H+S Y4

Question 1

Epidemiology of Suicide?

Answer 1

Rates are ^.
Peaks in April, May, June
Lowest in December
Men more likely to kill themselves successfully, so rates higher in men.
Peak age 60-75
Greatest incidence in divorcees, widows and widowers. Lowest in married
Highest rates in social classes 1 and 5
Highest rates in unemployed, but rates also high in: university, doctors, lawyers, farmers, policeman
Patients treated for an affective disorder have x30 risk of suicide.
Alcoholism accounts for 15% of suicides
15% of depressives will commit suicide and schizophrenics have lifetime risk of 10%

Question 2

Risk factors for suicide

Answer 2

Sex - male
Age - <19 or >45 years
Depression
Previous attempt
Excess alcohol or substance use
Rational thinking loss
Social support lacking
Organised plan
No spouse
Sickness

Unemployment
Urban environment
Bereavement

Question 3

Epidemiology of deliberate self harm

Answer 3

More common in young (contrast to suicide)
Peak age for men 20-24, women 15-19
More common in women
Divorced, single, married young
More common in lower SES
15-20% of those who self harm have psychiatric illness (50% depression, 30% personality D, 15% alcoholism)
Major life events/disruption to relationships
Criminal records
Child abuse
Social isolation
Anxiety of finances/work/housing

Question 4

Epidemiology of depression?

Answer 4

F>M (2:1) - due to hormonal effect and postnatal depression 
Greater incidence in lower SES (4+5)
Prevalence 2-3% in men, 2-9% in women. 
Lifetime risk 10% men, 20% women 
Onset of 50% of cases is <40
Peak age group 25-40
Urban populations
More common in separated, widowed, divorced

Question 5

RF’s for depression

Answer 5

Life events
Bereavement
PMHx of depression
Physical illness
Dementia
Refugees
Afro-Caribbean or Asian ethnicity
Social isolation
Unemployment

Question 6

The effect of dementia on carers?

Answer 6

• difficulty accepting there’s no cure
• frustration over lack of effective treatment
• worry about discomfort of patient
• overwhelmed by prospect of having to care
• hurt by personality changes of patient
• embarrassed by odd behaviour of patient
• angry with patient and their irritating behaviour
• guilty about resenting having to care, wanting them to go to permanent care or to die
• sadness over loss of the person they once knew
• cannot cope, go into state of despair

Question 7

Sources of help for carers

Answer 7

Day care for the patient, carer can have a break
District/community nurses
Social services
Welfare/disability benefits
Voluntary organisations - Age concern, The Alzheimer’s Society, Carers UK, Mind, British Red Cross, Crossroads

Question 8

Screening for dementia?

Answer 8

Little evidence to support population screening, but targeting high risk groups may be an effective strategy:
Elderly >75 years
History of falls/fractured hips
High attenders of community services
Known depression
New referrals

Question 9

Testing for dementia?

Answer 9

MMSE - gold standard, but is lengthy. Score <23/30 = dementia

6-CIT (6 item Cognitive impairment test) - short, easy to complete, easy to translate, highly sensitive, computer based, score >8/28 = significant

AMTS (abbreviated mental test score) = short, widely used, simple, limited validity, culturally specific, score <7/10 = significant

Addenbrooke’s cognitive exam = very lengthy, takes up to 45 mins, highly specific, score <82/100 = significant

Question 10

Who gets fertility treatment (based on NICE recommendations)?

Answer 10

Women aged <40 who have been unable to conceive after 2 years of regular unprotected intercourse are offered 3 cycles of IVF (with or w/o ICSI)

Women aged 40-42 in the same position are offered 1 cycle, but only is they have NOT has IVF in the past and do NOT have low ovarian reserve

Ovarian stimulation can be given in unexplained infertility, and IUI can be used if there is mild endometriosis, mild male infertility or physical or psychological problems with having sex

Question 11

Risks of fertility treatment

Answer 11

IVF is associated with increased risk of multiple births if more than 1 embryo is implanted at once, ectopic pregnancy, and OHSS

Question 12

Risks of multiple pregnancy

Answer 12

Miscarriage, anaemia, C-section, HTN, gestational diabetes, pre-eclampsia

Question 13

What happens at booking appointment?

