MICGP CKT cheat sheet

Primary care gatekeeping: first-contact, continuous, comprehensive, coordinated and community-oriented care (the five 'C's of Starfield) defines the discipline; each attribute is measurable in practice audits.

Consultation models: Pendleton's seven tasks, Neighbour's five checkpoints (connecting, summarising, handover, safety netting, housekeeping) and the Calgary-Cambridge framework structure most GP consultations.

Continuity of care is associated with lower all-cause mortality, fewer hospitalisations and higher patient satisfaction; it is strongest in small personal lists rather than large pooled lists.

The inverse care law (Tudor Hart, 1971): availability of good medical care varies inversely with need; practices in deprived areas have higher workload per patient and lower QOF achievement historically.

Epidemiological transition: the 'rule of halves' - of those with a condition, half are detected, half of those treated, half of those controlled; useful for framing hypertension and diabetes audits.

Consultation rates in UK general practice average roughly 5-6 face-to-face-equivalent contacts per patient per year; 10-minute appointments are the standard contracted default in England.

Deprivation scoring: the Index of Multiple Deprivation (IMD) is area-level, not individual; the 'postcode lottery' critique rests on area-level funding formulae such as Carr-Hill and the global sum.

Duty of care in unscheduled care: a GP must provide 'necessary and appropriate' treatment in an emergency even outside contracted hours; abandonment without handover is a fitness-to-practise risk.

Calgary-Cambridge structure: initiating the session, gathering information, physical examination, explanation and planning, closing the session; each phase has content and process skills.

Open-to-closed questioning funnel: begin with open questions ('What brings you in?'), narrow to closed questions for precision, then return to open for the patient's perspective.

ICE (ideas, concerns, expectations) elicits the patient's agenda; failure to elicit ICE is the commonest cause of unmet expectations and complaint in primary care.

Agenda setting at the start reduces 'doorknob' concerns; the 'golden minute' of uninterrupted speech lets patients complete their opening statement and reduces late-arising issues.

Safety netting: state the likely diagnosis, the expected timeline, specific red flags, and exactly how and when to recontact; document it explicitly.

Breaking bad news: SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary) is the standard six-step framework.

Challenging consultations: use the BATHE (Background, Affect, Trouble, Handling, Empathy) or FIFE (Feelings, Ideas, Function, Expectations) models for psychosocial presentations.

Interpreters: professional interpreters improve accuracy and reduce error; family members, especially children, should not be used for sensitive or consent-related discussions.

Written information and teach-back improve recall and adherence; roughly half of verbally delivered information is forgotten immediately, and recall is worse with anxiety.

Hypertension diagnosis: clinic BP ≥140/90 mmHg suggests hypertension; confirm with ambulatory (ABPM) or home monitoring (HBPM) using a threshold of ≥135/85 mmHg daytime average.

QRISK3 estimates 10-year cardiovascular risk; offer statin (atorvastatin 20 mg) when QRISK3 ≥10%, and consider when ≥7.5% with risk enhancers or patient preference.

Acute coronary syndrome: aspirin 300 mg chewed plus P2Y12 inhibitor and anticoagulation; STEMI needs primary PCI within 120 minutes of first medical contact where available.

Heart failure: measure NT-proBNP; <400 ng/L makes heart failure unlikely, >2000 ng/L warrants urgent echocardiography within 2 weeks; treat HFrEF with ACE inhibitor/ARNI, beta-blocker, MRA and SGLT2 inhibitor.

Atrial fibrillation: CHA2DS2-VASc ≥2 in men or ≥3 in women indicates anticoagulation; DOACs are preferred over warfarin except in mechanical valves or moderate-severe mitral stenosis.

Rate control in AF: beta-blocker or rate-limiting calcium channel blocker first line; target resting heart rate <90-110 bpm, and consider digoxin if sedentary or intolerant.

Lipids: for secondary prevention use atorvastatin 80 mg; target non-HDL cholesterol reduction of >40% and LDL <1.8 mmol/L (or <1.4 in very high risk).

Peripheral arterial disease: ABPI <0.9 supports diagnosis; ABPI >1.3 suggests medial calcification (falsely normal) and requires duplex or toe pressure assessment.

Warfarin reversal: vitamin K 5 mg IV plus prothrombin complex concentrate for major bleeding; for DOACs use specific reversal agents (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors where available).

Asthma diagnosis: confirm variable airflow obstruction with spirometry (FEV1/FVC <0.7 with reversibility >12% and >200 mL), peak flow variability >20%, or raised FeNO; symptoms alone are insufficient.

Asthma stepwise treatment (BTS/SIGN): step 1 low-dose ICS; step 2 ICS plus LABA; step 3 add LTRA or increase ICS; step 4 add LAMA or theophylline; step 5 specialist referral for biologic therapy.

