GP Flashcards

Question

What is health care need?

Answer 1

more specific in need for interventions and prevention provided by healthcare (for population, condition or an intervention can be applied)

Answer 2

individual perceptions of variation from normal health

Answer 3

individual seeks help to overcome variation in normal health (demand)

Answer 4

professional defines intervention appropriate for the expressed need

Answer 5

comparison between severity, range of interventions and cost

Answer 6

define problem; size of problem; services available; evidence base; models of care; existing services and recommendations

Answer 7

compares services received in different populations (inequities)

Answer 8

multiple conditions leading to complexity in care (think about cons)

Answer 9

5 or more drugs at once (think about cons); appropriate = where medicines use is optimised and good research into what the best ones are and the least drugs used with the least interactions and most benefit (inappropriate = opposite of this and don’t necessarily know why patient is taking some of them)

Answer 10

behaviour aimed to prevent disease (can be split up into health damaging and promoting)

Answer 11

behaviour to seek remedy

Answer 12

any activity aimed at getting well

Answer 13

turning a person into a statistic

Answer 14

use literature to study something

Answer 15

use literature and use statistics to analyse it

Answer 16

follow group of people over time and look at their exposure to stuff and see if they develop a disease

Answer 17

one behaviour may make chance of having another one more likely (smoking and alcohol abuse)

Answer 18

o Population = health promotion | o Individual = patient-centred approach

Answer 19

inaccurate perceptions of risk and susceptibility

Answer 20

pt factors = rebel, lack of motivation, socioeconomic; healthcare factors = time to educate, motivating pt and money to promote; society = responsibility with GP and advertising of risk factors (smoking/alcohol)

Answer 21

precontemplation (uninterested/unaware to make a change), contemplation (assess barriers and benefits of giving up), preparation (pt prepares to make the change), action (desire to change lifestyle but not going through prev steps my be less effective), maintenance and relapse prevention

Answer 22

asking questions “Have you ever thought about giving up?” “what’s stopping you?”

Answer 23

time in consultation, pressure of isolation in consultation, dealing with uncertainty in presentation, managing long-term relationships with pts, switching emotions to suit the pt presentation, pt demand vs budget, constant reorganisation

Answer 24

put pt first; explore disease and illness experience, understand whole person (psychosocial), find common ground for management, have prevention and health promotion, build on pt relationship and rapport, be realistic with time and resources

