OSCE counselling

What are the GI red flags?

blood in stools/vomit - black/tarry

dysphagia

unintentional weight loss

persistent vomiting - >48hrs, >24hrs in children

anaemia - pale, tired, breathless, palpitations

antacid treatment failure

What medicines can cause GI side effects?

Diarrhoea: antibiotics, metformin, SSRIs

Constipation: opioids, iron

Dyspepsia: NSAIDs, bisphosphonates, corticosteroids

IBS Drug Treatment

Antispasmodics: peppermint oil, mebeverine HCL, alverine citrate

Diarrhoea: Loperamide  

Constipation: ispaghula husk, fybogel (no lactulose)

IBS Lifestyle Advice

physical activity

regular meals

limit max 3x fresh fruit daily (sorbitol)

water

soluble fibre - oats

Dyspepsia other red flags

pain alleviated by eating - gastric/duodenal ulcer

pain radiates down arm

new onset if >55

IBD, UC, Crohn’s disease symptoms

inflammation/pain of joints, eye

fever

blood/mucus in stool

Dyspepsia lifestyle advice

avoid large meals esp. at night

raise head of bed 10-20cm using books/bricks or pillow underneath neck and shoulders

weight loss - more fat increases abdominal pressure

avoid tight clothing

avoid heavy lifting, bending at waist

avoid fatty/spicy/caffeine/mint/chocolate/alcohol

smoking cessation

Dyspepsia drug treatment

Antacids/Alginates: Gaviscon advance, Rennie, Pepto-Bismol
QDS: after meals and at bed
Leave 2 hour gap between other meds
Caution in people on salt-restricting diet (HPT)

PPIs: esomeprazole
30mins before breakfast
takes 2-4days for max effect - use antacids too

Constipation drug treatment

1. Bulk-forming: Fybogel/ispaghula husk (not it opioids, diabetic, thyroid hormones)

2. Osmotic: Macrogol, then lactulose

3. Stimulant: Senna (not if pregnant)

Gradual withdrawal at 3x weekly soft, formed stools without straining

Colic red flags

forceful vomiting

onset after 4 months

fever, lethargy, sudden inconsolable high pitch crying

bulging forehead

Colic advice

support parents - will resolve

hold through crying, gentle motion - push pram, car ride

white noise

warm water bath

burping post-feeds

Diarrhoea other red flags

recent travel/hospital/antibiotic treatment

painless, watery high-volume diarrhoea

dehydration: drowsiness, confusion, little urine, dry mouth, sunken eyes, weakness, cool hands/feet

not improving in 2-4days

taking meds that exacerbate dehydration/renal failure: diuretics, ACEi

Diarrhoea drug treatment

Oral rehydration: Dioralyte sachet
Mix in cup of water after each loose stool in addition to regular drinking

Loperamide only if inconvenient

Diarrhoea advice

avoid school/work for 48hrs after last episode

refer if food handing

always wash hands after toilet, before eating/prepping

Why aim to lower blood sugar levels?

decrease CVD risk as blood more sticky, more likely to clot

decrease kidney, nerve and eye damage

more susceptible to infections as better microorganism growth

what is HbA1c and targets?

Mean glucose level over 120 days

tested every 2-3 months to 6 months

Target: 48mmol/mol

Hypo risk target: 53mmol/mol

Key points for Metformin (Biguanides)

1st line if overweight

Reduce liver glucose production: no risk of hypos

GI side effects: start and low dose then titrate, use MR tabs

Lactic acidosis (more likely if renal impairment): breathless, muscle cramps, abdominal pain, hypothermia, lethargy

Key points for Sulfonylureas (gliclazide)

Stimulate pancreas to release insulin: risk of hypos

Take with meals, monitor glucose more regularly, alcohol increases hypo risk

Can cause weight gain

Key points for SGLT-2 inhibitors -flozins (empagliflozin)

Increase glucose excretion in urine

Increased UTI/fungal infection risk

Useful in CKD - blocks Na+ reabsorption reducing intra-glomerular pressure and proteinuria

Diabetic ketoacidosis: nausea, vomiting rapid weight loss, abdominal pain, difficulty breathing, excessive thirst, confusion, lethargy, sweet breath/taste

Key points for GLP-1 Agonists

Increase insulin excretion and slow gastric emptying

no hypo risk

aid in weight loss - liraglutide licensed in non-diabetics

Nausea: so usually given sub cut

Pancreatitis: severe rapid onset upper abdominal pain, vomiting, fever, swollen abdomen

Risk of dehydration due to GI S/Es so make sure to drink water

Key points for DPP-4 inhibitors

Increase insulin release and decrease glucose production

GLP-1 and GIP are glucose dependant, low hypo risk

Generally well-tolerated

Pancreatitis: severe rapid onset upper abdominal pain, vomiting, fever, swollen abdomen

