Hi everyone, I'm Brie. I'm going to be taking you through chronic diseases and preventative health in preparation for your year four exams. Before we started, just wanted to give a massive shout out to all the other previous year's lectures, revision lectures, they have some wonderful resources there. A lot of the information I got is from the Red Book, especially for the preventative health portion of it and ETG as well. GPS then also has a lot of amazing resources.
and study packs and we're also releasing a MCQ study pack this year as well for you guys so keep an eye out for those as well during the revision period. Otherwise if you have any questions please feel free to email me or to find me on Facebook and message me. I'm very happy to answer any questions and if there's any mistakes or anything in the slides just let me know as well. Perfect.
So this is what we'll be covering in the lecture today. We'll be starting with some management principles, lifestyle recommendations for all chronic diseases in general. This will form any part of your management plan that you make for GP for chronic diseases. Then we'll go through some specific conditions, in particular diabetes, hypertension and dyslipidemia, COPD and asthma, heart failure and AF. And then we'll look at some prevention and screening programs that you should be asking your patients about always.
So what I thought we'd start with is just looking at DKA Empire. So this is a nice general structure for when we do our management plans in GP. So it stands for Diagnosis, Knowledge, Attitudes, Educate, Management Plan, Prevention, Information, Reinforcement, Evaluate and Safety Netting.
You don't necessarily have to follow it in this order, but I do like having it written down on my sheet during an OSCE just so that I can tick it off as I go to make sure that I've covered. everything that needs to be said when explaining a diagnosis or when diagnosing a patient with something or explaining something to them. So diagnosis, we state it. So it might come in the form where you might say something along the lines of, after listening to your story and having an examination of you today and looking at the test or testing, sorry, the blood test that we've done, this suggests that you have a diagnosis of whatever it is.
Have you ever heard of this before? Or what do you know about this? That's... checking their knowledge of it. How do you feel?
Is there anything in particular that concerns you? Attitude. And then you just explain it and you want to make sure that you're doing it without any medical jargon.
So real bare bone explanations. Work through what it is and you sort of can work through your notes when you're educating a patient about it. So definition, epidemiology, if there's something really important there that you want to talk through them with.
You can link it to their symptoms and signs as well. so that the patient is able to see, oh, yes, that matches what I've been experiencing recently. And then that will lead nicely into your management plan. So with our management plan, it's good to always split it up into lifestyle or non-pharmacological versus pharmacological things. Or you can also do short-term versus long-term, depending on what the condition is and what's most appropriate.
Then after that, what we would do is we would do prevention. So just while we've got you here today. This is a good opportunity for me to just check that you're up to date with all our screening programs available. Of course, this differs depending with the age of the patient. So things you might ask about include like breast cancer screening, mammograms, FOBTs, vaccines for kids in particular, cervical screening tests, etc.
Then we always provide some information. So if you'd like, we can print out some information for you to take home and do some more reading on it. So just offer it. And reinforce. and ask them for any other questions that they'd like to ask you before you end the consult.
And with safety netting, you always just want to point out some red flag signs of when things might mean that they're deteriorating or the condition's getting more serious and advise them to either come back to you as a GP or to go to ED afterwards. Perfect. So I put a little case study here. So what we're going to do is we're going to try and explain a management plan to the mum of this child. And so what I'll do is just having a look at the picture.
So Mrs. X presents to you with her daughter who's five. Please explain your management plan to her. So just looking at this picture, think what's the rash suggestive of?
And then hopefully you get a diagnosis of that presents. You can see that it's on a flexural surface. It's not really well demarcated. It's erythematous.
It looks like it's got some scratch marks on it. Look. You know, it looks a bit like X-MAR hopefully is what we got. So, sorry, before I show you that, try and write out or try and practice a diagnosis or a management plan, sorry, using DK Empire.
And I've just left an example there for you. And you guys can read through that in your own time as well. All right.
What we might move on to now then is SNAP-W or lifestyle management. So these are things that we can advise most patients of in that first section of our management plan, so our non-pharmacological management plan. So S stands for smoking cessation.
So we always ask, are you a current smoker or have you ever smoked? Have you ever smoked before? And if they have smoked, we ask how much? And then have you ever thought about quitting?
If they say that they are sort of on the pathway of thinking about quitting or they would like some resources to help them with quitting, things that we can suggest or resources that we can suggest include Quitline, behavioural support through CBT. We can assess their nicotine dependence as well. And then there's also pharmacotherapy for that.
