Formative Flashcards
You are in a GP practice in a deprived urban area. A large number of your patients have IHD. You are considering setting up a clinic to prevent IHD.
Prior to setting up the IHD clinic you consider whether to screen for risk factors.
Wilson and Jungner (1968) stated that before setting up a screening programme for any disease, several factors need to be taken into consideration.
List 10 of them.
Will the test detect the condition at an early pre-clinical stage?
Is the disease an important public health problem?
Is the natural history of the disease adequately understood?
Is a test available for the condition?
Is the test sensitive (low false negatives)?
Is the test specific (low false positives)?
Is the test safe?
Is the test acceptable to the public and professionals involved?
Is the cost of the test reasonable?
Does the overall cost-benefit analysis make it worthwhile e.g. number of tests required to save one life?
Is treatment for the condition being screened for of proven effectiveness?
Is treatment for the condition being screened for safe?
Is treatment for the condition being screened for acceptable to public and professionals?
Are facilities for diagnosis and treatment available?
Several different types of study are encountered in epidemiological research. Give brief descriptions of both case control and cohort studies.
In case control studies, two groups of people are compared: a group of individuals who have the disease of interest are identified (cases), and a group of individuals who do not have the disease are identified (controls).
Data are then gathered on each individual to determine whether or not he or she has been exposed to the suspected aetiological factor(s) and whether or not a conclusion can be drawn that the suspected aetiological agent is a likely cause of the disease in question.
In cohort studies, baseline data on exposure are collected from a group of people who do not have the disease under study.
The group is then followed through time until a sufficient number have developed the disease to allow analysis.
List six possible sources of epidemiological data which may provide information on ischaemic heart disease.
Mortality data
Hospital activity statistics
General Practice morbidity/disease registers
Health and household surveys/population census data
Social security statistics
NHS expenditure data
(other reasonable sources)
Your first patient in morning surgery is a 45 year old male who moved to the UK from Russia 18 months ago and works on an offshore oil platform. He presents with dermatitis affecting his hands and lower arms and tells you that he thinks it is work related.
List 5 points from his history which would help you to decide whether occupational contact dermatitis is the likely diagnosis.
Does he work with chemical irritants?
How much exposure does he have to these irritants? (intensity/duration)
Do his symptoms improve when not at work e.g. onshore, on holiday?
Is personal protective equipment (PPE) used?
Does the patient comply with PPE?
Do other work colleagues have similar symptoms?
Has he any hobbies/pets/other activities which may be a likely cause?
Does he use hand cream or other topical agents he may be allergic to?
List 5 examples of psychological and/or social issues which may be affecting him? (45 y/o male offshore worker)
Anxiety re travel Depression, may be secondary to loneliness/being away from family Stress due to shift pattern Pressure to maintain standard of living Difficulty adjusting back into family life when onshore Abuse of drugs or alcohol Misses Russian culture/ethnic isolation Anxiety re job security
Your patient also tells you that he would like to stop smoking, following health promotion advice he received at work. He thinks the use of nicotine patches may be suitable for him. For health promotion to succeed, a change in behaviour by an individual and/or society is usually required. There are models relating to behaviour change. One of these models is the Stages (Cycle) of Change model.
The following descriptions show how this model can be applied to a patient who smokes, state which stage of the model applies to each description:
I no longer smoke and haven’t done so for 18 months.
I have booked an appointment to see my GP about nicotine patches (nicotine replacement therapy).
I currently smoke and do not intend to stop in the next 6 months.
I had stopped smoking but have had a few cigarettes recently because work is so stressful.
I stopped smoking one week ago.
I currently smoke but am thinking about giving up.
Stages - pre-contemplation, contemplation, preparation, action, maintenance, relapse
I no longer smoke and haven’t done so for 18 months - maintenance
I have booked an appointment to see my GP about nicotine patches (nicotine replacement therapy) - preparation
I currently smoke and do not intend to stop in the next 6 months - pre-contemplation
I had stopped smoking but have had a few cigarettes recently because work is so stressful - relapse
I stopped smoking one week ago - action
I currently smoke but am thinking about giving up - contemplation
List 10 potential difficulties which may arise in any consultation as a result of cultural differences.
Lack of knowledge about some health issues/NHS
Fear and distrust
Racism
Bias and ethnocentrism
Stereotyping
Ritualistic behaviour
Language barriers
Presence of third party e.g. family member/translator in the room
Differences in perceptions and expectations
Examination taboos
Gender difference between doctor and patient
Religious beliefs
Difficulties using language line
From population pyramids, the following differences in population demographics between 1951 and 2031 are shown:
Increasing elderly population
Fewer young people
Baby boom bulge noted in 2031 pyramid
Give two possible reasons for these trends.
List three issues this will present to health care services and three social issues relating to the trends shown in the pyramids.
