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Medicine > H & S > Flashcards

H & S Flashcards

1
Q

Beauchamp and Childress developed the Four Principles of Biomedical Ethics in 1978. They identified four principles that must be considered and balanced against each other in order to provide ethical healthcare.

A

Autonomy- patient should be provided with enough information and support to make their own informed decision about their healthcare, and this decision should be respected.

beneficence- care should always be “doing good”, i.e. acting in the patient’s best interests

non-maleficence - care should not cause a patient harm.

Justice- relates to the fair and equal distribution and access to healthcare resources.

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2
Q

Health education

A

give people knowledge & skill to change potentially health damaging behaviours, e.g. advice from health professionals, mass media campaigns.

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3
Q

Health protection

A

legislation to protect public health, e.g. not smoking inside, pollution, seat belts.

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4
Q

Give approaches to health promotion

A
  • Health persuasion e.g. campaigns, posters
  • Legislative action e.g. smoking bans in public places, pollution regulation, car seat belts, fluoride in water
  • Personal counselling e.g. opportunistic prevention in one-to-one setting, community settings with youth or community workers
  • Community development e.g. food cooperatives
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5
Q

Validity

A

assuming the premises are true, does the conclusion follow logically?

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6
Q

Sound

A

are the premises of the argument actually true?

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7
Q

BASIC REPRODUCTIVE NUMBER (R0) =

A

avg no. of individuals directly infected by an infectious case, in a totally susceptible population.
Determined by virulence factors, therefore specific to microorganism + population. Proportionate to:
- Length of time infectious case remains
- Number of contacts a case has with susceptible hosts, per unit time.
- Chance of transmission during one of these encounters (depends on pathogen’s innate virulence)
Doesn’t fluctuate in short term, not affected by vaccination, is a property of infectious agent. Can differ for same organism in different populations.

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8
Q

EFFECTIVE REPRODUCTIVE NUMBER (R or RE) =

A

is the average number of secondary infections produced by a typical infective agent, if this number is greater than 1 then it is impossible to eradicate an infection. Since for every one eradicated a new one will appear.

Usually smaller than R0, and reflects impact of control measures and <100% susceptibility in a population.

R = R0 x S

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9
Q

Requirements for eradication of a disease

A
  1. No other reservoirs of infectious agent (animals/environment)
  2. Scientific and political prioritisation of specific agent has to exist (money + time more available) - result of infection being serious and common
  3. Examples of eradicated diseases - polio and smallpox
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10
Q

Herd Immunity =

A

large portion of a community (the herd) becomes immune to a disease (due to vaccination usually) such that it is difficult for the disease to spread (because there are not as many people who can be infected)

The formula for calculating the herd-immunity threshold is 1–1/R0

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11
Q

Managing side effects of vaccines:

A

○ Prophylactic medication (i.e. paracetamol and ibuprofen)
○ Space out vaccines
○ Yellow cad system
○ Monitoring post vaccine
○ Ability to access healthcare if experience side effects
○ Make sure those with underlying conditions have advice (i.e. von Willerband Factor deficiency should take a dose of Transexamic Acid before the COVID vaccine)

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12
Q

Primary disease prevention

A

prevent onset of disease; hard for some conditions as hard to know when onset of disease is (could be before symptoms come on ) = address cause of causes, e.g. cause of obesity that causes DM
Different types:
Universal (whole population)
Selective (risk group)
Individual (identify high risk individuals, e.g. genetic mutations)

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13
Q

Secondary disease prevention

A

cure / identify disease earlier, e.g. screening

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14
Q

Definition of screening

A

Application of a test to identify individuals at sufficient risk of a disorder to warrant investigation or direct preventative action, amongst persons who have not sought medical attention on account of symptoms

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15
Q

Screening test requirements

A
  1. The condition being screened for should be an important health problem
  2. The natural history of the condition should be well understood
  3. There should be a detectable early stage (pre-clinical and/or risk factor, long enough so there is chance of detection)
  4. Treatment at an early stage should be of more benefit than at a later stage
  5. A suitable test should be devised for the early stage
  6. The test should be acceptable
  7. Intervals for repeating the test should be determined
  8. Adequate health service provision should be made for the extra clinical workload resulting from screening
  9. The risks, both physical and psychological, should be less than the benefits
  10. The costs should be balanced against the benefits
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16
Q

Tertiary disease prevention

A

manage disease

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17
Q

Breast screening

A

50 - 70
Mammography
Routine Repeat after 3 years

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18
Q

Bowel screening

A

60 to 74 sent FIT test every 2 years

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19
Q

term used to describe the phenomenon that only a proportion of symptoms experienced by patients lead to a consultation

A

‘Symptoms iceberg’

70% of symptoms are never reported.

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20
Q

Triggers for seeking healthcare:

A

Interference with work / hobbies / house work
Interference with social relations
Interpersonal crisis = death of relative / friend, divorce, loss of child etc.
Putting a time limit on symptoms = will seek help if not resolved by certain time
Sanctioning = told to be someone else

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21
Q

Black Report conclusions on inequalities in health care:

A 
Statistical artefact (not genuine)
Natural selection (less well become poorer)
Materialistic exploitation of the lower socioeconomic classes
Cultural / behavioral explanations

determinants of health inequalities

  • Healthy people move up the classes
  • Poverty causes ill health
  • Life style differences
  • Social selection
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22
Q

Barriers influencing access to care

A 
provision/availabilty of services
cultural/family attitudes
previous bad experience
logistics
risk perception
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23
Q

Exercise guidelines

A

150 minutes of moderate intensity exercise OR 75 minutes of vigorous intensity per week = minimum of 30 mins each time
2x muscle strengthening activity per week
Limited time sat sedentary
Balance & co-ordination twice a week in elderly

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24
Q

National Service Frameworks:

role

A

“Policies set by NHS to define care standards for major diseases (Cancer, CHD, COPD, DM etc.) or for specific patient groups (elderly, palliative care)”

1) Set formal quality requirements, based on best evidence for / against treatments and services
2) Offer strategies / support to help organisations attain these

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25
Q

Who is involved in National service frameworks

A

Department of Health = create the strategy, after identifying need for one
Strategic Health Authority = implement + manage it
Consultation with patients, carers, public, charities, healthcare professionals and industry

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26
Q

Epidemic:

A

Occurrence in a community / region of cases of an illness / health-related behaviour clearly in excess of normally expected

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27
Q

Endemic:

A

Persistent, usual, or expected level of disease in a given population

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28
Q

Pandemic:

A

Epidemic over a very wide area, crossing international boundaries

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29
Q

Adverse event

A

“An unintended event resulting from clinical care and causing patient harm (physical or psychological)”
very preventable and common

eg prescribing error

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30
Q

Near miss:

A

events or omissions arising during clinical care but not developing far enough to cause injury to a patient i.e. not an adverse event.

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31
Q

Never event:

A

serious patients safety incidents that should not occur if the available preventative measures have been implemented
e.g. wrong site surgery / retained instrument in surgery / wrong chemotherapy admin route / inpatient suicide using collapsible rails / postpartum haemorrhage = maternal death after elective C-section / IV administration of concentrated KCl

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32
Q

For successful negligence claim relating to treatment/diagnosis, 3 things need to be proven

A

Causation
Duty: a duty of care existed between doctor and patient
Breach: the doctor’s practice fellow below the standard of care expected

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33
Q

Bolam v Bolitho

A

Bolam Test is used to see if the doctor’s actions are supported by a responsible body of medical opinion.
If they are not, then there has been a breach in the duty of care.
If they are, then the Bolitho Test is applied.

Bolitho Test is used to scrutinise if the actions undertaken by the doctor and supported by the medical opinion are logical.
If they are not, then there has been a breach in the duty of care.
If they are, then the duty of care has not been breached.

