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Phase 3a GP Lectures (Domestic Abuse (Definition (Forms- Physical,…
Phase 3a GP Lectures
Domestic Abuse
Definition
Forms- Physical, Emotional, Psychological, Sexual, Financial, Psychological
Abuser- itnimate partner (current/ex) or family members
Age >16
Incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse to someone aged over 16 from someone who is/has been intimate partners/family members e.g (forms below)
Risk Assessment tools
DASH
Risk levels
Standard- no indication of likelihood of serious harm
Medium- indicators of risk of serious harm, offender has potential to cause serious harm but unlikely unless change of circumstances
High- indicators of immediate risk of serious harm. Dynamic- could happen at any time and impact would be serious.
Notable factors
Perpetrator suicidal
Access to weapons
Strangling / drowning
Helping with DA
High Risk (can break confidentiality)
IDVA (Independent Domestic Violence Advocate)- represents victim at MARAC. Help to increase safety by providing housing, legal services etc.
MARAC- Mutli-Agency Risk Assessment Conference
Standard/Medium Risk
Refer to Helpline / other DA services
DA impact on health
DA presentations
Chronic illness from living with abuse- headaches, GI disorders, chronic pain,
Psychological / Psychosocial- PTSD, attempted suicide, substance misuse, depression, eating disorders
Injuries following assaults- bruises, fractures, miscarriage
DA prevalence and suspicion
20-30% F injuries A&E= physical abuse from partners
Best indicator- "unwitnessed by anyone else"
61% felt they should always be asked about DA
Children
Always consider whether children are in the setting
Case examples
Sam & Grace
Background: 34 weeks preg, partner- physical abuse, alcohol, unemployment
Financial pressures, how much earning, how much on mat leave (Maternity Pay 90% salary, then 640/month) ???
Toxic Triangle- Domestic abuse, substance misuse, parental mental health issues
"Deluth Model" of power and control (wheel):
Intimidation, emotional abuse, isolation, using children, financial abuse, coercion and threats, minimising/denying/blaming abuse
Scaled up to physical and sexual abuse
Actions:
HC involvement- Adult safeguarding lead/DA lead, Community midwife (complete DASH), Health visitor
Support for Ptx: ?Counselling ?Alternative accommodation
Jody and Kyle
Background: 17yo F 16wk preg, separated from father because verbally aggressive (hx 9mo prison for assault on ptx, prev drugs and other offences) receiving threatening messages, frightened
Concerns: lack of parental support, pregnant- vulnerable, partner hx of violence and prison, ?still has access to the flat
If ptx is frightened then they are statistically significantly more likely to be at risk of abuse
Rubena and Junaid
Other children- other sources of info e.g nursery, health visitor
Background: 27 F 22wks preg, married, 3 children, prev verbal argument, worried about finances, sister says think he's cheatng
Health Psychology, behavioural change and smoking cessation
Additional reading
NICE short summary human behavioural change
Theories of behavioural change (PTS)
Health Belief Model
Theory of planned behaviour
Transtheoretical Model
Social Norms Theory
Motivational Interview
Nudging
Def. health psychology
the role of psychological factors in the cause, progression and consequences of health and illness
Why do patients engage in health damaging behaviour
Weinstein's Unrealistic optimism- individuals continue to practice health damaging behaviour due to inaccurate perception or risk and susceptibility
Perception of risk influences by:
Lack of personal experience with problem
Preventable by personal action
If not happened by now it's not likely to do
Problem infrequent
Health behaviours
Types of behaviour
Illness behaviour
behaviour aimed at seeking remedy e.g seeing doctor
Health behaviours
behaviour aimed to prevent disease e.g eating healthily
Sick role behaviour
activity aimed at getting well e.g taking prescribed medications
Categories of behaviour
Health damaging/impairing
Smoking, alcohol, risky sexual behaviour
Health promoting
exercise, healthy eating, attending health checks, vaccinations
Smoking cessation- email certificate to
teachingoffice1@sheffield.ac.uk
titled "smoking cessation"
GP Module and My GP
GP Module
Assessment/Hand-in
Smoking Cessation Course
Public Health Assignment
Summative Assessment (2x mini-cex, on e-portfolio)
Small Group Tutor Proforma
Practise Tutor Proforma
Self-Assessment Proforma
E-portfolio patient cases- build up patient bank
ILAs: 1) IHD 2)Febrile Toddler 3) Vaginal discharge 4)Stroke/TIA/Dementia 5) Substance misuse / Depression 6) Cough
Public Health Assignment- Social Prescribing- Parkrun?
