Inhaler technique

Demo and observsation

A
  • Demonstrate it yourself
  • With different placebo inhaler, ask patient to demo
  • Observe and correct any mistakes
  • Get patient to repeat until correct
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19
Q

Inhaler technique

Other advice

A
  • Seek emergency help if symptoms are severe/not relieved
  • See GP/specialist nurse if SEs or using reliever more than 3 times a week
  • Ask if any questions or concerns
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20
Q

Inhaler technique

Spacer device steps

A
  1. Assemble spacer
  2. Shake inhaler and remove cap
  3. Attach to spacer
  4. Breathe out
  5. Seal mouth around spacer
  6. Press on canister to release drug
  7. Breathe in slowly and deeply for 3-5 seconds then hold for 10 seconds (alternatively take 5 normal breaths in and out through mouth)
  8. Repeat if required after 30 secs
  9. If device whistles - breathing in too quickly
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21
Q

Inhaler technique

Looking after spacer

A
  • Wash spacer with warm water and soap
  • Always leave to drip dry
  • Replace every 6-12 months
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22
Q

Operation-specific risks

Gastrectomy

A
  • Dumping syndrome
  • Malasbsorption
  • Peptic ulcers/gastric cancer
  • Blind loop syndrome
  • Abdo fullness
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23
Q

Operation-specific risks

Small and large bowel ops

A
  • Ileus
  • Anastomotic leaks
  • Stoma restraction
  • Intra-abdo collections
  • Pre-sacral plexus damage
  • Adhesions/intestinal obstruction
  • Damage to other local structures, e.g. kidneys
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24
Q

Operation-specific risks

Cholecystectomy

A
  • Common bile duct injury/bile leak
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25
Q

Operation-specific risks

Biliary

A
  • Common bile duct injury/bile leak
  • Common bile duct stricture
  • Anastomotic leak
  • Bleeding into biliary tree
  • Pancreatitis
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26
Q

Operation-specific risks

CABG/stenting

A
  • Reperfusion arrhythmias
  • Post-op acute coronary syndrome
  • Often need inotropes post-op that may reduce organ perfusion elsewhere
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27
Q

Operation-specific risks

Grafts/stents/bypass procedures

A
  • Failure of graft
  • Haemorrhage/haematoma
  • Infection
  • Re-thrombosis
  • Limb/organ ischaemia
  • AV fistula
  • Cholesterol embolism
  • Areteriopaths are at high risk of ACS, stroke, PE
  • Contrast complications - renal injury, anaphylaxis
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28
Q

Operation-specific risks

Thyroidectomy

A
  • Airway obstruction secondary to hemorrhage
  • Hypocalcaemia (damage to parathyroid glands)
  • Recurrent laryngeal nerve damage
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29
Q

Operation-specific risks

Parotidectomy

A
  • Facial nerve damage
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30
Q

Operation-specific risks

Any orthopaedics operation

A
  • Infection of prosthesis
  • Loss of position/failure of fixation
  • Neurovascular injury
  • Compartment syndrome
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31
Q

Operation-specific risks

Total hip arthroplasty

A
  • Sciatic nerve damage
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32
Q

Operation-specific risks

Cystoscopy/TURP

A
  • High risk of UTI
  • TURP sundrome (hyponatraemia)
  • Impotence/retrograde ejaculation
  • External sphincter damage (incontinence)
  • Urethral stricture
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33
Q

Operation-specific risks

Endovascular surgery

A
  • Retroperitoneal haemorrhage
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34
Q

Operation-specific risks

Lymph node dissection

A
  • Lymphoedema
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35
Q

Operation-specific risks

Neck dissection (e.g. brachial cyst excision)

A
  • Cranial nerve damage (11, 12)
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36
Q

Scope procedures

Bronchosopy
Procedure prep

A
  • 6hrs before: clear fluids only
  • 2hrs before: NBM

Also:

  • Clotting test
  • Stop aspirin, warfarin or anticoags 1 week pre-procedure
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37
Q

Scope procedures

Bronchosopy
During procedure

A
  • Midazolam sedative

- Lignocaine gel for airways

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38
Q

Scope procedures

Bronchosopy
After procedure

A
  • No eating or drinking 2 hrs after as throat still numb
  • No driving, alcohol, operating machinery
  • Keep someone there for 24 hrs
  • Arrange follow up
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39
Q

Scope procedures

Bronchosopy
Risks (> 1%) and benefits

A
  • Sore nose/throat
  • Infection
  • Haemoptysis next day or so if biopsied
  • Lung damage/collapse
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40
Q

Scope procedures

Gastroscopy
Procedure prep

A
  • 6hrs before: clear fluids only
  • 2hrs before: NBM

Also:
- Stop antacids 2 weeks prior

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41
Q

Scope procedures

Gastroscopy
During procedure

A
  • Midazolam sedative
  • Lidocaine spray
  • Continuous suction
  • Air passed through scope –> belching/fullness
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42
Q

Scope procedures

Gastroscopy
After procedure

A
  • No eating/drinking for 2 hrs after as throat still numb
  • No driving, alcohol, operating machinery
  • Keep somewhere there for 24 hrs
  • Arrange follow up
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43
Q

Scope procedures

Gastroscopy
Risks (> 1%) and benefits

A
  • Perforation (< 0.1%)
  • Bleeding
  • Infection
  • Dental damage
  • Sedation SEs
  • Transient sore throat
  • Elderly: cardio-resp arrest (< 0.1%)
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44
Q

Scope procedures

Colonoscopy
Procedure prep

A
  • 2 days before: no bran/roughage
  • 1 day before: clear fluids only after light breakfast
  • 2 hrs before: NBM

Also:

  • Sodium picosulphate sachet for afternoon before and morning of
  • Stop iron tablest 1 week before and constipating agents 4 days before (e.g. codeine)
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45
Q

Scope procedures

Colonoscopy
During procedure

A
  • PR first
  • Midazolam sedative
  • Air passed through scope (bloating, feel like need to go to toilet)
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46
Q

Scope procedures

Colonoscopy
After procedure

A
  • No driving, alcohol, operating machinery
  • Keep somewhere there for 24 hrs
  • Arrange follow up
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47
Q

Scope procedures

Colonoscopy
Risks (> 1%) and benefits

A
  • Perforation (< 0.1%)
  • Bleeding
  • Infection
  • Haemorrhage after biopsy
  • Abdo discomfort
  • Incomplete exam
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48
Q

Scope procedures

Cystoscopy (rigid or flexi)
Procedure prep

A
  • 6hrs before: clear fluid only
  • 2hrs before: NBM

Normal pre-op assessment

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49
Q

Scope procedures

Cystoscopy (rigid or flexi)
During procedure

A
  • May have sedative or anaesthesia
  • Anaesthetic jelly
  • Water passed through
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50
Q

Scope procedures

Cystoscopy (rigid or flexi)
After procedure

A
  • Can go home after passed urine
  • No driving, alcohol, operating machinery
  • Keep somewhere there for 24 hrs
  • Arrange follow up
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51
Q

Scope procedures

Cystoscopy (rigid or flexi)
Risks (> 1%) and benefits

A
  • Bleeding due to structural damage
  • Infection
  • Mild burning on urinating for up to 24 hrs
  • Haematuria after biopsy
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52
Q

Scope procedures

Flexi Sig
Procedure prep

A
  • 2hrs before: clear fluids only

Also:
- x2 phosphate enemas 2 hrs before (can be administered at home)

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53
Q

Scope procedures

Flexi Sig
During procedure

A
  • PR first

- No sedation required

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54
Q

Scope procedures

Flexi Sig
After procedure

A

N/A

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55
Q

Scope procedures

Flexi Sig
Risks (> 1%) and benefits

A
  • Perforation (< 0.1%)
  • Bleeding
  • Infection
  • Haemorrhage after biopsy
  • Abdo discomfort
  • Incomplete exam
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56
Q

