Why is lifestyle modification better than medication for hypertension?
Can lower QRISK3 score. Medications can have adverse effects, side effects, and cause polypharmacy. They also can’t replicate healthy diet, and other changes. Lifestyle changes can also reduce risk of other health concerns like cancer
What additional investigations for someone diagnosed with hypertension and why?
To ensure heart, kidneys and pancreas still working (no end organ damage)
Ix: Urine albumin:creatinine ratio (protein), HbA1c (DM), Electrolytes, creatinine, eGFR (CKD), Dipstick (blood), ECG (cardiac function/LVHT), HDL/serum cholesterol
Stages of hypertension
- Clinic BP from 140/90 to 159/99 and ABPM daytime average or HBPM avg ranging 135/85 - <160/100
- Clinic 160/100 - <180/120 or subsequent avg of 150/95<
- Clinical systolic of 180/120+
What medications for who in hypertension?
Type 2 diabetes or under 55: 1. ACEi or ARB (candesartan)
2. + CCB/TZD
55+ or Black African/Afro-Caribbean:
1. CCB
2. + A/A/TZD
- A/A + CCB + TZD
- low dose spironolactone or beta blocker if K+ +4.5mmol/l
When is Palliative care considered and what are indications?
When condition is life limiting, progressive and associated with significant symptom burden
Indications:
Repeated hospital admissions
Progressive symptoms despite maximal therapy
Poor functional status
Difference between palliative care and terminal care
Palliative : Holistic approach - improving QoL by managing symptoms, addressing psychological, social and spiritual needs. Can run alongside treatment
Terminal : Provided in last days/weeks of life, when death expected soon, focus entirely comfort
End-stage heart failure symptoms/signs, and prognosis
Symptoms : Severe at rest or minimal exertion with optimal medical therapy, significant oedema
Prognosis: less than one year once eGFR is reduced, recurrent hospitalisations, advanced RI, poor functional status
Serious illness conversation: what’s included?
- Private space
- Determine family/pt understanding and explain
- Ask about priorities and values
- Document on ReSPECT
- Discuss chances of successful resus and following impact
Professionals involved in palliative care for heart failure
Specialist nurses, Palliative care team, GP involvement for ACP, Social services for care packages, Pharmacist for med reviews, physio/occ therapy, support groups
Support available for palliative patient’s support network
Social services assessment for carer support, Respite care, Carer’s allowance, GP support, Counselling/bereavement support, community nursing, support groups, social/green prescribing
Palliative meds for breathlessness, respiratory secretions and agitation. Include SE
Opioids (Morphine) - breathlessness, pain and cough - SE: retention, RI
Benzos (Midazolam) - psych, seizures and terminal restlessness - SE: Sedation, Resp depression, falls, delirium
Antimuscarinics (Hyoscine hydrobromide) - noisy resp secretions - SE: Dry mouth, retention, blurred vision, confusion/delirium
Other palliative meds (not benzos, antimuscarinics or opioids)
Laxatives (Senna, Bisacodyl Docusate) - constipation - SE: Diarrhoea, cramping, bloating, dehydration
Antipsychotics (Haloperidol) - delirium, agitation, SE: Extrapyramidal, QT prolongation, sedation
Antiemetics - Ondansetron
Anticonvulsants (Gabapentin, pregabalin) - neuropathic pain, seizures - SE: Sedation, dizziness, ataxia
Difference in presentation of anxiety vs depression
Anxiety: Uncontrollable worry, autonomic symptoms (palpitations, sweating, hot flushes, dry mouth, trembling, breathlessness, dizziness), Cognitive (hypervigilance, racing thoughts, difficulty concentrating), behavioural (avoidance, restlessness, insomnia, panic attacks)
Depression: Persistent low mood, anhedonia, 2+ weeks, reduced energy, appetite changes, feelings of worthlessness/guilt, behavioural (withdrawal, reduced self-care), suicidal ideation
Screening tools for depression and anxiety
PHQ-9 for depression, GAD-7 for Anxiety
How to quantify person’s alcoholic intake
Pint = 2.3. Small glass wine = 1.5. Standard glass wine = 2.1 Bottle wine = 9
Who to talk to in NHS if your job becomes unmanageable
Seniors, BMA, Documentation, Occupational Health
How to differentiate between different rashes in children
Roseola infantum - asymptomatic, maculopapular, cold like symptoms, swollen eyelids/glands
Parvovirus - erythema infectiosum - Fever, malaise, headache, myalgia - progresses to maculopapular lace-like on trunk and limbs
Kawasaki - Widespread maculopapular
Measles - Starts on head and neck
Rubella - spares palms, lasts 3 days - head and behind ears
Viral urticaria - itchy raised whelts after viral infections
Scarlet fever treatment and why it’s treated
Due to group A step so could develop to rheumatic fever and post strep glomerulonephritis. Avoid school for 24hrs after first dose of Abx
What to do if patient refuses admission/isolation for high risk infection i.e. TB
Trial course Abx and if no improvement contact PHE, if living alone and can isolate, this may be okay
Difficulties for migrants accessing health care in the UK
Lack of knowledge/understanding of where to get help, how NHS works. Language barriers, culture differences, cist, transport, perception of discrimination due to race, religion, and immigration status
Entitlements and not entitlements for asylum seekers
Entitled to 49.18/week or 8.86/week with meals
Housing, free healthcare.
Under 18: School, free school meals, Social services key worker
What is used to assess when under 16y/o can make decisions regarding healthcare + for sexual advice
Gillick competence - 13-16 receiving treatment or support.
Looks at capacity, maturity, and age. They can refuse unless refusal can lead to death or serious harm
Frasier Guidelines
Specific to advice and treatment about contraception and sexual health.
Looks at whether they can be persuaded to involve parents, if they understand, if physical/mental health is likely to suffer without treatment, if they’re likely to continue having sex with/without treatment
Red flags in underage relationship
Do parents know, are they receiving gifts or anything, learning disabilities, under 13 (CPS), recurrent STIs