So we've got replacement patches. It comes in like a gum form as well. And then we also have like medication, which you'll probably learn more about in psych.
And it's for nutrition. So in our histories, we generally ask, can you tell me a little bit about what you eat and what you drink? Do you have a lot of sugary drinks? Do you have a balanced diet?
Do you eat your veggies? How many times a week do you tend to get takeout? We can refer to a dietician where...
appropriate as well and we can apply some smart goals there um the oski is centered around nutrition in particular a is for alcohol again we ask uh do you currently or do you drink alcohol how much you drink um how much you drink a week do you and then you can ask your cage questions so um do you ever use it to um you ever drink alcohol in the morning in particular uh do you feel guilty when people ask you to cut down etc etc Ideally they shouldn't be drinking more than 10 standards a week and no more than four a day and there's a high risk of thiamine deficiency with high alcohol intake and we know that that's linked to our Wernicke's and Kloddekopf's encephalopathies. In terms of what we can do and what we can offer, we can offer AA drug and alcohol counselling and education. We can also suggest some pharmacotherapy so things like acamprosate, naltrexone and disulfiram. Those are all of our different options. And I think it's good to know what the sort of dosing regimen is for each of those, as well as some common side effects and whether they interact with the alcohol, as well as some important things to know about these particular medications.
In particular, disulfiram is the one that if they drink alcohol whilst being on this medication, they get symptoms. So that is a really good option, or that's how you differentiate it in an MCQ per se. P is for physical exercise.
So do you currently exercise or do you tend to, like, have a very sedentary lifestyle? Our aim is for 30 minutes five times a week, ideally. And, again, we can do our SMART goals, so starting low, maybe just doing some walks or doing some light swims and then increasing that appropriately as well and having someone to keep them accountable is often really good. And then W is for weight. So is there BMI?
currently elevated and by how much so so looking at the BMI sort of categories of course we have to remember that BMI has its limitations in itself and then we can also offer some pharmacotherapy as well in certain cases for weight loss as well but again advocating for physical exercise nutrition etc first line for management management of weight loss in terms of the behavioral change model and this is more relevant if you have a like an alcohol or smoking uh cessation cessation station um so things we want to do is ask so um ask them if they're currently eating or if they're currently smoking sorry drinking etc assess how much um advise them on you know why this is bad for them what could possibly go wrong and how this could impact them and then assist them so that's where we put in our dk empires plans arrange follow-up and always check in so these are the five a's that you can just sort of tick off as you're assessing risk and it works for everything not just alcohol and smoking but also when we're thinking about like the need for behavioral change to prevent things like diabetes osteoporosis etc things with modifiable risk factors. So we might look into some specific conditions now the first being diabetes or type 2 in particular. So we should already know a few things about type 2 diabetes from third year. Definition, how would we explain it to a patient? You might say something along the lines of like...
Have you heard of diabetes before? How do you feel about it? Is there anything in particular that concerns you about it? What I can tell you is that diabetes means that your sugars in your body are typically higher than what they should be and your body is having some difficulty regulating the levels of sugar in your blood. Something simple.
From third year we should also know our risk factors, which of course we can split into non-modifiable versus modifiable. We should know our clinical features, our signs and symptoms. Our complications, in particular, the three macro and microvascular ones, these are particularly important to know because we want to be making sure that in our GP consults we're always checking for them and we're advising them that they should go and check with their relevant specialist or the podiatrist, etc, every year or two years and making sure they're on top of that.
We should also know our medications for diabetes as well, how they work and their common side effects. But we'll go into medication management a little bit here as well. Perfect.
So with type 2 diabetes, for diagnosing it, there are three things that we can look at. So the first, which I've written last, sorry, is the HbA1c being above 6.5%. So if that is above 6.5%, that's a diagnosis of diabetes without any other questions that need to be asked. If it's between 6 to 6.4, that's pre-diabetes. You've got some room to sort of prevent it.
formal diagnosis and there's some leeway there but anything above 6.5 we would say is a diagnosis of type 2 diabetes otherwise if they're symptomatic they only need one abnormal blood sugar reading or if they're asymptomatic they'll need two abnormal sugar readings um the different sugar readings that you can look at are things like the OGTT or fasting blood sugar um or random blood glucose as well or where and this is from the red book you In terms of screening and how often we do it, we can use the OSRIC tool. This is just a questionnaire and you put in the patient's details in it and it tells you the risk of diabetes and how often we should test them. However, normally we do it every three years from the age of 40 if they're non-Indigenous or annually from 18. And again, if OSRIC suggests that they're high risk, they undergo diagnostic screening using the HbA1c fasting blood glucose.