Contacts: Joanne Senior (module co-ordinator)
Greener GP Practise
Inhaler recycling- where is local pharmacy that does it?
Social Prescribing
Waste labelling correctly
Green Impact Certificate- RCGP
Greenerpractice.co.uk, Greener Practice Audit
My GP Practise
Thurncroft practise:
Surgery Consulting times:
Mon 7-9 or 8:30-10:30 // 4-6
Tue 8:30-10:30 // 4-6
Wed 7-9 or 8:30-10:30 // 4-6
Thur 8:30-10:30 // 4-6
Fri 7-9 or 8:30-10:30 // 4-6
Clinics Available:
Alcohol Misuse, Asthma, BP, Counselling, Cryotherapy, DM, Ear clinics, HD, LARC, Lifestyle trainer, Minor surgery, Midwifery, Physiotherapy, Smoking Cessation, Spirometry, Substance Misuse, Wound Care
The Village Surgery
Laughton Road, Thurncroft, S66 9LP
01709542725
Staff:
Duncan Wilson- Mon, Tue, Wed, Minor Surgery on Tues
Johnathan Cobb- Mon, Tue, Wed, GP trainer, MRCGP examiner
Gail Crowley- Mon, Wed, LARC clinic Wed
Avanthi Gunasekera- Mon, Tue, Thur, Fri. LARC Thur
Jennifer Rebora- Mon, Thur, Fri. Care-home Thur.
Lucie Ritchie- Wed, Thur, Fri
Practise Manager- Jill Meaburn-
Jill.meaburn@gp-c87022.nhs.uk
Timetable:
Monday- Morning tutorial- Maddy
Wednesday- Maddy
Friday (1/2)- Public Transport
Placement activities
Attached Staff
District Nurse, Health Visitor, School Nurse, Midwife, CPN, Counsellor, Grad Mental Health Worker
Community
John street mental handicap, Duty Social Worker, local undertaker, Pharmacy, Community mental health team
Sheffield
Contraceptive clinic
PHCT
GP, Receptionist, Admin staff, Practise nurse, District nurse, Midwife, Health visitor, School nurse
GP patient experiences `
PC 80M, Tiredness, SOB, snoring, bibasal crackles
Nxt PC: Dizziness on standing, worse in morning, vomitting, decreased appetite
T: ?neuro
S: ?change visual ?numbness/tinging
D:
Next PC: Confusion
T: delerium 2nd UTI? Met CA
S:
D:
Answer- brain mets from bronchogenic carcinoma, central sleep apnoea caused by increased ICP
T: HF, Anaemia, Airway obstruction, Sleep apnoea
S:
D: CXR, Bloods
PC: 7wks F, struggling with feeds, bringing milk up non-projectile, always hungry, breastfed, NVD, blocked nose, noisy at night
T: ?pyloric stenosis ?reflux ?overfeeding ?cong hitatus hernia ?CMPA (through mothers milk)
?laryngomalacia ?foreign body
S: ?green ?projectile ?time frame ?bleeding ?rashes ?ok in self ?signs of cyanosis
D: HR-132, RR-26, temp 36.8, refer to paeds ENT, nose suction
PC: 56M, left-sided temporal headache/ pain, throbbing, numbing
T: temporal arteritis? trigeminal neuralgia ?GCA ?migraine ?cluster ?CVA ?medicine overuse headache
S: eyes involved? ears? how long?
D:
GP ILAs
Broken Heart
Chronic Heart Failure
Causes
High output
Normal HR, increased demand e.g hyperthyroidism, anaemia, AV malformation
Low output
Increased pre-load e.g MR
Pump failure
Muscle e.g cardiomyopathy
Filling e.g restrictive cardiomyopathy/tamponade
Rate e.g B.Blockers, Heart block, Post-MI
Co-ordination e.g AF
Power e.g neg inotropic dx verapamil
Chronic excessive overload e.g increased BP / AS
Ix
NT-proBNP
_>2.000ng/L refer to specialist within 2 weeks
0.400-2.00ng/L refer to specialist within 6 weeks
<0.400ng/L consider other causes
ECG, CXR, Bloods, Urine, (Echo at specialists)
Case Background
Jargon Translator:
Indapamide= Thiazide-like diuretic
EGFR: Normal/ Stg1 >90. Stg2 (60-89) mild loss. Stg3a (45-59) mild/mod loss. Stg 3b (30-44) mod/severe loss. Stg 4 (15-29) severe. Stg 5 (<15) kidney failure
60yo M.