Answer 25

``` o Important condition o Acceptable treatment o Treatment and diagnostics available o Recognisable stage o Opinions on who to treat as a pt o Guaranteed safety, highly discriminatory, valid and reproducible o Exam must be acceptable by pt o Natural hx of disease known o Inexpensive test o Continuous screening and not one-off ```

Answer 26

may disadvantage from it by having false positive etc

Answer 27

pap smear, mammography, finding smokers, faecal occult, abdo aortic aneurysm, chlamydia

Answer 28

mental test, urine dip, antenatal procedures, PSA

Answer 29

most at risk don’t present for screening; ‘worried well’ overload the service; services for invest +ve inadequate; -ve result may mean keep taking risks

Answer 30

* Biomedical – history-taking, exam, invest, diagnosis, treatment, review (takes time) * Balint * Byrne and long – establish a relationship, finds reason for attendance, verbal/physical exam, consider condition, treatment/invest, end * Pendleton – reason for attending, other problems considered, choose action for each problem with pt, pt involved in management, relationship maintained * Neighbour – connect with pt, summarise (pts expectations and presenting complaint), handing over, safety netting, house keeping * The Calgary-cambridge model – initiating session, gather information, build relationship, explanation and planning, closing session

Answer 31

consider differentials, time as a tool, evidence-based medicine, share uncertainty with pt, safety netting if things don’t go to plan, gamble safety so ‘most luck’, clinical governance

Answer 32

reflect on mistakes to maintain and improve excellence; risk avoidance, infrastructure, clinical effectiveness, audit, education training, staff; record: description of event, learning outcomes and action plan

Answer 33

systematic critical analysis of quality of health care; looks at current practice, measures against pre-selected standards, identifies and implements areas for change; continuous; improves: care for pts, aid to administration, enhanced staff professionalism, efficient use of resources, continues education, accountability held

Answer 34

identify issue, agree criteria, set standards, plan and prepare (what data etc), first data collection, implement changes, second data collection, summary of findings

Answer 35

must register for any regulated activities they perform; treatment of disease/disorder/injury, diagnostic and screening, surgeries, family planning

Answer 36

should be heard and investigated properly; genuine apology received and assured steps taken; <1yr after event or when event came to light

Answer 37

annual; general info, keep up to date, review of practice, feedback on practice, continuing professional development, quality improvement activity (audit), significant events, feedback from colleagues/pts, review of complaints/compliments

Answer 38

happens every 5 yrs and must pass this each time so can continue to practice and be a registered doctor

Answer 39

identify with doctor, pt’s satisfaction with dr, simple regimens, written info, longer consultations, educate, continuity of care, shorter waiting times, self-monitoring by pt; can monitor plasma drug levels; aim for most cost-effective treatment

Answer 40

place diagnosis in context of pt’s life; listen; examine pt thoroughly; cost-effective treatment; differentials in biopsychosocial terms; explain diagnosis simply; additional problems and risks; list treatments and guidelines; balance your pros and cons with pt’s; follow-up and communication arranged; arrange for treatment purchase, cost implications, accountability, justify treatment choice using 4 pillars of ethics; try to be professional and authentic

Answer 41

multiple and complex health problems; more difficult now as need quicker accessibility so not always same GP; better for rapport and communication

Answer 42

Older and poorer socioeconomic

Answer 43

finding and using health resources; know how to recognise and mange changes in disease; deal with problems/emergencies; using treatments effectively; managing stress/depression with chronic diseases; managing fatigue/sleep/pain problems; exercising enough and good nutrition; managing ADLs and relationships

Answer 44

involve fam; collaborate; personalised care plan; tailored education in self-management; planned follow-up; monitor outcome and treatment adherence; tools and protocols for stepping-up the care; using specialist services; monitor process using clinical governance

Answer 45

encourage belief in one’s own health; explain about minor illness; encourage self-medication where appropriate; larder technique (honey and lemon for sore throat); watch and wait; deferred prescribing; use pharmacists; pre-empting requests for abx

Answer 46

cope with ADLs, understand illness and cope, able to keep healthy, confidence on handling issues and self-help

Answer 47

physical illness; trauma; media highlighting illness (develop enhanced sense of bodily awareness or mis-attribution of symptoms); stressful life events

Answer 48

specific pain location; functional disturbance somewhere (palpitation); fatigue/exhaustion

Answer 49

>3months, affects function but cannot be explained; check mental health and stressors and impact on ADLs; psychosocial

Answer 50

Amitriptyline

Answer 51

o MSK, minor illness and stress/depression/anxiety main causes o Longer they are off, less likely to return o Find ways to keep going to work if possible and understand underlying cause; involve occupational health o Can be emergencies for dependants, for themselves or from post-ops (TABLE ON PG 490) o Before doctor can do statement of fitness to work (either completely can’t work or only under certain circumstances) for pt they themselves must claim 7 days incapacity

Answer 52

o TIA/stroke = 1 month, diabetes if insulin controlled then assessed every 1/2/3yrs for control, epilepsy = 1 year after last attack, first fit then 6 months, sleep apnoea don’t drive, significant head injury stop for 6 months, psychosis = 3 months, alcohol/drugs = 6months-1yr, check about drugs and if can affect driving (benzos, methadone, morphine, other opiates cannot drive), old age

Answer 53

o Most with cardiac are ok o Mainly haematological like severe sickle cell where reduced oxygen carrying capacity may need O2 or cannot o Not after 36wks pregnant o COPD may need extra O2, pneumothorax until 2wks after successful drainage, resp infection until is resolved o Can’t if disturbed/unpredictable psychotic behaviour o Otitis media/sinusitis advised against o 10days wait for chest/abdo surgery, 24 hours for laparoscopy, 7 days for neurosurgeryo Fx – 24 hours if less than 2 hours and 48 if more o Most need to take necessary PRN meds

Answer 54

• Reduce risk of cvd like coronary HD, stroke, TIA, peripheral artery disease and improve QOL and life expectancy

Answer 55

high age, male, FH, ethnicity

Answer 56

smoking, low HDL cholesterol, sedentary lifestyle, unhealthy diet, alcohol excess, obesity

Answer 57

hypertension, diabetes, CKD, dyslipidaemia, AF, SLE/RA, severe mental health problems

Answer 58

low income and social deprivation

Answer 59

o Primary – NHS health check programme for 40-74yrs every 5yrs o Secondary – RF modification and cardiac rehab for those with disease o Population-based – promote walking and cycling for recreation

Answer 60

QRISK 2 = age, sex, ethnicity, postcode, smoking, FH, PMH, bp, BMI, HDL-cholesterol ratio as percentage likelihood to get CVD in next 10 yrs o <10% - reduce RFs o >10% - advice on lifestyle and recommend statin

Answer 61

less lung cancer; less chronic lung disease; less CVD; fewer pregnancy problems (pre-eclampsia, IUGR, preterm delivery, neonatal and late foetal death); less risk of passive smoking (cot deaths, lung disease and lung cancers); return of taste, smell and relative wealth

Answer 62

ask about it in consultations and greet any success with enthusiasm; advise according to needs; motivate by getting pt to list advantages; assist in practical ways (get quit date, get rid of all smoking equipment, inform friends of change); arrange follow-up and give messages of encouragement

Answer 63

increases quit chance by 1.5x; higher doses for heavier; 3 months and taper for 2wks; don’t give for cardiac problems

Answer 64

over 18s and take 1wk before quit date and taper up each day before quite date; cessation rate 2x increase; stop if agitated, depressed or suicidal

Answer 65

over 18s 1-2wks before quit date; cessation increased 2x; don’t give if eating disorders, bipolar or epilepsy

Answer 66

lower socioeconomic and mental health

Answer 67

10ml or 8g of ethanol

Answer 68

14 units per week = recommended; binge = more than 8 units

Answer 69

excess intake causing potential/actual harm without dependence

Answer 70

alcohol reduced then experience withdrawal symptoms

Answer 71

CAGE and FAST questionnaire and also AUDIT

Answer 72

more non-alcoholic drinks; sip; don’t drink alone; limit opening hours; don’t buy yourself a drink when it is your turn to buy the round; go out to pub later; take rest days

Answer 73

alcohol diary; teach how to estimate weekly intake; feedback; enlist family support; rewards for sobriety; community alcohol and treatment teams

Answer 74

reduce drug-related mortality and infections; decrease criminal activity; identify IVDUs; assess health and willingness to modify behaviour

Answer 75

safer routes of administration (smoking or rectal for heroine not injected); risks of psychosis and contamination; safe injecting, OD practice and first aid; safe sex practice; driving discuss; check for blood bourne diseases and hep B immunise

Answer 76

set realistic goals; set conditions for acceptable treatment and behaviour; review regularly; refer to community substance misuse team; report to relevant authorities

Answer 77

BMI over 34

Answer 78

mortality, T2DM, gallbladder disease, dyslipidaemia, insulin resistance, breathlessness, sleep apnoea; less = CHD, hypertension, OA, gout, cancer, reproductive hormone abnormal, impaired fertility, PCOS, low back pain, stress incontinence, surgical risks, suicide, bullying

Answer 79

physical inactive, cultural, low education, genes, smoking cessation, childbirth, drugs (steroids), endocrine

Answer 80

best in childhood prevention; assess willingness to change, eating, physical exercise, psych distress, social and family; aim for 0.5-1kg per week loss; group therapy (Weight Watchers); surgery if everything else failed and over 40 BMI

Answer 81

BMI or waist circ

Answer 82

Mediterranean and 5/2

Answer 83

* Hba1c over 80 maybe think definitely metformin straight away; if under probs should but can think about it and not imminent but maybe in next week or so * Self-management is very effective for treating diabetes and bp – lifestyle changes and adhering to meds * If lots of polypharmacy and pt has high bp and diabetes with hypotension then probs stop the CCB first * Don’t jump the gun if something like eGFR has decreased with bp meds if hf well controlled as if is stable then should be ok and eGFR decreases anyways with age; if affecting the kidney function then decrease ACEi first and maybe diuretic * If eGFR is less then 30 then must stop metformin as can go into acidotic state from lactic acidosis

Answer 84

disturbed or inadequate sleep; increases with age; cons = affects conc, memory, ADLs, relationship problems

Answer 85

travel, stress, shifts, small children, mental health problems, drugs (steroids), pain, pruritus, tinnitus, nocturia, OSA

Answer 86

<30 min fall asleep, 6-8hours, <3 awakenings, feeling well and refreshed waking up

Answer 87

evaluate if unrealistic sleep expectations; eliminate physical problems (treat asthma etc and painkillers to last night); treat psych problems; relaxation techniques; consider drugs (hypnotics)

Answer 88

don’t go to bed until sleepy, avoid naps, reserve room for sleep only, avoid caffeine, alcohol etc; rise at same time each morning; don’t stay in bed if not asleep; establish reg bedtime; make sure bed comfortable; have a warm bath at bedtime; sleep diary

Answer 89

zolpidem, zopiclone, benzos, low-dose amitriptyline; can cause SEs amnesia and daytime sleepiness (heavy machinery etc); can get dependent and withdrawals from benzos (don’t do beyond 4wks)

Answer 90

secondary cancer or for chronic non-malignant pain

Answer 91

physical (can become used to a certain kind of pain – synapses have less of neurotransmitters), psychological (anxiety, tired, expect pain), environmental, sensitisation (allodynia {pain from a non-painful stimulus} and hyperalgesia {low pain threshold}) components

Answer 92

addiction, constipation, drowsiness, overdose, decreased resp rate (not for obstructive sleep apnoea, COPD and MND), hallaucinations, desensitisation (start having to increase dose which increases problems described above – can use a more powerful one with a lower dose and stuff like that), destroys NKCs (reduces immune system {pneumonia} and increases cancer risk from less NKCs – theoretical risk so don’t need to say to pt), CNS effects, endocrine (reduce all hormones from anterior pituitary gland FLAT PIG) • Pregabalin with opioids give better high • Pregabalin and gabapentin also decrease resp rate

Answer 93

weigh up SEs against benefits (tolerance, withdrawal, weight gain see slides)

Answer 94

counselling, cbt, music, meditation, relaxation (psych); weight loss, smoking stop, exercise, physio, yoga, pilates, joint injections (phys); massage, reflexology (complementary therapy); work based review (occupational)

Answer 95

non-opioids (NSAIDs, cox-2 inhibitors, paracetamol); opioids (intermittent use and slow and low); adjuvants (anti-convulsants, antidepressants, lidocaine) • Don’t forget about fentanyl and tramadol

Answer 96

under/over nourishment; stunting, wasting and things like this from lack of certain nourishment

Answer 97

``` o Cancer o CF o Coeliacs o IBD o Type 1 DM – diabulimia o Type 2 DM o Failure to thrive o Eating disorders o Overweight/obesity o Sarcopenic obesity in elderly (low muscle mass with high fat) ```

Answer 98

* Amniotic fluid is influenced by maternal diet and gives taste exposure to baby and may influence what they want to eat * Breastfeeding very important for baby’s development and low amongst young mothers and low socioeconomic groups * What like when 3 years old and what eat will affect what like and health of child aged 17 * Breastfed – have novel foods when weaning; less picky eaters and diet rich in fruit and veg; also protects against obesity