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34
Q

Most common errors

A

Prescribing = wrong dose, drug, route of admission

Communication failure

Delay / failure in diagnosis

Obstetricians get sued the most (around 85% have been sued at some point)

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35
Q

Duty of Candour

A
  1. Must tell patient when something has gone wrong
  2. Must apologise & offer appropriate resolution
  3. Must explain the potential short & long-term effects
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36
Q

Common complaints:

A
  • Safety issues
  • Poor / insufficient information
  • Ineffective clinical practice, including poor coordination of discharge
  • Poor handling of complaints ie failure acknowledge validity / to apologise / jargon in response / not explained what done
  • Lack of dignity / respect / poor attitudes of staff
  • Failure to follow consent procedure
  • Poor environment including poor hygiene
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37
Q

What is standardised mortality ratio (SMR)?

A

Ratio between observed number of deaths in a study population to the number of expected deaths

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38
Q

Calman-Hine Report (1995)

A

Concluded unacceptable variation in quality of treatment between hospitals = services were disjointed & outcomes were poor
Highlighted need for strategic clinical cancer networks

  • So would be better to centralize treatment to improve quality, with primary care at the center of this
  • Should ensure all patient have equal access to care
  • Public & professionals educated on recognizing early signs
  • Services should be patient centered, given clear info on treatment options & outcomes
  • Cancer registration & monitoring of outcomes is essential
  • Psychosocial needs of carers & patient recognized
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39
Q

Cancer Networks (34 in total) – 3 levels of care:

A 
Primary Care - prevention & early diagnosis
Cancer Unit (1 per 250,000) - treat common cancer, make diagnosis (non-complex chemo & surgery)
Cancer Center (1 per million) - treat rare cancers, radiotherapy, complex chemotherapy & surgery
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40
Q

Role of strategic cancer networks/what they do:

A

development of strategic plans for delivering better care
bring together those who use, provide and commission services to make improvements in outcomes for complex patient pathways using an integrated, whole system approach
Implementation of national policies
Deliver the improvements in care
Provide a channel for communication between groups across the network
Provide resources for audits and research

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41
Q

benefits of strategic cancer networks

A

Accurate studies on epidemiology of different cancers- useful for guiding future research
Commision care in a way to reduce inequalities in care throughout the SCN region , Reduces postcode lottery
Reduces incidence of cancer - through better screening programs and greater focus of cancer in primary care
Maximise survival of CA patients
Enhance quality of life of patients and families
Improve the patient experience of cancer services

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42
Q

Concentraing specialist care in cancer centres

A

pros- better case management of less common conditions
cons- increased geographical inequalities in cancer service provision, barriers to accessing care ( cost of travel, effort)

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43
Q

National Cancer Research Network:

A

Established in 2001
They support and promotes recruitment of patients into cancer trials and improves the speed of research into clinical practice to ensure patients receiving best possible and up to date care
Closely matched to cancer networks to improve patient numbers etc.

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44
Q

National Cancer Research Institute:

A

created to develop common plans for cancer research and to avoid unnecessary duplication of studies / effort
Established in 2001
Roles:
Invest in facilities + resources for research
Maintain cancer research database and analyze new research
Develop research initiatives
Coordinate clinical trials for new drugs

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45
Q

The audit cycle:

A
  1. Identify the issue
  2. Obtain or define standards Find the guideline which you are going to compare your data to
  3. Collect data/measure current performance
  4. Compare performance with standards and identify causes of non achievement
  5. Implement change
  6. Re-audit
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46
Q

Why audit?

A

Improves patient care by identifying shortcomings
Provides opportunities for clinical education.
Assess progress against national standards.guidelines are based on best evidence so important that they are closely followed on the front line in hospital
Financial benefits. Can check Services running efficiently and resources used appropriately
Fulfils contractual obligation
Encourages teamwork

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47
Q

Limitations audit

A 
The only thing you are comparing to is current best practice
May not always help 
Costs time, money and resources
If it doesn't change anything, resources have been wasted
‘Snapshot’ nature of information 
Lack of generalisability 
Accuracy of data collection 
Size of results examined
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48
Q

Research ethics principles - Nuremberg Code

A
  1. Voluntary consent is required
  2. Should yield results beneficial to society that cannot be acquired by other means
  3. Based on animal experimentation and a knowledge of natural history of the disease
  4. Avoid all unnecessary physical and mental suffering
  5. Should not be performed if there is a reason to believe the intervention is harmful
  6. Risk should not exceed the benefits
  7. Preparations and facilities should be provided to protect subjects and injury, disability, or death
  8. Should be conducted by scientifically qualified people
  9. Subjects should be able to leave whenever they wish
  10. Scientists in charge must be prepared to end the experiment is there is evidence of harm (or likely to be)
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49
Q

Incidence:

A

Number of new cases over a period of time

New cases of disease within a period / number initially free of disease

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50
Q

Prevalence:

A

Number of cases present in a population at a given time

Number of people with disease at particular point in time / total population

Changes as people die/emigrate/are cured

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51
Q

10 legal requirements for a post-mortem:

A

Sudden / unexpected death
Unknown cause of death / unnatural death (accident / suicide / suspicious)
History of violence or substance abuse, alcoholism etc.
Death may be due to a medical procedure either invasive or not
Industrial disease death
Death from negligence
Death within 24 hours of admission
Not seen by doctor for 14 days
Patient detained under MHA
Receiving war pension / industrial disability pension unless death shown to be unconnected

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52
Q

For consent to be valid it must me

A

voluntary informed and patient must have capacity

to make consent informed the patient must be provided with basic overview of their condition, likely outcome of their decision, their treatment options including a second opinion

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53
Q

Name three statutes that oblige physicians to disclose information without the consent of the patient.

A

Public Health (Control of Diseases) Act 1984 (Notifiable diseases)
Abortion Act 1967
Birth and Deaths Registration Act 1953
Road Traffic Act 1988
Human Fertilization and Embryology Act 1990
NHS Venereal Diseases Regulations 1974
Prevention of Terrorism Act 1989/terrorism act 2000
Drug trafficking act 1986

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54
Q

Criteria to fulfil when breaching confidentiality under a public interest defence

A

A risk of harm needs to be identified
Patient consent should be gained if possible
You do not need to attempt to gain consent if doing so would put you at risk of serious harm, or would prejudice the prevention, detection or prosecution of crime.
The patient should be warned that disclosure will be made
Disclosure should be made on a need-to-know basis (i.e. only to the relevant people)
The disclosures made should be kept to a minimum (i.e. only disclosing relevant information)
The information should be anonymised, if possible.

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55
Q

Impairment

A
  • Temporary or permanent loss or abnormality of body structure or function
  • May be functional, physiological or psychological
    eg amputated leg/ muscle pain
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56
Q

Disability

A

Restriction of normal activity from impairment

Lack of ability to perform an activity in the manner/within a range considered normal

eg walking

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57
Q

Handicap

A

Limits or prevents the fulfilment of a role that is normal for that individual

eg going to shop

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58
Q

Human Rights acts relevant to healthcare

A
  • Article 2 = right to life
  • Article 3 = prohibition of torture (or inhuman or degrading treatment of punishment)
  • Article 5 = right to liberty and security
  • Article 6 = right to a fair trial
  • Article 8 = right to respect for private and family life
  • Article 9 = freedom of thought, conscience and religion
  • Article 10 = freedom of expression
  • Article 12 = right to marry and found a family
  • Article 14 = prohibition of discrimination
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59
Q

Chance of conception

A

People who are concerned about their fertility should be informed that over 80% of couples in the general population will conceive within 1 year if:

  • the woman is aged under 40 years and
  • they do not use contraception and have regular sexual intercourse.

Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over 90%)
aginal sexual intercourse every 2 to 3 days optimises the chance of pregnancy.

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60
Q

causes of infertility

A 
○	Male/ Sperm problems (30%)
○	Ovulation problems (25%)
○	Tubal problems (15%)
○	Uterine problems (10%)
○	Unexplained (20%)
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61
Q

Consider unstimulated intrauterine insemination as a treatment option in the following groups as an alternative to vaginal sexual intercourse:

A

people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem who are using partner or donor sperm

people with conditions that require specific consideration in relation to methods of conception (for example, after sperm washing where the man is HIV positive)

people in same-sex relationships.