Decrease in premature mortality/increased life expectancy
Decrease in birth/fertility rates
Migration
Greater availability of contraception
Improvements in housing
Improvements in sanitation
Baby boom post-war recovery years followed by greater sexual freedom
Health education programmes e.g. smoking, exercise, diet
Improved safety and reduction of injury
Health services
- increased numbers of geriatricians and allied health professionals required
- increased wards/health care facilities for elderly health care
- increased prevalence of long-term conditions such as diabetes, CVD, renal disease
- need for specific health promotion campaigns aimed at elderly
Social
- increasing dependence on families and/or carers who are also ageing
- demand for home carers and nursing home places likely to increase
- increasing emphasis on social activities for the elderly within communities
- role of elderly as grandparents as carers of grandchildren likely to change
- housing demands are likely to change as more elderly people live alone
Later in your surgery you see Kathy, a 50 year old who cares for her 82 year old mother. Her mother has several co-morbidities and is on multiple medications. She lives with Kathy and her family.
List 5 ways in which her role as a carer might affect Kathy.
Poor mental health e.g. stress, anxiety, depression, emotional demands
May have to give up work/work fewer hours
Financial implications e.g. due to impact on work, extra expense of caring for her mother
Lack of privacy for Kathy and her family
Restriction on social activities/social isolation
Less times for hobbies
Adaptation to Kathy’s house e.g. bathroom modifications, stain lift
Positively - may gain satisfaction from/enjoy her role
Suggest 5 ways in which problems Kathy may experience in her role as a carer could be alleviated
Sitter services e.g. Crossroads
Home carers to assist with her mother’s personal care
Elderly frozen food deliveries
Day care centre
Respite care
Benefits e.g. attendance allowance, carers allowance
Psychological support e.g. carer’s centres, counselling
Disabled badge scheme
Physiotherapy/OT assessment and support
Medication review
Additional help from other family members/friends/neighbours
Amongst her multiple pathologies, Kathy’s mother has osteoarthritis, IHD, T2DM and severe renal disease. Her health is rapidly deteriorating. Several members of the multi-professional team are involved in her care. List 5 team members other than the GP and give a brief description of their role in relation to her care.
District nurse/practice nurse - pressure areas, bloods, BP monitoring
Home carer - practical tasks e.g. bathing, dressing
Pharmacist - advice on medication, dossett box
Social worker - benefits, contact with agencies
OT - adaptation to living environment to maximise independence e.g. stair lift, hoist, shower modification
Physiotherapist - maintain any remaining mobility, walking aids
GMED/NHS 24 - out of hours care if unexpected problems
Nurse practitioner - initial assessment during house call if change in health, GP supported prescribing
Dietician - advice on diet to minimise further deterioration in renal function
Practice staff e.g. receptionist - passing on concerns/first point of contact
Physician’s assistant - GP supported medical assessment and care
Following surgery, you go on a house call to Michael, a 63 year old who has just registered with the practice following discharge from hospital.
He has severe COPD and has moved into his 59 year old sister’s home to facilitate her involvement in his care.
He has now stopped smoking but was a heavy smoker for most of his adult life. He is breathless at rest/on minimal exertion with FEV1< 30%, spends 50% of the day in a chair or in bed and receives long-term oxygen therapy.
He has had three admissions to hospital with infective exacerbations of COPD in the last 6 months. You realise it is unlikely that he will still be alive in 6 months and that him and his sister are unaware of the severity of his COPD, and find yourself in the situation of breaking bad news.
List 6 points to consider when breaking bad news to Michael and his sister.
Listen to the patient and their carers
Set the scene
Check whether Michael wants to speak himself or with his sister present
Find out what the patient already understands
Find out how much the patient wants to know
Share the information using a common language/avoid jargon
Review and summarise the information
Allow opportunities for questions
Agree follow up and support
Patients and their carers show a variety of emotional reactions when receiving bad news, some immediately and some over a period of time. List 2 examples of typical emotional reactions which may be experienced in this situation and state how they manifest.
Shock - news is completely unexpected, patient may be tearful and anxious.
Anger - angry with themselves for earlier health related behaviour e.g. smoking, or angry with health care professionals for not being able to provide cure
Denial - patient does not believe it can be true and for a time will fail to acknowledge reality of situation
Bargaining - “if I change something in my life, perhaps I will get better”
Relief - patient glad to finally know what is wrong so they can plan for the future
Sadness/depression - low mood common, especially if patient has been ill for some time or following bad news
Fear/anxiety - fear of dying, worry about pain, worry about family who are left
Guilt - not able to provide for family any more, guilt that earlier behaviours may have affected health e.g. lack of exercise, XS alcohol intake
Distress - patient unable to cope with news and shows acute anxiety/tearfulness
Identify five aspects in Michael’s history which indicate he is a suitable patient to receive supportive and palliative care
Not expected to be alive in next 6-12 months
Breathless at rest/minimal exertion
FEV1 < 30%
Spends more than 50% of day in bed or chair
Long term O2 therapy
Three hospital admissions with acute exacerbations in last 6 months
List 5 points relating to the proactive care resulting from anticipatory care planning
Patient on GP palliative care registered and discussed at team meetings
Information on social and financial support given to patients and their carers, and referral to relevant team members to facilitate provision of this
Usual GP and District Nurse support visits and phone calls
Assessment of symptoms and partnership with specialists to customise care to patient and carer needs
Overall care assessed, including respite and psychosocial needs
Preferred place of care noted and organised
Care plan and medication issued for home
End of life pathway/LCP used
Dies in preferred place, family bereavement support
Staff reflect - SEA, audit, gaps in care identified, learn, improve care