Answer 99

``` o Modelling healthful eating behaviours o Recognising hunger and satiety o Variety of food o Avoiding pressure to eat o Restriction o Authoritative parenting o Don’t use food as a reward o Indulgent/neglectful feeding practices ```

Answer 100

o Children younger than 6 | o Parents using maladaptive feeding techniques

Answer 101

Anorexia, bulimia and binge-eating disorders

Answer 102

clinically meaningful behaviour or psych pattern to do with eating or weight associated with distress, disability with high chance of morbidity/mortality

Answer 103

restraint, strict dieting, disinhibition, emotional eating, binge-eating, night eating, weight and shape concerns, inappropriate compensatory behaviours that don’t need clinical diagnosis

Answer 104

restrict total amount of food eaten, don’t eaten certain types of food, avoid eating for long periods of time

Answer 105

may overshoot afterwards and gain too much weight (weight cycling)

Answer 106

* Adults = 30mins+/day 5days+/week | * Children = 1hour+/day

Answer 107

less risk of: DM, CVD, osteoporosis and cancer and treatment for BP high, arthritis, back pain, high cholesterol, mental health problems and in elderly = more functional capacity, less risk of falls and fx, improves sleep

Answer 108

* Ask about exercise and give info on benefits to improve, congratulate success * Rehab and exercise schemes for those after MI or something and disability and also with counselling

Answer 109

mainly starchy, 5 fruit and veg, plenty of fibre, 2x fish per week, lean meat, use skimmed milk, avoid adding salt, avoid adding sugar, 2-3L drank per day

Answer 110

low income, living alone, MH problems, dementia, recent bereavement, gastric surgery, malabsorption, high metabolism, difficulty eating, chronic disease

Answer 111

eat more and consider supplements, dietician advice; sometimes social services to shop or OT for using utensils

Answer 112

• Acupuncture for control of nausea, addiction, back pain (NICE recommended); homeopathy not recommended; osteopathy/chiropractor for MSK and others like asthma; holism (treating pt holistically – a lot like GP); check for alternative medicines (herbs etc in NICE guidelines)

Answer 113

any incident/pattern of incidents of controlling (isolate from support, exploit them, get rid of independence, regulate their behaviour), coercive (act or do assault/threats/humiliate/intimidate to harm/punish/frighten) or threatening behaviour, violence or abuse from 16yrs+ who are/have been intimate partners, family members; can be psychological, sexual, financial, physical, emotional

Answer 114

psych disorders (depression, self-damaging), drug/alcohol abuse, suicide

Answer 115

loss of self-esteem, disruption of family and children relationships, loss of intimate relationship with partner, fear, fall in income, risk of homelessness, fear of unknown

Answer 116

ask them directly; emphasise confidentiality, never confront abuser, document accurately over time, assess current sitch and gather as much info as poss, provide info and contact other agencies, devise safety plan, don’t pressure victim, if child inform social services/police hopefully with pt’s consent

Answer 117

inconsistent story from pt/carer, inconsistency on exam, fear when carer there, freq ER, freq GP visits, carer avoiding GP

Answer 118

talk through with pt, carer and services; assess risk level; maybe admit to safe place

Answer 119

has community care, unable to look after themselves, unable to protect themselves

Answer 120

o Initial assessment – history from patient and close family member/friend with emphasis on cognitive, behavioural and psych problems impacting life o Dementia suspected after initial assessment – physical examination, appropriate bloods and cognitive testing (assume this has been covered in previous bullet point) o Also refer to specialist dementia diagnostic service like memory clinic or community old age psychiatric service (explore reversible causes of cognitive decline like delirium and depression

Answer 121

o Mild at first – lose keys, forget friend’s names or lose track of convo, forget about recent convos/events, get lost in familiar places, forget appts and dates; difference between this and normal ageing is that it interferes with everyday life and job (chores and household stuff) o Other problems other than memory – speech (repeat themselves or struggle to follow convo); visuospatial skills worsen (judging distances); concentrating, planning, organising; orientation of days of the week; change in mood (anxious, depressed or annoyed) o Later stages – all symptoms above get worse and progress to affect their life more noticeably, may become more agitated, repeat same question, disturbed sleep, react aggressively; eventually get to stage where need help with all ADLs and eating and walking

Answer 122

 Donepezil – reversible inhibitor of acteylcholinesterase  Rivastigmine – reversible non-competitive inhibitor of acetylcholinesterases  Galantamine - reversible inhibitor of acetylcholinesterase with nicotinic receptor agonist properties  Drugs reduce anxiety, help with memory, improve conc and motivation, help with ADLs  In later stages – memantine (glutamate receptor antagonist)  Other drugs for treating symptoms – bp meds for diabetes, depression/anxiety pills, sleeping tabs and antipsychotics

Answer 123

 Have a routine or ways to remember things (weekly pill box, alarm reminders etc)  Talking therapies if depressed or anxious  Keep mentally active – attend sessions or do some brain teasers/puzzles  Keep socially and physically active  As progresses use stuff to reminisce (photos/objects)  If behaviour becomes more aggressive may be because: • Thirst/hungry • In pain • Environment too noisy, bright or cluttered • Glasses or hearing aids not working • Misunderstood something

Answer 124

Following a diagnosis of dementia, a health and social care assessment should be performed. The assessment is to see what help is available from the local authority. If a person with dementia has ongoing medical conditions, they may be entitled to continuing care, assessed by NHS staff. Many people with dementia eventually require residential or nursing care. Those with severe dementia may require palliative care. Admiral nurses are registered nurses who are experts in dementia. They work in the community, care homes, hospitals and hospices. There are several dementia charities such as Alzheimer’s society and Dementia UK who can give information and advice. Online forums may be useful for help and support and include talking point (Alzheimer’s society). Also reading well books available on prescription or the library.

Answer 125

On a dementia diagnosis, it is important to get professional advice on wills and pensions and may result in becoming lasting power of attorney. The patient may be entitled to attendance allowance and the carer carer’s allowance. You may have to pay for some of the help from social services, depending on income. The services available depend on the person and how much the council/NHS is willing to pay. NHS support can also include mental health nurses, physiotherapy, audiology, optometry, podiatry, speech and language therapy and mobility specialists.

Answer 126

• A paid careworker could work at a patient’s home and help with every day tasks. Support could come from the local authority such as Meals on Wheels or laundry/library services. Home care may be useful if you need help with personal care, housekeeping, cooking, healthcare and companionship. It is very flexible. The different types of care include 24 hour care, short breaks for unpaid family, emergency care, day care and sessions of various length. If home care is needed, contact social services to have a care and support assessment. The local authority or yourself can arrange home care. AgeUK and carer’s trust can provide home help and domestic assistance services.

Answer 127

• Telecare includes personal alarms and health monitoring devices and these can be useful for those with dementia to enable families to know they are safe.

Answer 128

Choosing a care home requires an assessment from social services to assess needs. If a patient relies on local authority funding, they will have to go into a home that the authority can afford unless family pay the difference.

Answer 129

• Mental capacity is the ability to make your own decisions. Mental capacity act 2005 includes Deprivation of Liberty Safeguards, a set of checks that aims to make sure that any care that restricts a person’s liberty is both appropriate and in their best interests. It only applies in care homes and hospitals. An assessment of DoLS determines if the deprivation of liberty is allowed to happen or not. The assessment involves age, mental health, mental capacity, best interest, eligibility and no refusals. It only lasts for 12 months and should have regular reviews.

Answer 130

• Best interest is when a decision is made on behalf of a person who lacks capacity. It should ensure their rights are respected and the decision is the best one for them. It should never be the best for the carer. The best interests checklist encompasses if the patient will regain capacity, past/present/future wishes, views of family/friends/carers and circumstances. Lasting power of attorney allows decisions to be made and they include for property and financial affairs as well as health and welfare. Advance statements are where the patient without capacity makes a decision beforehand on their preference of care/future plans.

Answer 131

• DNACPR – ensures a patient’s death is dignified and peaceful, considered when: o Dying patient has a decent risk of cardiac/respiratory arrest and CPR not clinically appropriate o Resus involves CPR, defib, respirator and some medicines (adrenaline or adenosine etc) o Risks of CPR could outweigh any of its benefits o Patient with capacity has expressed a wish not to be given CPR

Answer 132

o Be specific to patient and their situation o Discussion with patient always unless thought might cause physical/psychological harm o Include in discussion about patient’s care and include pros and cons of CPR especially personal to them

Answer 133

o See if patient has valid advance decision to refuse treatment or if have lasting power of attorney or independent mental capacity advocate (IMCA) o If not then senior doctor decides on treatment with best benefit o Discuss decisions with family/friends and ask for advice and input where appropriate but at the end of the day it is the doctor’s decision if there is no power of attorney • If child treat same as if no power of attorney

Answer 134

o Healthcare team think CPR would be unsuccessful o Healthcare team feel it’s unclear if CPR would be successful and after discussion decide you don’t want CPR (think about best interests) o Legally can’t demand a treatment but rarely will it be refused for CPR if requested and possible of it succeeding and having healthy recovery o Legally don’t have right to 2nd opinion but doctor rarely refuses this

Answer 135