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62
Q

Intracytoplasmic sperm injection (ICSI)

A

Same as IVF but instead of allowing the insemination mixing, sperm are injected into oocytes.Indicated when quality of sperm is poor/low sperm count or when pregnancy has failed in the past

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63
Q

IVF criteria according to NICE if <40

A

In women aged under 40 years who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where 6 or more are by intrauterine insemination), offer 3 full cycles of IVF, with or without ICSI. If the woman reaches the age of 40 during treatment, complete the current full cycle but do not offer further full cycles.
In women aged under 40 years any previous full IVF cycle, whether self- or NHS-funded, should count towards the total of 3 full cycles that should be offered by the NHS.

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64
Q

IVF criteria according to NICE if >40

A

In women aged 40–42 years who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of artificial insemination (where 6 or more are by intrauterine insemination), offer 1 full cycle of IVF, with or without ICSI, provided the following 3 criteria are fulfilled:

  1. they have never previously had IVF treatment
  2. there is no evidence of low ovarian reserve
  3. there has been a discussion of the additional implications of IVF and pregnancy at this age.
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65
Q

CCGs may have additional criteria you need to meet before you can have IVF on the NHS, such as:

A

not having any children already, from both your current and any previous relationships
being a healthy weight
not smoking
falling into a certain age range (for example, some CCGs only fund treatment for women under 35)

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66
Q

Human Fertilization & Embryology Act 1990

A

Established the Human Fertilisation and Embryology Authority = statutory body that regulates and inspects all clinics in the United Kingdom providingIVF,artificial inseminationand the storage of humaneggs,spermorembryos. It also regulates human embryo research
“Women should not be provided with treatment unless account has been taken of welfare of any child who may be born as a result (including need for a father)”
2008 revision of father to supportive parenting

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67
Q

Ethical scenario IVF

A

FOR
- procreative autonomy: respect patient choices, minimalize state interference
- infertility can affect mental health
- welfare interest of future child
AGAINST
- embryos have moral status (destruction of embryos)
- harm to those conceive (OHSS, multiple, ectopics)

  • Positive rights: no obligation to provide parents with means to have children
  • Negative right: obligation not to interfere with peoples decision to have children
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68
Q

Abortion Act 1967 (amended 1990)

A

Must meet 1 of the following criteria:

  1. Pregnancy not 24+ weeks, and continuation would involve risk (of injury to physical/mental health of woman/existing kids) greater than that of termination
  2. Termination >24 weeks if necessary to prevent grave permanent injury (physical/mental), including saving mothers life
  3. Substantial risk that child, when born, would suffer serious handicap (due to physical / mental abnormalities)
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69
Q

Anti-Abortion (“pro-life”):

A
  1. Abortion ends life of foetus –> foetus has moral status of person –> wrong to end life of something with this moral status –>Abortion is morally wrong = justice
  2. Abortion is doing harm = non-maleficence
  3. Can lead to medical complications later in life both physical & psychological = non-maleficence
  4. Many couples are looking to adopt & abortion is depriving them of this option = justice
  5. Religious reasons
  6. abortions for Down’s syndrome – suggest they have a lower moral status than other children
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70
Q

Pro-abortion:

A
  1. Even if foetus is human, what about risk to mothers life? = non-maleficence
  2. Foetus isn’t alive so doesn’t have the rights of a human –> especially as most take place at a stage where foetus wont survive =non maleficence
  3. Banning will just encourage the use of unsafe & harmful methods = beneficence
  4. Women should be able to avoid the emotional harm of bearing a child by rape = non-malificence
  5. May be due to a contraceptive failure / mistake and pregnancy may reduce quality of life for mother and she may not be able to provide good quality of life for future child = beneficence
  6. Will allow women in teenage years to achieve full potential = justice
  7. women have right to decide what happens to their body/pregnnacy (autonomy)
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71
Q

Ethical scenario: Down’s syndrome screening

FOR

A
  • allows parents to prepare and plan

- gives them an informed choice if they want to terminate

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72
Q

Ethical scenario: Down’s syndrome screening

AGAINST

A
  • risk of false positive and negatives
  • spontaneous abortion with diagnostic testing (1%)
  • suggesting Down’s syndrome life is less important
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73
Q

cervical screening programme

A

Ages 25-49 invited every 3 years

Ages 50-64 invited every 5 years

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74
Q

most common sexually transmitted infection in the UK

A

Chlamydia

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75
Q

National Chlamydia Screening Programme

A

aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner. Everyone that tests positive should have a re-test three months after treatment. This re-testing is to ensure they have not contracted chlamydia again

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76
Q

Preventing HIV transmission:

A
  • media campaigns
  • education in school
  • testing HIV and counselling
  • ART
  • condom use, Distribution of condom for free espiecally amongst high risk places, e.g. brothels
  • contraception reduces the risk man to woman by 50%.
  • treat chlamydia and gonorrhea as these facilitate HIV transmission during sex.
  • IVDU and needle change
  • Effective post-exposure prophylaxis
  • HIV mothers not breastfeeding
  • Limiting number of sexual partners
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77
Q

most common non-viral sexually transmitted infections worldwide

A

Trichomonas vaginalis- a protozoan, and is a single-celled organism with flagella.

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78
Q

female genital mutilation (FGM)

A

‘all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons’.

Type 1
Partial or total removal of clitoris and/ prepuce (clitoridectomy)
Type 2
Removal of clitoris and labia minora (w/wo excision of labia majora)
Type 3
Narrowing of vaginal orifice creating a seal by cutting and appositioning the labia minora and/or labia majora with/ without excision of clitoris
Type 4
All other harmful procedures for non-medical purposes e.g. pricking, incising, scraping

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79
Q

Laws around FGM

A

ANY form of FGM is AGAINST the law in the UK INCLUDING REFIBULATION AFTER DELIVERY ( stitching up again) It carries a 14 year prison sentence

Law + child protection
Female Circumcision Act 1985 made it criminal to
Excise, infibulate or otherwise mutilate the whole or any part of the labia majora or labia minora or clitoris of another person
Aid, abet, counsel or procure a girl to mutilate her own genitalia

Law Updated
Female Genital Mutilation Act 2003 which added a further criminal offence
Aid, abet, counsel or procure another person who is not a UK national to mutilate a girl’s genitalia outside the UK

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80
Q

Most common gynae cancers

A
  1. endometrial
  2. ovarian
  3. cervical
  4. vulva
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81
Q

Complications of Domestic Abuse in obstetrics and gynaecology

A 
higher rate of miscarriage 
premature birth & LBW 
fetal injury & death 
premature labour & delivery 
chorioamnionitis & maternal infections 
poor weight gain 
Violent pregnancies are high risk
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82
Q

Recommendations for domestic violence issues in obstetrics and gynaecology

A

Routine enquiry.
A named midwife should be responsible for and provide the majority of the antenatal care to a woman who has experienced domestic abuse.
Women should be given the opportunity to disclose domestic abuse in an environment in which they feel secure.

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83
Q

Alerts for domestic violence

A 
Late booker/poor attender 
Repeat minor injury attendance 
Unexplained admissions 
Depression/anxiety/self harm 
Injuries of different ages (minimalisation) 
STD/UTI/vaginal infections 
Poor obstetric history 
Domineering partner
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84
Q

Risk factors of significant harm or neglect to any child who may be born or to any existing child

A
  1. Past or current circumstances that may lead to any child experiencing serious physical or psychological harm or neglect,
  2. Previous convictions relating to harming children
  3. Child protection measures taken regarding existing children, or violence or serious discord in the family environment
  4. Past or current circumstances that are likely to lead to an inability to care throughout childhood for any child who may be born, or that are already seriously impairing the care of any existing child of the family, for example;
    a. mental or physical conditions,
    b. Drug or alcohol abuse.
    c. Medical history, where the medical history indicates that any child who may be born is likely to suffer from a
    serious medical condition,
    d. Circumstances that the centre considers likely to cause serious harm to any child mentioned above.
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85
Q

Epidemiology non melanoma skin cancers

A

BCC is the commonest form of skin cancer. It is 4-5x more common than squamous cell carcinoma (SCC).

