Quiting Alcohol

Stages of change and our jobs

  1. Precontemplation
    1. Raise doubts
    2. Educate patients on risks
    3. Harm minimise
  2. Contemplation
    1. Weigh pros and cons
    2. Explore ambivalence
    3. Explore alternatives
    4. Identify reasons for change / not changing
    5. Increase patient confidence in ability to change
  3. Preparation
    1. Set clear goals
  4. Action
  5. Maintenance
    1. Sort them out
  6. Relapse
    1. Normalise relapse
    2. Get them back on for another go

NHMRC tagets

  • Short term: 4 standard drinks on a single occasion
  • Long term: 2 standard drinks on any day

Pharamcology

  • Disulfiram
    • Inhibits acetaldehyde dehydrogenase
    • Accumulation of acetaldehyde leading to nausea, flushing, palpitations
  • Acamprosate
    • GABA and glutamine neuromodulation
    • SE: diarrhoea, insomnia, depression
  • Naltrexone
    • Opiod competitive receptor antagonist
    • May be given IM as a monthly depot
    • SE: nausea, headache, anorexia, insomnia

Non-pharmacological services

  • Alcoholics Anonymous
  • Clinical psychologist
  • Next Step
    • Inpatient withdrawal service
    • Outpatient withdrawal service
    • Drug and Alcohol Youth Service
  • Private services
    • The Marian Centre
    • Perth Clinic
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PSA Pros(tates) and Cons

Con

  1. Poor sensitivity of 21%
    1. Will not detect sufficient cases to be uuseful as a population screening tool
    2. People would be falsely reassured by a negative or normal test
  2. Inability to distinguish between indolent cancers that might never become symptomatic in the patient’s lifetime from more aggressive growths
  3. Investigation and treatment of elevated PSA carries significant psychological and physiological harms to the patient. Due to the poor specificity of the PSA, overtreatment is likely
  4. The evidence is against it (2013 Cochrane review)
    1. No benfit from mortality from pooled RCTs
    2. Evidence of increased harm
      1. If you screen 1,400 men for prostate cancer you’re likely to negatively affect the quality of life to 7 (erectile dysfunction, incontinence)

Pro

  1. Specificity of 91% means that a detected lesion has a reasonable chance of needing further intervention
  2. Earlier interventuions may reduce effects of late-stage porstate disease
  3. Decisions aren’t made on the PSA alone: the PSA can be used in concert with imaging and clinical history to give a better estimate of risk before making decision to biopsy or workup further. This mitigates the effects of overtreatment / overinvestigation
  4. 1 recent large study showed a modest benefit in mortality (1 life saved per 1400 men tested)

Passing a Suturing OSCE Station

Suture Choice

  • Material choice
    • Deep: absorbable sutures
      • PDS (mono)
      • Vicryl (multi)
      • Monocryl
      • Caprosyn (monofilament)
    • Superficial: monofilament nonabsorbable sutures
      • Nylon
      • Prolene (polypropylene)
  • Suture size
    • Face – 6.0
    • Most places – 4.0 / 5.0
    • Back, foot, thick muscle – 3.0
  • Monofilament versus braided
    • Monofilament less infection risk, less inflammatory reaction
    • Multifilament easier to tie, less risk of slippage

Suture Removal

  1. Face: 3 days
  2. Ear, lip: 4 days
  3. Chest, abdomen, penis: 8 days
  4. Extremeties: 10 days
  5. Foot, back: 12 days
  6. Chronic steroid use, T2DM: 2-3 weeks

Anaesthetic

  • Lignocaine +/- adrenaline
  • Avoid adrenaline in end-arterial circulation sites
  • Handy tips
    • Inject through the wound edge
    • Use an insulin needle for minimal pain
    • Wait plz before stabbing people
    • A Biers block may be used if there are extensive lacerations on forearms
  • Maximum dosages
    • Lignocaine + adrenaline = 7mg/kg
    • Lignocaine without adrenaline = 3mg/kg
  • Local anaesthetic toxicity
    • Sentinel effects – tinnitus, dizziness, confusion, perioral numbness
    • CNS toxicity – seizures, coma
    • CVS toxicity – Na+ blockade effects (QRS prolongation, dysrhythymias, hypotension, bradycardia)
    • Sodium bicarb, benzos, fluid load, intralipid

Periprocedural considerations

  • Cleaning + sterile technique (but more like clean-contaminated)
  • Decontamination of wound
  • Tetanus vaccination
  • Consider flucloxacillin for wound infections