``` o Restlessness o Sense of dread o Constantly ‘on edge’ o Concentration difficulty o Irritable o Withdraw from socialising o Work becomes stressful (sick-leave) o Reduce self-esteem ```

Answer 136

``` o Dizzy o Fatigue o Palpitations o Malaise and muscle aches o Tremors o Dry mouth o Excessive sweating o Stomach ache o SOB o Feeling sick o Headache o Paraesthesia o Insomnia ```

Answer 137

o Phobias of certain things (claustrophobia etc) | o Work and life stress building up

Answer 138

o Worrying significantly affects daily life o Worries are stressful and upsetting o Worst-case scenario type of person o Uncontrollable worrying o Felt worried nearly everyday for at least 6 months

Answer 139

• Extreme anxiety or panic (severe anxiety) attacks that can occur regularly and at any time usually for no apparent reason; may be triggered by certain events that can be avoided but can also lead to a fear of having an attack leading to more attacks (vicious cycle)

Answer 140

``` o Tachycardia o Syncope o Sweating o Nausea o Chest pain o SOB o Tremors o Hot flushes o Chills o Choking sensation o Dizziness o Paraesthesia/numbness o Dry mouth o Urinary urgency o Tinnitus o Feeling of dread/dying o Churning stomach o Feeling disconnected to body o Can sometimes feel like an MI o Last for 5-20 mins and sometimes up to an hour – no physical harm though ```

Answer 141

* Propranolol – can cross BBB and less cardio-selective * Other than hf use betablockers for essential tremor and anxiety but make sure don’t get depression as anxiety and depression can have neg feedback for each other * Verapamil with betablockers do not give together

Answer 142

7 days and 2-3 readings 2x a day

Answer 143

with removed lymph nodes as could damage lymph system on that side completely as not much of it left

Answer 144

* Parkinson’s – may have postural hypotension * Blood tests – U&Es, hba1c, lipids, lfts * Urinalysis – acr, blood, proteins * Ecg

Answer 145

* ACEi and ARBs can cause hyperkalaemia * CCBs can get oedema, gum recession and hypertrophy, hypotension * Indapamide (first line thiazide) * Alpha blockers (docsazin – look up spelling), beta blockers and spironolactone after all of the above drugs

Answer 146

* Need to be wary of using words that don’t offend when taking history when referring to genitals and to clarify that sex means penetration * Say that taking this sexual history will involve some personal questions being asked and gain consent * May have to break confidentiality if someone at harm though and tell them this * To start off consultation ask same thing and just remember this is just a focussed history (what has brought you in today?, etc) * Try to use SOCRATES when possible for each symptom presented and also if its relapsing and remitting or continuous and any previous episodes

Answer 147

``` o Genital skin changes (blisters?, sore?, itchy?, where?) o Vulval itching/soreness o Dysuria (passing urine more frequently as well as painful? And any blood) o Abnormal vaginal discharge (volume, colour, consistency and smell) o Abnormal vaginal bleeding (post-coital, intermenstrual [between periods]) o Dyspareunia (painful intercourse - SOCRATES) o Abdo/pelvic pain o Systemic symptoms (fever, malaise, weight loss, rash, swelling of large joints, conjunctivitis and cervicitis) ```

Answer 148

o Duration o Frequency o Blood flow (heaviness, blood clots, period pain, impact on ADLs, flooding sanitary pads)

Answer 149

o Cervical screening (when and result and any treatment from this) o Past diagnoses and treatments (ectopic pregnancy, STI, endometriosis, malignancy)

Answer 150

o Pregnancy (gestation, complications [low BMI], fetal movements)

Answer 151

``` o Testicular pain or swelling o Itching or sore skin o Skin lesions (painful or itchy, tingling or burning in lesion area) o Urethral discharge o Dysuria (any blood and frequency) o Systemic symptoms (same as above) ```

Answer 152

o Timing (when last sexed) o Consent obtained? o Relationship or not? o Partner demographics (sex and country of partner) o Types of sex (oral?, vaginal?, anal?, drugs before or during?, group?) o Contraception used (what, issues with it, was any used?) o Other sexual partners in last 3 months