Answer 13

Happens by 10 weeks

Identify women in need of additional care

Calculate BMI, measure BP, dipstick urine, risk factors for pre-eclampsia and gestational diabetes, blood test for group, rhesus, HBopathies, HIV, HepB, syphilis

Offer Down’s screening - combined at 11-14wks or quadruple at 15-20wks

USS for gestational age and anomalies

Ask about mental health, depression, occupation to identify risks

Give info on pregnancy, nutrition, exercises, benefits, planning birth

Question 14

What happens at 16 weeks antenatal appointment?

Answer 14

Review, discuss and record screening test results

Measure BP and test urine for protein

Question 15

What happens at 28 weeks antenatal appointment?

Answer 15

Measure BP, test urine for protein
Measure/plot symphysis-fundal heigh
Offer Anti-D prophylaxis to Rhesus D negative women
Offer more screening for anaemia and atypical RBC autoantibodies

Question 16

What happens at 34 weeks antenatal appointment?

Answer 16

Review, discuss and record screening results from tests at 28 wks
Measure BP, test urine for protein
Measure symphysis-fundal height

Question 17

What happens at 36 weeks antenatal appointment?

Answer 17

Measure BP, test urine for protein
Measure/plot symphysis-fundal height
Check position of baby, offer ECV for breech
Give info on breastfeeding, care of newborns, vitamin K, postnatal depression

Question 18

What happens at 38 weeks antenatal appointment?

Answer 18

Measure BP, test urine for protein
Measure/plot symphysis-fundal height
Give info about prolonged pregnancy

Question 19

What happens at 40 weeks antenatal appointment?

Answer 19

Measure BP, test urine for protein
Measure/plot symphysis-fundal height
Give more info about prolonged pregnancy

Question 20

What happens at 41 weeks antenatal appointment?

Answer 20

Measure BP, test urine for protein
Measure/plot symphysis-fundal height
Offer membrane sweep, induction of labour

Question 21

What data is available on the process and outcome of antenatal care?

Answer 21

Maternal morbidity and mortality

Perinatal mortality and stillbirths

Question 22

Why is cervical screening not performed for patients <25?

Answer 22

Because invasive cancer is rare in this age group and evidence suggests it will do more harm than good

Question 23

Why is cervical screening not performed in patients >65?

Answer 23

Women in this age group with 3 negative smears are very unlikely to develop the disease

Question 24

Frequency of cervical screening?

Answer 24

First invitation - 25
3 yearly from 25-49
5 yearly - 50-64

Question 25

What is the evidence that cervical cancer screening is effective?

Answer 25

Uptake of 80% in the population can prevent up to 95% of cervical cancers

Incidence of cervical cancer fell by 42% from 1988-97

Question 26

Key groups at risk of STIs

Answer 26

Young
Black/minority ethnics
Gay/bisexual
Injecting drug users
HIV infected
Sex workers
Prison inmates

Question 27

What are the key messages of sexual health promotion?

Answer 27

Reduce transmission of HIV/STIs

Reduce prevalence of undiagnosed HIV/STIs

Reduce unintended pregnancy rates

Improve health/social care for HIV infected

Reduce stigma associated with HIV and STIs

Question 28

What is chlamydia screening?

Answer 28

Aims to ensure people <25 are aware of the risk of acquiring chlamydia and its complications, and have access to screening, prevention and treatment

Opportunistic screening the preferred approach, with kits available at frequently visited places (uni, college, GP, pharmacy, contraception clinics) and through postal kits

Question 29

Epidemiology of STIs

Answer 29

Trends over the last 10 years show risk in the number of new and recurrent STI diagnsoses, and risk in the number of other GUM clinic diagnose (BV and candidiasis)

Syphilis has risen enormously, especially for men

Gonorrhoea was on the rise, but is now decreasing

Chlamydia, herpes and genital warts diagnoses are still rising

Chlamydia is most common STI

The risk in STI diagnoses can be put down to decreased sexual health among the young and MSM, but also greater acceptability and uptake of GUM services

Question 30

What support is there for newborn infants?

Answer 30

Hospital at birth:
Kept in 4-5 days if C-section
Can be as fast as 6 hours for an uncomplicated birth provided baby has opened bladder / bowels

GP – new babies can be registered with a practice as soon as possible – pink card given at hospital

Health visitor – usually 1st visit or seen at clinic within 10 days
Nurse with specialist neonatal training
Holistic family assessment, check that everyone is managing (not just baby)
Can offer extra support, put you in touch with groups / other mothers etc.