or an OGTT as well. So we can see a diagram here, I think it's from RACGP, sorry. So from here we can see that if the fasting blood glucose is below 5.5, diabetes unlikely, we can retest in three years. 5.5 to 6.9 in fasting is possible, so we do an OGTT then. And then if it's above 7, fasted, or 11.1.
uh randomly then we would do another confirmation test um to confirm that the patient has diabetes diabetes and again this is important to note that it's an asymptomatic population so therefore we need two abnormal readings you can see one and then two um but we're testing hba1c's you can just use that one number definitely and i've just got the numbers there for you again so fasting blood glucose above seven random above 11 should be 11.1, HbA1c above 6.5 percent. Again if we want to use, if we want to check for type 1 diabetes as a differential we can do our markers for those as well. And then once someone's got a diagnosis of type 2 diabetes what we have is some management targets for bloods. So this is once they're diagnosed they're on treatment whether that is non-medicated or medicated.
There are some management targets that we have for blood. So fasting between 4 to 7, random between 5 to 10, and a HbA1c equal to or less than 7%. And you might see that in an older population group, they're a bit more lenient with the HbA1c being a little bit higher.
That's just because of the risk of hypoglycemia. And we don't want them having falls if we can avoid it. In terms of management of type 2 diabetes, again, we have a non-pharm versus pharm. So non-pharmacological...
management includes SNAPW. In particular here we would refer to a dietitian and a diabetes educator so that's sort of like the allied health team that you would link in and we get them to regularly check their blood sugar levels and the diabetes educator will be happy, often the ones to teach them how to use the finger prick and then every three to six months we'll be checking their HbA1c, blood sugar levels, blood pressure, BMI and every 12 months they need eye checks. renal function and lipid levels as well.
In terms of pharmacological management, there is a really good ROCGP. algorithm for medications which we'll go over in the next slide. But key medications to know and also note their side effects things like metformin, SGLC2 inhibitors, GLP-1 inhibitors and DPP-4 inhibitors.
Again we often review our medications and adjust them as need be. So this is the from RICGP, the management algorithm and you'll see that It goes from monotherapy to dual to multiple therapies, and then eventually we consider insulin. Monotherapy is typically with metformin and metformin alone, so knowing the side effects and being able to counsel metformin is particularly important. Dual therapy, we might add an SGLT2 inhibitor, a GLP-1 or a DPP-4.
Again, you can see the green meaning that these two are more common, and then et cetera for multiple therapies. All right. Next, we might go into hypertension and dyslipidemia.
I've just put there like the blood pressure categories and how abnormal they are as well for you to look at. All right. So with high blood pressure, this is all from the Red Book and RICGP. Normally, we should be measuring blood pressure every two years in adults over age 18. We use the absolute cardiovascular disease risk assessment calculator tool after the age of 45 or 35 if they're Aboriginal or Torres Strait Islander.
They recently changed the, not recently, like when I was in fourth year, they changed the low risk, medium, high risk percentages. So we'll go through that in a second as well. The things that the calculator or the risk assessment tool needs is the patient's sex, age, systolic blood pressure, smoking status, cholesterol and HDL, diabetes, if it's present or not.
And then. and ECG for potential left ventricular hypertrophy if it's available. In terms of the risk, so low risk is now defined as less than 5% in the next five years. And if that's the case, we measure blood pressure every two years. Moderate risk is 5% to 10% absolute risk.
And in this case, we would measure blood pressure every six to 12 months. And high risk is now defined as more than 10% of absolute risk. And in this scenario, we would do blood pressure every six to 12 weeks.
Regardless with hypertension, we can always advise lifestyle recommendations. So again, that's your SNAPW. So things like encouraging physical activity of at least 30 minutes, five times a week, recommending for them to stop smoking if they are, aiming for a healthy BMR, encouraging salt restriction, and then encouraging limiting alcohol intake as well.
So you can see here an example of the risk calculator and on the left hand side you have one from the red blood pressure and when we start to measure it in red. Again this is just like grades of hypertension depending on the systolic and diastolic. In terms of management we've been a little bit through the lifestyle already.