Answer 153

o Normal questions o Previous STIs o Hep A/B and HPV vaccinations

Answer 154

``` o Partner with HIV positive? o Sex with bi man/had gay sex o Sex abroad or someone from different country o IVDU?/partners who were IVDU o Paid for sex or been paid for sex ```

Answer 155

* Normal vaginal discharge has a thin, watery consistency and clear/white in colour. It does not have odour and is not associated with itching or pain. Normal discharge is composed of cervical mucus, vaginal fluid, cells and bacteria. During sexual arousal and intercourse, discharge increases due to engorgement of vaginal veins. In neonates, discharge can occur a few days after birth. Vaginal discharge of girls before puberty is thinner and has different flora. During puberty, volume of discharge increases and changes in composition. * In the days after menstruation, discharge is minimal and consistency is thick and sticky. When approaching ovulation, levels of discharge increase. After ovulation, progesterone increases so discharge decreases. During pregnancy, discharge increases, appears white or grey and has a musty smell. The discharge returns to pre-puberty after menopause.

Answer 156

occurs in infections and changes to vaginal flora or pH.

Answer 157

* Bacterial vaginosis is infection caused by change in the vaginal flora. It experiences a decrease in lactobacilli and an increase in anaerobes such as Gardnerella vaginalis. The discharge has a strong fish odour and is often thin and grey. It is sometimes accompanied with burning on urination. Factors include abx use, unprotected sex and IUCD. Vaginal yeast infection results from the overgrowth of candida albicans. Risk factors include abx use, diabetes, immunosuppression, increased oestrogen levels and some contraception. * Discharge is often thick, white and odourless. Women may also experience pain in sex or burning. Diagnosis of candida vulvovaginitis is made on vaginal sample under microscope. Trichomonas vaginitis is an infection acquired through sex. Discharge is usually yellow/green in colour. It is sometimes frothy and can have a foul smell. Other symptoms include pain on sex and burning.

Answer 158

Treatment is often with metronidazole. Foreign objects can cause discharge. Discharge in pre-puberty is often due to harsh soaps or tight clothing.

Answer 159

* Intimate exams include breast, genitalia and rectum but could include any exam in which you are close to the patient. Before, explain why the exam is necessary and give opportunity for questions. Explain what the examination will involve. Get the patient’s permission and record this. Offer the patient a chaperone. If dealing with a child/young person, you must assess capacity for consent and if they lack capacity, gain parent’s consent. Give the patient privacy to address and undress and keep them covered up as much as possible. * Do not help the patient to remove clothing. During the exam, gain consent, stop the exam if the patient requests it and keep discussion relevant. Before an exam on anaesthetised patient, gain written consent. When performing an intimate exam, always offer a chaperone

Answer 160

A chaperone is usually a health professional and you must be satisfied the chaperone is sensitive, respects confidentiality, reassure the patient in distress, be familiar with procedures, stay for the whole exam and be prepared to raise concerns if necessary

Answer 161

• A relative or friend of the patient would not make a good chaperone as they are not impartial. If either patient or doctor does not want the exam to take place without a chaperone or either is uncomfortable with the choice of chaperone, postpone, providing the patient’s health isn’t affected. If you want a chaperone but the patient doesn’t, explain to the patient why and you may want to consider referring them to a colleague. You should record a discussion about chaperones on the patient’s record and the chaperone’s identity

Answer 162

• The contraceptive cap is inserted into the vagina before sex and covers the cervix. It should be used with spermicide. The cap should be left in place 6 hours after sex. They are reusable. The cap is 92-96% effective. There are no health risks and you can put it in several hours before. Patients need to be fitted. A cap doesn’t prevent STIs. It can take time to learn how to use a cap.

Answer 163

Contraceptive pill contains artificial versions of oestrogen and progesterone. It can be taken to prevent pregnancy but also for endometriosis, heavy/painful periods and premenstrual syndrome. The pill is >99% effective. The pill needs to be taken once every 21 days then off for a week. It should be taken at the same time every day. Side effects include mood swings, breast tenderness and headaches. The combined pill is not suitable for those >35 who smoke. The pill does not protect against STIs. It prevents ovulation, thickens mucus in neck of the uterus and thins its lining.

Answer 164

• Monophasic 21 day pills are the most common type. Phasic pills contain 2-3 different sections in each pack and they should be taken in the right order. Every day pills contain 21 real tablets and 7 placebos. Most can start the pill at any time in the menstrual cycle. Missing a pill for 24 hours will not mean the woman is no longer protected from pregnancy.

Answer 165

The pill reduces the risk of colon, uterine and ovarian cancer. It can reduce PMS and acne. It can increase blood pressure with increased risk of thrombosis and breast cancer.

Answer 166

• Female condoms are worn inside the vagina to prevent semen from reaching the uterus. They protect against both pregnancy and STIs. Most people can use them and are 95% effective. In most cases they have no side effects but some couples say it can interrupt sex by using them. If it slips or fails, use emergency contraception.

Answer 167

. Implant is inserted under the skin of the arm and lasts for 3 years. It stops ovulation by releasing progesterone and is >99% effective. In the first year of the implant, periods can become irregular. It is fitted during the first 5 days of the menstrual cycle. Fertility should return to normal when it is removed. Medications for HIV and epilepsy reduce its efficacy.

Answer 168

• Contraceptive injections include depo-provera (12 weeks), sayana press (13 weeks) and noristerat (8 weeks). The injection contains progesterone. It is >99% effective and is not affected by medications. It can provide protection against uterine cancer and pelvic inflammatory disease. Side effects include headache, weight gain and mood swings. It can take up to 1 year for fertility to return to normal after use. If it is given outside the first 5 menstrual days, it will take a week to work. Depo-provera may not be ideal for women at risk of osteoporosis.

Answer 169

• The contraceptive patch works in the same way as the OC pill by preventing ovulation, thickening cervical mucus and thinning the uterus lining. The patch lasts 1 week and is >99% effective. The patch can increase blood pressure. It may protect against ovarian, uterine and colon cancer. It can increase the risk of blood clots and breast cancer.

Answer 170

• Contraceptive diaphragm covers the cervix to prevent the passage of semen and is used with spermicide. It must be left in place for 6 hours after sex. It is 92-96% effective and has no health risks. Some women can develop cystitis and it does not protect against STIs.

Answer 171

• IUD is inserted into the uterus. It stops the sperm and egg surviving in the uterus or fallopian tubes. It may prevent a fertilised egg implanting in the uterus. It is long-acting and reversible. They are >99% effective, work straight away and last 5-10 years. It can be inserted and removed at any time. It doesn’t protect against STIs. IUD releases copper, changing the consistency of the fluid inside the uterus. It can take 15-20 minutes to implant and should be checked 3-6 weeks after. IUS is similar but releases progesterone.

Answer 172

. The vaginal ring is inserted and releases oestrogen and progesterone. It is >99% effective and can last for 21 days.

Answer 173

• Used to describe a child under 16 who is considered a sufficient age and understanding to be competent to receive contraception advice, without parental knowledge or consent. The doctor must be satisfied the child can understand the advice, cannot be persuaded to tell their parents, is likely to begin or continue having unprotected sex and their physical/mental health will suffer without contraception.

Answer 174

* Children are more likely to suffer health, social and emotional problems when born to younger mothers. Women who become pregnant younger are also likely to suffer premature labour. Teenage births are associated with lower annual income for the mother, often having to rely on welfare. Mothers are also likely to drop out of school and teenage pregnancies are associated with increased rates of alcohol and substance abuse and reduced earning potential in teenage fathers. Teenagers may also not receive adequate prenatal care. * Pregnant teenagers also have a higher risk of HT and a higher risk of pre-eclampsia. Babies born to these mothers also have a higher risk of a low birth weight. Teens who have sex during pregnancy are at risk of STIs, in particular chlamydia and HIV. Pregnant teens are also at a greater risk from postpartum depression. A pregnant teen may also suffer socially due to having to care for their child, instead of socialising.

Answer 175

* A child under 13 is not legally capable of consenting to sexual activity. Any offence <13 is very serious and should indicate significant harm to the child. Under the sexual offences act, penetrative sex with a child <13 is classed as rape. Cases under 13 should be discussed with a designated child protection lead. Sexual activity with a child <16 is also an offence but may be less serious if consensual than <13. Within the age range of 13-15, the younger the child is, the stronger the presumption that sexual activity is a cause for concern. Practitioners should discuss their concerns with the safeguarding children professional. Discussion can still take place without identifying the child if confidentiality need not be broken. * The law is not intended to prosecute mutually agreed sexual activity between 2 people of a similar age, unless it involves abuse or exploitation. Decisions by health professionals not to share information should be determined by Fraser guidelines. On each occasion the healthcare professional has contact with the young person, a review of circumstances should be sought.

Answer 176

• Risk factors are used to determine if the relationship presents harm to the young person i.e. whether the child is competent to understand, their living circumstances, nature of the relationship, substance misuse affecting consent, previous criminal offences from the partner and attempts to secure secrecy by the sexual partner. Disabled children and young people are more likely to be abused than non-disabled, especially living away from home. The GP must make it clear to the child that duty of confidentiality is not absolute and there may be some situations in which confidentiality has to be broken. The discussion with the child should involve asking their thoughts, feelings and wishes.

Answer 177

For 16-17 year olds, it is an offence for a person to have a sexual relationship if they hold a position of trust or authority in relation to them.

Answer 178

• Most healthy people can fight off tb themselves and have few symptoms or be asymptomatic; the bacteria can remain in their body however and remain dormant to develop symptoms years later when their immune system is weaker (5-10% of untreated patients with latent TB)

Answer 179

people recently infected with TB and immunocompromised patients

Answer 180

o Close contacts of person with TB o Person immigrated from areas of world with high TB rates o Groups with high TB transmission rates – homeless, IVDU, HIV infected o People who work or reside with people at high TB risk (hospitals, homeless shelters, correctional facilities, nursing homes and residential homes for HIV patients)

Answer 181

``` o HIV infected o Substance abuse (alcohol abuse) o Smoking o Silicosis o Diabetes o CKD o Low BMI o Organ transplants o Head and neck cancer o Elderly and young o Undernutrition o Steroid/immunosuppressant treatment ```

Answer 182

India, China, Indonesia, Philippines, Pakistan, Nigeria, Bangladesh and South Africa

Answer 183

• Coughs are divided into acute, subacute and chronic. Acute causes typically last less than 3 weeks and include URTI. LRTIs are less common and can cause bronchitis and pneumonia. Infective exacerbation of asthma can cause an acute cough, as well as irritants causing airway irritation. Subacute causes of cough last 3-8 weeks and include airway hyper-responsiveness (following infection), whooping cough and TB. Common causes of chronic cough include postnasal drip, acid reflux, asthma, side effects of medication, lung disease i.e. COPD and irritants. Less common causes of cough include foreign body, lung cancer, pneumothorax, bronchiectasis, cystic fibrosis and pulmonary embolus.

Answer 184

• Pre-entry screening can be used which involves screening those before entering the UK from high risk countries. This includes chest x-ray and symptom assessment. If positive, a person must have treatment before a visa is granted. The BCG vaccination can offer some protection in high risk groups. This vaccine gives limited protection outside these groups. Therefore important factors in control include early detection and diagnosis (particularly for infectious causes) and treatment completion. These all reduce transmission of the disease. It is important to complete full treatment to prevent relapse, prolonged infectiousness and development of drug-resistant strains.