Insulin treatment for T2D

Basal regime: intermediate (detemir) at night or long-acting (glargine, degludec)

Insulin regime for T1D

Basal-bolus mimics body’s natural secretion: long-acting at night, 3x rapid acting before meals

Twice daily: biphasic insulin with breakfast and evening meal

Symptoms of hypos

sweating, fatigue, dizziness, hunger, palpitations, irritability

Hypos advice

1. 7 jelly beans, glucose gel, fruit juice

2. check blood glucose in 10-15 mins and repeat if not >4mmol/L

3. have slow releasing carb/main meal: bread, biscuits, cow’s milk

Insulin administration advice

rotate site of injection to prevent lumps forming under skin which decrease insulin absorption

inject in fatty tissue: abdomen, buttocks, side of thighs, upper arm

1. wash hands

2. attach needle to pen – peel sticker, twist needle on, remove outer and inner cap

3. prime to regulate dosage by removing any air: Dial 2 units of insulin, point pen up, press plunger until insulin comes out

4. dial dosage – may hear clicks at every half a unit

5. insert needle at 90 degrees/straight, no need to pinch, press plunger until dial is down to zero

6. count to 10 to give insulin time to enter body, remove needle

7. dispose of needle in sharps bin

Osteoporosis drug treatment

bisphosphonate: Alendronic acid 70mg once weekly

take on same day each week
Take whilst upright for 30mins – sitting/standing
Take with full glass of water
Do not eat, drink or take other meds for at least 30mins

Femoral fracture – report thigh/hip/groin pain
Osteonecrosis of jaw – regular dental checks, tell dentist on Alendronic acid
Osteonecrosis of ear canal – report hearing issues/ear pain

Osteoporosis lifestyle advice

high FRAX score: post-menopausal women likely

Calcium and vit D supplements

Strength exercises 2x a week and regular movement (brisk walking)

Hypothyroidism symptoms

Tiredness

muscle pain/weakness

weight gain

sensitive to cold

dry sin

brittle hair/nails

depression

reduced libido

Hypothyroidism drug treatment

Levothyroxine

Take FTIM 30-60mins before anything else for better absorption

CVD risk start at lower dose and titrate up

Leave longer gap with antacids, calcium, iron

Lifelong treatment: adherence

Hyperthyroidism symptoms

Tremors

warm sweaty palms

weight loss despite increased appetite

heat intolerance

hair thinning

tachycardia

diarrhoea

Hyperthyroidism treatment

Carbimazole

Bone marrow suppression risk: immediately tell doctor if signs of infection/sore throat/mouth ulcers/fever

Acute pancreatitis: severe rapid onset upper abdominal pain, vomiting, fever, swollen abdomen

Beta blocker for symptoms

Radioactive iodine: not if pregnancy in next 6 months, close contacts small children/immunosuppressed

Surgical removal

Oral steroid treatment

Take with/just after food to protect stomach from ulceration

Take in morning to mimic body’s own cortisol levels, can cause difficulty sleeping if taken too late, repeat evening doses may necessitate withdrawal

Steroid warning card if >40mg daily or for >3 weeks or multiple repeat courses

NRT Patches advice

Apply to clean, dry hairless area – hip, upper arm, chest

Alternate application site daily

Slowly reducing strength of patch over 10-12 weeks

NRT Gum advice

‘chew and rest’ – chew slowly until strong taste, rest between gum and cheek, chew again when taste faded

Important to chew enough to maintain cessation

Angina symptom control drug advice

GTN spray

sublingual

sit down after use as causes hypotensive drop

call 999 if 2nd dose doesn’t relieve symptoms

Secondar prevention of ACS

1. atorvastatin

2. aspirin

3. prasugrel (only 1 year)

4. beta blocker - slows HR, increases ventricular ejection fraction, reduce cardiac remodelling

5. ACEi - reduces cardiac remodelling

Beta blockers key points

not indicated for HPT, used post ACS

contraindicated in asthmatics, COPD cause bronchial vasoconstriction

cautioned in diabetics - mask tachycardia

not used in heart block as slow heart rate, increasing ventricular ejection fraction

bisoprolol

exhausted/cold: self-limiting in 2-3 weeks of dose adjustment

exercise intolerance

ACEi key points

1st choice for T2D

Dry cough - consider dose reduction/switch to ARB

Renal impairment - tell doctor if jaundice, do not stop taking abruptly, can switch or titrate dose down

Monitor K+ and renal function

Ramipril

ARB examples

-sartans e.g. candesartan, losartan

CCBs key points

^1st choice if >55 or black as low renin hypertensives

Amlodipine – 1^st choice as no negative inotropic effect, vascular selective CCB

diltiazem, verapamil – significant effect of cardiac inotropy so decreases strength of heart muscle contraction – not indicated in heart failure/any changes to heart pathophysiology

S/Es:
Flushing, headache – get better usually in a few days
Ankle swelling – not always resolved by diuretics

Diuretics key points

Take in morning as increase urination - disrupt sleep if at night

indapamide, chlortalidone

Why take HPT meds?