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86
Q

Epidemiology Melanoma

A

In the UK, it accounts for approximately 4% of all new cancers.represents the fifth most common cancer.
M>F

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87
Q

Premalignant lesions

A

actinic keratosis and Bowen’s disease

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88
Q

Counsel patients on appropriate sun protection behaviours

A

SMART ways to avoid excessive sun exposure
Spend time in the shade between 11am-3pm
Make sure you never burn
Aim to cover up with a t-shirt, wide-brimmed hat and sunglasses
Remember to take extra care with children
Then use Sun Protection Factor (SPF) 30+ sunscreen

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89
Q

Dx Hypertension

A

clinic blood pressure of 140/90 mmHg or higher and

ABPM daytime average or HBPM average of 135/85 mmHg or higher.

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90
Q

<80 y HTN target

A

below 140/90 mmHg

abpm/hbpm: below 135/85 mmHg

91
Q

> 80y HTN target

A

below 150/90 mmHg

abpm/hbpm: below 145/85 mmHg

92
Q

diabetes HTN target

A

135/85 mmHg - type 1 diabetes.

130/80 mmHg - albuminuria or 2 or more features of metabolic syndrome

93
Q

CKD and ACR ratio under 70 mg/mmol HTN target

A

aim for below 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure below 90 mmHg.

94
Q

CKD and an ACR ratio of 70 mg/mmol or more HTN target

A

aim for below 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure below 80 mmHg

95
Q

HTN target in pregnancy

A

135/85 mmHg.

96
Q

services for patients with visual impairment and deafness impairment

A

organisations like royal institution of blind/deaf people , charity eg deafblind uk,vision aids, hearing aids ,braille

97
Q

Tests for downs syndrome- more likely if ..

A

beta hcg - increased
papp-a - reduced
AFP- reduced
Inhibit A - increased

98
Q

Stillbirth definition

A

is when a baby is born dead after 24 completed weeks of pregnancy/ 1000 births

99
Q

Stillbirth epidemiology

A

1 in every 200 births in England.

Findings Globally in 2019, an estimated 2·0 million babies were stillborn at 28 weeks or more of gestation

100
Q

Perinatal mortality definition

A

perinatal mortality rate = number of stillbirths + early neonatal deaths per 1000 total births - WHO definition
the perinatal period commences at 22 completed weeks (154 days) of gestation, and ends seven completed days after birth”

101
Q

Neonatal mortality:

A

Death of a live born infant –> 28 days

Early neonatal = < 7 days

102
Q

Maternal mortality

A

Includes up to 42 days post-pregnancy if is due to any cause related to or aggravated by the pregnancy
Doesn’t include incidental RTA etc.

103
Q

Risk factors for still birth

A 
Foetal growth restriction is biggest
Congenital anomaly
Multiple pregnancy
Age of extremes of maternity (<25/>40)
Obesity
Smoking
Obstetric complications  APH/PPH
Geographical variation
Ethnicity  Black or Asian have significantly higher rates
Lower socioeconomic status
104
Q

Preventing still birth

A

not smoking
avoiding alcohol and drugs during pregnancy
not going to sleep on your back after 28 weeks
attending all your antenatal appointments
taking folic acid before pregnancy and having a flu vaccine during your pregnancy
limiting the amount of caffeine
Better supervision during labour/identifying women at risk in labour such as placental abruption/cord prolapse
Identifying babies not doing well eg infection and providing antibiotics quickly etc

105
Q

Preterm definition

A

A premature infant is an infant born before 37 weeks’ gestation.

Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm

106
Q

Risk factors for prematurity

A

intra-uterine infection
preterm premature rupture of membranes (PPROM)
pre-eclampsia/pregnancy-induced hypertension
placental abruption/antepartum haemorrhage
abnormal amniotic fluid volume
severe bacterial vaginosis
multiple gestation
previous preterm birth/family history
foetal abnormality
cervical incompetence/uterine abnormality
gestational diabetes
maternal surgery during pregnancy
chronic maternal illness
maternal pregnancy body mass index <19 or >35
short interpregnancy time interval
drug use (tobacco, cocaine, heroin)
stress/depression
non-white race

107
Q

Preterm complications

A

low oxygen levels at birth, hypothermia, trouble feeding and gaining weight, respiratory distress syndrome, infection and necrotising enterocolitis, brain injury IVH

108
Q

Low birth weight definition

A

weight lower than 2.5 kg 5 pounds, 8 ounces.

Normal range of weight for babies is around 3200 -3600g

109
Q

Causes of low birth weight

A

born premature
IUGR-could be due to problems with the baby’s health, the mother’s health of the placenta. Often related to pregnancy associated hypertension
infection during pregnancy, smoking, alcohol or drug use.
Globally, malaria and malnutrition

110
Q

Causes of low birth weight

A

born premature
IUGR-could be due to problems with the baby’s health, the mother’s health of the placenta. Often related to pregnancy associated hypertension
infection during pregnancy, smoking, alcohol or drug use.
Globally, malaria and malnutrition

111
Q

Sudden infant death syndrome (SIDS) definition

A

sudden unexplained death in an infant. It is sometimes referred to as “cot death”. This usually occurs within the first six months of life. In the UK 230 babies die unexpectedly and suddenly.

112
Q

SIDS risk factors

A 
Prematurity
Low birth weight
Smoking during pregnancy
Parental smoking 
Male baby (only slightly increased risk)
Co sleeping with adult
Sleeping on soft surface
Sleeping on stomach/front
113
Q

Measures to reduce the risk of SIDS

A

Put the baby on their back when not directly supervised
Keep their head uncovered
Place their feet at the foot of the bed to prevent them sliding down and under the blanket
Keep the cot clear of lots of toys and blankets
Maintain a comfortable room temperature (16 – 20 ºC)
Avoid smoking. Avoid handling the baby after smoking
Avoid co-sleeping, particularly on a sofa or chair
If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers
The lullaby trust is a charity to help support families affected. Bereavement services and bereavement counselling should be available for affected families.
The Care of Next Infant (CONI) team supports parents with their next infant after a sudden infant death.

114
Q

congenital dysplasia of the hip

A

caused by abnormal development of the hip joint.In DDH, the socket of the hip is too shallow and the femoral head is not held tightly in place, so the hip joint is loose. In severe cases, the femur can come out of the socket

115
Q

Risk Factors for DDH

A 
Female sex 
First born
positive family history
breech presentation
postural deformity
can be associated with foot and spine abnormalities like talipes
restricted intrauterine space
incorrect lower-extremity swaddling

more common in the left hip
More common if European origin.

116
Q

DDH Screening

A

Checked in NIPE within 72h of birth
ultrasound scan of their hip between 4 and 6 weeks old if a doctor, midwife or nurse thinks their hip feels unstable.
US if childhood hip problems in first degree family,baby was in the breech position in the last month of pregnancy (at or after 36 weeks), or baby was born in the breech position after 28 weeks of pregnancy
in the case of multiple births with these risk factors, all babies in the pregnancy should have a hip ultrasound

117
Q

Living with a chronic condition, its effects on young person

A

Distress for patients and family
Chronic burneder of disease- never a break from regimen
Impairs spontaneity esp as its likely to be food related
How is emotional distress expressed eg parents might be anxious, can reinforce mentality for children
Time off school and difficulty completing coursework and exams
Feeling different to friends
Needing to plan day meals medications etc
Increased dependence on parents at at time of when independence is normally developing Impact on employment eg t1d and being a pilot,epilepsy and driving
Future fertility eg cf
Life expectancy eg cf

118
Q

Why might a young person miss their medications ?