PC: Swollen ankles, SOB, sleep apnoea
PMH: HTN MI.
DHx: Amlodipine, Indapamide, Atorvastatin, Aspirin.
Ix: NTproBNP 1500, eGFR 47, echo- reduced ejection fraction / severe LV systolic dysfunction
Definition
Cardiac output inadequate to meet the needs of the body (supply & demand)
S&S
SOBOE, Fatigue, Low exercise tolerance, Confusion/dizziness, Peripheral Oedema, abdo discomfort
Increased RR, HR, JVP
Basal creps, pitting oedema, ascites
Differentials
Hypoalbuminaemia, PE, Severe anaemia, Obesity, Pitting Oedema,
Mx
Pharamcological
Offer diuretics
Preserved ejection fraction
Mx co-morbidities e.g HTN, AF, IHD, DM
Reduced ejection fraction
Offer ACEi (or ARB) / BB
Non-pharmacological
Education, Diet, Smoking, Vaccination
Prognosis
50% diagnosed with HF die within 5 years
Poor prognostic factors: age, smoking, DM, obesity
Hypertension
Diagnosis
Clinic BP
140/90 - 179/119
Offer ABPM, Ix organ damage, Assess CV risk
180/120
Ix organ damage, start Mx, repeat BP in 7 days
HTN staging
Stage 2 = > 150/95
Stage 1 = 135/85 - 149/94
Mx
Age<55 / T2DM
ACEi/ARB
+CCB
+Thiazide-like diuretic
Expert advice / Spirolonactone / Alpha blocker/ Beta Blocker
Age > 55 / Afrocaribbean
CCB
+ACEi/ARB
+Thiazide-like diuretic
Expert advice / Spirolonactone / Alpha blocker/ Beta Blocker
Ptx develop: Malignant HTN
BP >180/120
?proteinuria
High BP = risk of cerebral haemorrhage
?blurred vision = Papilloedema (optic disc swelling due to increased ICP)
Admit to hospital
Mx= Labetalol
Ptx develop: 180/116 no symptoms
Check heart sounds ?aortic stenosis
Enalapril 5mg (28) O.N
Check U+E 1wk after prescription (K+ levels) ACEi can cause hyperkalaemia --> death
HBPM- ptx check BP at home B.D, record results. Throw away 1st days recordings, take average.
Extra Info
HTN highest in morning when cortisol released
B.Blocker- SE = ED, Alpha Blocker tx BP and helps with ED
CHD
Primary prevention
Exercise, X smoking/alcohol, good diet etc.
Secondary prevention
QRISK, BP Checks
Tertiary prevention
Balloon valvuloplasty
Postural Hypotension 90MmHg difference on standing
Differentials: Aortic Stenosis, Phaeochromocytoma, Regurg
Look us professor Burton - Heart Failure
VIZHUB GBD
GP Lectures
Health Inequalities
Core Principles of NHS
Meets the needs of everyone, free at the point of delivery, based on clinical need not ability to pay
What is Health Inequality?
Inverse Care Law?
The provision of healthcare is inversely proportional to the
"vulnerable groups" of patients in NHS
Homeless, Asylum seekers, LGBTQ, Ex-prisoners, Care leavers, Learning disabilities, Mental Health Problems
Why do ptx. find it difficult to access healthcare?
Maslow's hierarchy of needs?
Physiological
Safety Needs
Belongings and Love needs
Esteem
Self-Actualisation
Needs Assessment
What is need?
