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HottopicsforMRCGP
DrImtiazAhmadBSc(hons)MBBSDFFPDRCOGPgCMedEdFRCGP
MScSEM,MFSEM(UK)AdvDipMH(dist)PgCMSKUS(dist)
Londonmrcgp CSA Courses•Prior to each CSA:
8.10.17 14.1.18 28.1.18 18.2.18
•Small Groups
•4 Mock CSA’s each!
•RCGP Examiner
•Written Feedback
•ST Educational allowance
HowtopasstheCSAexam• ToptipsforCSA,mockCSAcasesandDVD
• ForewordbyRogerNeighbour:http://www.londonmrcgp.co.uk/documents/RN-
Foreword.pdf
• RCGPbookshop:http://www.rcgp.org.uk/bookshop/mrcgp-study-
aids/how-to-pass-the-csa-exam.aspx• 10%offformembers• 20%offifboughttoday
• SampleVideo:https://www.youtube.com/watch?v=ysOfg1Fv7Dw
• Towinafreecopytoday:follow@londonmrcgp &tweetuswithAKTorCSApreparationtipswith#londonmrcgp
• TweetofthedaychosenafterMockAKT• PleaseneversendusanyofficialRCGPexam
questions
So what’s a Hot topic??• A topic likely to come up
in your exam• Wide range of choices!• Need to target learning• Try and predict areas
likely to come up• Major chronic diseases• Common conditions• NICE, SIGN, Cochrane• BMJ, BJGP, BNF, DoH
Common things are COMMON!• URTIs• Otitis media• Gastroenteritis• UTI’s• Red eye• Headaches• Back pain• Contraception• Periods• Immunisation/vaccination• Rashes• Arthritis• Sexual health
Random Others….
• ‘Red Flag’ conditions• Practice accounts• Practice management• Clinical Governance• Maternity leave• Developmental
milestones• Mental Health Act• Child Protection• Specific drugs• Specific conditions
NICE is hot!
• Examiner’s favourite• Should be our favourite!• Easy to access• Free resource• Guidance by DATE is the
key….
June 15 – Jan16DM x4Mental Health x5UTI, CKD, MSCoeliac, MenopauseOA, Skin cancers
Feb 16NOACsMyelomaMotor neurone diseaseIBS
Mar 16ADHDFood allergyAnaphylaxis
Apr 16Venous thromboembolism
May 16Haem cancers
Jun 16BronchiolitisSuspected ca
July 16Non-alcoholic fatty liver diseaseLiver cirrhosisSepsisNHLDM - Paeds
Aug 16Mental healthObesity
Sep 16Mental health – LDMultimorbidityContraception
Oct 16Coeliac disease
Nov 16Back PainPrison medicineSubstance misuse
Dec 16End of life care –PaedsHIV testing
Jan 17Cereberal palsyLearning disabilities
Feb 17Substance misuseMenopause
Mar 17Mental health prisonsEnd of life care
Apr 17Osteoporosis
NICEuidance byDate 8
RCGP Summary Reports are Essential!• Produced after every exam since
Oct 2007• ‘No excuse for lack of knowledge
about clinical areas that form the “bread & butter” of GP’
• ‘We include items on child health, women`s health & contraception in every AKT’
• ‘For the 3rd consecutive occasion, we report difficulty with items related to the diagnosis of DM. Again we remind candidates that they should ensure familiarity with national guidance on this common condition.’
BNF– RCGPSummaryReport
• ‘WewouldalsohighlighttheuseoftheBNFforguidanceonprescribing,includingthemoregeneralinformationintheopeningchapters.Thismaybemoreaccessibleandobviousintheprintedversion.’