A

Poorly developed abstract thinking and planning. They genuinely forget!
Difficulty in imagining the future self . Feels “Bullet proof”
Rejection of medical professional as part of NORMAL peer identification and separation from parents
Side effects of treatment unacceptable to young person eg weight gain with insulin, “spaced out” feeling of anticonvulsants

119
Q

legislation that sets out basic human rights of all children up to 18 years of age and responsibilities of countries to uphold these

A

United nations convention on the rights of the child 1989
Article19 Governments should ensure that children are properly cared for and protect them from violence, abuse and neglect by their parents, or anyone else who looks after them.

Children act 2004 is an updated version

120
Q

Children’s Act 2004 Section 17

A

places duty on local authorities to provide support and services for children in need. child is in need -> parents need to change their behaviour.

121
Q

Children’s Act 2004 Section 47

A

places duty on local authorities to make enquiries in cases where there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. child is at risk of significant harm -> child needs to be removed from the household.

122
Q

if you are concerned that the young person might be at risk of significant harm

A

Make a note of your concerns and observations
Discuss with senior medical and nursing colleagues
Discuss what you are going to do and why with the child and their parent(s) or carer(s) - as long as this does not put them at increased risk
Notify and refer to children’s social services by phone. In an emergency (e.g. the child absconds or parent tries to take the child), call the police
Participate in a strategy discussion with social services, police and other agencies (e.g. school)
If the strategy discussion concludes the young person is at risk of significant harm, a Section 47 Child Protection enquiry should be called
After completion of the enquiry, a case conference is held
The case conference decides whether or not the young person should be placed on the Child Protection Register and subject to a Child Protection Plan

123
Q

Burns and children

A
  • children < 5 suffer 45% of all burns and scald accidents, usually in kitchen (hot water, irons, ovens)
  • consider sunburn (sunscreen, hat, out of sun)
  • get smoke alarms, don’t smoke near bed/sofa
  • keep hot objects out of their reach
124
Q

Types of childhood accidents

A

Babies = burns, scalds and being dropped
Toddlers = falls, burns, scalds, POISONING
Older children = falls

125
Q

methods of prevention of childhood injury/accidents

A

road safety and use of cycle helmets, gates on stairs, safety in kitchen, smoke alarms, protection against fire hazards, covering electric sockets and keeping medicines/poisons out of reach
Choking: hold them when feeding, cut food into small bits, sit with child
Suffocation: no loose bedding, dispose of plastic bags safely
Falls: careful carrying baby, strap a child in high chair
Poisoning: CO alarms, medicines out of reach
Drowning: never leave baby in bath alone
Road accidents: correctly fitting rear seat every journey

126
Q

Worrying NAI signs

A
  • Explanation for injury absent or unsuitable
  • Child is not independently mobile
  • Injury on an area that wouldn’t come into contact with hot surface e.g. soles of feet, back, buttocks
  • Injury in the shape of an object e.g. iron, belt etc. well demarcated
  • Delayed presentation
  • Evasive or changing history
  • Inconsistency between age of injury and examination findings
  • Signs of restraint on limbs
  • Excessive multiple bruises of different ages
  • spiral/ metaphysis fractures
127
Q

Risk factors child maltreatment

A 
Chronic disease
Disability
Social isolation
Poverty and poor housing.
Unplanned pregnant
Challenging behavioural needs 
wrong gender

toxic trio:
Parental mental health
Domestic violence and abuse
Parental substance misuse

128
Q

Sexual abuse in children

A
  • recurrent GU symptoms (enuresis, constipation, soiling)
  • abdo pain
  • self harm
  • alcohol/drug misuse
  • pregnancy
  • emotional/behavioural problems
  • sexualized behavior
129
Q

Neglect:

A
  • persistent failure to meet child’s basic physical and psychological needs
  • poor interactions, poor growth, poor dental health, cleanliness, missed appointments
130
Q

Emotional abuse:

A
  • persistent emotional maltreatment such as to cause severe and persistent adverse effects on a child or young persons emotional development.
131
Q

Definition safeguarding

A

“Action to promote the welfare of children and protect them from harm”
Protect from maltreatment
Prevent impairment of health and development
Ensure that children grow up in circumstances consistent with provision of safe and effective care
Take action to enable all children to have good outcomes

132
Q

Healthy child programme

A

all children receive a basic service with increased input according to a child or family’s needs

Encouraging a strong bond between parents and child and helping parents enhance their parenting skills
Promoting children from serious diseases through immunisation and screening
Promoting healthy eating, physical activity and reducing obesity
Identifying problems in children’s health and development ( such as learning difficulties) and safety ( such as parental neglect) and directing families for help
Making sure children are ready for school
Identifying and helping children with problems that may affect their changes in later life

133
Q

Health promotion in school

A 
Nutrition
Dental health 
Physical activity
Reducing risk factors for obesity
Drugs and alcohol abuse
Contraception and safe sex
Sti
Smoking
Healthy relationships
Caring for young children
134
Q

Consequences of poor early health

A

Start life in poor health > LD + poor mental health, poor diet
Adolescents > leave school early, physically inactive
Adulthood: mortality risk, physical/mental health, social stigma

135
Q

Children exposed to passive smoking are at increased risk of

A

sudden infant death syndrome, middle ear disease, lower respiratory tract illness and asthma.

136
Q

Conditions for valid consent

A

Under the Mental Capacity Act, there are a number of conditions that have to be met for valid consent to be obtained from a patient:

  1. The patient must have capacity.
  2. The consent must be freely given (i.e. uncoerced) and the patient must be suitably informed (i.e. have been given a suitable level of detail of the procedure, and expected outcomes and risks).
137
Q

Mental Capacity Act (MCA) 2005 key principles

A

Capacity is assumed; it needs to be proven otherwise
Enabling people to make their own decisions
Unwise decisions
Best interests
Less restrictive option

138
Q

Capacity

A

A person can consent to treatment provided he or she is competent to understand the nature, purpose and possible consequences of the treatment proposed
• understand its principal benefits, risks and alternatives;
• understand in broad terms what will be the consequences of not receiving the proposed treatment;
• retain the information for long enough to use it and weigh it in the balance in order to arrive at a decision.

139
Q

Fraser (Gillick) competence

A

A young person under 16 can consent to treatment provided he or she is competent to understand the nature, purpose and possible consequences of the treatment proposed . eg contraception or sexual health treatment

140
Q

Competent for fraser if

A
  • The young person understands the doctor’s advice.
  • The doctor cannot persuade the young person to inform his or her parents
  • The young person is very likely to begin or continue having sexual intercourse with or without contraception
  • The young person’s physical or mental health or both are likely to deteriorate if he or she does not receive contraceptive treatment
  • The young person’s best interests require the doctor to give contraceptive advice or treatment or both without parental consent
141
Q

children and consent

A

People aged 16 or over are entitled to consent to their own treatment.
Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment. This is known as being Gillick competent.Otherwise, someone with parental responsibility can consent for them.
If a young person refuses treatment, which may lead to their death or a severe permanent injury, their decision can be overruled by the Court of Protection.

142
Q

Transition of care definition

A

“a purposeful, planned process that addresses the medical, psychological and educational/ vocational needs of adolescents and young adults with chronic physical and medical conditions as they move from child centred to adult-oriented health care systems”

143
Q

Ingredients of a good programme

A

Discuss the matter during childhood and as the young person grows up
Acknowledge issues facing both the patient and his/her parents
Identify colleagues who have an interest in young adults who may supervise them
Select a health worker (family practitioner, nurse etc.) who may supervise the transfer
Organised common meetings with the new team
Secure some follow-up phone calls
Identify individuals (adults, peers) who can give support

144
Q

Primary prevention diabetic eye disease

A 
Glycaemic control
Blood pressure control
Lipid control 
Healthy balanced diet and exercise
Smoking cessation

screening every year

145
Q

Optometrists:
Opthalmologist:
Orthoptists:

A

Optometrists: examine eyes for defect in visions and screening for diseases
Opthalmologist: operations on eye, work in eye hospitals/ departments
Orthoptists: work with ophthalmologist, concerned with eye movement and inability for eyes to work together e.g. strabismus, amblyopia, diplopia

146
Q

causes of squint

A

Refractive errors, especially hypermetropia.
Other causes of poor visual acuity (including occular malformations, optic neuropathy, amblyopia (lazy eye) congenital cataract, and retinoblastoma.
Neurodevelopmental conditions/ syndromes (cerebral palsy and downs syndrome)
Congenital abnormalities of the extra-ocular muscles or their innervation, such as Brown’s syndrome and Duane’s syndrome.
Diseases that can affect one or more of the extra-ocular muscles or their innervation, such as brain tumours, other brain lesions, head injury, post-viral problems, hydrocephalus, and muscle disorders (for example myasthenia gravis).

