Block 43 Flashcards
List the 7 criteria which classify a baby as ‘at risk’ of DDH, warranting a referral for US scan.
1) All babies born breech from 36 weeks onwards, breech births (vaginal or caesarean) including those where ECV was carried out.
2) FHx of hip dysplasia or dislocation.
3) Congenital deformity the feet.
4) Clicky hips
5) Unstable hips
6) Limited abduction in flexion.
7) Apparent shortening of one/ both legs.
Why can the use of USS to screen for DDH lead to over treatment?
Because USS for DDH has a high sensitivity but a low specificity.
1) Pathological DDH is mainly associated with which sex?
2) Describe the PPV of the 6-8 week GP hip check for DDH.
3) What is a useful clinical sign in diagnosis of pathological DDH?
1) Pathological DDH is mainly a female condition.
2) GP 6-8 week hip check has a very low PPV for pathological DDH.
3) Unilateral limitation of hip abduction.
Give 3 ways in which abnormal gait/ posture can socially impact upon a patient and they family.
1) Only a small proportion of these abnormalities are clinically significant, but they can cause much parental anxiety.
2) Child may get stigmatised/ bullied for different gait or posture.
3) May become socially withdrawn.
Give 3 psychological/ socioeconomic consequences of hip fractures for patients, their families or the wider community.
1) Injury can cause massive change in lifestyle (previously dependent elderly patient may become dependent and require carers).
2) An elderly person suddenly becoming much less independent may lead to social isolation and subsequently depression.
3) In a young person, may mean an inability to get back to playing sports which may lead to depression.
4) 30% mortality within a year.
5) Hip fractures cost NHS £2billion annually.
Name 5 risk factors for osteoporosis.
1) Female
2) CKD
3) GI disease/ poor calcium intake
4) Oestrogen deficiency (i.e. menopause)
5) Hyperparathyroidism
6) Increased age
7) Decreased BMI
8) Smoking and alcohol intake
Name 3 drugs which can increase the risk of developing osteoporosis.
1) Glucocorticoids
2) Aromatase inhibitors
3) SERMs
4) Anti-androgens
5) PPIs
6) SSRIs
According to NICE, which patients may need a falls assessment?
Those aged over 65 who:
1) have had one or more falls in the last 12/12
2) are at risk due to:
- cognitive/ visual impairment
- frailty/ a condition which affects balance (PD, arthritis, stroke)
- taking multiple/ psychoactive/ anti-hypertensive drugs
State 2 tests which can be done to assess a patient’s falls risk.
1) ‘Time up and go test’ = patient is timed to get up and out of a chair, walk 3m and then return to the chair. 12-14s = increased risk of fall.
2) 180 degree turn test = ask patient to stand and turn 180 degrees about the spot. If this requires more than 4 steps, there is an increased falls risk.
State 5 factors that a multifactorial falls assessment might assess.
1) identification of falls history
2) assessment of gait, balance and mobility, and muscle weakness
3) assessment of osteoporosis risk
4) assessment of the older person’s perceived functional ability and fear relating to falling
5) assessment of visual impairment
6) assessment of cognitive impairment and neurological examination
7) assessment of urinary incontinence
8) assessment of home hazards
9) cardiovascular examination and medication review
1) What percentage of the community aged over 65 have a fall each year?
2) What percentage of the community aged over 65 who have experienced at least one fall then have recurrent falls each year?
3) How much more common are falls in institutions compared to in the community?
4) What percentage of those in the community aged over 90 have a fall each year?
1) 30%
2) 50%
3) 3x more common
4) 55% of those over 90 will have a fall each year
1) What are the most common cause of injury in the elderly?
2) What percentage of falls cause a hip fracture?
1) Falls
2) 1-2% falls cause a hip fracture.
Name 3 consequences of an elderly person having a fall or recurrent falls.
1) Hip fracture (50% no longer live independently after this)
2) Minor injuries (cuts, contusions)
3) ‘Long lie’ leading to hypothermia, pressure sores, pneumonia, rhabdomyolysis, AKI, CKD.