Child health clinics – regular GP clinics for vaccinations and development reviews. Also screen maternal health

Sure Start Children’s Centres (local authority) – focus on improving outcomes for young children and families, focus on the most disadvantaged families, aim to reduce inequalities in child development and school readiness

Can offer educational support & full / part time child care

Question 31

WHO 10 steps to successful breastfeeding

Answer 31

Have a written breastfeeding policy that is routinely communicated to all healthcare staff = visibly posted in all areas serving mothers / children and for staff to refer to

Train all healthcare staff in skills necessary to implement policy = all staff in contact with mothers should know how to implement the policy

Inform all pregnant women about the benefits and management of breastfeeding

Help mothers initiate breastfeeding within 30mins of birth = normal vaginal deliveries should have skin-skin contact for 30mins and help with starting feeding > Earlier start makes it more likely to be successful

Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants = teach positioning and attachment techniques e.g. if separated for medical reason

Give newborn infants no food or drink other than breastmilk unless medically indicated

Practice rooming-in – allow mothers and infants to remain together 24hrs a day = no nurseries! Allows mother to learn feeding cues and helps establish bond / feeding relationship

Encourage breastfeeding on demand = no restrictions on number or length of feeds e.g. ‘greedy baby’

No artificial teats or pacifiers to breastfeeding infants = interferes with suckling and baby’s learning of how to suckle/ feed

Establishment of breastfeeding support groups and refer mothers to them on discharge from hospital

UK uses UNICEF Baby Friendly Initiative = similar to above 🡪 massively increasing breastfeeding levels

Question 32

Childood to adult transition for care of chronic conditions

Answer 32

Involve young people & carers:
Co-produce strategies, agree goals / outcomes, and feedback about what effect their involvement had

Ensure it’s developmentally appropriate, taking into account: maturity, cognitive ability, social and personal circumstances, communication needs

Treat as equal partner, not as parent

Start discussions about process of transition young when possible

Aim to allow as much independence as possible

Share important clinical details:
Highest quality of care
Cross-over / joint appointments

Allocate named transition worker - someone involved in young person’s care

Develop transition plan

Develop a personal folder - held by young person, describing their preferences, care needs and history

Offer support for a minimum of six months before and after transfer

Transition planning should be developmentally appropriate

Education and employment, community inclusion, health and wellbeing, and independent living should all be assessed

Question 33

Impact of chronic conditions on child

Answer 33

visible v non visible > non-visible is harder to adjust to

Impact:
Time off school / difficulty completing school work / exams
Have worse academic performance
Feeling different to friends
Needing to plan day around meals / medications etc.
Increased dependence on parents at a time of when independence is normally developing
Impact on employment
Future fertility
Life expectancy

Cognitive:
Over-acceptance > letting illness take-over = level of impairment above what would be expected
Denial > symptoms + advice ignored, treatment poorly adhered to

Emotional:
May be similar to abnormal or normal bereavement

Behavioral:
Maturing
Could cause regression > act younger, including reduced school performance, bed-wetting
May manifest symptoms somatically

Family:
May suppress feelings to try and support child = can create tension / long-term issues

Social :
Rebellion
As children > adolescents = ↑ autonomy + independence
May not understand or think medication is important
Poor disease knowledge may influence this
Peer relationships and self-image – very important, don’t want to seem different to others or become labelled
Their assessment of risk is skewed – risk of being socially disregarded is much higher than the risk of not taking medication
Side-effects of medication may affect appearance – delayed puberty, short stature

Reaction dependent on:
Nature of illness + symptoms
Stage of illness
Age of the child
Temperament
Family factors
Intellectual capacity

Question 34

RF’s for child abuse?

Answer 34

1/3 UK children vulnerable = most at risk don’t experience!

Risk factors:
Toxic trio:
Substance Misuse
Domestic Violence 
Mental Health / LDs

Environment:
Poverty, poor housing, overcrowding = increased stress
Groups where children less visible > migrants, ethnic minority, travelers, home-educated

Family:
Mental health problems, substance misuse, Hx of criminal behavior, being in care
Step parents
Domestic abuse
Young parental age / multiple or closely spaced births

Child:
Failure to meet prior parental expectations – e.g. gender, disabled
Born due to forced sex / commercial sex
Previous child abuse of other family members
Young children & adolescents
Learning Disabilities

Question 35

Definition of child protection?