147
Q

Blindness in children:

A
  • high income: lesions of optic nerve, higher visual pathways
  • lower income: measles, vitamin A deficiency, rubella, corneal scarring
148
Q

blindness epidemiology

A

● Causes worldwide: Cataracts > Glaucoma > ARMD > Corneal opacity > Trachoma > Childhood (vit A deficiency)
● Causes in developed world: ARMD > Congenital causes > Cataract > Glaucoma > Diabetes

149
Q

Routine screening for eyes

A

NIPE- 72h of birth
6 week check
At school entry (around 4 or 5 years of age), vision screening is offered

150
Q

Newborn hearing screening

A

automated otoacoustic emissions (AOAE). if test is abnormal they can do Automated auditory brainstem responses (AABR)

AABR is also used with AOAE for babies who have spent over 48 hours in the Special Care Baby Unit or Neonatal Intensive Care Unit

151
Q

Distraction test

A

6-9 months
Performed by a health visitor, requires two trained staff.Sounds are produced to the right or left of the baby out of their field of view and the loudness required until they react to these is assessed

152
Q

Recognition of familiar objects

A

18 months - 2.5 years

Uses familiar objects e.g. teddy, cup. Ask child simple questions - e.g. ‘where is the teddy?’

153
Q

> 2.5 years hearing tests

A

Performance testing

Speech discrimination tests- ssess the child’s ability to understand speech and differentiate it from background noise.

154
Q

Pure tone audiometry

A

> 3 years

Done at school entry in most areas of the UK

155
Q

Risk factors VTE

A
  • Recent surgery, especially abdominal/pelvic or hip/knee replacement.
  • Thrombophilia, eg antiphospholipid syndrome
  • Leg fracture.
  • Prolonged bed rest/reduced mobility eg travel
  • Malignancy.
  • Pregnancy/postpartum; combined contraceptive pill; HRT (lower risk).
  • Previous PE.
156
Q

possibility of fractures as an indicator of non-accidental injury

A

rib fracture
multiple fractures
Injuries to the long bones were invariably spiral or oblique fractures or subperiosteal new bone formation–both “gripping or twisting” injuries eg Spiral fracture of the humeral shaft

157
Q

Signs of burn NAI

A

Delay in seeking medical attention.
The details of the mechanism of injury are implausible, change over time, or are inconsistent with the developmental stage of the child
Lack of concern by the person accompanying the child.
Abnormal behaviour or demeanour by the child e.g. withdrawn
Direct disclosure by the child that the injury was deliberately inflicted.
Lines of demarcation ( glove and stocking, donut sparing)
No splash marks
Sparing of flexor creases
Maybe circumferational
history form different carers slightly different

158
Q

health promotion with relation to burns and scald

A

Keep hot drinks away from kids
Keep toddler out of kitchen
Double check temperature of bath for child, don’t leave kid <5 alone
Make sure hot items out of reach while they cool down
Hats and reapply sunscreen for kids, encourage them to play in shade
keep babies under the age of 6 months out of direct sunlight, especially around midday

159
Q

Paediatric palliative care conditions

A

Life-threatening for which curative treatment is feasible, e.g. malignancy
Premature death inevitable, where may be long periods of intensive treatment, e.g. CF
Progressive conditions without curative treatment options, e.g. DMD
Irreversible but non-progressive conditions causing severe disability leading to susceptibility to health complications & likelihood of premature death

160
Q

Hospices in paediatric palliative care

A

Can provide symptom control & respite stays, along with support at the home
Specialists in play, music & art therapists, chefs  includes support to sibling
Most hospices have refrigerated bedrooms allowing time with child after death
Support for family & siblings, including for funeral & for months / years to come

161
Q

Level 0

A

Patients whose needs can be met through normal ward care in acute hospital
Majority of inpatient wards

162
Q

Level 1

A

Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team
Could be a part of the AMU or nurse enhanced unit
May have lower GCS
4 to 1

163
Q

Level 2

A

HDU areas
Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those stepping down from higher levels of care
2 to 1

164
Q

Level 3

A

ICU
Patients require advanced respiratory support alone ( if on a ventilator will be sedated) or basic respiratory support (e.g. nasal high flow) together with support of at least 2 organ systems. This level includes all complex patients requiring support for multiorgan failure.
1 to 1 nursing

165
Q

epilepsy driving restrictions

A

first unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months

for patients with established epilepsy or those with multiple unprovoked seizures:may qualify for a driving licence if they have been free from any seizure for 12 months

166
Q

Syncope driving restrictions

A

simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off

167
Q

stroke driving restrictions

A

single TIA: must not drive for 1 month but need not notify DVLA.
People who have multiple TIAs: must not drive for 3 months and must notify DVLA. Driving may resume after 3 months if there have been no further TIAs.

People who have had a stroke must not drive for 1 month but may not need to notify DVLA. Driving may resume after 1 month if there has been satisfactory clinical recovery. DVLA does not need to be notified unless there is residual neurological deficit 1 month after the episode and, in particular: visual field defects, cognitive defects, impaired limb function.

168
Q

social and medicolegal implications of a diagnosis of epilepsy

A

Education for patient, carers, family, friends colleague
Avoiding stimulants
Implications on jobs eg pilot
Safety: driving, heights, open water swimming- drowning risk

169
Q

impact of untreated inflammatory arthritis

A

severe damage to joints, lead to disability, and harm major organs.
cardiovascular disease
infection
also known to be associated with higher risks for lymphoma, anemia, osteoporosis, and depression.

170
Q

Back pain Red flags – associated with potentially serious secondary physical pathologies.

A

Age of onset <20 years (inflammatory spinal conditions) or >55 years (malignancy or vertebral fractures)
Recent trauma (sudden onset) important to exclude fractures
Nocturnal pain
Thoracic pain
Pain not relieved with rest (shows its not mechanical)
Past history of malignancy
Osteoporosis risk (increased risk of vertebral fractures)
Infection risk (immunosuppression, IVDU)
Systemic features (fever, weight loss) need to rule out malignancy and infection
Progressive neurological signs/bladder/bowel dysfunction (cauda equina, spinal cord compression)
Structural deformity ( ankylosing spondylitis, fractures)
Spinal (rather than paraspinal) tenderness.

171
Q

Back pain Yellow flags – potential psychosocial pathologies that may prolong recovery/influence outcome.

A

Belief that pain and activity are harmful
Abnormal sickness behaviour (extended rest)
Low/negative mood
Work environment (low support/dissatisfaction)
Seeking treatments that seem excessive/inappropriate
Ongoing litigation

172
Q

Complimentary therapy

A

Osteopathy-Tough physical manipulation, stretching and massage, goof for back pain, sports injuries
Chiropractor- dx, treat and prevent MSK – more manual treatments for back, neck, shoulder
evidence: small benefit after a year
recommend for lower back pain and osteoarthritis
Acupuncture- Release neurohumoral and endorphins.
NICE recommend for headache and migraine.