Need- ability to benefit from intervention,
Supply- what is provided
Demand- what people ask for
PH Approaches
Epidemiological Approach
Define problem, size of problem, services available, evidence base, models of care, existing services,
Corporate Approach
using perspectives from politicians, press, patients, professionals, commissioners
Comparative Approach
compares services received by different populations or sub-groups
Planning cycle- Needs Assessment--> Planning--> Implementation --> Evaluation
Health Needs Assessment- systemic method for reviewing the health issues facing a population learning to agreed priorities and resource allocation that will improve health and reduce inequalities
Can be carried out for: population/sub-group, a condition, an intervention
GP patient experiences
22yo lower abdo cramps
Think
STI?--> PID?
Pregnant?
Is this an emergency??
Contact tracing?
Risk of infertility?
Say
Any bleeding?
Pain /bleeding with sex?
How long you've had this?
PMH?
Come back if gets worse/concerned
Do
Check HR, BP, Abdo Exam
Speculum / Vaginal exam
Endocervical swabs- gonorrhea/chlamydia,
High Vaginal Swab MC&S
Opportunistic Cervical Smear
Pregnancy test
Give Antibiotics: Ofloxacin and Metronidazole
Ptx. ED follow-up,
results= raised prolactin
Say:
?change in results, change in yourself?
?visual symptoms
Think:
?prolactinoma
?pituitary
?kleinfelters XXY
?medications
?referral to
__
?is this an emergency
Do:
Check meds- SSRIs? Anti-psychotics?
Examine visual fields
PMHx
SHx
Learning outcomes
Hyperprolactinaemia- rare cause of erectile dysfunction.
Investigate Prolactin levels in ptx with ED
Dopamine inhibits prolactin hence anti-psychotics which are anti-dopamie can have SE of galactorrhoea
GP ILA
Hot and Bothered
Recognising sepsis
RFs: Age (very young <1 or very old >75), Immunocompromised (long-term steroids, immunosuppresants, splenectomy), IVDU, Prev surgery, break in skin, Pregnant, indwelling catheter
Suspect Sepsis: National Early Warning System (NEWS score)
Temperature, Consciousness
HR, BP,CRT
RR, O2 Sats
S&S: RR>25, HR>130, BP< 90/40, Not PU 18hrs, Mottled or ashen appearance, cyanotic skin, lips or tongue, non-blanching skin rash
Suspect Sepsis? Bufalo!
Take Blood Cultures, Measure Urine Output, Start IV Fluids, Give IV Antibiotics, Measure serum Lactate, Titrate Oxygen to 94% target
HPC: Presented earlier with focus of infection, deteriorate rapidly despite PO Abx, Non=specific sx e.g N+V, Abdo pain, Diarrhoea,
Childhood Immunisation Schedule
8 weeks
6-in-1, Pneumoccocal, Rotavirus, MenB
12 weeks
6-in-1, Rotavirus
16 weeks
6-in-1, Pneumococcal, MenB
1 year
Hib/MenC, MMR, Pneumoccocal, MenB
2-10 years
Flu (every year)
12-13 years
HPV vaccine
3 years
MMR, 4-in-1 pre-school booster
14 years
3-in-1 teenage booster, MenACWY
Vaccines
6-in-1: DTaP / Hep B / HiB / Polio
4-in-1: DTaP / Polio
3-in-1: DTaP
PHE notifiable diseases
Acute menigitis, encephalitis, poliomyelitis
Measles, Mumps, Rubella
Tetanus, Diphtheria, Pertussis (whooping cough)
Malaria, TB,
Yellow fever, Typhoid,
Anthrax, Plague, Small
Infectious bloody diarrhoea, Food poisioning
Haemolytic Uraemic Syndrome
Invasive group A step / Legionnaires'
Notifiable diseases- important not for receiving treatment but for highly contagious diseases that need contact tracing
NICE traffic light guidance of unwell child
Learning Points:
Strep Throat
Complications
of strep throat
Rheumatic Fever, Glomerulonephritis
Very contagious
FPAIN- score for bacterial tonsilitis
Fever, Pus, Attend within 24hrs, Inflamed tonsils, No cough
Live vaccines
Rotavirus, MMR, Varicella Zoster, BCG
Influences on decisions to vaccinate:
Socioeconomic background- better SE less likely to have vaccines
Religion/Vegan- flus cultures in egg
Phase 3a GP Lectures
Food and Behaviour
Malnutrition
Early influences on eating behaviour/taste preference developent
Dieting success
GP EK