Answer 35

“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

Question 36

Role of HCP in child protection & safeguarding?

Answer 36

f a child discloses abuse to you then you have a STATUTORY OBLIGATION to tell an appropriate agency > often discuss with senior / child protection doctor, then inform:

Social services, Police, NSPCC = Child at Risk will have case conference

Social Services, School, Police, relevant Doctors (Paediatrician or GP) and Family members

MDT share concerns & identify risk > identify what to do to protect child = draw up Child Protection Plan

Question 37

5 Outcomes of Every Child Matters Initiative?

Answer 37

SHEEP

Safe
Healthy
Enjoy / Achieve 
Economic Well-being
Positive Contribution

Question 38

What is Children’s Act 1989?

Answer 38

Allocates duties to local authorities, courts, parents and other agencies in the United Kingdom, to ensure children are safeguarded and their welfare is promoted = it is a basic human right of children

Encourages negotiation to try and enable child to remain within their own family

Parental responsibility can be awarded to others – see Safeguarding

Practitioners who suspect child abuse should refer to social services, confirmed in writing within 24 hours

Question 39

What is Children’s Act 2004?

Answer 39

Amended the Children’s Act 1989, largely in consequence of the Victoria Climbié inquiry – basically to make sure everyone works together / shares information

Girl tortured and killed by guardian (aunt) in 2000 who thought she was possessed by the devil – led to Every Child Matters initiative in 2003 which led to this a year later

Obligation to share information and an obligation to co-operate to safeguard and promote the welfare of children

If have concerns about sharing information with others, they should obtain advice from named or designated professionals for safeguarding children = should be undertaken as soon as possible to ensure little delay to the safety of the child or young person

If concerns are based on information given by a child, healthcare professionals should explain to the child why they are unable to maintain confidentiality = child protection outweighs confidentiality

Question 40

What is Working Together to Safeguard Children 2018?

Answer 40

Key statutory guidance for anyone working with children in England

Sets out how organisations and individuals should work together and how practitioners should conduct the assessment of children

Updated regularly

Question 41

Most common cause of death in children > 1yo?

Answer 41

Injury

M>F

Question 42

Aetiology of childhood accidents in different age groups?

Answer 42

Babies = burns, scalds and being dropped

Toddlers = falls, burns, scalds, POISONING

Older children = falls

Question 43

Causes of falls in children?

Answer 43

still achieving motor milestones

growth constantly changing center of gravity

at age where explore a lot but with poor cognitive understanding (e.g. consequence)

Question 44

Prevention of falls in children?

Answer 44

Stair gates up to 2, preferably not at top of steep stairs as if do get over serious consequence = bedroom

Don’t leave babies unattended

Don’t change nappies on raised surface

Question 45

Causes of poisoning in children?

Answer 45

Infants like to explore through putting things in their mouths

Attracted to bright things, like medicine bottles / pills = look like sweets

Less developed gustatory sense = cant discriminate toxic

Question 46

Prevention of poisoning in children?

Answer 46

Child resistant containers

Keep things out of reach

Child resistant packaging

Question 47

Causes of scalds in children?

Answer 47

Peak age for injury with this mechanism is 1yr = lots of admission, rarely deaths

Age of exploration & just achieved ability to grab things, but no cognitive development to know not to do it

Question 48

Prevention of scalds in children?

Answer 48

Hot drinks out of reach / don’t hold baby whilst drinking hot drink

Teach child not to climb on things

Keeping saucepan handles turned away from hob or on back burners out of reach

Thermostatic mixing valves fixed to taps to prevent water being too hot

Question 49

Most common causes of accidental deaths in children?

Answer 49

Transport (34.9%)

Asphyxia (29.1%)

Drowning (12.8%)

Smoke, fire and flames (5.8%)

Poisoning (4.1%)

Falls

Struck by object

Electrocution

Other

Question 50

Signs of NAI

Answer 50

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.

Delayed presentation

Evasive or changing history

Inconsistency between age of injury and examination findings

Signs of restraint on limbs

Question 51

Risk factors for falls?