4) Psychological problems (fear of falling, self-imposed activity restriction, loss of mobility, depression)
**note that there are also impacts on carers as the patient often is increasingly dependent and more disabled.
Clinically, describe the presentation of a hip fracture.
Characteristically externally rotated and shortened.
**NOF fracture may impinge blood supply to femoral head, leading to avascular necrosis.
State the 4 ways in which outcome from hip fractures can be improved.
1) Fast admission.
2) Operate within 24 hours.
3) Mobilise within 24 hours.
4) Initiate early discharge planning with carers.
If a patient performs poorly in the ‘time up and go’ and ‘180 degrees turn test’, what might be offered?
A multifactorial falls assessment.
Describe 2 ways in which hip fractures can be prevented.
1) Falls prevention
2) Bone protection (bisphosphonates, calcium/ vitamin D supplements, HRT)
1) Describe the effect of calcium/vitamin D supplements on preventing hip fractures)
2) Why do bisphosphonates often have poor compliance?
3) What are the risks of taking HRT?
4) By what percentage do bisphosphonates decrease hip fracture occurrence?
5) By what percentage does HRT decrease hip fracture occurrence?
1) Calcium and vitamin D have a modest effect when used in combination but vitamin D does not have an effect when used in isolation.
2) Because daily use causes gastric SEs.
3) Increased risk of DVT, breast cancer and dementia.
4) 30%
5) 20-30%
Name 5 risk factors for hip fractures.
1) Increasing age (every 5yrs = 2x increased risk)
2) Female
3) Low BMI
4) Smoking
5) PMHx of fractures
6) FHx of fractures
7) Corticosteroid use
8) Ethnicity (Afrocaribbean = decreased risk)
State 3 risk factors for falling along with their relative risk of causing a fall.
1) Muscle weakness (RR - 4.4)
2) Fall Hx (RR - 3)
3) Gait + balance deficit (RR - 2.9)
4) Visual deficit (RR - 2.5)
**Risk varies for different visual problems (depth perception > contrast sensitivity > acuity).
Is polypharmacy a risk factor for falls?
It is thought that the risk of fall due to chronic disease and multiple pathologies is higher than the polypharmacy needed to control these.
Give 3 ways that Tinetti suggested falls risk can be reduced.
1) Psychotropic drug withdrawal (decreased falls by 66% but also decreased QoL)
2) OT assessment (assess at home risk and make recommendations to decrease risk)
3) Podiatry input (better footwear, orthotic devices, calf-ankle exercises)
What are the aims of rehabilitation after a fall causing injury?
Aims are to maximise independence, enable normal ADLs and to maintain social participation.
Briefly describe the rehab process following a hip fracture.
Following fracture, patients are referred to an MDT who will coordinate their rehabilitation care.
Give examples of 3 professions which work within a hip fracture MDT.
1) PT
2) OT
3) Social workers
4) Geriatricians (some hospitals now have orthogeriatricians)
What is the role of an MDT after rehabilitation of a patient who had a hip fracture?
To assess needs for discharge and that the patient is safe to be discharged.
Give the leading causes of TBI.
1) Falls - 35.2%
2) Motor vehicle crash - 17.3%
3) Struck by/ against an object - 16%
4) Assaults - 10%
5) Sports-related - 10%
6) Others - 21%
1) What is the leading cause of death in children and young adults under 44 years of age?
2) TBI accounts for what percentage of deaths occurring as a result of acute injury?
3) How many attend A&E with head trauma per annum?
1) TBI (10,000 p.a. in the UK)
2) 40%
3) 1 million
Describe the distribution of TBIs across the ages.
Trimodal distribution:
1) 5-9
2) 15-24
3) 80+
Give 3 risk factors for suffering polytraumas or TBIs.
1) Age
2) Gender
3) >50% transport-related
4) Lower SES
5) Previous TBI
6) Sports and dangerous occupations
Describe the positive prognostic factors for TBI (4).
1) Shorter duration of coma (>4 weeks = very poor outcome)
2) Better motor response on GCS
3) Shorter duration of post-traumatic amnesia (>11 weeks is inconsistent with independent living)
4) Younger age (<20 better than >60)
5) Minimal brainstem involvement
6) Premorbid psychosocial status (higher = improved outcomes.