Reduce CV risk, limit damage to kidney, vasculature, heart

How to take HPT meds

Take first few doses at night as could make you feel dizzy on standing
Take care standing in the morning, lie back down and rise slowly
Then switch to taking any time of day, just take at same time each day

Statin key points

Atorvastatin 1st line

Simvastatin (less used) to be taken at night

as HMG CoA reductase enzyme it inhibits is most active at night

Liver function tests monitoring

When should you offer anticoagulation treatment

CHADVASC =/> 2
Consider offering to men if CHADVASC = 1 if lower bleeding risk ORBIT

Who should warfarin be offered to

Severe renal impairment

poor hepatic function

valvular AF

antiphospholipid syndrome

anti-epileptics as interact with all so better to have closer monitoring

patients more likely to miss a dose as anticoagulation not lost

Who should DOACs be offered to and differences between them

1. Apixaban 5mg BD, can be in dosette box

Rivaroxaban - take OD with main meal, can be in dosette box

Dabigatran - BD, higher renal function, no dosette

Edoxaban - OD, no dosette, no reversal agent

No food interactions (like green leafy veg, liver, cranberries, grapefruit, alcohol)

What medicines are given for heart failure?

Beta blocker – easy to start quickly, delay if patients have pulmonary oedema/severe oedema
SGLT2s – not if T1D as high risk of DKA
Sacubitril valsartan – caution in patients with low BP, relax BV to reduce BP and heart strain
MRA – block aldosterone effects e.g. spironolactone, eplerenone

When is the estimated date of ovulation?

Full cycle length -14

How long is sperm viable for?

5 days

When can copper IUD be given

Up to 5 days after UPSI or ovulation - whatever is latest (so ideal if UPSI after ovulation)

When is ellaOne indicated?

up to 120hrs/5days after UPSI

more effective if >70kg

if only taken 1-2 times in a cycle

When is levonelle indicated?

cheaper OTC

taking enzyme inducer e.g. epilepsy meds

taking oral glucocorticoids in severe asthma

needed more than once per cycle

How long post-partum is contraception not needed?

21 days post-partum as predicted ovulation = day 28

if exclusively breast-feeding and so no period, first 6 months

When is a good time to switch birth controls?

usually if last pill week or pill-free week

Key points to cover when regular oral contraception started

effectiveness

how to take - same time each day

any initial additional contraception

what to do if late/missed pills

vomiting/diarrhoea

bleeding patterns

side effects

Other contraception methods

progesterone only implant - 3 years

progesterone only injection - cannot be removed, have to wait course (14 weeks)

levonorgestrel IUD - 3-5 years

copper IUD - 5-10 years, no hormones

patch or vaginal ring

How to use an MDI

1. Hold inhaler upright, take cap off, check mouthpiece, shake inhaler
2. Sit/stand straight, tilt chin slightly up
3. Breath out gently and slowly away, put lips around mouthpiece and form a tight seal
4. Breath in slowly, press down on canister once, until lungs feel full
5. Remove mouth, keep lips closed, hold breath to 10s/comfortable
6. Breath out gently away
7. Wait 30s, shake inhaler then repeat

How to use spacer

Make sure valve on spacer is facing upwards
Put inhaler into hole at back of spacer, take any spacer cap off
Some spacers will whistle if breathing too fast

Single breath and hold: press canister, then breath in slowly
Tidal breathing: breath in/out slowly and steadily 5 times, spacer should make clicking sound as valve opens/closes, wait 1 minute before next puff

How to use DPI (e.g. accuhaler the round, disk one)

1. Slide open cover, check mouthpiece and dose counter
2. Hold inhaler horizontally – do not tip upside down or shake as drug may fall out
3. Load device – pushing leaver with thumb until it clicks
4. Sit/stand straight, tilt chin slightly up
5. Breath out gently and slowly away, put lips around mouthpiece and form a tight seal
6. Breath in quickly and deeply
7. Remove mouth, keep lips closed, hold breath to 10s/comfortable
8. Breath out gently
9. Slide cover closed to rest inhaler for 2^nd puff

Drug history taking key points

Name, dose, strength, formulation, time of day, why taking, any S/Es, compliance:

prescription meds, OTC/borrowed/herbal/supplements, any recently stopped meds, acute meds

Allergies? detail

Dose patient have any questions?

NSAIDs contraindications

chickenpox

heart failure

history of GI bleeds

kidney problems (reduce kidney blood flow)

uncontrolled hypertension

asthmatics - ask if previous use exacerbated symptoms, may be ok

cardiac impairment/dehydration (increased MI and kidney risk)

elderly (increased GI bleeds and kidney risk)

on blood thinners (increased bleed risk)