• ‘Weregularlyfeedbackonissuesconcerningsafeprescribing,includingbeingawareofdrugmonitoringrequirements.Candidatesareencouragedtobefamiliarwithmonitoringrequirementswhicharespecifictoindividualdrugs’
Immunisations-RCGPSummaryReport
• ‘Itemsonimmunisation wereagainnotwellanswered.Therehavebeenanumberofrecentchangestoimmunisationprogrammes,withmorechangesonthehorizon.AlthoughGPsrarelyadministervaccinationspersonally,itisimportantthattheyareawareofnewvaccines,andinparticularindications andcontraindications.Werecommendthatcandidatesregularlyreadthe“Vaccineupdate” newsletter(seelinkhttps://www.gov.uk/government/collections/vaccine-update)’
Oct 07Emcare,AsthmaContraceptionCerts, Travel,ENT
Jan 08Asthma/COPDCerts,GMCguidanceTravel,DermWomen’shealth
May 08Derm,EyesPaeds:InfectionsGMC,Travel
Oct 08Elderlycare,EmcarePaeds:AsthmaCVS,CKD,GMC
Jan 09Paeds:Dev,DrugsClinicalGovInfDiseaseContraception
Apr 09Paeds:AsthmaGenderspecificCerts,EmCare
Oct 09•Headache•Contraception•Imms,GMC
Jan 10AlcoholPaeds:DevChecksAntenatalCareCerts,EmCare
Apr 10Derm,Rheum/MSKHeadacheContraceptionDM– Mx
Oct 10ECGPaeds:Dev,ImmsRheum/MSKDM- diagnosis
Jan 11Prescribing-AbxEmcareEyes,GMC
May 11EmCare,EyesCancer/Palliativecare
Oct 11Paeds:Dev,ENT,InfContraceptionDrugdosesCerts
Jan 12Paeds:Dev.DrugdosesContraception,CertsQualitative,EDDementia,NeuroDrugs
Apr 12Paeds:Anaphylaxis/Asthma,MigraineQuantitative,GMCHT,Spirometry
Oct12Paeds:Dev,ImmsContraception- LARCOsteoporosisDerm,DM- diagnosis
Jan 13Paeds:Dev,ImmsContraception– LARCDM- diagnosisAsthmaBreast/colorectalCa
May 13Derm,ImmsDrugmonitoringEnteralFeedsContraception– EmDM- diagnosis
Oct 13DruginteractionsDM- managementDerm- psoriasisImmsPVDDementia
Jan 14DruginteractionsPaeds:DevDM- insulinEyesMSK- OsteoporosisCerts
Apr 14DeathcertsContraception– LARCMentalHealth– AnxietyGI:IBS,coeliacDrugs/alcoholPoisoningDerm
Oct 14ScreeningObesityPaeds:Dev,illnessAntenatalcare:ImmsIncontinenceGI:IBS,nutritionDM
Jan 15ScreeningPaeds:Imms,drugdosesEm care:CPR,anaphylaxisAsthmaContraceptionHeadaches
Apr 15InfectioncontrolCertsPrescribingPaeds:Imms,DevDementiaSubstancemisuseDM
Oct 16Prescribing- CDs,legalPaed:DevMenshealth:ED,prostateECGsEyes
Jan 16Prescribing:goutCerts:infdisnotificationStressincontinenceContraceptionEyes:maculardegenDMmedsDerm:guttatepsoriasis
Apr 16DruginteractionsGoodMedicalPractice(consent,capacity,access)Paeds:immsDrugs/alcoholMiscarriageDM:OGTT
Oct 16Em care:Em medsPaeds:Dev,2wwcaDrugmonitoring–antipsychoticsENT:hearingloss/infectionsDerm:approp Abx use
Jan 17Certs - deathPaeds:2wwcaContraceptionHRT,incontinenceMentalHealth– Anx/DepEyeemergenciesType1DMFungalSkinInf
Apr 17Paeds:ImmsContraceptionHRT,infertilityDM- diagnosisAsthmaDerm:minorsurgerycomplicationsDrugmonitoring–antipsychotics
Using Guidance
• Summarise• 1-2 sheets A4 Max• Study Groups• Tutorials• Practice/VTS
presentations• Examples…
AntenatalandPostnatalMentalHealthNICEFeb07,Aug10,Mar/May/Sep/Nov/Dec11,Sep12,Jan/May13,
Dec14,Feb15RCGPSummaryreportJan08,Jan10,Jan17
RCGP Curriculum:Women’s Health
1Primarycaremanagement•1.1 Demonstrateknowledgeofwomen’shealthproblems,conditionsanddiseases,andrecognisethatsomenon-genderspecificissuespresentdifferentlyinwomen,suchasdepression,alcoholism,eatingdisordersanddomesticviolence
3Specificproblem-solvingskills•3.6 Knowhowthesocialandbiologicalfeaturesoftheperimenopauseandmenopauseperiodinteractandaffectheath,socialwell-beingandrelationships(e.g.moodswings,anxietyanddepression,reducedlibido)
4Acomprehensiveapproach•4.1 Usescreeningstrategiesrelevanttowomen(e.g.cervical,breast,othercancers,postnataldepression)andadvisepatientsontheiradvantages/disadvantages
Prediction and Detection• Past and present psych hx/tx & FH• ‘During the past month, have you often
been bothered by feeling down, depressed or hopeless?’