**NOTE: site of TBI bears a weak/ no correlation to outcomes.
Give 3 different groups of people who may be involved in ongoing assessment of patients after multi-trauma injuries.
1) PTs
2) OTs
3) Speech and language therapy
4) Psychological therapy (CBT)
5) Charities (E.G. HEADWAY - a charitable brain injury association)
State the ‘yellow flags’ for chronicity.
Psychosocial and behavioural factors which have been shown to be indicative of long term chronicity and disability:
1) Negative attitude that back pain is harmful/ severely disabling
2) Fear avoidance behaviour and decreased activity levels
3) An expectation that passive, rather than active treatment, will be beneficial
4) Tendency to depression, low morale and social withdrawal
5) Social or financial problems
What does NICE recommend should be used in order to informalities management for chronic back pain?
NICE suggests using the ‘STarT Back’ risk stratification tool to inform management of patients with chronic back pain.
What does the ‘STarT Back’ tool do?
Stratify’s the risk that a patient is at of having persistent disabling symptoms or poor outcomes in relation to back pain.
Name 3 things that you should not offer for a person with chronic or disabling back pain.
1) Acupuncture
2) Electrotherapy
3) Orthotics/ traction
4) Spinal injections
5) Disc replacement or spinal fusion (unless part of an RCT).
State the 9 factors taken into consideration on the ‘STarT Back’ risk stratification tool for chronic or disabling back pain.
1) Referred leg pain
2) Co-morbid pain elsewhere
3) Disability (two questions)
4) Fear avoidance
5) Anxiety
6) Catastrophising
7) Depression
8) Overall impact
How is the ‘STarT back’ screening tool interpreted?
- 0-3 = low risk + minimal treatment required
- 4 or more on total score = medium risk + physiotherapy required
- 4 or more on sub score = high risk + enhanced physiotherapy required
Describe the impact of persistent, disabling back pain or amputation on an individual.
1) Withdrawal from activities - ‘fear behaviour’
2) May feel stigmatised, especially if others feel they are feigning their illness
3) May lead to psychological sequalae
4) Altered body image in amputation
Describe the impact of persistent, disabling back pain or amputation on a patient’s family members.
1) Individual becomes increasingly dependent on family (may become burdensome)
2) Role reversal (with children, for example)
3) Reduced income if main bread winner/ self employed
Describe the impact of persistent, disabling back pain or amputation on society/ workplaces.
1) Impact is greatest on small businesses who depend heavily on their workforce
2) Back pain is the second most common for long term sickness
**Decreased productivity, decreased efficiency, decreased profit, decreased business stability = increased likelihood or redundancies/ closure
What is the second most common cause for long term sickness from work in the UK?
Persistent/ chronic back pain.
Define the following types of stigma:
1) Discreditable
2) Discrediting
3) Felt
4) Enacted
5) Courtesy
1) Keeping stigmatising conditions hidden, except to close friends/ family (e.g. HIV)
2) When a stigmatising condition cannot be hidden (e.g. obesity/ acne).
3) Sense of fear and shame projected onto oneself.
4) Acting upon stigma, this discriminating against people
5) Stigma felt by somebody on behalf of another who is susceptible to stigmatisation (e.g. parent of a child with Down’s syndrome)
Name the 5 types of stigma.
1) Discreditable
2) Discrediting
3) Felt
4) Enacted
5) Courtesy
What is internalising with regards to stigma?
When a stigmatised person absorbs the social views of being inferior and the consequences that this has on beliefs and behaviours
Give 3 ways that stigma can be non-disclosed.
1) Covering
2) Passing
3) Withdrawal
Describe what is meant by the following in terms of reactions to stigma:
1) Covering
2) Passing
3) Withdrawal
1) Concealing the physical thing (e.g. someone bling wearing sunglasses) - can make discrediting stigma discreditable.
2) Concealing discreditable stigma by passing oneself off as normal to others - may still experience felt stigma.