Contraception counselling

Qs to ask before beginning

A
  • Age
  • Relationship (regular/multiple partners)
  • Menstrual history (dysmennorhea, menorrhagia, cycle legnth, regularity)
  • If menopausal –> need cover for 1 year after periods, or 2 years after for < 50 yrs
  • Recent pregnancy/breastfeeding
  • Prev contraception
  • PMHx: current, past, STIs, migraine w aura, HTN, VTE hx, BP, weight, height, liver problems
  • Dx and allergies
  • SHx: SMOKING
  • Fx: breast/cervical cancer, VTE history, migraine with aura
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57
Q

Contraceptive counselling

Q’s specific to type

A
  • Any preference
  • Preferred delivery
  • Ability to remember to take pills
  • Would they tolerate injections?
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58
Q

DVLA rules

Diabetes - normal licence

A

No immediate restriction

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59
Q

DVLA rules

Diabetes - HGV licence

A

Stop driving

Must meet certain criteria

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60
Q

DVLA rules

First unprovoked seizure - normal licence

A

6 months

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61
Q

DVLA rules

First unprovoked seizure - HGV licence

A

5 years

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62
Q

DVLA rules

Other seizure - normal licence

A

12 months

63
Q

DVLA rules

Other seizure - HGV licence

A

10 years

64
Q

DVLA rules

Stroke/TIA - normal licence

A

1 month

Do not need to tell DVLA if no residual symptoms

65
Q

DVLA rules

Stroke/TIA - HGV licence

A

1 year

66
Q

DVLA rules

Unexplained syncope - normal licence

A

6 months

67
Q

DVLA rules

Unexplained syncope - HGV licence

A

1 year

68
Q

DVLA rules

Treated cardiac syncope, or vaso-vagal - normal licence

A

1 month

69
Q

DVLA rules

Treated cardiac syncope, or vaso-vagal - HGV licence

A

3 months

70
Q

DVLA rules

MI treated with stent - normal licence

A

1 week

Do not need to tell DVLA if no residual symptoms

71
Q

DVLA rules

MI treated with stent - HGV licence

A

6 weeks (but need tests)

72
Q

What to do if patient refuses to comply with DVLA notifying?

A
  • Doctors duty to advise patient not to drive and advise to tell DVLA
  • If patient refuses and says they will continue to drive then involve senior and have multiple conversations
  • If still insist –> break confidentiality and inform DVLA
73
Q

Childhood vaccinations

Diphtheria
Illness

A
  • Fever
  • Sore throat
  • Grey membrane on tonsils - can narrow lumen
74
Q

Childhood vaccinations

Diphtheria
Complications

A
  • Cardiomyopathy

- Kidney injury

75
Q

Childhood vaccinations

Tetanus
Illness

A

Muscle spasm in jaw and other muscles, including respiratory muscles

76
Q

Childhood vaccinations

Tetanus
Complications

A

Respiratory muscle impairment

77
Q

Childhood vaccinations

Polio
Illness

A

Destruction of nerves, resulting in muscle weakness and paralysis

78
Q

Childhood vaccinations

Polio
Complications

A

Paralysis

79
Q

Childhood vaccinations

Pertussis
Illness

A

Whooping cough (‘hundred day cough’)

80
Q

Childhood vaccinations

Pertussis
Complications

A
  • Pneumonia
  • Convulsions
  • Bronchiectsasis
81
Q

Childhood vaccinations

H. influenza B
Illness

A
  • Meningitis
  • Epiglottitis
  • Pneumonia
82
Q

Childhood vaccinations

Hep B
Illness

A

Liver cirrhosis

83
Q

Childhood vaccinations

Rotavirus
Illness

A

Diarrhoea and vomiting

84
Q

Childhood vaccinations

Rotavirus
Complications

A

Extreme dehydration

85
Q

Childhood vaccinations

Pneumococcal
Illness

A
  • Meningitis

- Pneumonia

86
Q

Childhood vaccinations

Meningitis B/C/ACWY
Illness

A

Different strains of meningitis

87
Q

Childhood vaccinations

Meningitis B/C/ACWY
Complications

A
  • Deafness
  • Cerebral oedema
  • Memory difficulty
  • Learning disability
88
Q