Answer 185

• Diagnosing TB as a GP involves assessing of the TB is dormant, active or extra-pulmonary. For dormant TB, mantoux testing should be performed in high-risk patients. For positive results, consider for interferon gamma blood testing. For those with active TB, suggest chest x-ray and check multiple early morning sputums for TB microscopy and culture.

Answer 186

Patients should be referred urgently to chest clinic if TB is confirmed. If a patient is diagnosed with TB in the community, it is notifiable to PHE. PHE will then trace contacts of the infected person, examine them and perform Mantoux test and CXR. Young children, even if Mantoux negative will be given BCG vaccine.

Answer 187

acute otitis media, acute sore throat, common cold, acute rhinosinusitis and acute cough

Answer 188

Patients concerns and expectations should be addressed in no prescribing, delayed prescribing and immediate prescribing. No antibiotics or delayed antibiotics should be agreed with patients with the above conditions.

Answer 189

bilateral otitis media in children <2, acute otitis media in children with otorrhoea and acute sore throat when >3 of Centor score are present

Answer 190

• Advice on natural history of illness should be given i.e. acute otitis media (4 days), acute sore throat (1 week), common cold (1.5 weeks), acute rhinosinusitis (2.5 weeks) and acute cough (3 weeks). Advice should be given about managing symptoms i.e. fever. When there is no antibiotic prescribing, reassure patient that abx are not needed and to come back if symptoms get worse. When delayed abx are advised, reassure that abx are not immediately needed, advice about delayed prescription and advice about reconsulting

Answer 191

patient is systemically very unwell, symptoms suggestive of serious illness, high risk of complications due to other illness (heart, lung, renal, liver, neuromuscular, immunosuppression, cystic fibrosis, premature children) or if the patient is over 65 with acute cough and >2 symptoms/ >85 with >1 symptoms of hospitalisation in past year, type ½ diabetes, congestive heart failure or oral glucocorticoids

Answer 192

• Migrants may work in physical jobs which may be stressful. The trauma of migration itself means migrants can often have mental illness including PTSD, anxiety, stress, depression, substance abuse or suicide ideations. Migrants tend to be poorer than the rest of the population so have an increased risk of cancer. Their diagnosis tends to come later which affects survival. Risk factors for this include genetics, local environment, cultural perspectives/practices, occupational exposure, access to health services and other social determinants of health. Occupational exposure is due to migrants working in jobs involving chemicals which are known carcinogens.

Answer 193

• Children may experience pre/peri/post migration trauma. Health challenges for migrant children include substandard housing, language barriers, interrupted schooling, parental poverty, food insecurity and poor sanitation

Answer 194

Migrants tend to experience a greater number of disease complications. Family violence can also be an issue due to different culture. Migrants experience increased risk factors for HIV/AIDS including substandard housing, poverty, low income, limited education and limited access to healthcare. Migrants also have an increased risk of hepatitis A, B and C. Childhood immunisation programmes may be different in certain countries and migrants may have an incomplete vaccination history, putting them at risk of certain illnesses. Migrants also tend to have worse oral health and are at a greater risk of having TB. Female migrants have other health issues such as poor antenatal care, reduced breast/cervical screening and STIs. Sexual and intimate partner violence tend to be more prevalent in migrant communities. This can also include trafficking and FGM.

Answer 195

The 6 in one vaccine (diphtheria, tetanus, polio, whooping cough, haemophilus influenza type b, hep b) is given at 2, 3 and 4 months as a single injection each time. At 2 months, the pneumococcal conjugate vaccine, rotavirus and meningitis B vaccines are given. At 3 months, rotavirus is given once more in the form of oral drops. At 4 months, there is a 2nd dose of PCV and meningitis B. Between 12-13 months, there is a combined injection of Hib and meningitis C, along with MMR and the 3rd doses of PCV and meningitis B. From 2-7 years, the nasal flu spray is given annually. At 3 years 4 months, there is a 4 in one injection (diphtheria, tetanus, polio and whooping cough), along with a 2nd dose of MMR. At 12-13 years in girls, there is the HPV vaccine, covering types 16 and 18, given over 2 injections. At 14, there is diphtheria, tetanus and polio, alongside meningitis ACWY.

Answer 196

Vaccines work by active immunity (long-lasting harnessing the body’s immune system) and passive (transfer of antibodies from immune individual). Vaccines using inactive organisms include pertussis and polio. Attenuated live vaccines include MMR, nasal flu and rotavirus. Inactivated toxins or cell products include diphtheria, tetanus, flu and pneumococcal.

Answer 197

Vaccines are contraindicated in those who have had confirmed anaphylactic shock to a previous dose containing the same antigens. Those with confirmed anaphylaxis to egg shouldn’t receive flu or yellow fever vaccines. Live vaccines are contraindicated the immunosuppressed or pregnant women.

Answer 198

Consent for each vaccination should be recorded. A child can refuse consent if they are thought to be Gillick competent.

Answer 199

Most vaccines are given IM but can be given SC if people have a bleeding disorder. Pain and inflammation at the injection site, shivering, muscle pain, fatigue, headache and fever are common side effects. All vaccines have the possibility to cause side effects and these can last a few days but some don’t experience any side effects. Anaphylactic shock is very rare and is completely reversible if treated promptly. Common side effects in young children and babies include swelling, redness and small hard lump.

Answer 200

Coverage of the 5-1 vaccine has decreased in the past year. The uptake of the 5-1 vaccine is lowest in northern Lancashire and London.

Answer 201

Coverage since 2003-2004 has increased after discreditation of the MMR-autism link. MMR coverage is lowest in London and the south-east.

Answer 202

Rates of immunisation are lower in the lower socioeconomic groups. Children identified for being at a higher risk of incomplete vaccination schedule include those who have missed vaccinations, those in care, physical/learning disability, children of teenage parents, those not registered with a GP, those from large families, hospitalised, ethnic minority groups, non-English speaking parents and vulnerable children. Parents who found it difficult to book appointments or lacked information on the immunisation programme were less likely to have fully vaccinated children. MMR vaccine uptake has decreased in the more affluent households.

Answer 203

Fears of the safety and efficacy of vaccines have led to some parents refusing vaccinations for their children. A couple of ethical questions include: are parents within their rights to refuse vaccinations for their children? How should physicians respond to this refusal of consent? This can be partly explained by the varying amounts of information that parents have on childhood immunisation.

Answer 204

There is a statutory requirement to notify the local council or health protection team for certain diseases. Complete a notification form immediately after diagnosis and do not wait for laboratory confirmation. Send this form to the officer within 3 days or notify them within 24 hours if the case is urgent. All proper officers must pass this information on to public health England within 3 days or 24 hours for urgent cases

Answer 205

meningitis, encephalitis, diphtheria, enteric fever, food poisoning, infectious bloody diarrhoea, measles, meningococcal septicaemia, rubella, scarlet fever, TB, typhus, whooping cough and viral haemorrhagic fever

Answer 206

Points from the history should include fever duration, measuring temperature and how, rash, respiratory symptoms, clutching at ears, excessive/abnormal crying, swellings/lumps, joint problems, D+V, recent travel, contact with unwell, eating and drinking normally, urine output, how child is handling, convulsions/rigors and PMH/DH/SH. It is also worth considering parental anxiety, social circumstance and has the child experienced similar symptoms before. Key points from the examination include identifying any life-threatening features, measure body temperature, look at skin/lips/tongue, activity levels of the child, examine respiratory and cardiovascular system, assess hydration level, capillary refill, swellings, rash and neurological signs.

Answer 207

Tachypnoea is classed as >60 in those <5 months, >50 in 6-12 months and >40 in those >12 months. Measure O2 sats if possible.

Answer 208

Meningococcal disease should be considered in those with fever and non-blanching rash.

Answer 209

Consider meningitis in those with fever plus neck stiffness, bulging fontanelle, decreased consciousness or convulsion.

Answer 210

Consider herpes simplex encephalitis in those with fever plus focal neurological signs.