So second line would be pharmacotherapy. So the question becomes, when do we start pharmacotherapy? So we only start it if it's high risk is guaranteed start and we would start that with a statin as well.
But if it's medium risk, we often give them an opportunity to use lifestyle management to see whether that's been effective or not. And then afterwards, if it's not effective or there's minimal change of blood pressure, then we would start it. But in low risk, we don't start any hypertension management, of course. The target blood pressure is below 140 or 90. So often the drug for first-line treatment is an ACE or an ARB, a calcium channel blocker or a thiazide diuretic, but we never start with a beta blocker, which is important to know. In particular, we would start the patient on a calcium channel blocker as first line if they have lots of vascular risk factors or if they're over the age of 55 in particular.
Often we start over the very low dose of the first drug, and then we'll up-hydrate that before adding a second drug. because of the risk of interactions, but also side effects that increase when adding another drug as well. And again, if they're high risk, according to ETG, we give blood pressure lowering as well as lipid modifying drug therapy at the same time.
With these medications, it's very common to be asked about side effects and it's very important that you are able to counsel them adequately. So things to note with an ACE inhibitor, it's all contraindicated if the patient has bilateral renal artery stenosis. We want to make sure that we avoid the triple whammy, so ACE, diuretics and NSAIDs.
If they're pregnant, no ACE or ARBs as well. And side effects include a drop in renal function, and that is mostly temporary, but we want to watch out for it, a dry cough, a swelling, especially around the lips, and then a raise in potassium as well on blood tests. With calcium channel blockers, some adverse effects that you'd want to consider telling the patient about include peripheral edema, so swelling of the ankles, hypotension and bradycardia.
And again, combinations that are common to occur. So you might start someone on an ACE or an ARB and then add a calcium channel blocker, so that might be your second line. Or you might start them with an ACE or an ARB and then add a thiazide as well.
But typically beta blockers aren't your first line. It's important to know. Dyslipidemia. So screening for abnormalities in lipid levels.
We only do this... from the age of 45 and then we only do it every five years if low risk um if they're low risk again we repeat every five years if they're medium risk so five to ten percent on the calculator then we would provide lifestyle advice and consider pharmacotherapy but that's after a trial of lifestyle therapy alone then after that we would repeat lipids every two years so instead of five years every two years and then higher risk is um we commence you cholesterol lowering therapy with anti-hypertension medications and repeat delivered every 12 months. Again, sorry, I just made a mistake. And the high risk should be above 10%, not above 15%.
So under 5% for low risk, 5 to 10% for medium risk, and above 10% for high risk. Again, this is all from Red Book. But this is from the old Red Book when the percentages were a bit different. the boundaries are a bit different. Then we have our targets.
So this is when, so sorry the first group is abnormal concentrations of lipid in the blood. So when these, these are the upper limits of normal. So 5.5 for total cholesterol, LDL cholesterol above 3.5, HDL cholesterol below 1 or 1.3 and triglycerides above 2. And then once we're on lipid lowering therapy, For primary prevention, so that they haven't had a heart attack or a stroke or something yet, we have aims for the bloods for the lipid levels. And an easy way to remember this is 4-2-2-1.
So total cholesterol below 4, LDL and triglycerides below 2 is the aim, and HDL above 1 is the aim. For secondary prevention, the targets change a little bit. And I don't think you have to know them per se, but it's just good to know that the targets of what we're aiming for are changing. And you can see them there for you.
pharmacotherapy the first line is always non-pharmacological and then sorry non-pharmacological and then first line pharmacologically is statins important to know how to counsel these drugs as well the side effects include myalgia myopathy liver or renal function deterioration and akai second line depends more so on what you're targeting specifically so ezetimamide lowers ldl levels in particular you Our fibrates lower triglyceride levels and PCSK9 inhibitors are more to do with LDL as well. But important to note that fibrates are the ones that lower triglycerides. Cool.
COPD and asthma. So asthma I think is actually being covered in acute GP emergencies. But just a reminder of things to note. So definition, epidemiology, signs and symptoms, severity. our pathophysiology briefly and then management so what would we do in an acute attack what do we do when someone's being diagnosed how do we prep them for long-term management and then we also want to be able to explain how to use a puffer like ventolin and how to counsel parents on how to appropriately use a puffer um as well as this if you haven't already have a look at what an asthma management plan looks like um as well but i also have that for allergy and anaphylaxis so in peds that might be particularly important to know The other one that we were looking at for airways is COPD.