3) Acknowledging symptom, but withdrawing from the normal social world and secluding oneself OR surrounding oneself with others that have a similar issue (support group).
1) Describe what is meant by ‘resisting’ in terms of stigma.
2) Give an example of positive resisting.
3) Give an example of negative resisting.
4) What can resisting provoke?
1) Contesting the stigma related outcomes.
2) A disabled person becoming a Paralympian.
3) Not accepting help as the person does not acknowledge that it is needed.
4) Social change.
Give 3 implications of stigma within medicine.
1) Fear of stigma may act as a health-seeking barrier (i.e. doctors judging patients)
2) Concerns about confidentially (who will see records, and will that person stigmatise the patient?)
3) Treatments can lead to stigma (i.e. people using wheelchairs following amputation).
Give 4 categories of uncertainty for patients after they have been diagnosed with a long term condition, and give examples.
1) social (employment, finances, relationships)
2) Clinical (varying prognoses, changes between treatments)
3) Uncertainty in the diagnosis itself (i.e. epilepsy)
4) Psycho-social (identity, re-visiting proposed life trajectory)
Give 2 different reactions to a patient being diagnosed with a long term condition.
1) Metaphysical questioning - ‘why me?’
2) Positive meaning - ‘everything happens for a reason’
**Note that culture has a big influence on reactions.
What is ‘biological disruption’ with regards to long term conditions?
A disruption to structures of everyday life.
Describe 3 aspects of biological disruption in those with long term conditions.
1) Taken for granted assumptions/ behaviour - body can’t do certain things anymore.
2) Of biography - self/ identity - re-evaluation of life plans.
3) Response to disruption - demands and resources
What is meant by the term ‘normal crises’ with regards to a patient being diagnosed with a long term condition?
That diagnoses is a continuation/ biographical reinforcement of someone’s normal life.
For example, a patient may have experienced crises throughout life (poverty, ageing, poor housing), and a diagnosis is just one more thing in the chain, so not a big deal to them.
Diagnosis may also be expected (i.e. osteoporosis after life-long hard manual labour/ a complication of a previous disease/ illness).
State 2 aspects of further management that may be required for a patient who has a long term illness.
1) Contact with employer - explain circumstances and recommendation (e.g. altered seating/ equipment, adjusted hours with regular short breaks, encourage potential of finding a new role within the organisation).
2) Contact with social services - ‘access to work’ system works with both patient and employer to find a role that suits the patient.
Aside from the ‘access to work’ system, state 3 other methods of help that social services can offer to patients.
1) Help to find alternative work
2) Help accessing disability benefits
3) Help o find housing suitable for needs
4) Help to pay for transport costs.
Define the term ‘guidelines’.
Systematically developed statements to assist practitioner and patient decisions regarding appropriate healthcare for specific clinical circumstances.
Give 3 benefits of the development of clinical guidelines.
1) Enable consistent care across the country (decrease practice variance).
Bridge
2) Bridge the gap between what evidence recommends and the reality of clinical treatment.
3) Indicate useful and cost-effective intervention/ investigations
4) Adherence to guidelines has been shown to significantly increase positive outcomes.
**Note that guidelines should assist and not dictate.
Give 3 reasons why guidelines might not be adhered to.
1) Lack of knowledge of the guideline.
2) Conflicting guidelines for patients with multiple morbidities.
3) Rapidly developing areas of treatment.
Give 2 limitations of guidelines.
1) Need be applied in the context of individual patients - they are not the final word on investigation and management.
2) May endorse the use of technology which is unavailable locally - this means that it may be difficult to implement guidance.
State 5 methods of health promotion with regards to reducing incidents involving burns and scalds.
1) Fire alarm testing/ houses encouraged to regularly check fire alarms
2) Electrical PAT registration
3) Chip pan fire awareness scheme
4) Bonfire night ad campaigns
5) Building regulations
6) Public area health and safety regulations (fire extinguishers, fire exits, fire retardant materials)
7) Dedicated fire safety wardens in public places and schools
8) Regular fire drills
9) Fire safety training
10) Fire alarms in public buildings
11) Charities (i.e. Red Cross) raising awareness of how to treat burns
12) Having kettles and hot appliances away from edge of kitchen top
State 4 major complications of joint replacement surgery.