Answer 211

Consider pneumonia in those with fever, tachypnoea, chest crackles, nasal flaring or O2 sats <95%.

Answer 212

Consider UTI in any child <3 months with fever. In children >3 months, consider if there is associated vomiting, poor feeding, lethargy, irritability, abdo pain or urinary symptoms.

Answer 213

Consider Kawasaki disease if fever >5 days plus bilateral conjunctival injection, change in mucous membranes/extremities, polymorphous rash or cervical lymphadenopathy

Answer 214

Any life-threatening symptoms should be addressed using ABC. When assessing those with learning difficulties, take this into account when using the traffic light scoring system. Recognise children with the following symptoms are in the high risk group: pale/mottled/blue skin/tongue or lips, no response to social cues, does not wake/stay awake, change in crying, grunting, RR>60, severe chest indrawing, reduced skin turgor and bulging fontanelle. Children with the following symptoms have intermediate risk: pallor of skin/tongue/lips, not responding to social cues, no smile, wakes only on prolonged stimulation, decreased activity, nasal flaring, dry mucous membranes, poor feeding, reduced urine output and rigors. Capillary refill of >3 seconds is intermediate risk factor. In children >6 months, do not use the height of body temperature to identify illness. Those <3 months with a temperature >38 are in a high risk group. Duration of fever cannot be used to predict severity of illness. Children with fever and any of the high risk symptoms are classed as high risk. Management of those with fever should be according to the level of risk.

Answer 215

Children whose symptoms suggest life-threatening illness should be immediately referred for emergency care via 999 ambulance. Children with high risk symptoms who are not considered to be in a life-threatening situation should be assessed by a healthcare professional (paeds specialist) face to face within 2 hours.

Answer 216

Children with amber but no red features should be assessed face to face but the urgency should be determined by clinical judgement. Children with green features should be cared for at home with appropriate advice when to seek extra help. If amber features are present and no diagnosis has been reached, provide parents with a safety net or refer to specialist paediatric care. The safety net should contain information on symptoms and how to seek further help, arranging further follow up or liaising with out-of-hours providers for further assessment of the child.

Answer 217

Children who are suspected to have pneumonia should not have routine CXR. Test urine in children with fever. Do not prescribe oral abx to children with fever of no obvious source. Give parenteral abx (benzylpenicillin or 3rd gen cephalosporin) to those with suspected meningococcal disease. In children <3 months, measure temperature, heart rate and respiratory rate. Perform FBC, blood culture, CRP, urine testing, CXR and stool culture (if diarrhoea present). Perform lumbar puncture in infants <1 month, all those 1-3 months feeling unwell and high WCC. Perform lumbar puncture without delay and administer abx. Those <3 months should be given cefotaxime/ceftriaxone plus abx against listeria i.e. amox.

Answer 218

In children >3 months, perform FBC, blood culture, CRP and urine testing. In those with red features, perform lumbar puncture, CXR, serum electrolytes and blood gas. In children with amber features, check urine, FBC, blood culture, CRP, lumbar puncture (<1 year) and CXR (if temp >39). Those with green features should be tested for UTI and assessed for signs and sx of pneumonia. Febrile children with proven flu or respiratory syncytial virus should be assessed for serious illness. Children presenting with fever and shock should be given IV sodium chloride 0.9% 20ml/kg body weight. Give immediate abx if they present with fever and are shocked, unrousable and show signs of meningococcal disease

Answer 219

Immediate abx should be given to children with fever and reduced consciousness. Give IV acyclovir to those with fever and symptoms suggestive of herpes simplex encephalitis. Oxygen should be given to those with fever and shock/O2 sats <92%. In children presenting with fever and suggestive of serious bacterial infection, they should be given abx against N. meningitidis, S. pneumoniae, E. coli, S. aureus and Hib. A 3rd gen cephalosporin is suitable till culture results available. Antipyretic agents do not work against febrile convulsions. Consider ibuprofen or paracetamol in children with fever who are distressed

Answer 220

• When using paracetamol/ibuprofen, only continue if child is distressed and do not give both simultaneously. At home, encourage a regular fluid intake. Tell them to be vigilant for dehydration (sunken fontanelle, dry mouth, sunken eyes, absence of tears). Get them to identify a non-blanching rash and check the child at night. Also get them to keep their child away from school/nursery while they are feverish. Get them to seek further help if the child develops a non-blanching rash, seizures, deterioration in condition, parent/carer is distressed and if the fever lasts longer than 5 days

Answer 221

o Nature of suspected disease o Ease of its spread o How spread can be prevented/controlled o Patient’s circumstances (age, sex, occupation etc)

Answer 222

 Details of potentially exposed contacts  Vaccination history  Epidemiologically linked cases – age categories etc  Factors making contacts more vulnerable – old/young people, autoimmune, homeless  Potential source of infection/contamination – bad hygiene, cuts etc  Wider public health context

Answer 223

 Isolation, exclusion and decontamination  Further lab testing  Post-exposure prophylaxis and immunisation  Other control measures – advice on hand hygiene, avoid touching other people’s things etc

Answer 224

measure with the patient supine then standing for at least a minute prior to measurement. If blood pressure falls 20 systolic, review medication, take more readings and refer to specialist care if necessary

Answer 225

measure BP in both arms. If BP is 140/90>, take another reading. If the measurements are different in both arms, take the lowest. If 140/90 is detected, offer ABPM to confirm Dx. If person has severe HT, medicate immediately. While waiting for Dx, carry out tests for LVH, CKD and hypertensive retinopathy, as well as Qrisk2. If there is no HT but organ damage, carry out further tests. When using ABPM, take 2 readings between 8am-10pm, preferably average of 14.

Answer 226

test for proteinuria, haematuria, blood (glucose, electrolytes, creatinine, eGFR and cholesterol) and a 12 lead ECG

Answer 227

Lifestyle advice should be offered encompassing diet and exercise, as well as alcohol. Discourage excess consumption of caffeinated drinks. Encourage them to lower their salt intake and help them quit smoking. Offer antihypertensives to those with stage 1 under 80 who have either organ damage, CKD, CVD, DM and 10 year CVS risk of >20%. Also offer to anyone with stage 2 HT. Anyone <40 with evidence of the above with stage 1 HT, consider specialist evaluation

Answer 228

Aim for below 140/90 <80. Aim for below 150/90 >80. Those <50 with stage 1, offer ACEI and if intolerant, low-cost ARB. Offer CCB to those >55 or black people. If intolerant, give a thiazide-type diuretic i.e. chlortalidone 12.5-25.0mg daily or indapamide 1.5-2.5mg. Beta blockers are considered in younger people if there is intolerance to ACEI or ARB, women with child-bearing potential or those with increased sympathetic drive. If BB initiated and 2nd therapy needed, offer CCB. At step 2, offer CCB in <55 or thiazide diuretic in those >55. In black people, consider ARB instead of ACEI. Before step 3, review medication. If triple needed, use ACEI/ARB, CCB and TTD

Answer 229

consider specialist help. For treatment for resistant HT, consider low dose spironolactone (25mg OD), although use with caution in those with reduced eGFR. Consider high dose TTD if K+ is >4.5. If further diuretic therapy is not tolerated, use alpha or beta blocker. Provide guidance on benefits and side effects of drugs. Provide annual care review

Answer 230

Refer those with suspected HF or previous MI to transthoracic Doppler 2D echo and specialist assessment within 2 weeks. Measure BNP or N-terminal pro-B type natriuretic peptide (NTproBNP) in those without previous MI. Refer those with BNP of 100-400 pg/ml or NTproBNP between 400-2000 to Doppler and specialist within 6 weeks

Answer 231

Obesity and medications can decrease serum natriuretic peptides and they can also be caused by CKD, sepsis, DM and cirrhosis. Perform Doppler to rule out ventricular dysfunction and valve disease. Consider cardiac MRI if image is poor. Consider SNP test if ECHO shows preserved LVEF

Answer 232

. Perform ECG, CXR, bloods (U&Es, creatinine, eGFR, thyroid function, liver function, fasting lipids, glucose, FBC), urinalysis and peak flow