Quiting the Smokes

Stages of change and our jobs

  1. Precontemplation
    1. Raise doubts
    2. Educate patients on risks
    3. Harm minimise
  2. Contemplation
    1. Weigh pros and cons
    2. Explore ambivalence
    3. Explore alternatives
    4. Identify reasons for change / not changing
    5. Increase patient confidence in ability to change
  3. Preparation
    1. Set clear goals
  4. Maintenance
    1. Sort them out
  5. Relapse
    1. Normalise relapse
    2. Get them back on for another go

Basic Quit Plan

  1. Identify barriers to quitting
  2. Identify smoking associations (eg. smoking, relaxation) and offer alternatives
  3. Aim to taper cigarettes by 20% per month
    1. Stretch interval between cigarettes
    2. Try replacing cigarettes with other things
  4. Set quite date
  5. Offer varenicline (if no contraindications)
  6. Offer nicotine replacement gum, patches, sprays as baseline and for breakthrough cravings

Varenicline (Champix)

  • E: 25% 1 year quit rate vs 10% in placebo
  • M: nicotinic receptor partial agonist: reduces cravings and decreases pleasure of smoking
  • Instructions to patient
    • Start 1 week before quit date
      • D1-D3 0.5mg o
      • D4-D7 0.5mg bd
      • D8+  1mg bd
    • Take with water and food to help with nausea
    • Cease and contact doctor if neuropsychiatric symptoms manifest
    • Can only prescribe 12+12 weeks course under PBS
  • Contraindications
    • Neuropsychiatric disorders
    • Cardiac disease
  • SEs:
    • Nausea
    • Abnormal dreams
    • Insomnia

Bupropion

  • E: 15% 1 year quit rate vs 10% in placebo
  • M: non-competitive antagonist of neuronal nicotinic ACh receptors; weak norepi-dopamine reuptake inhibitor
  • CI: epilepsy, concomitant MAOI use
  • SE: rare epileptic seizures, headache, insomnia

 

Hypertension management

Treatment targets

  • >80 yrs old SBP 140-150 mmHg
  • <80 yrs old SBP<140 mmHg
  • Diastolic <90mmHg always recommended
  • T2DM BP <130/85 mmHg
  • Nephropathy SBP<130  mmHg

Treatment approach

  1. Exclude endocrine causes
  2. Lifestyle modification
    1. Salt restriction 5g a day
    2. <30g of EtOH a day
    3. SNAP
  3. Diuretics, BB, CCB, ACE-I and ARB are ALL suitable as initial monotherapy
  4. Choose initial agent based on SE profile and other effects
  5. Special cases
    1. Elderly with isolated systolic hypertension – CCB/diuretics
    2. Pregnancy – methyldopa, labetalol, nifeipine
    3. Nephropathy – ACE-I
    4. Angina pectoris – BB and CCB
    5. LVH – ACE-I, CCB
  6. Resistant hypertension
    1. Mineralocorticoid receptor antagonist
    2. Amiloride
    3. Doxazocin

Follow-up

  • 4 weekly after initiation of drug therapy
  • 3 monthly after taget BP reached
  • Asses risk factors and asymptomatic organ damage every 2 years

Treatment of associated risk factors

  • Low dose aspirin in patients with previous CVD
  • Aspirin only for primary prevention in high risk patients
  • GP to review for hypertensive nephropathy and retinopathy