Childhood vaccinations

Measles
Illness

A
  • high fever
  • cough
  • conjunctivitis
  • coryza
  • rash
89
Q

Childhood vaccinations

Measles
Complications

A
  • Encephalitis

- Corneal ulcers/scarring

90
Q

Childhood vaccinations

Mumps
Illness

A

Mild illness with gland swelling and headache

91
Q

Childhood vaccinations

Mumps
Complications

A
  • Orchitis (and infertility)
  • Unilateral deafness
  • Encephalitis
  • Meningitis
92
Q

Childhood vaccinations

Rubella
Illness

A
  • Flu-like illness with rash
93
Q

Childhood vaccinations

Rubella
Complications

A

Complications in pregnant women: congenital rubella syndrome

  • Miscarriages
  • Stillbirth
  • Constellation of severe birth defects in infants - cataracts, cardiac abnormalities, deafness, poor growth, learning disabilities
94
Q

Childhood vaccinations

HPV
Complications

A
  • Cervical cancer
  • Oral cancer
  • Anal cancer
  • Vaginal cancer

Given as 2 injections, 6 months apart

95
Q

Childhood vaccinations

Benefits of vaccinations

A
  • Prevent serious diseases with severe consequences
  • To maintain eradication of diseases that can kill and disable millions of children
  • Much safer to have the vaccines than not have them
96
Q

Childhood vaccinations

Risks of vaccinations

A
  • As will all meds, can have SEs (see below)

- However, these are rarely serious and generally only last a few days

97
Q

Childhood vaccinations

Safety of vaccinations

A
  • Vaccines are extremely safe

- Continually monitored

98
Q

Childhood vaccinations

Contraindications to vaccinations

A
  • Illness with a FEVER - postpone vaccine
  • Avoid live vaccines in immunocompromised
  • Avoid if known anaphylactic shock to vaccine or any ingredient
  • Egg products - flu vaccine
99
Q

Childhood vaccinations

Possible side effects of vaccinations

A
  • Local effects: swelling, redness, lump
  • Fever
  • Allergic reaction and anaphylaxis (can be treated)
  • Specific side effects
    • MMR: swollen glands, rash, fever
100
Q

Childhood vaccinations

Which are live vaccines

A
  • MMR
  • BCG
  • Varicella
  • Nasal flu vaccine
101
Q

Childhood vaccinations

Which vaccines contain egg

A
  • MMR: BUT chick embryos and does NOT trigger allergy

- Flu vaccine - use egg-free alternative

102
Q

Childhood vaccinations

MMR and autism

A
  • The research was conducted in 1998 and has seen been found to be false
  • The author has been struck off the medical register for serious misconduct
  • Further far more detailed studies that have been conducted have proven no link between MMR and autism
103
Q

Contraception

Methods of action

A

Inhibits ovulation:

  • COCP
  • Injectables
  • Implant

Thickens cervical mucus:

  • POP
  • Injectables
  • Implant
  • IUS

Decreases sperm mobility and survival:
- IUD (copper = spermocide)

Prevents endometrial proliferation:
- IUS

104
Q

Contraception

Absolute CIs of the COCP

A
  • Smoker > 35 yrs
  • < 6/52 postpartum
  • Breastfeeding
  • Hypertensive
  • Current/past VTE
  • Migraine with aura
  • CVD
  • Current breast cancer
  • Liver cirrhosis
105
Q