COPD diagnosis requires post-bronchodilator FEV1/FVC <0.7 in a symptomatic patient with relevant exposure; severity is graded by FEV1 percent predicted (GOLD 1-4).

COPD management: smoking cessation is the only intervention that slows decline in FEV1; offer LAMA+LABA for persistent breathlessness, and pulmonary rehabilitation for MRC grade ≥3.

Home oxygen in COPD: assess with arterial blood gases on two occasions; long-term oxygen therapy criteria are PaO2 <7.3 kPa, or <8.0 kPa with polycythaemia, pulmonary hypertension or peripheral oedema.

Community-acquired pneumonia: CRB-65 (confusion, respiratory rate ≥30, BP systolic <90 or diastolic ≤60, age ≥65) stratifies; score 0-1 usually managed at home.

Pneumothorax: primary spontaneous in a stable patient with <2 cm rim may be observed; tension pneumothorax is a clinical diagnosis requiring immediate needle decompression, never awaiting imaging.

Pulmonary embolism: use Wells score then D-dimer in low/intermediate probability; in high probability go straight to CT pulmonary angiography; PERC rule can exclude PE in very low risk.

Obstructive sleep apnoea: screen with Epworth Sleepiness Scale and STOP-BANG; refer for overnight oximetry or polysomnography; untreated OSA increases cardiovascular and road traffic risk.

Dyspepsia: test-and-treat for H. pylori in patients under 55 without alarm features; alarm features (weight loss, dysphagia, anaemia, vomiting, upper GI bleed) mandate urgent endoscopy.

Coeliac disease: check IgA tissue transglutaminase with total IgA (IgA deficiency causes false negatives); patients must remain on gluten before testing.

Inflammatory bowel disease: faecal calprotectin distinguishes inflammatory from functional bowel disease; values <50 mcg/g make IBD unlikely, >250 mcg/g warrant referral.

Irritable bowel syndrome: symptom-based Rome IV criteria plus exclusion of red flags; first-line is dietary and lifestyle advice, then antispasmodics, then low-dose tricyclics for pain.

Liver function interpretation: isolated raised ALT suggests hepatocellular injury, isolated raised ALP suggests cholestasis; an AST:ALT ratio >2 suggests alcohol-related liver disease.

Cirrhosis monitoring: calculate MELD or Child-Pugh; offer 6-monthly ultrasound surveillance for hepatocellular carcinoma in cirrhosis, and variceal screening by endoscopy.

Acute upper GI bleed: Glasgow-Blatchford score ≤1 may allow outpatient management; give terlipressin and antibiotics in suspected variceal bleeding, and transfuse to a restrictive threshold (Hb ~70-80 g/L).

Hepatitis B: HBsAg positive with IgM anti-HBc indicates acute infection; HBsAg positive beyond 6 months defines chronic infection, requiring fibrosis assessment and antiviral consideration.

Diverticular disease: high-fibre diet for prevention; antibiotics are not routinely indicated for uncomplicated diverticulitis in the community, and colonoscopy follows an episode to exclude malignancy.

Type 2 diabetes diagnostic thresholds: HbA1c ≥48 mmol/mol (6.5%), fasting glucose ≥7.0 mmol/L, or random ≥11.1 mmol/L with symptoms; repeat to confirm in asymptomatic patients.

HbA1c targets: 48 mmol/mol for most; 53 mmol/mol if on hypoglycaemia-causing therapy; 58-64 mmol/mol for frail, elderly or limited-life-expectancy patients.

Type 2 diabetes medication: metformin first line; add SGLT2 inhibitor if cardiovascular or renal disease, or GLP-1 receptor agonist if cardiovascular disease or obesity predominates.

Sick-day rules for insulin and sulfonylureas: never stop basal insulin abruptly; check ketones and seek advice if vomiting or blood glucose persistently >14 mmol/L.

Thyroid: subclinical hypothyroidism is TSH raised with normal free T4; treat with levothyroxine if TSH >10 mIU/L, or if 5-10 with symptoms or positive thyroid peroxidase antibodies.

Thyroid emergency: myxoedema coma and thyroid storm are clinical diagnoses; thyroid storm is treated with propranolol, carbimazole or PTU, iodine after thionamide, and steroids.

Adrenal insufficiency: suspect in unexplained hyponatraemia, hyperkalaemia and hypotension; short Synacthen test is diagnostic; give hydrocortisone before results if adrenal crisis is suspected.

Osteoporosis: DEXA T-score ≤-2.5 defines osteoporosis; FRAX or QFracture guides treatment; bisphosphonates are first line, with calcium and vitamin D repletion.