So revision, COPD is an obstructive lung disease caused by irreversible airway obstruction from inflammation. Diagnostically, our FEV1 over FEC ratio is below 70%. Risk factors we can break up into modifiable versus non-modifiable. And then we have two etiologies, chronic obstructive bronchitis versus emphysema.
And you can see that in the image there as well. It's quite well delivered. differentiated.
We can also classify COPD based on severity as per ETG as well. So here you can see the ETG classification of COPD. And we can either do it based on lung function tests or we can do it based on symptoms.
In terms of management of COPD, so we can do something known as COPD-X and then lifestyle measures. and then medications. So COPD-X is an acronym used for COPD management and so it stands for C, confirm the diagnosis via symptoms and investigation, so that's like your lung function. O is to optimise function and that's our ADLs or activities of daily living.
We have our personal ADLs as well as our instrumental ADLs and depending on which one's affected can also influence the severity of the COPD and how you might describe it. P is for preventing deterioration, so picking a preventative approach. D is for development of a care plan.
And then X is for managing exacerbations. In terms of lifestyle things, we strongly advocate to stop smoking because it's the only intervention shown to improve the natural history of COPD. Treat poor nutrition, mental health support, ensure vaccines are updated, especially influenza and pneumococcal vaccines.
and then pulmonary rehab in some cases as well. In terms of medications, we follow a stepwise approach. So this is from the COPD management, I think from RACGP or from the Lung Foundation. But most of the time we start with a Saba or a Sama, and then we add monotherapy of a Laba or a Lama.
After that, we would add dual therapy of a Laba and Lama. This is done based on symptoms, and we're finding that... the monotherapies and then after control symptoms, we would move up to dual therapy.
And then there's specific criteria that needs to be met to move on to triple therapy. So triple therapy is our LARBA, LAMA and ICS combination. And the only reason why we would do this is A, if the patient has had a severe exacerbation that's needed hospitalization.
B, it has had two moderate exacerbations in the last year. or see if they're still symptomatic despite dual therapy as well. This is the ETG equivalent of the Lung Foundations Diagram. And I've also included there the COPD Action Plan as well and just having a look at that.
It's a bit similar to the asthma one, but you might have to fill this out in GP for some of your patients. It might be useful just to have a look and see what it looks like as well. Again, remember that our oxygen aim...
for our patients with COPD, especially if they're CO2 retaining, is 88% to 92%. If they have a flare-up or an exacerbation, things that we would do include antibiotics if it's infective or prednisolone or some sort of steroid as well. Heart failure and AR. So heart failure, just a reminder, is... when there's a structural or functional impairment of the heart that reduces either ventricular filling or ejection.
So we have HFREF or HFPEF. Etiology, you can have a read. Exacerbating factors, you can also have a read. Important to note that diagnostic gold standard is our TTE and primary prevention involves treating any potential causes early on.
In terms of management, there's quite a bit that we can do. for lifestyle again snapdiving, patient education, alcohol, fluid restriction, salt restriction, exercising, stopping smoking etc. We want to try and increase their capacity and their ability to do their everyday things so their activities of daily living.
In terms of drug therapy it differs between reduced ejection fraction versus preserved ejection fraction. So if it's a reduced ejection fraction there's four medications that we would prescribe so one is a renin angiotensin system inhibitor so you've got some choices there whether that's an ACE an ARB or an ARNI the second is a heart failure specific beta blocker the third being a mineral corticoid receptor antagonist and then the fourth being an SGLT2 inhibitor um your choice of a renin angiotensin system inhibitor is typically based on patient tolerability of side effect profiles and efficacy. Typically either the ARNI or the ACEs first line, but often some patients can't tolerate the dry cough, so that's why they might change from one to the other. as well. We also need to remember if we are changing from the ACE inhibitor to another medication.
An ACE inhibitor has a washout period of 36 hours, so we don't want to be double dosing by accident within that 36 hours. So let the medication be completely removed from the patient system before adding on a next medication as well. It's important to note.
