Week 15: GP/VS Flashcards
What is treatment burden?
Workload that patients experience/need to do in order to manage their chronic condition
High levels of treatment burden can cause:
Poor adherence
Disengagment with healthcare services
Poorer quality of life
How does treatment burden arise?
Due to workload volume or care deficiencies
Illness work: Work that patients and families need to do to understand their chronic illness
Treatment work: Tasks that need to be done to manage health and follow treatments set by their healthcare providers
What is patient capacity
Degree to which pts can cope with their illness and lives
Needs to be considered with workload
What is polypharmacy?
5 or more medications to a pt at one time
Due to ageing population, multi-morbidity, preventative medication
What is the clinical presentation of John Darlington and how do you treat it?
Clinical presentation:
- Idiot (due to excessive crap in his head causing increased ICP and decreased CPP)
- Micropenis
- Mood disturbances
Treatment:
- Love and tender care, or
- Getting the stick out of his arse
Types of polypharmacy
Appropriate - pescribing for a pt with muitlple conditions where medications aligned with best evidence
Inappropriate - pescribing medications inappropriately, intended benefit not gained
What are the 2 main reasons for elderly to be at risk of polypharmacy?
Pharmacokinetics
Pharmacodynaimics
What types of patients are most at risk of ADRs from polypharmacy?
Increasing age
Increased fraility
Residents in care homes
High risk medications
Deprivation
How to identify which patients most at risk from polypharmacy?
STOPP/START (STOPP - screeining tool of older people’s medication, START - screening too to alert right treatment)
7 steps to appropriate polypharmacy:
- Identify what matters to pt
- Identify essential medications
- Is the pt taking uneccesary drugs?
- Are therapeutic objectives being acheived?
- Are they at risk of ADRs or suffering from them?
- Is the drug cost-effective?
- Is the pt willing/able to take the drug as intended
4 components of pt-centred care
Affording people dignity, compassion, respect
Offering co-ordinated care
Offering personalised care
Supporting people to enable them to live an independent, fulfilling life
Ways to support self-management
Open questions
Affirmation
Normalisation
Reflective listening
Agenda setting - explore priorieites and produce an agenda with pt
Goal setting and action planning - support pt to identify goals and how they can work towards it
Goal follow up - explore challenges, give positive affirmation of progress and effort
What is person-centred self management?
Supporting individual to build skills, behaviours to live with their long term condition. Listening to what matter to them, and work with their families to help them manage
Not about replacing services or expecting them do everything for themselves
What are the social determinants of health?
Socio-economic, cultural and environmental conditions
Education, living and working conditions, health care services
Social and comminity networks
Individual lifestyle factors
Age, sex, constitutional factors
What is candidacy?
What shape’s poeple knowledge of and acess to health services
E.g. financial status, residency, language barriers
Population vs. high risk approach
Treating people at highest ,evel of risk reduces indiviual risk but not marked reductions in population risk
Unoviersal prevention measures, shifts population risk to left, preventing disease in large proportion of people at low risk, reducing proportion of people above treatment threshold
Obesity
Tier 1: Information and guidance on healthy eating, exercise
Tier 2: Multi-component weight management services inc. lifestyle interventions
Tier 3: Muti-disciplinary treatments e.g. psycholoical, pharmacotherapy
Tier 4: Bariatric surgery
What should weight loss targets be based on?
Individual’s comorbidities and risk, rather than their weight alone
Barriers to access of Glasgow Weight Management Services
For patients: location/timing of classes, lack of awareness of service, delay in referral-assessment-classes
For dcotors:
don’t know where the nearest centre is, lack of knowledge what service involves, practice nurses better to discuss weight than GPs
When to refer someone for weight management services?
BMI >25 + diabetes
BMI 30 + Diabetes, CVD, mobility issues
BMI >40 (no comorbidity required)
How to make John Darlington lose weight?
Give all his empire biscuits to Jo
Acutally lift some proper weights
Erectile dysfucntion
Investigations
Psychosexual history
General - BP, BMI
Exam external genitalia
DRE
ED can be risk marker of CVD:
HbA1c
LFTs
Testosterone (hypogonadism)
PSA ( not routine). Consider if:
Age >50, abnormal DRE, risk factors for prostate Ca
Types:
Psychogenic (5%) - no physiological or neurovascular condition
Causes: stress, peformance anxiety, psycholgical problems
Organic (10%) - physical cause
Causes: CVD, Diabetes, hormonal (low testosterone, high prolactin) or drugs (Citalopram, Bblockers, Digoxin)
Treatment:
Sildenafil (phosphodiesterase type 5 (PDE5) inhibitors) - promotes smooth muscle relaxation, increaseing blood flow to penis
SE: back pain, migraine, nausea/vomiting
2nd line: alprostaldil (synthetic prostaglandin E1 analogue)
Child protection
Where would you gain more information about the pt?