1) Clotting > DVT > PE
2) Wound haematoma
3) Infection
4) Nerve injury
What are the 4 main categories of aids to daily living that are available?
1) Mobility
2) Feeding
3) Dressing
4) Other
Give examples within the following categories of aids to daily living that are available:
1) Mobility
2) Feeding
3) Dressing
4) Other
1) grab rails, crutches, ramps, walking frames, toilet frames, commodes, hoists, stair lifts.
2) adapted ergonomic cutlery, beakers, easy-use jar/ bottle/ tin openers
3) Shoehorns, stocking aids
4) Lighting, magnifiers, phones with large buttons
Give 3 longer term functional or socioeconomic consequences of upper limb trauma.
1) Chronic problems - weakness, spasticity - may cause trouble with ADLs.
2) Reliance on upper limbs for working - may need adaptions, become unemployed or need to take time off work.
3) Lack of or dysfunction of upper limb may affect relationships.
4) More difficult to play with and help with young children
Briefly outline the main roles of occupational therapists in those with chronic pain.
1) Help individuals adapt to their life with chronic pain:
- Increase independence
- Increase confidence and control
2) Do ADL assessment (i.e. Barthel index) to inform necessary level of care
3) Home adaptations, work adaptations
4) Help with leisure and social activities.
Briefly outline the main roles of physiotherapists.
- Assist in rehab, providing individual plans tailored to the need of the patient.
- Exercises and manoeuvres to increase function and minimise impact of condition.
Describe the role of complementary and alternative medicines in back pain.
There is limited evidence. NICE explicitly does not recommend some CAMs for back pain, for example, acupuncture.
State 4 potential adverse effects of complementary and alternative medicine approaches.
1) Allergy - sensitising capacity of numerous herbal remedies.
2) Mechanical injury - acupuncture leading to pneumothorax, cardiac tamponade or spinal injury or chiropractor practice leading to spinal cord injury.
3) Infection - after acupuncture.
4) Nutrition - severe deficiencies result in those given strict alternative diets.
Give the 3 instances where NICE does recommend CAMs.
1) Alexander technique for PD.
2) Ginger and acupressure for morning sickness.
3) Manual therapy for lower back pain.
What is a major consideration to undertake when thinking about seeking help within CAM?
Are practitioners qualified, registered, audited and revalidated by a responsible/independent national accrediting body?
What is the main negative perception about those who offer CAMs?
That they are preying on the vulnerable who are desperate for solutions to problems that conventional western medicine has failed to answer.
Describe the relationship between placebos and CAMs.
There are few CAM trials that exist which demonstrate that the CAM is more effective than the placebo.
What forms the basis of chiropractic?
Manual adjustments of spine and joints to relieve MSK mechanical disorders and nervous system disorders.
What forms the basis of osteopathy?
Touch, physical manipulation and stretching to increase mobility and blood flow to relieve spasms.
Define the term ‘medical unexplained symptoms’.
Physical symptoms with no organic disease explanation, assumed to be caused by psychological factors.
They often arise from normal body physiology or minor existing pathology but are exaggerated by stress and often misinterpreted.
1) What percentage of primary care symptoms are MUS?
2) What percentage of secondary care symptoms are MUS?
1) 25%
2) 40-50%
1) Name 2 direct mechanisms of stress causing MUS.
2) Name 3 indirect mechanisms of stress causing MUS.
1) Sympathetic adrenal-medullar axis and HPA axis.
2) Stress causing poor medication compliance, increased maladaptive coping, decreased exercise.
State 2 ways in which stress can lead to the presentation of MUS.
1) Chronic stress = up regulation HPA axis = pathology (i.e. stress myocardiopathy/ broken heart syndrome).
2) Stress due to a significant life event (a major aetiological factor in mental health).
Response to illness is dependent on what?
Several individual and illness specific factors.
State 3 individual factors that can influence a patient’s response to illness.