• ‘During the past month, have you often been bothered by having little interest or pleasure in doing things?’
• ‘Is this something you feel you need or want help with?’
Diagnosis• ‘DESPAIRS’ DSM IV criteria, American Psychiatric Assoc 1994
• Depressed mood or Disinterest in usual activities• Energy loss, tiredness• Sleep disturbance• Pessimism, hopelessness, worthlessness• Appetite and weight change• Impaired concentration• Retardation or agitation• Suicidal ideas
• Mild/Moderate/Severe DTB 2003, NICE 04/07• PHQ-9 QOF 2006• Biopsychosocial assessment QOF 2013
Treatment• Psychological tx: seen within 1-3m• Treatment options: pros/cons• Drug tx: lower risk profiles, lowest effective
dose, monotherapy• Explaining risks:
- acknowledge uncertainty- explain background risks of fetal deformities- describe using natural frequencies- decision aids- written material
Management of Depression
• Mild/moderate depression:- Self-help strategies (guided self-help,
computerised CBT, exercise)- Counselling- Brief CBT
• Severe depression:- Antidepressant medication- specialist mental health service/perinatal mental health service
Management of DepressionTAD:
• lower known fetal risk during pregnancy
• higher risk of fatal overdose
• impipramine/noritriptyline low levels in breast milkSNRI:
• Venlafaxine high BP, worse in overdose, difficulty in withdrawal
SSRI:• fluoxetine safest• fluoxetine/citalopram
high levels in breast milk. Setraline low levels
• after 20/40 increased risk Pulm HT in neonate
• SSRI: Paroxetine 1st
trimester assoc fetal heart defects
Other Drugs• Benzos: cleft palate, floppy baby syndrome• Antipsychotics: raised PRL, so reduced
conception• Clozapine: agranulocytosis fetus/infant• Olanzapine: gestational DM, weight gain• Valproate: increased NTD. Add folic acid 5mg• Lithium: fetal heart defects• Carbamazepine: NTDs, FHD
Childhood UTINICE Aug 07, May/Oct 10,Aug 12, May 13, June 15
RCGP Summary report May 08, Jan 09, Oct 11, Oct 14RCGP Curriculum: Care of Children:1.1.9 Urinary tract infection
Childhood UTI• Child-centred Care• Consider in any child with unexplained fever
> 38• <3m: Fever, vomiting, lethargy, irritability
Poor feeding, FTT, jaundice, haematuria• >3m: Fever, freq, dysuria
Abdo pain, loin pain, haematuria,vomitingincontinence, lethargy, malaise, irritability
UTI Risk factors• Poor urine flow• Previous UTI• Recurrent fever unknown origin• Renal abnormality• FH renal disease• Enlarged bladder/Abdominal mass
or spinal lesion• Constipation• Dysfunctional voiding• Poor growth• Hypertension
Urine Collection
• Clean catch• If not possible – urine bags/collection
pads• Consider catheter sample/suprapubic
aspiration
Urine Testing Strategies• < 3yrs
- Send urgent m,c,s.- If specific urinary sx can start Abx, otherwise wait
• > 3 yrs- If nitrite +ve: TREAT- If nitrite -ve: ONLY treat if leuc +ve &
good clinical evidence UTI• Always send urine unless both nitrite/leuc -
ve & asymptomatic
TreatmentChildren < 3mAcutely unwell
Refer PaedsIV Abx
Upper UTI Treat 7-10d oral Abx(ceph/co-amoxiclav)
Lower UTI 3d oral Abx(trimethoprim,ceph,nitrofurantoin, amoxicillin)
Prevention
• Encourage fluids• Avoid delaying voiding• Avoid constipation• Abx prophyaxis NOT recommended after
first UTI• Consider after recurrent UTI (3 lower, 2
upper)
Atypical and Recurrent UTI
• Atypical- seriously ill, poor urine flow, abdo mass, raised creatinine, septicaemia, not responding to Abx tx within 48h, non-Ecoli infection.