Contraception

Relative CIs of COCP

A
  • Hypertension - controlled
  • Migraine > 35 yrs
  • BMI > 35
  • Enzyme-inducing medications
106
Q

Contraception

CIs of POP

A
  • Forgetfulness (forget to take)
  • Breast cancer
  • Undiagnosed PV bleeding
  • Liver disease
  • Severe arterial disease
107
Q

Contraception

CIs of IUS/IUD

A
  • Pelvic infection
  • PID < 3 months ago
  • Gynae cancer
  • Small uterine cavity
  • Fibroid that distorts uterine cavity
  • Undiagnosed PV bleeding
  • Copper allergy (IUD)
  • IHD (IUS)
108
Q

Contraception

CIs of implant/injection

A
  • Liver/genital/breast cancer
  • Liver disease
  • Undiagnosed PV bleeding
  • Enzyme inducers
109
Q

Contraception

SEs of COCP

A
  • Hormonal
  • Blood clots
  • Breast/cervical cancer
  • Periods may be lighter
  • Local irritation from patch
  • Pain from ring during intercourse - can be removed for max of 3 hrs
110
Q

Contraception

Pros of COCP

A
  • Control pain and bleeding

- Reduced risk of endometrial and ovarian cancer

111
Q

Steroid use

How to take?

A

One tablet, once a day

112
Q

Steroid use

Risks

A
  • Peptic ulcers
  • Diabetes
  • Hypertension
  • Osteoporosis
  • Infection risk
113
Q

Steroid use

Side effects

A
  • Skin thinning
  • Acne
  • Weight gain
  • Mood changes
  • Proximal myopathy
114
Q

Steroid use

Relevant PMH

A
  • Peptic ulcers?
  • Osteoporosis?
  • Hypertension?
  • Already on meds? e.g. NSAIDs - risk of PU
  • Allergies?
115
Q

Steroid use

Advice

A
  • Do not stop
  • Do not continue to take NSAIDs
  • Watch out for DM symptoms (urinary freq and thirst) and any abdominal pain
116
Q

Steroid use

Monitoring?

A
  • BP measurements
117
Q

HRT

Indications

A
  • Tx of menopausal symptoms
  • Tx of early menopause
  • Osteoporotic fracture prophylaxis in women < 60 yrs
118
Q

HRT

CIs

A
  • Undiagnosed PV bleeding
  • Pregnancy/breastfeeding
  • Oestrogen dependant cancer
  • Acute liver failure
  • Uncontrolled HTN
  • Hx of breast cancer
  • Hx of VTE
  • Hx of stroke/MI/angina
119
Q

HRT

Benefits

A
  • Relief of vasomotor symptoms
  • Relief of psychological symptoms
  • Reduced libido
  • Urogenital atrophy
  • Reduction in osteoporosis
  • Reduction in CVS disease (< 65 yrs)
120
Q

HRT

Risks

A
  • VTE
  • Stroke
  • Breast cancer (small increased with combined HRT)
  • Ovarian cancer (if used for > 5yrs)
  • Endometrial cancer (if women with uterus take oestrogen-only)
121
Q

HRT

SEs

A
  • Oestrogen: breast tenderness, leg cramps, nausea/bloating
  • Progesterone: pre-menstrual syndrome
  • Bleeding: PV bleeding occurs towards the end of progesterone phase of cyclical HRT
122
Q

HRT

Routes

A
  • Systemic: oral, transdermal

- Vaginal (for atrophy): tablet, cream, pessary or vaginal ring

123
Q

HRT

Types

A
  • No uterus –> oestrogen-only HRT
  • Uterus:
    • Peri-menopausal: cyclical HRT
    • Post-menopausal (no periods for > 1 yr or on cyclical for > 1 yr): continuous HRT
124
Q

HRT

Duration

A
  • No max duration, individualize to women’s risk vs benefits

- Risk increases after 65 yrs

125
Q

HRT

Qs to ask

A
  • Age (45-55)
  • COnfirm menopause if possible
  • Discuss symptoms
  • PV bleeding
    • Still having periods? regularity?
    • No longer having: when was last? any post-menopausal or post-coital bleeding?