Medical notes
GP Child protection Lead
Child protection unit
Social Work Services
School nurse
Teacher
Risk factors:
Domestic abuse, perental alcohol/drugs misuse, child/parent mental health difficulties, non-engaging families, FGM
Next step if suspicous:
Raiase a notification of concern (NOC) - made to social work and child protection unit
Role of healthcare professional;
Act on and refer early signs of abuse
Keep accurate record keeping
Listen to views of child
Share information appropriately
Types of abuse
Physical, emotional, sexual, neglect
Definition of child protection
When a child requires from child abuse/neglect. Not required for it to already have taken place, but a risk assessment.
Child protection Register:
Register where children are put on, if there are reasonable grounds to believe a child will/have suffered abuse/neglect
Red flags of GI
Dysphagia
Melaena
Haematemesis
Fresh PR bleeding
Weight loss
Drugs which can cause dyspepsia/GI bleed?
NSAIDs
Anti-platelets
Anti-coagulants
SSRIs
Ca channel blockers
How can you indentify pts risk of polypharmacy
STOP/START screening tool
Ways to safe guard pts from polypharmacy
Pharmacists - blister packs
Social carers - prompt pt to take medication
District nurse - checkw weight, BP, HR, blood monitoring
DDx of memory loss
AD
Delerium
Depression
Vacular dementia
Dementia with lewy bodies
MSSE
Orientation
Registration
Attention and calculation
Recall
Language
< 23/30 - cognitive impairment
< 18/30: severe impariment
AD
Symptoms:
Cogntive
- Problems with carrying out activities of daily living
Non-cognitive
- Behavioural and psychological
Agitation, wandering, aggression, depression
Treatment
Mild-moderate:
Donezepil: AChEi (acetylcholinesterase inhibtor)
SE: bracycardia, GI upset
Moderate-severe:
Memantine (NMDA anatagonist)
SE: dizziness, constipation
Cycle of change
Pre-complentation
Complentation
Planning
Action - Maintenance or Relapse
5 domains in which behaviour changes occurs:
Congitive - info from the doctor makes raises pt awareness
Attitudinal - doctor helps pt develop commitment to change
Instrumental - skills pt needs are built
Planning - preparing for the time ahead inc. anticipating problems
Social support - support from friends, families, other agencies
What does pt empowerment mean?
Enabling people to gain an advantage over the circumstances they are in
What is concordance, and best predictor of it?
Agreement between pt and doctor, which respects the beliefs and wishes of the pt, in determining how and when medicines are to be taken
Doctor and pt relationship
Other factors: if the doctor doesn’t explain things properly, pt too tired/distracted to take in much
Upper GI Endoscopy
Upper GI endoscopy is the examination of lining of oesophagus, stomach and duodenum, using a flexible endoscope insterted through the throat. Biopsy can be taken.
Used for:
- Upper GI bleeding
- Dysphagia
- Persistenct vomiting
- Persistent anaemia inc. IDA
Complications:
- Respiratory distress
- Aspiration pneumonia
Bloated (due to air used)
- Bleeding from biopsy site
- Perforations
Colonscopy
Examintion of the lining of the mucosa of the colon by a flexible telescope. Passed through anus to visualise rectum, sigmoid colon, descending, transverse and ascending colon. Biospies can be taken.
Peformed when:
Rectal bleeding
Change in bowel habits
Faceal occult blood +ve
Unexplained anaemia in a, at risk group
Fitness for colonscopy:
Pt needs to be assessed for:
FBC, ESR, renal function, liver function
Complications:
Rectal bleeding
Colonic bleeding
Peforation of colon
DRE (digital rectal exam) should be done first
Uusally sigmoidoscopy, done before
Mammography
X-ray of the breast, using limited amount of radiation
Screening mammogram part of early detection scheme
Diagnostic mammogram evaluates a pt with exsisting breast lumps
When is it peformed:
Women 50-70, every 3 yrs
If women have had sugery for a previous breast disease
Strong family hx, of early breast cancer
Contra-indications:
Pregnancy, breast-feeding
Complications
False positives, false negatives