• Recurrent UTI- 3 lower UTI- 2 upper UTI- 1 upper & 1 lower
Imaging< 6m 6m – 3y > 3y
U/S during acute infection
Only Atypical or recurrent
Only Atypical Only Atypical
U/S within 6w Yes Only recurrent
Only recurrent
DMSA after 4-6m
Only Atypical or recurrent
Only Atypical or recurrent
Only recurrent
MCUG Only Atypical or recurrent
No No
Follow-up• If asymptomatic post UTI: no need to re-test
urine• Asymptomatic bacteriuria: no need f/u• If no imaging: no need f/u• If normal imaging: no need f/u• Refer: - abnormal imaging
- recurrent UTI
Congenital Cataract
BMJ May 2011NICE 2015
RCGP Summary Reports Jan 09, Jan/Oct 10,Oct 11, Jan/Oct 12, Jan 13, Jan 14, Oct 15, Jan 16, Oct 16
Congenital cataract
• Preventable cause of visual impairment• Early diagnosis is vital• 200-300 UK children each year• Red reflex• Screening efficacy?• Less than half detected at either the
newborn (35%) or 6-8 wk checks (12%)
Importance of diagnosis• Severe, lifelong visual impairment if untreated• Can start after 6w of life• Some studies show long term visual
outcomes showing an average loss of one Snellen visual acuity line for every three weeks of surgical delay during first 14 weeks of life
• Cataract surgery essential before these irreversible changes take place
SameDayOphth Referral– BMJ2011
• Presenceofopacitiesinthereflex
• Absenceofanyreflex
• Whitepupillaryreflex(leukocoria)
Urgent Written Referral Ophth
• Inequality in colour, intensity, or clarity of the reflection
• No detectable abnormality but a parent or observer describes a history suspicious of leukocoria on observation or in a photograph
PaediatricsuspectedCaNICE2015
• Retinoblastoma
• Considerurgentreferral(foranappointmentwithin2 weeks)forophthalmologicalassessmentforretinoblastomainchildrenwithanabsentredreflex
Erectile Dysfunction
BNF RCGP Summary Reports Jan 12, Oct 16
Clinical Knowledge SummariesBSSM Guidelines 2008
RCGP Curriculum:Men’s Health
1Primarycaremanagement• 1.5 Manageprimarycontactwithpatientswhohaveamalegenito-
urinaryproblem
3Specificproblem-solvingskills• 3.5 Knowthaterectiledysfunctionisanearlywarningformany
conditionsincludingcoronaryvasculardisease,diabetes,depressionandlowerurinarytractsymptoms,occurringonaveragethreeyearspriortotheonsetofsuchmedicalproblems
Erectile dysfunction
• Aetiology:Psychogenic,Vascular,Endocrine,Hypogonadism
• Hx:Medical,Psych,Sexual,Drughx,Social(Exercise,Smoking,ETOH)
• Ex:BP,HR,BMI.?Genital(?hypogonadism,?Peyronies),
PR
• Ix:HbA1c&Lipids?Testosterone,PSA,TFT,PRL
Lifestyle Changes Evidence• RCT Esposito2004(n=110):
ObeseEDtoreceivegenerallifestyleadvice (Control)vsspecificadviceonlosing10%bodyweightwi Calorie-controlledDiet+ Exercise(Intervention).BMIreduced&EDimproved(p<0.01)
• Cohort Derby2000(n=1156):EDassociatedwi Obesity&LackofExercise
• SR Tends&Osgood2001 (19studies):EDassociatedwi Smoking
Phosphodiesterase 5 inhibitor
• Sildenafil,Tadalafil&Vardenafil.RCT’s/SR/Cochranereviews.Sameefficacy.NNT=2
• C/i:Nitrates,Non-arteriticischaemicopticneuropathy,RecentStroke,Hypotension,MI,Unstableangina
• Cautions:CVdisease,Peniledisorders,Priapismrisk,Alpha-blockers
• SE:Headaches,flushing,dyspepsia,rhinitis,backpain,visualdisturbance
Prescribing on the NHS
• DM• MS, PD, Polio, Single gene neurological disease• Prostate cancer, Spina bifida, Spinal cord injury• Severe pelvic injury or surgery• Dialysis, kidney transplant• Severe distress (ONLY if assessed by specialist