173
Q

end of life pain

A

Total Pain= Physical + Emotional + Social + Spiritual
•Physical- disease related, treatment related, debility, other health conditions e.g. arthritis
•Emotional- depression, anxiety, loneliness, guilt
•Social- financial worries, relationships with loved ones, loss of role
•Spiritual- religious uncertainty, feeling lost, uncertainty of the future
-Background Pain: pain that is consistently/ permanent
-Breakthrough/ Incidental Pain: transient, exacerbation of pain that occurs on movement or in relation to a trigger

174
Q

Euthanasia

A

an act of ending a patient’s life to relieve suffering

175
Q 
Types of euthanasia:
Active - 
Passive - 
Voluntary - 
Non-voluntary - 
Involuntary -
A

Active - does the act of ending life
passive - withholds life-prolonging treatment = patient can consent to this & make advanced directives to refuse this
Voluntary - when person dying consent
Non-voluntary - when person dying can’t consent, so make decision for them, often based on statement of wishes
Involuntary - against persons wishes = murder

176
Q

Arguments for euthanasia

A
  1. Allows patient autonomy to control own body & how one dies
  2. Is already done in some sense –> DNACPR is passive & sedation to shorten life by ending suffering in palliative = as being carried out anyway may as well legalize
  3. Acts in beneficence of patient
177
Q

Arguments against euthanasia

A
  1. Religious –> only God has right to end human life
  2. slippery slope- could change attitudes regarding human lives –> very ill may feel have to accept, may hinder research in cures to conditions, misdiagnosis could lead to euthanasia when death wasn’t imminent
  3. Violates non-maleficence –> could lead to lack of respect for terminally ill / feel like doctor wants to kill them!
  4. Detracts from instead improving end of life care = good quality should solve the suffering and thus the problem (does palliative care remove the need for euthanasia?)
178
Q

Situations where a patient and their loved one may request euthanasia

A

terminal diagnoses where cure is not possible (cancer, MND, Dementia, many), loss of function (e.g. C-spine injuries) or when a patient is in a coma (little brain activity, loved ones request)

179
Q

Physician Assisted Suicide:

A

“Suicide by a patient facilitated by means (as a drug prescription) or by information (as an indication of a lethal dosage) provided by a physician who is aware of the patient’s intent”

Unlike euthanasia, it is not legally equivalent to murder because the final act is done by the patient themselves. However, it is still illegal in the UK under the Suicide Act 1961 and can result in a sentence of up to 14 years.

Assisted dying is legal in some countries (e.g. Switzerland), and so some people from the UK have been known to travel abroad to end their lives.

180
Q

How doctors should respond to requests for euthanasia / assisted suicide according to GMC:

A

Be prepared to listen and to discuss the reasons for the patient’s request
Limit any advice or information to:
- An explanation that it is a criminal offence for anyone to encourage or assist a person to commit or attempt suicide
- Objective advice about the lawful clinical options (e.g. sedation and other palliative care) which would be available if a patient were to reach a settled decision to kill them self.
Be respectful and compassionate and continue to provide appropriate care for the patient
Explore the patient’s understanding of their current condition and care plan
Assess whether the patient has any unmet palliative care needs, including pain and symptom management, psychological, social or spiritual support

181
Q

Principles of palliative care as outlined by WHO

A

The prevention and relief of suffering of adult and paediatric patients and their families facing the problems associated with life-threatening illness’
Enhances quality of life
Promotes dignity and comfort, positively influences course of illness
Early identification, assessment and treatment of issues
Supports bereaved family members after a patient’s death
Does not intentionally hasten death
Accessible at all levels and integrated into disease management

182
Q

Types of nurses:

A
  • district nurse: community based, generic skills, hands on
  • practice nurse: practice based, general palliative care
  • marie curie: community based, district nurse for palliative care/ terminal illness
  • macmillan: community/hospital, cancer.
183
Q

Definition of Advanced Decisions

A

An Advanced Decision, short for Advanced Decision to Refuse Treatment, is a legally binding document. Its purpose is to ensure that an individual can refuse a specific treatment(s) that they do not want to have in the future.

184
Q

Advanced Decision Criteria

A

In order for an Advanced Decision to be legally binding, it must meet certain criteria:

​ It must be valid (this means it must have been made at a time when the individual had capacity to make that decision).

​ It must be applicable (this means the wording must be specific to the medical circumstances, and not vague or unclear).

​ It must have been made when the individual was over 18, and fully informed about their decision.

​ It must not have been made under the influence or duress of other people

​ It must be written down, be signed and witnessed (if it concerns a refusal of life-saving treatment)

185
Q

Definition of Advanced Statement

A

An Advance Statement is sometimes called a “Statement of Wishes and Care Preferences”. It allows an individual to make general statements about their wishes, beliefs, feelings and values and how these influence their preferences for their future care and treatment.

An Advance Statement is not by itself legally binding, but legally must be taken into consideration when making a “best interests” decision on someone’s behalf under the Mental Capacity Act (MCA), 2005. This is because one of the criteria of the MCA is that a patient’s “wishes, feelings, beliefs and values” must be taken into consideration; an Advanced Statement provides evidence of this.

186
Q

Information that can be included in an Advanced Statement can be anything that is important to the individual.

A

Religious or spiritual views, and those that might relate to care

​ Food preferences

​ Information about your daily routine
​ Where you would like to be cared for (in hospital, at home, in a care home etc.)

​ Any people who you would like to be consulted when best interests decisions are being made on your behalf (however this does not give the same legal power as creating a Lasting Power of Attorney)

187
Q

End of Life Strategy 2008

A

promoting high quality care for all adults at the end of life
Framework for local services to use to deliver end of life care

188
Q

gold standard framework

A

a practical systematic, evidence-based approach to optimising care for all people nearing the end of life.The motto of GSF is ‘right person, right care, right place, right time, every time’

189
Q

When to consider making a DNAPCR decision.

A
  • cardiac/respiratory arrest likely to be part of dying process and CPR will not be successful > advanced decision.
  • last hours/ days spent in their preferred place of care
  • CPR may be successful, clinical outcomes may still be bad – consider risk/benefit
    of treatment.
  • may want CPR even if unlikely to be successful.
190
Q

Colin Murray Parkes’ four phases bereavement

A

numbness, yearning/anger, disorganization/despair, re-organization.

191
Q

3 main types of moral theory in medical ethics

A
  1. Consequentialism = the best overall outcome is achieved
  2. Deontology = duty-based, according to moral rights/duties. May have more negative consequences
  3. Virtue = the good and right thing to do, what a ‘virtuous’ person would do
192
Q

Doctrine of ‘double effect’

A

explains how we can accept an action if the intention is to cause a ‘good outcome’ (e.g. pain relief), even if it may foreseeably lead to a ‘bad outcome’ (e.g. death).

193
Q

Recognised stages of grief- Elisabeth Kubler-Ross

A 
Denial 
Anger 
Depression 
Bargaining 
Acceptance
194
Q

Colin Murray Parkes and psychologist John Bowlby stages of grief

A

Shock and Numbness:
Yearning and Searching:
Disorganization and Despair:
Reorganization and Recovery:

195
Q

assessment of suicide risk.

A

Can use SAD PERSONS assessment scale
- assess reasons for self-poisoning, suicidal intent, difficulties, psychiatric disorders, risk assessment in future, social support.
- SAD PERSONS: < 6 outpatient; 6-9 emergency psych evaluation; > 9 inpatient
- sex (male) (1)
- age (<19, > 45) (1)
- depression (1)
- previous attempts (1)
- excessive alcohol or drug use (1)
- rational thinking loss (2)
- single/ divorced (1)
- organized or serious suicidal attempt (2)
- no social support (1)
- stated future intent (2)
< 16y and self-poisoned admit to paeds ward.

196
Q

Types of accommodation:

A
  • sheltered accommodation w warden control: live in own flat but communal areas, maybe pull cords with responder system
  • residential homes: staffed by carers but not nurses, not suitable for complex behavior or mobility issues
  • nursing homes: nurses and carers: dependent and higher care needs.
197
Q

RF: Substance misuse in the elderly

A

physical mental health, long term prescription (painkillers, hypnotics, anti-anxiety), bereavement, retirement, boredom, loneliness, homelessness and depression.