Hypercalcaemia: in primary care, raised corrected calcium with inappropriately normal or high PTH indicates primary hyperparathyroidism; malignancy is the commonest cause in hospital inpatients.

Acute monoarthritis: aspirate before antibiotics if septic arthritis is possible; Gram stain and culture plus crystal analysis; do not delay empirical treatment in a hot swollen joint with systemic illness.

Gout: urate-lowering therapy (allopurinol) targets serum urate <360 micromol/L (<300 in tophaceous disease); co-prescribe colchicine or NSAID prophylaxis for the first 3-6 months.

Rheumatoid arthritis: refer urgently (within 3 working days) if persistent synovitis in small joints; DMARDs should start within 6 weeks of referral; anti-CCP is more specific than rheumatoid factor.

Polymyalgia rheumatica: age >50, bilateral shoulder/hip girdle pain and raised ESR/CRP; respond dramatically to 15 mg prednisolone; check for giant cell arteritis symptoms.

Giant cell arteritis: new headache, jaw claudication, visual symptoms; give high-dose glucocorticoid immediately and arrange urgent temporal artery biopsy or ultrasound; do not wait for biopsy.

Low back pain: red flags include age <20 or >55 with new onset, night pain, weight loss, neurological deficit, cauda equina features (saddle anaesthesia, bladder dysfunction) requiring emergency referral.

Osteoarthritis: diagnosis is clinical; exercise and weight loss are core; paracetamol has limited efficacy; topical NSAIDs are preferred for knee and hand OA in older adults.

Cauda equina syndrome: bilateral sciatica, saddle anaesthesia, urinary retention or incontinence, faecal incontinence; emergency MRI and neurosurgical referral within hours.

Fracture risk: steroid-induced osteoporosis occurs with ≥5 mg prednisolone daily for ≥3 months; give bone protection and check vitamin D at initiation.

Depression: use PHQ-9 or HADS to grade severity; mild cases favour psychological therapy; moderate-severe warrants SSRI plus psychological therapy; SSRIs take 2-4 weeks to work.

Suicide risk assessment: ask directly about thoughts, plans, intent and means; document; safety planning and urgent referral if high risk; asking does not increase risk.

Serotonin syndrome: clonus, hyperreflexia, agitation, hyperthermia after serotonergic agents; stop the agent, supportive care, and consider cyproheptadine in severe cases.

Dementia screening: use MMSE or MoCA; MoCA is more sensitive to mild cognitive impairment; reversible causes include B12, thyroid, depression and medication review.

Delirium: acute onset, fluctuating course, inattention; use 4AT or CAM; hyperactive, hypoactive and mixed subtypes; hypoactive delirium is commonly missed.

Headache red flags: thunderclap onset, fever with neck stiffness, new focal neurology, papilloedema, age >50 with new headache, and cancer or immunosuppression history.

Epilepsy: first seizure needs referral to a first-fit clinic within 2 weeks; driving must cease for at least 6 months after a single unprovoked seizure (DVLA rules vary by seizure type).

Parkinson's disease: bradykinesia plus rigidity or tremor; treat with levodopa; avoid dopamine antagonists; watch for impulse control disorders and postural hypotension.

Contraception: combined oral contraceptive is contraindicated in migraine with aura, smoking over 35, and uncontrolled hypertension (UKMEC 4); progestogen-only methods are safer alternatives.

Emergency contraception: levonorgestrel 1.5 mg is licensed to 72 hours but more effective the sooner taken; ulipristal acetate is effective to 120 hours; copper IUD is the most effective option up to 5 days.

Antenatal care: folic acid 400 micrograms daily pre-conception to 12 weeks (5 mg if high risk); vitamin D supplementation; avoid alcohol and smoking; discuss screening at booking.

Pre-eclampsia: hypertension after 20 weeks with proteinuria or end-organ dysfunction; aspirin 75-150 mg from 12 weeks for high-risk women; urgent assessment for headache, visual disturbance or epigastric pain.

Menopause: HRT is the most effective treatment for vasomotor symptoms; use the lowest effective dose; transdermal oestrogen is preferred with a history of migraine or raised VTE risk.

Cervical screening: UK programme from age 25 to 64 (25-49 every 3 years, 50-64 every 5 years); HPV primary screening with cytology triage; colposcopy for abnormal results.

Paediatric fever: use the NICE traffic-light system (green/amber/red) to stratify risk; red features (pale/mottled, capillary refill >3 s, reduced consciousness, grunting, non-blanching rash) need urgent assessment.

Childhood immunisation schedule (UK): 8, 12 and 16 weeks for primary course; MMR at 1 year and 3 years 4 months; HPV at 12-13; teenage boosters at 14.