1) Premorbid personality (worrier)
2) Prior experience of that illness
3) Pre-existing mental state illness
4) Childhood experiences (core beliefs)
**All affect appraisal style + resultant response.
State 3 illness-specific factors that can influence a patient’s response to illness
1) Immediacy – life threatening?
2) Uncontrollability – XS pain
3) Ambiguity/’not-knowing’ re: prognosis
4) Undesirability of treatment regimens or disfiguring treatments (i.e. mastectomy)
Describe what is meant by the term ‘Levanthal cognitions’.
Patient’s own implicit beliefs regarding the illness.
Name the 5 cognitive categories which can influence a patient’s beliefs about illness, according to the ‘Levanthal’s cognitions’ framework, and give examples of considerations within these categories.
1) ID – what is it?
2) Timeline – perceived duration? Life-long or acute?
3) Consequence – expected outcome: bleeding? Loss of function? Death?
4) Cause – Pt personal ideas: ‘catch it from someone’? Result of lifestyle? God punishing them?
5) Control – how pt can control it/recover
Name and describe the 2 main coping strategies?
1) Problem solving - seeking information, taking control, reconstructing the illness be manageable and developing realistic plans/ goals.
2) Emotion focused - talking about the problem, using supportive friendships, seeking religious support.
In basic terms, how does a patient decide which coping strategy to use?
Interpret the illness using Levanthal’s cognitions > select coping strategy > appraise coping strategy.
**This tends to work transiently though, and patient care encouraged to use both strategies.
What is the difference between the terms ‘illness and disease’?
Illness is the subjective experience of a pathology (symptoms), where as disease is a pathological process in the body.
What are the 4 most common types of MUS?
1) Chest pain
2) Chronic fatigue
3) Headaches
4) Muscle/ joint pain
Why can MUS prove to be problematic?
Symptoms + no disease present means that patient needs are not met and there is increased risk of iatrogenic harm.
Doctors can become frustrated at the lack of diagnosis.
There is inefficient use of resources.
State 3 assumptions that doctors make about patients with MUS.
1) Explanation for MUS lies within the patient.
2) Half of patients deny psychological cause/ somatisation of psychological distress
3) They seek cure and diagnosis
4) They get physical intervention because they demand it (it is easier to give in than to argue)
5) To avoid physical intervention, doctors should help patients to appreciate psychological factors.
State 3 things that patients actually want with regards to their MUS.
1) Alliance - with the doctor (shared problem - both in same boat)
2) Exculpation - realise reality from their suffering and confirm it isn’t the patient’s fault (clear them of blame)
3) Convincing explanation - that seems plausible to the patient
What are the 3 main explanations that patients tend to receive to explain MUS?
1) Rejecting
2) Colluding
3) Empowering
What is meant by the ‘rejecting’ explanation of MUS?
Denial of the reality of the symptom and the implication that it is imaging (causes stigma, an unresolved problem and distrust in the doctor).
What is meant by the ‘colluding’ explanation of MUS?
Sanctioning the patient’s beliefs because it is easier - leads to questioning of the doctors integrity, openness and competence (?FTP)
What is meant by the ‘empowering’ explanation of MUS?
Offering a tangible mechanism, exculpation ad opportunities for self-management.
This legitimises the patient’s suffering, gives the patient ‘ownership’ of explanation, removes blame and forms an alliance between the doctor and patient.
This encourages a continuing and healthy professional relationship and concordance.
What is the main reason for carrying out qualitative research for patients with MUS?
To gather data on experiences, views and opinions via interviews, focus groups and documents.
What does qualitative research generate in regards to MUS?
Subjective data on personal experiences of symptoms.
How is qualitative data analysed with regards to MUS?
For themes (thematic analysis) in order to identify key ideas and patterns.
State and describe 3 of the main themes discovered when analysing qualitative research from MUS patients.
1) Lives become socially precarious (strained relationships with family and friends)
2) Uncertainty with regards to diagnsis/ prognosis (impacts on future planning = biological disruption)
3) Lack of legitimacy (can’t enter sick role, can’t access support groups, social isolation)
4) Questioning self and identity (blame themselves, guilt of being a fraud/ time-waster).