198
Q

Lasting Power of Attorney (LPA)

A

If an individual wants to legally appoint someone they trust to make decisions on their behalf in the future if they lose capacity, they can do this by making a lasting power of attorney (LPA). Usually an individual chooses a close relative or friend to be their “attorney”, who is given legal power to make decisions about their health and care if they lose capacity at some point in the future.

An individual’s attorney can make decisions about health and care decisions, including:

Where an individual should live, what care or treatment they should receive, decisions about their daily routine (food, activities, etc.). If special permission has been given, an attorney can also make decisions about life-saving treatment.

199
Q

Independent Mental Capacity Advocates (IMCAs)

A

IMCAs are used when an individual lacks the capacity to make a specific important decision, when there is no-one independent of services (e.g. a family member or friend) appropriate to represent the individual lacking capacity.

IMCAs support and represent the individual who lacks capacity, ensuring the Mental Capacity Act, 2005 is followed.

200
Q

Court of Protection

A

The Court of Protection is a court that if applied to, can make decisions about an individual’s health, welfare, finances and property under the Mental Capacity Act 2005.

The types of decisions the court can rule on include:
Whether an individual has capacity to make a decision, whether a decision is in an individual’s best interests, removing an attorney under a lasting power of attorney.

201
Q

Legal requirements of post mortem examination

A 
Sudden death 
Unknown cause of death
Unnatural death - accident/suicide/suspicious
Death from industrial disease
Death from negligence
Death during surgery/anesthesia
Death within 24hr admission 
Not seen by a doctor for 14 days
Any patient detained under the MHA
202
Q

Benefits of post mortem examination

A

Gain deeper insight into pathological processes
Learn how to prevent patients death in future
Help with teaching or medical research ,particularly for rare or poorly understood diseases
Further understand long term effects of drug therapy eg effects on other organs, might inform future choices about drug therapy
Study and monitor uptake of levels of chemical and radioactive elements absorbed from the environment

203
Q

The ‘high-risk’ strategy: targeting minority with high risk

A

Pros- appropriate interventions, cost-effective use of resources, favourable benefit: risk ratio
Cons- cost/difficulty of screening, limited potential for change in the population

204
Q

The ‘population’ strategy: targets majority, low risk

A

Pros- large potential for change, radical
Cons- small benefit to the individual, little motivation for patients, questionable benefit: risk ratio
a preventative measure which brings great change to the population offers little to the participating individual.

205
Q

What are the main approaches to preventing liver disease?

A

Diet – decrease fat intake
Moderate alcohol intake
Vaccinations – Hep B, yellow fever
Practice safe sex
Care with blood products – avoid contamination
Hygiene with IV drug use, tattoos, piercings
Safety and hygiene in areas of poor sanitation
Safe work environment – to avoid risk of things like leptospirosis
Safety/ care with prescribed drugs – paracetamol, statins, steroids, COCP

206
Q

Types of transplant

A
  • Deceased - anonymous, (usually brainstem deceased or sometimes cardiac arrest related)
  • Living pooled/paired - when a donor wants to give a relative but their blood groups are mismatched then are paired with another couple in the same situation to get the best kidney for each party. Operations must happen at the same time.
  • Living altruistic donation - when a patient donates to an unknown recipient.
  • Illegal - payment, abduction & forced donation.
207
Q

The Human Tissue Act 2004

A

• Regulates the donation by living people of
• Solid organs
• Bone marrow
• Stem cells
The Independent Assessor will discuss capacity to consent, duress, coercion and reward.

208
Q

Transplant rationing

A

All patients needing a transplant are placed on the UK transplant national transplant database
This ensures fair rationing
Points system based on:
• Time on the waiting list (favouring patients who have waited longest).
• Tissue match and age combined (favouring well-matched transplants for younger patients).
• The age difference between donor and patient (favouring closer age matches).
• Location of patient relative to the donor (favouring patients who are closer in order to minimise the transportation time of the kidney).
• Three other factors relating to blood group match and rareness of the patient’s tissue type.

209
Q

DCCT Diabetes Control and Complications Trial TRIAL

A

provided quantifiable justification to healthcare providers that the additional
expenses associated with intensive glycaemic control and close monitoring of diabetes are
cost effective.

reduces the development and progression of all diabetes micro-vascular, specific complications by as much as 76% (retinopathy), albuminuria (40%), neuropathy (60%)

Intensive therapy reduces measures of atherosclerosis over time, and probably reduces CVD events as well
Intensive intervention is most effective when implemented early in the course of diabetes; if intensive intervention is delayed, the momentum of complications is harder to slow, as shown by the results of the secondary intervention group

210
Q

Diabetes Prevention Programme Trial (DPP) = 1996-2001

A

Found that early aggressive lifestyle interventions (58% reduction) in obese patient with impaired glucose tolerance was more effective at preventing the onset of DM in comparison to placebo or metformin (31% reduction)
Trial highlighted the importance of lifestyle interventions in preventing DM = better than pharmacology

211
Q

tackling obesity

A

• Implementation of easy access exercise schemes and cheaper/free access to gyms and sports clubs.
• Establish regular meals and encourage healthier foods for long term weight management
• Reduce dietary fat, avoid fried foods, buy lean meats, use semi-skimmed milk and low fat alternatives.
• Educate about what constitutes a ‘balanced diet’ (including ‘5-a-day’ fruit and veg).
• Encourage parents to observe food labeling and make healthier decisions when buying foods.
• Promote healthy eating in the young through school dinners and healthy packed-lunches
Eg sugar tax

212
Q

Energy intake?
Energy expenditure?
Energy balance?

A

Energy intake? Calories consumed as food
Energy expenditure? A sum of internal heat produced and external work.
Energy balance? Energy balance is achieved when input (dietary energy intake) is equal to output (total energy expenditure) plus the energy cost of growth in childhood or pregnancy/ cost of milk production during lactation.

213
Q

Person-level human factors

A

Emphasises the skills that allow the individual to apply their clinical expertise efficiently, effectively and safely. These are often referred to as non-technical skills.

214
Q

System-level human factors

A

Emphasises analytical approaches for managing the human element within the healthcare system in support of activities such as incident investigation, assessment of new procedures, designing equipment, and maintaining a record of how human-related risks are managed.

215
Q

Bipolar disorder epidemiology

A

M=F

216
Q

Preventing falls

A

Home based strength and balance retaining programmes
daily cleaning of spectacles/vision checks
staff monitoring in nursing homes
home safety assessment/modifications
podiatry/chiropody services and walking aids

217
Q

Psychological effects of falls

A 
loss of confidence
immobility 
isolation 
depression 
increased dependence
long term care
effect on ADLS
218
Q

Releasing performance data

A

Advantages= focuses attention on improving patient care, public reassurance about effectiveness and safety, completion will boost performance

Disadvantages= Unmeasured performance will suffer, opportunity for data manipulation (choose healthier patients), some areas/ centres only receive patients with poor prognosis

219
Q

Opportunity costs

A

represent the potential benefits that an individual, investor, or business misses out on when choosing one alternative over another.

220
Q

two pieces of legislation that support carers.

A

Employment Act
Carers & Disability Act
Carers Act 2014
Equality Act 2010

221
Q

financial support available for carers

A

Carer’s Allowance
Disability Living Allowance
Attendance Allowance

222
Q

reasons why evidence based decision making is important

A

Deals with uncertainty
Medical knowledge is incomplete/shifting
Patients will receive most appropriate treatment
Constant need for innovation/improvement
Improving efficiency of healthcare services
Reduces practice variation

223
Q

factors that influence rate of infection

A

Infectious agent – pathogenicity, ability to spread
Environment – animals, water, population
Mode of transmission – airborne, faecal-oral, droplet, aerosol
Portal of entry – mouth, nose, GI tract
Host factors- chronic illness, nutrition, age

Medicine (72 decks)

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