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

Osteoporosis

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’

Osteoporosis QOF 2013/4

www.eguidelines.co.uk

NICE - Osteoporosis• NICETA161(Jan11)SecondaryPrevention

• NICETA160(Aug12)PrimaryPrevention

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