Relevant PMH/Fx

  • PE/Stroke/MI/angina
  • Oestrogen dependent cancer (breast/endometrial)
  • Do they have a uterus?
126
Q

Explaining menopause

A
  • Time when periods cease and a woman is no longer able to get pregnant
  • Occurs because ovaries stop producing hormones
  • These hormones regulate female repro system but also have other effects on body, e.g. mood, libido
  • Symptoms lasts for 4 yrs on average (but can be 12)
127
Q

Contraception on HRT

A
  • Women are potentially still fertile for 1 year after last menstrual period (or 2 yrs if <50)
  • Explain HRT is NOT contraception
  • Contraceptive options for women on HRT:
    • Progesterone only pill
    • Mirena coil
128
Q

Alternatives to HRT

A
  • Mood: CBT, antidepressants
  • Vasomotor symptoms: SSRIs, SNRIs, clonidine
  • Vaginal dryness: lubricants/moisturizers
  • Irregular periods: Mirena coil
129
Q

Domestic violence

Establishing details

A
  • Types of abuse: physical, emotional, financial, sexual
  • Who is the perpetrator and their relationship to you?
  • Pattern: when? is alcohol involved? drugs?
  • Timeframe: how long has it been going on for? has it been escalating?
  • Coping: how have they coped? have they tried anything to get away or stop it?
  • Who else is involved? Children or vulnerable adults?
130
Q

Domestic violence

Determining social situation

A
  • Who do they live with?
  • Are there weapons in the house?
  • Does they patient have a safety/emergency plan?
  • If not, might be worth constructing one
  • Tell them they can always call the police
  • Do they work?
131
Q

Domestic violence

Tips

A
  • Offer emotional support and tissues
  • Be relaxed and compassionate
  • Don’t pressure them into telling you, but they may need to be asked several times before opening up
  • Allow time for patient to talk
132
Q

Domestic violence

Risk assessment
NEVER FORGET

A
  • Risk from partner: do they currently feel in danger? what would happen if they went home now?
  • Risk to self: has it affected their mood? have they considered self-harming or taking own life?
  • Risk to others: Any children or vulnerable adults?
133
Q

Domestic violence

Risk assessment
Abuse risk factor assessment

A
  • Victim: low self-esteem
  • Partner: pregnancy, alcohol or drug use, psychiatric issues, personality disorders, unemployment, being a victim of poor parenting, abus, physical discipline, convictions
  • Relationship: separation/divorce, poor housing situation
134
Q

Domestic violence

Management

A
  • Reassure and acknowledge
  • Assure of confidentiality
  • Explain sources of support: establish support from friends/family, suggest counselling/support helplines, refuge is available if needed
  • GIVE LEAFLETS
  • Others: police, local domestic abuse services, counselling, social services must be informed in children or vulnerable adults are involved
  • Formulate a plan together and arrange FOLLOW UP
135
Q

Safeguarding

Sources of help for parents and children

A
  • Health visitors: until5 yrs
  • Social services: up to 18 yrs
  • Children’s centres: parenting classes, advice, support, activities, childcare, early education
  • Family nurse partnership: specialist nurse home visits from pregnancy until 2 yrs
  • GP
  • PAediatrician
  • CAMHS
  • Free prescriptions, dentist and opticians
  • Special educational needs coordinator (SENCO)
  • Some childcare is free - visit www.gov.uk website
  • Local drug/alcohol services
136
Q

Safeguarding

Recognising a child with a non-accidental injury
Suggestive factors

A
  • Injury incompatible with story
  • Inconsistent stories from all involved
  • Delay in seeking help
  • Abnormal interaction from child
  • Abnormal affect on parent
137
Q