Breastfeeding: exclusive breastfeeding is recommended for around 6 months; contraindications include certain drugs (e.g. cytotoxic agents) and untreated maternal HIV in resource-rich settings.

Comprehensive geriatric assessment (CGA) is multidimensional and multidisciplinary; it reduces mortality and institutionalisation when delivered to frail older people.

Frailty: use the Clinical Frailty Scale (1-9) or electronic frailty index; a score ≥5 identifies increased risk and should inform treatment escalation discussions.

Falls: multifactorial assessment includes gait and balance, vision, medication review (especially sedatives, antihypertensives and anticholinergics), continence, and home hazards.

Polypharmacy: use STOPP/START criteria or the Anticholinergic Burden scale; deprescribe one drug at a time with monitoring; review after any hospital admission.

Delirium in the elderly: non-pharmacological measures first (orientation, hydration, sleep hygiene); antipsychotics only for severe distress and for the shortest time, avoiding in Parkinson's disease.

Palliative care: the 'surprise question' ('Would I be surprised if this patient died within 12 months?') triggers advance care planning; use the Gold Standards Framework.

Pain in palliative care: follow the WHO analgesic ladder; for moderate-severe pain start a strong opioid (morphine or oxycodone) with laxatives; consider syringe drivers in the last days of life.

End-of-life symptom control: use the Liverpool Care Pathway principles (now superseded but its symptom guidance persists); anticipatory prescribing for pain, agitation, respiratory secretions, nausea and breathlessness.

Deprescribing in renal impairment: adjust doses (e.g., metformin avoided if eGFR <30, gabapentin reduced); review all medicines when eGFR falls.

Skin cancer: use the 7-point checklist (major: change in size, irregular colour, irregular border; minor: diameter >6 mm, inflammation, oozing, change in sensation) to refer suspected melanoma urgently.

Basal cell carcinoma: pearly nodule with telangiectasia and rolled edge; rarely metastasises; treat with excision, cryotherapy or topical imiquimod depending on subtype and site.

Eczema: emollients as the foundation; topical corticosteroids by potency and site (mild for face, moderate for trunk, potent for limbs); step up for flares, then step down.

Psoriasis: chronic plaques on extensor surfaces; topical vitamin D analogue plus corticosteroid; assess for psoriatic arthritis and cardiovascular risk; refer if >10% BSA or unstable.

Acne: mild-topical retinoid or benzoyl peroxide; moderate-add oral antibiotic (usually tetracycline) for 3 months; severe or scarring-refer for isotretinoin.

Otitis media: most cases resolve spontaneously; antibiotics for children under 2 with bilateral infection, or with otorrhoea, or systemically unwell; amoxicillin first line.

Otitis externa: topical antibiotic with corticosteroid; keep ear dry; consider fungal cause if not responding; refer if diabetic or immunocompromised with severe pain (malignant otitis externa).

Vertigo: Dix-Hallpike manoeuvre diagnoses posterior canal BPPV; Epley manoeuvre is therapeutic; differentiate from vestibular neuronitis and Meniere's disease.

Red eye: unilateral red painful eye with reduced vision, photophobia or contact lens use needs urgent ophthalmology review; do not prescribe topical steroids without slit-lamp assessment.

Four principles of biomedical ethics: autonomy, beneficence, non-maleficence and justice; used to reason through consent, capacity and resource allocation dilemmas.

Mental Capacity Act 2005: presume capacity; assess with the two-stage test (understand, retain, weigh, communicate); best interests decision if lacking; advance decisions and lasting powers of attorney apply.

Consent: valid consent requires capacity, sufficient information and voluntariness; Montgomery v Lanarkshire (2015) shifted the standard to what a reasonable patient would want to know.

Confidentiality: disclose only with consent or where required by law (e.g., notifiable diseases, terrorism, court order); GMC guidance permits disclosure in the public interest for serious harm.

Significant event analysis: review incidents with a systems approach; blame-free; identify contributing factors and implement change; document learning and re-audit.

Clinical audit cycle: define standards, measure practice, compare, implement change, re-audit; distinct from research (which generates new knowledge) and from quality improvement.

Appraisal and revalidation: annual appraisal and 5-yearly revalidation with the GMC; supporting information includes CPD, quality improvement activity, significant events, and patient and colleague feedback.

Prescribing governance: repeat prescribing requires review intervals; controlled drugs have specific legal requirements (CD register, safe custody, FP10MDA for instalments); report adverse drug reactions to the MHRA Yellow Card scheme.

Practice finance: the global sum funds essential services; QOF and enhanced services are additional; partnership models vary (GP partners, salaried GPs, PCNs) with different tax and liability implications.