With our spinal lactate, so our mineral corticoid receptor antagonist. um because we're adding it on top of an ACE inhibitor or an ARB there is that potential for um hyperkalemia so it's just important to monitor that in the long term and throughout their treatment especially if they have a low EGFR or radial failure as well um that would put them at higher risk of hyperkalemia and all the side effects associated with it um typically speaking as soon as we diagnose um reduced ejection fraction heart failure we would start all of these medications within two to four weeks of diagnosis and then we will slowly up titrate the doses depending on whether it's controlling symptoms or not and whether we're seeing an improvement in the clinical signs as well. But monitoring electrolytes as mentioned is very very important. So you can see this chart for management as per ETG.
So you can see that if the patients can, uvolemic we'll start here, at diagnosis or within two to four weeks we would start the RNA or ACE, the beta blocker, the Spiralactone and the SGLT2 inhibitors. That's all four medications. But if they're congested, so they're overloaded, then we would start everything except the beta blocker and only start that when they're euvolemy. HPEF, our HPEF only needs two medications.
So lifestyle is still the same. We'd always advocate for lifestyle management. And then pharmacological management, there's two things that we would give. So the SGRT2 inhibitor and the beta blocker. Cool.
Atrial fibrillation. So again, our definition is revision. Irregularly irregular tachyarrhythmia when there are multiple electrical waves resulting in the failure of the atria to contract. And so instead the atria fibrillates.
It tends to be in the left atrium where the pulmonary veins enter and it's associated with hypertrophy of the left atrium. You can see an ECG there as well of what a AFib looks like just for a revision. In terms of classification, we can classify them two different ways. So based on how long it's been there for, so paroxysmal being resolved within seven days of onset, permanent being for more than seven days, I'm sorry, persistent being for more than seven days and permanent being for more than a year.
Alternatively, we can classify AFib based on rate, so rapid versus slow. And that's when we're looking at the heart rate, so above 100 versus below 100. Etiology and exacerbating factors, you can have a read of. And then also just review the risk factors and classical symptoms of AF as well. But what we'll be looking at more is the management of AF. So there's five main aims or there's five main priorities for the management of AFib.
The first will be to manage the thrombin embolism and stroke risk. You would have to use a CHAD-VASc score to determine if the patient needs anticoagulation. And you're definitely not expected to memorise the CHAD-VASc score. You will be provided this if it's required to be used in an OSCE stem. But just be aware that it is something that you might have to ask for.
The second priority in management is symptom relief. So whether that is rate control or rhythm control. Typically speaking, rate control is a priority, especially if it's fast AF.
And the first line here would be beta blockers. So whether atenolol or metoprolol, or we can also use our heart failure specific beta blockers if the ejection fraction is below 40. So then HEF, REF. Second line would be a calcium channel blocker. And the third line would be digoxin.
For rhythm control, we can do it through medications. or we can do it through like cardioversion or catheter ablation to restore the rhythm. Our options for that would be flecainide, sotelo or amiodarone.
Flecainide is often first line and there's this concept of pill in the pocket. So pill in the pocket is a type of cardioversion that we give to the patient. And it's a single dose of oral flecainide to restore sinus rhythm.
And so the patient can self-administer this at home. if they have infrequent symptomatic episodes of AFib. Acetalol is more used for long-term control, but note that it can increase the QT interval, so we do want to be checking ECGs to prevent this or to catch on to it early if it does happen.
But we would want to do like cardioversion or catheter ablation especially in our younger fit patients. The third priority of AF management is to manage comorbidities. Four is to consider the need for cardioversion and then five is to treat any underlying disease or the underlying cause where appropriate.
Again you can see here from our this is from RACGP um the AF sort of flowchart so diagnose the AF can we find something that is causing it um can we rhythm control and or are we going to rate control um and you can see here the different ways that you can do both of those things perfect the last little thing that we'll chat about is screening programs so there's many types of screening programs or a few that we need to know about But in particular, one of the big ones is colorectal cancer. So why is it so important that we screen for it? It's because it's the third most commonly diagnosed cancer in Australia and catching onto it early can help to reduce disease burden and get us onto treatment pathways quicker. Risk factors include age being over 50, family history, IBD, male, Western diet with high red meat consumption or Lynch syndrome. So the screening program itself is the National Bowel Screening Program.
And the criteria to fall into this is if you're between 50 and 74, then you do two yearly FOBTs. So it's a stool sample or stool test kit that gets sent to your mail or to your postbox every two years. They do a bowel action, smear a little bit, and then send it back off.