Safeguarding

Recognising a child with a non-accidental injury
General indicators

A
  • Multiple bruises
  • Black eye
  • Torn frenulum
  • Bite marks
  • Injuries on non-mobile child
138
Q

Safeguarding

Recognising a child with a non-accidental injury
Common non-accidental injuries

A
  • Bruises: on soft tissues, ears, face, eyes, neck, inner arms, abdomen, groin, buttocks
  • Fractures: multiple, ribs, humeral, metaphyseal, spiral
  • Burns: hands, buttocks, feet

Remember, could be other causes: ITP/leukaemia for abnormal bruising, osteogenesis imperfecta can cause multiple fractures

139
Q

Safeguarding

Raising safeguarding concerns
Children and vulnerable adults w/o capacity

A
  • Vulnerable adult: unable to care for or protect themselves against harm or exploitation
  • If risk if posed to a child (< 18 yrs) or vulnerable adult w/o capacity –> MUST break confidentiality even if they object
140
Q

Safeguarding

Raising safeguarding concerns
Adults with capacity

A
  • If the person is an adult with capacity then must explain risks as you perceive them and what help is available
  • Encourage them to accept help and allow you to refer them on
  • If they have capacity and do not give consent, you can NOT disclose their situation to anyone else
141
Q

Safeguarding

Raising safeguarding concerns
Who to refer to

A
  • Children and vulnerable adults: social services

- Adults who are not vulnerable: police, local domestic abuse services, counselling services

142
Q

Safeguarding

Sources of help and advice

A
  • Seniors
  • Safeguarding lead in hospital
  • Social services or local domestic abuse services
143
Q

Safeguarding

Explaining safeguarding concerns to a parent

A
  • Tell the parents you are making a referral to social services
  • If you feel an urgent social services assessment is required or child is at immediate risk then emergency protection order can be sought
  • Do not accuse the parents - explain that all children with these types of injuries have to be referred for assessment
  • Explain why it is important - some injuries like this are not accidental and it is very difficult for us to tell which, so we have to refer all cases
  • Explain what it will involve
  • Emphasise all the rules are in place to ensure children are safe and protected
  • Remember you may be met with anger
144
Q

What is an advanced directive

A
  • Legally binding document outlining what medical treatment a patient would NOT want in the future if they lack capacity
145
Q

What makes an advanced directive legally binding?

A
  • Signed
  • Witnessed
  • No doubt about the patient’s state of mind at time of signing
  • Not felt it may have been done under distress
146
Q

What rights do relatives have in advanced directives?

A

Relatives can not rescind or modify and advanced decision

147
Q

Limitations of advanced directives

A

Can not specify which treatments they want, only those that they would not want

148
Q

Lasting power of attorney

What

A

A third party appointed in advance to make decisions on behalf of the patient should they lose capacity

  • May be one person or multiple people
  • Can act together or separately
  • Can be a relative, a friend, a legal advocate
149
Q

Lasting power of attorney

Types

A
  • Health and welfare

- Property and finance

150
Q

Lasting power of attorney

Health and welfare, what can they decide?

A
  • For decision regarding health
  • Only takes effect if lacks capacity
  • Can make decisions about daily routine, medical care, moving into care home, refusing life-saving treatment
  • Can NOT choose with treatments to have, only refuse offered medical treatments
151
Q

Lasting power of attorney

How to register

A
  • Fee payable to Office of the Public Guardian to register
  • Additional legal fees if solicitor is used
  • Can be made through a solicitor or independently online or by paper forms
  • Documents will also need to be signed by witnesses
152
Q

Lasting power of attorney

Cost

A

£130 for each type

153
Q

CAGE questionnaire

A

C: Ever thought about cutting down?
A: Angry if others mention drinking?
G: Guilty about drinking?
E: Eye-opener`

154
Q

Chlamydia risks to baby

A
  • Premature rupture of membranes
  • Pre-term labour
  • Low birth weight
  • Eye infections
  • Lung infections

Finals (21 decks)

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