Answer 233

assess precipitating factors and correctable causes. Help the patient to quit smoking and those with alcohol related HF should stop drinking. Patients should be offered flu and pneumococcal vaccines. Air travel is possible for the majority. DVLA should be informed. ACEI and BB are considered first line for HF. Start ACEI at low dose and titrate up. Measure kidney function after each titration. Titrate BB up

Answer 234

* Seek specialist advice before offering 2nd line treatments. For those with mild HF, use ARB, those with severe use aldosterone antagonist and hydralazine with nitrate for black people. Monitor potassium and kidney function in those taking AA and ARB. Start 3-14 days after MI in those with acute MI. Digoxin is recommended for severe or worsening LVSD HF as a 3rd line. Those with HFPEF should be treated with low-medium dose loop diuretics. CCB should be considered in those with HF and HT/angina but not non-dihydropyridines. If amiodarone is prescribed, this should be reviewed regularly with liver and thyroid function. * Anticoagulation should be considered in those with thromboembolism, left ventricular aneurysm or intracardiac thrombus. Aspirin (75-150mg) should be prescribed to those with HF and CHD. Tolerance and side effects of drugs should be monitored closer in older patients. In women of reproductive age, contraception and pregnancy should be discussed

Answer 235

Transplantation should be considered in those with severe refractory symptoms or refractory cardiogenic shock. Offer supervised group exercise rehabilitation. Ensure patient is stable

Answer 236

• Patients should be monitored regularly by clinical assessment of functional capacity, fluid status, cardiac rhythm and cognitive/nutrition status, medication review as well as U&Es, creatinine and eGFR. Monitoring should be a day-2 weeks if the condition or medication has changed but 6 months for others. Refer patients for special multidisciplinary team for initial diagnosis and the management of severe heart failure. Patients should only be discharged from hospital when clinically stable and a management plan is in place. Diagnosis of depression should be considered in those with HF

Answer 237

• Mortality after hospitalisation is 10.4% after 30 days, 22% at 1 year and 42.3% after 5 years. Each rehospitalisation increases the mortality. Mortality is >50% with HYHA class 4 HF. HF associated with inpatient MI is 20-40%. HF related to systolic dysfunction is 50% after 5 years.

Answer 238

• Polypharmacy increases healthcare costs and increased the risk of hospitalisation/outpatient visits. There is also increased risk of ADRs. Drug interactions are more likely with an increase in the number of medications. The risk of polypharmacy increases with age as older patients tend to have an increase in co-morbidity, with an increased reliance on drug therapy. Non-adherence to medication in people with chronic disease has been partly attributed to complicated medication regimens and polypharmacy. Non-adherence is associated with potential disease progression, treatment failure and hospitalisation, all which can be life threatening. Polypharmacy has been associated with functional decline in older patients

Answer 239

cognitive impairment, urinary incontinence, falls and malnutrition

Answer 240

What is the patient meant to be taking and what are they taking? What conditions are active and inactive? Is there a valid indication for each drug? What are the benefits and harms of each medication? Can new symptoms be linked with starting the new medication?

Answer 241

Tools should be applied to identify unnecessary medications. The objective is to ensure each medication is tailored to the patient’s needs. Use prognostic tools to calculate life expectancy, in order to work out if the patient will benefit from the medication. If there are doubts with a medication, discontinue it, reduce the dose/frequency, substitute for a safer drug or wait, see and review.

Answer 242

• High risk approaches may be more effective than population approaches. Those identified as high risk may have more motivation to change than an entire population. It is easier for health professionals to promote health on an individual basis. Individuals are usually aware of their exposure to risk whereas not everyone in society will have been exposed. High risk approaches can be expensive and can fail to address public health problems arising from small widespread risks. It ignores the point that a large number of people exposed to a small risk will generate more cases than small number exposed to a large risk. Strategies for individuals tend to be palliative

Answer 243

* It is important to distinguish major depressive disorder from persistent mild depression. Patients with dysthymia must present with low mood for at least 2 years as the primary symptom. Misdiagnosis of bipolar disorder as unipolar depression may occur if there isn’t identification of hypomania between depression episodes. Patients with anxiety disorders are at a higher risk from co-morbid depression. Patients with personality disorders may present with mood changes as the prominent symptom. People with eating disorders often have depression. * Major depressive disorder can produce measurable cognitive deficits or worsening of dementia. Mood disorders are also prominent in Parkinson’s, MS, epilepsy, stroke and Huntington’s. Endocrine disorders including Cushing syndrome, hyper/hypothyroidism, prolactinomas and hyperparathyroidism. Certain medications can cause changes in mood including anti-hypertensives, smoking cessation aids, steroids, sex hormones, H2 blockers, sedatives, muscle relaxants, appetite suppressants and chemotherapy agents. * Substance abuse can cause significant mood symptoms. This is true for alcohol, cocaine, amphetamines, cannabinoids and narcotics. Infectious diseases can cause mood and behaviour changes including Lyme disease, mononucleosis, HIV and syphilis. Obstructive sleep apnoea can cause psychiatric symptoms and is often missed as a diagnosis

Answer 244

• Risk factors include genetics, death, conflict, abuse, major events, serious illness, certain medications, substance abuse and social isolation

Answer 245

• For those who don’t want intervention or who may recover without, discuss any concerns, provide information on nature and course of depression and arrange further assessment within 2 weeks. For those with persistent sub-threshold depressive symptoms or mild-moderate depression, offer individual, self guided help on CBT, computerised CBT and structured group physical activity programme. Self-help on CBT should include provision of written materials, be supported by trained practitioner and 6-8 sessions over 9-12 weeks plus follow up. For those who decline low intensity psychosocial interventions, consider group based CBT. It should consist of 10-12 meetings over 12-16 weeks. Consider anti-depressants for those with past history of moderate/severe depression, initial presentation of subthreshold symptoms for >2 years and symptoms that persist after psychosocial interventions

Answer 246

• Venlafaxine can exacerbate cardiac arrhythmias and hypertension and potential of postural hypotension with TCAs. Monitor patient after 2 weeks from starting on antidepressant. If side effects occur, monitor if mild or stop/change. If depression shows no improvement after 2-4 weeks, check adherence. If response is absent/minimal after 3-4 weeks, increase level of support or switch to another antidepressant. If depression improves, monitor for 2-4 weeks. Switch to another antidepressant if response is inadequate, side effects or person prefers to change treatment. Duration of psychological interventions may be reduced if remission is achieved or increased if progress

Answer 247

consider 2 sessions a week in the first 2-3 weeks in those with severe depression. If drug treatments haven’t worked, check adherence, increase frequency of appointments to monitor, consider previous treatments or switching antidepressant

Answer 248

• Review patient for continued antidepressant use >6 months after remission taking into account number of previous episodes, residual symptoms and other health problems. Those who have significant risk of relapse continue meds, augment meds or CBT. Treatment should be influenced by treatment history and patient preference. Advise patients to continue antidepressants for at least 2 years after remission if risk of relapse. When deciding to continue after 2 years, re-evaluate age, co-morbidity and risk factors

Answer 249

• People who are at risk of relapse or are unable to take antidepressants should be offered individual CBT or mindfulness-based cognitive therapy. When stopping antidepressant, reduce dose over 4 week period. Seek advice if they experience discontinuation symptoms. Assessment of patient referred to mental health services should include symptom profile, suicide risk, treatment history, psychosocial stressors, personality factors and substance abuse including alcohol and drugs. Use crisis resolution and home treatment teams for those with severe depression

Answer 250

• Consider inpatient treatment for those at risk of suicide, self harm and self neglect. Full range of high intensity psychological interventions should be offered in inpatient setting. Consider electroconvulsive therapy as acute treatment in those with severe depression

Answer 251

felt you needed to cut down, annoyed by people commenting on your drinking, ever felt guilty, eye-openers

Answer 252

Dose response, temporality, strength, reversibility, consistency, biological plausibility

Answer 253

Systematic error in selection of study participants or allocation of participants to study groups

Answer 254

Either recall, equipment