Just know that we don't do an FOBT if they have... macroscopic blood so if the patients come in and telling you that they've had a PR bleed or they've noticed some fresh blood in their stool or when they did a bowel action we wouldn't be doing an FOBT because that would be positive anyway so what the FOBT is looking for is microscopic blood if positive we send for a colonoscopy again this is the red book that tells us sort of category one category two based on risk you and how often their screening needs or what their screening needs to look like. So you can see category one would be most people or people with who are asymptomatic with no family history and that's every two years from the age of 50 we would do an FOBT and then if they have a relative depending on how old the relative was when they were diagnosed that changes their screening. I've just continued it here as well so for high risk. population.
Breast cancer screening program the risk factors female being over 40, family history of breast cancer, ovarian cancer, endometrial cancer, nulliparous women, bracket A1 or 2 genes, having a family history of male breast cancer as well and certain ethnicities. The screening program falls under breast screen and it's a two yearly mammogram from the ages of four from 50 to 74 so the same ages as the fast screening one. Important to note that women from the ages of 40 to 49 and those over 74 can also still have a free mammogram but they don't receive a formal invitation so there's not going to be like a text or a letter that's going to ask them whether they want to do one or that to remind them that they should do one. However if they come to you and you have a patient who's maybe like 45 wondering if they can have a mammogram because they might have had a lump the answer will be yes.
and I think it is covered for under the public health system. Within our primary healthcare setting as well always important to remember to do a triple assessment so that is examination and history, imaging and biopsy. With that imaging if they're over 40 we do a mammogram and if they're under 40 we would send them for an ultrasound.
The difference is because when you're younger or when the patient's younger the breasts are a bit more cystic and dense So a mammogram is not as good at picking it up, whereas an ultrasound will be more sensitive. This is the red book for breast screening as well, so you have a read through of that. And then cervical cancer.
So cervical cancer is an infection with HPV, and it's responsible for many cervical cancer cases. But there are many different strains of HPV, and some are more likely to cause... cancer than others.
And the ones that are more concerning include HPV 16 and 18. But cervical cancer... is a very slowly progressing malignancy. So that's why screenings change to every five years now instead of every two years. So you might have some patients who maybe are still used to the two yearly screen and but you can just advise them that it's recently been changed to five years and for that reason. Risk factors include sexual activity, not being immunised, smoking, family history.
Signs and symptoms typically it's asymptomatic. But in the later stage, they might have some symptoms including bleeding, whether that's just abnormal, randomly irregular vaginal bleeding, heavier than usual menstrual bleeding or post-quartal bleeding, abnormal discharge, pelvic pain or discomfort. And then if they've started to have some infiltration of the cancer, depending on where it's infiltrated into, might change the symptoms.
So into the bladder, they might have some hematuria, into the rectum, some constipation. And if they're getting some... edema in the legs, some pains of hydronephrosis.
That's the pelvic wall that might have been infiltrated. Etiology, so it mostly occurs in the transitional dome. So that's where our squamous cells turn into columnar cells of the cervix. And we have our CIN scoring system as well.
But when you have a biopsy sample, you can score it according to where it sits. Prevention, we have our Gynosol 9 vaccine. It's given in year seven to all Australian school kids. And it was only recently introduced in 2018. So there's currently still a catch-up program that you can ask patients if they want to do.
For screening, we do our CST. They can now be self-collected or done by the doctor or the GP. A self-collection is only appropriate if the patient's asymptomatic and has never had a positive CST and has no family history.
We do this from age 25 to 74 every five years. And positive results will either need a CST or a colposcopy. When you do a CST that's self-collected, it only tells you if HPV is positive or not and doesn't actually tell you the strain.
So if that comes back positive, then the patient will actually have to do a CST at the doctor's. And when that one comes back, depending on what that shows, whether it's the highest HPV, so 16 or 18. versus if it's like a different type of HPV that determines what happens after that and you can see this in the red book as well and I'm sure you'll learn about it a bit more in women's as well but you can see here in this flow chart which I think is from women from my the ONG notes but also from the National Cervical Screening Program what happens is that if HPV is detected then they undergo it. reflex LBC and then it depends on like what type of it is so they take a sample like colposcopy and then if it's H still a low grade or high grade and then etc etc and that will determine what happens from there on and the future screening program and eventually if negative for a period of time they go back into the five yearly community screening. But that brings me to the end of my presentation.
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