Asthma & Asthma Attacks

Asthma

  1.  Definition
    1. reversible airway obstruction
    2. airway inflmmation
    3. increased broncho- hyperresponsiveness (hypersensitive)
  2. Epi
    1. prevalence of 1 in 10 (> 2 million australians)
    2. > 300 million worldwide
  3. Types
    1. Extrinsic (allergic trigger e.g. inside – dust mites, outside – spores; IgE mediated)
    2. Intrinsic (irritant trigger e.g. pollution or infection; non IgE mediated)
    3. Mixed
    4. Exercise-induced
    5. Occupational
    6. Aspirin or NSAID induced
  4. Risk Factors
    1. Family History
    2. Parental smoking
    3. Past medical history, allergic march.
    4. Medications eg aspirin or NSAIDs
    5. RSV infections
  5. Workup
    1. History (Diagnostic)
      1. Symptoms – Wheeze, dysponea, cough, chest tightness, provocative factors.
      2. Always confirm history with spirometry.
      3. Early life – bronchopulmonary dysplasia, neonatal incubation, parental smoking
      4. Allergen screening of home and work environment.
      5. At risk groups – elderly, pregnant.
    2. History (Control)
      1. How often did Asthma interfere with activities?
      2. How often are you short of breath?
      3. How often are you awakened by your Asthma?
      4. How often do you use your rescue inhaler?
    3. Examination (General)
      1. expiratory wheeze
      2. prolonged inspiration to expiration ratio.
      3. hyper-expanded chest
      4. systemic signs of atopy e.g. eczema.
    4. Examination (Resp distress)
      1. Tachypnea, dyspnea, accessory muscle use, anxiety, cyanosis (if severe)
      2. Tachycardia, pulsus paradoxus.
  6. Investigations
    1. Spirometry – obstructive pattern
      1. Reduced FEV1, reduced or normal FVC, reduced FEV1/FVC.
      2. > 12% improvement with bronchodilator in FEV1.
    2.  X ray (not diagnostic)
      1. hyper-expansion
      2. flattened diaphragm
      3. increased wall markings (due to inflamed airways)
  7. Management, by severity (NIH recommendations)
    1. Asthma education
    2. Write action plan
    3. Intermittent asthma: aSx, normal PFT, <2 exacerbation/wk
      1. Long term: no regular medications
      2. Rescue: inhaled SABA
      3. step up Mx if > 2 exacerbations per wk.
    4. Mild persistent: > 2+ episodes/wk affecting activity, occasional nocturnal sx
      1. Long term: inhaled low dose ICS for long term inflammatory control
      2. Rescue: inhaled SABA
    5. Moderate persistent: daily Sx with SABA effecting activity, 2+ episodes possibly lasting days, nocturnal sx >1/wk
      1. Long term: ICS + LABA
        1. Consider lowering dose of each over time.
      2. Rescue: inhaled SABA
    6. Severe persistent: freq episodes interfering with sleep and activity
      1. Long term: high dose ICS + LABA. Monteleukasts. Consider IV steroids,  Anti-IgE Therapy (Omalizumab).
      2. Rescue: high dose inhaled SABA

Asthma Attacks 

  1. Be calm, assure patient. Anxiety worsens.
  2. Sx: tachypnea, tachy/bradycardia, silent chest.
  3. Management
    1. Treat before assessment, consider ICU referral.
    2. Upright posture, high flow 100% oxygen
    3. salbutamol 5mg & ipratropium bromide 0.5mg nebs.
    4. Consider hydrocortisone 100mg IV

 

 

 

 

 

 

GP OSCE STI Screening

  1. Take a sexual history:
    1. Orientation
    2. Practices
    3. Partners
    4. Protection
  2. Describe the tests:
    1. FVU PCR
      1. Chlamydia
      2. Gonorrhea
    2. Lower genital tract
      1. Urethral discharge swabs for CT/NG
      2. Endocervical swab
      3. High and low vaginal swabs
      4. Fluid PCR from any lesion
    3. Anal swabs
      1. Insert 3cm into anus and rotate; may be self-obtained
    4. Pharyngeal swabs
    5. Bloods
      1. Hepatitis serology
      2. HSV serology
      3. HIV serology – requires pre-test counseling
      4. Syphilis
  3. Raise the need for mandatory reporting
    1. Obligation to contact trace
    2. DoH can anonymously contact previous partners

Specific organisms

  1. Herpes simplex
    1. Active lesions – HSV PCR of lesion fluid
    2. Screening – Type-specific serological assay
  2. Syphilis
    1. Screen with treponemal specific tests
      1. Higher sensitivity and specificity but cannot distinguish between active or past infection
      2. Serum treponemal EIA, TPHA (haemagglutination assay), TPPA (particle agglutination assay
    2. Determine if active infection + monitor treatment progress with non-treponemal tests
      1. VDRL (veneral diseases research laboratory), RPR (rapid plasma reagin), serum cardiolipin
  3. HIV
    1. Screen first with HIV ELISA
    2. Traditionally, window period of 3 months to allow for seroconversion to rule out false negative
    3. Newer 4th generation tests + tests against HIV IgM reduced window period to 4 weeks
    4. If screening tests are positive, proceed to Western blot for confirmation of diagnosis

Related things: vaginal discharge

  1. Wet mount microscopy from 2X locations
  2. Vaginal pH
  3. Endocervical, high vaginal and low vaginal swabs
  4. Consider vaginal culture for trichomonas / candidiasis if negative wet mount but suspicious clinical picture for either condition