centres)• Usually prescribed as one tablet a week but may be
more (at NHS cost)
• Since 2014: generic sildenafil not on SLS list (Selective List Scheme) so can prescribe for any indication
RCGP Summary report Oct 12‘Candidates seemed unfamiliar with some areas concerning diagnosis of osteoporosis. This is an important clinical topic in which NICE has recently issued guidelines and appears in QOF for the first time in 2012/13.We would recommend candidates to update themselves’
RCGP Curriculum
• 3.05 Care of Older Adults
• 3.06 Women’s Health 4.2 be able to advise on prevention strategies relevant to women e.g. osteoporosis
• 3.20 Care of people with MSK Problems
1.1Identifyredflagsthatrelatetofracture(e.g.fragilityfractureinosteoporosis)
Definitions• Osteoporosis(OP):Tscore≤2.5SDonDXAbelowmeanpeakbonemass
• FragilityFracture:‘trauma≤fallingfromastandingheight’
• RiskFactors(RF):- Useoforalsteroids- Hxoffalls,FHhipfracture- LowBMI<18.5kg/m2- Smoking>10/d- Alcohol>4u/d
• SecondarycausesOP:- Rheum:RA,Arthropathies- GI:IBD,Coeliac,Malabsorption- Endo:PrematureMenopause,Hyperthyroid,Hyperparathyroid,Type1DM,Cushing’s- Haem:HIV,Myeloma- CKD- COPDonlongtermsteroids- Highdosesteroids(>7.5mg/d)- Immobility
Assessing Fracture Risk
• < 50 no need unless RF • 50 - 65 if fragility
fracture• > 65 assess risk• **Remember if >75 +
fragility fracture no need to assess risk, just treat**
• Calculate FRAX• www.shef.ac.uk/FRAX/t
ool.jsp• NOGG
recommendations• Low: lifestyle advice• Intermediate: measure
BMD• High: treat
Treatment in Women
• SecondaryPrevention:>75<75+BMDOP
• PrimaryPrevention:>70+1RF65-69+1RF+BMDOP<65+2RF+BMDOP
• 10mins middaysun• Dietarycalcium>1000mg/d• Oralcalcium+vit Dsupplements (localguidelines)
• Bisphosphonate- Alendronate70mg/wk- 200mlswater,stayupright>30mins
Intolerance to alendronate• Persistent GI SE• Try risedronate or
etindronate• Strontium (MHRA
2013 says risk CVS safety so restrict to severe OP, secondary care)
• Raloxifene• Teriparatide
• Unsatisfactory response = another fragility fracture despite tx 1y + decline BMD from baseline
OsteoporosisQOF 2012/13
NICE Jan 11, Aug 12RCGP Summary report Oct 12, Jan 14
RCGP Curriculum: 3.05 Care of Older Adults 3.20 Care of people with MSK Problems
‘Candidates seemed unfamiliar with some areas concerning diagnosis of osteoporosis. This is an important clinical topic in which NICE has recently issued guidelines and appears in QOF
for the first time in 2012/13.We would recommend candidates to update themselves’
Small Group Work• Groups of 4’s• 45 minutes• Chose a topic • Review topic• Make AKT question (s)• Test each other• Tweet your questions• follow@londonmrcgp ontwitter&tweetuswithyourAKTquestionwith#londonmrcgp
Londonmrcgp CSA Courses•Prior to each CSA:
8.10.17 14.1.18 28.1.18 18.2.18
•Small Groups
•4 Mock CSA’s each!
•RCGP Examiner
•Written Feedback
•ST Educational allowance
HowtopasstheCSAexam• ToptipsforCSA,mockCSAcasesandDVD
• ForewordbyRogerNeighbour:http://www.londonmrcgp.co.uk/documents/RN-
Foreword.pdf
• RCGPbookshop:http://www.rcgp.org.uk/bookshop/mrcgp-study-
aids/how-to-pass-the-csa-exam.aspx• 10%offformembers• 20%offifboughttoday
• SampleVideo:https://www.youtube.com/watch?v=ysOfg1Fv7Dw
• Towinafreecopytoday:follow@londonmrcgp &tweetuswithAKTorCSApreparationtipswith#londonmrcgp
• TweetofthedaychosenafterMockAKT• PleaseneversendusanyofficialRCGPexam
questions