Answer 51

DAME

Drugs

Ageing = age-related changes – e.g. sarcopenia, decreased vestibular function, decreased visual acuity

Medical = neurological, CV, GU 🡪 incontinence, urgency / MSK = myopathy, arthritis, reduced cognitive function

Environment = poor footwear, pets, poor lighting, slippery floor, rugs

Question 52

What congenital abnormalities are screened for antenatally?

Answer 52

Foetal anomalies and Down’s
> Anencephaly, Spina Bifida, Cleft Palate/Lip, Diaphragm Hernia, Gastroschisis, Exomphalos, Cardiac, Renal agenesis, Edwards & Patau syndromes

o Sickle cell and thalassaemia
o Infectious disease in Pregnancy
> Hep. B, HIV, syphilis, Rubella

Question 53

What is newborn blood spot test?

Answer 53

day 5-8, but can be up to 1 year if decline (except CF!)

o	CF (needs to be done before 8 weeks)
o	Congenital hypothyroidism
o	Sickle cell disease
o	Phenylketonuria (PKU)
o	Medium chain acyl-CoA dehydrogenase deficiency (MCADD)
o	Maple-syrup urine disease (MSUD)
o	Isovaleric acidaemia (IVA)
o	Glutaric aciduria type 1 (GA1)

Sick Children Get Chubby Ingesting Pizza, McDonalds, and Maple syrup

Question 54

When is hearing screening done in children?

Answer 54

before 5 weeks – automated otoacoustic emission (AOAE) and automated auditory brainstem response (AABR)

Question 55

What is Wilson’s Criteria for Screening?

Answer 55

o	Well defined disorder
o	Known incidence
o	Significant morbidity or mortality 
o	Effective treatment
o	Sub-clinical period where treatment improves outcomes 
o	Ethical, safe, simple, accurate
o	Cost-effective

Question 56

Calendar of routine UK childhood immunisations

Answer 56

Birth – BCG and Hep B (if at risk)

2 months – 5 in 1 (dipheria, tetanus, pertussis, polio, HiB), Rotavirus, Men. B

3 months – 5 in 1 (DTPPH), PCV (Pneumococcus conjugate vaccine), Rotavirus

4 months – 5 in 1 (DTPPH), Men. B

12-13 months – HiB/MenC (combined), MMR, PCV, Men. B

2-7 years – nasal flu spray annually – at school or GP

3 years 4 months to 5 years – preschool booster of 4 in 1 (DTPP), MMR

12-13 years (boys and girls) - HPV subtypes 16 and 18

14 years (year 9) – diphtheria, tetanus, polio booster, Men. ACWY

Adults – influenza and PCV (over 65 or at risk), 4 in 1 (DTPP) (pregnancy women 28-38w gestation), shingles (aged 70-79)

Question 57

Contraindications to vaccines

Answer 57

For all vaccines:
o Previous analphylaxis to vaccine with same antigen
o Acute febrile illness
o Egg anaphylaxis – no INFLUENZA or YELLOW FEVER (may receive under controlled conditions)

• Live vaccines (BCG, oral polio, MMR) contraindicated if – primary immunodeficiency (IgA deficiency, transient hypogammaglobulinaemia of infancy, Bruton X-linked agammaglobulinaemia), on high dose of steroids, bone marrow transplant in last 6 months, taking immunosuppressive drugs, receiving treatment for cancer (chemo/radio) or have finished treatment in the last 6 months. Some LAVs can be given to HIV +ve (except BCG in low TB prevalence countries)
• Live vaccines timing – any time before or after each other, except for:
  o Yellow fever + MMR – at least 4 weeks apart
  o VZV and MMR same time, but if not on same day then need > 4 weeks between them
  o Mantoux (Tuberculin skin test) + MMR – MMR should be delayed until skin test read, and >4 weeks before Mantoux if MMR is done

Question 58

Ethical issues with childhood vaccinations

Answer 58

dependent on other making decisions in their best interests

under-developed decision making capacity or value systems

limited power (physical, emotional + legal) with regards to defending their rights

difficulty accessing services

Parental autonomy + child welfare - assumption that parents know their child’s best interest and that the close parental bond motivates them to do their best for their children

Question 59

Purpose of MDTs for child safety?

Answer 59

o Children get the help they need when they need it
o Professional take timely action to protect children
o Professionals ensure children are listened to & respected
o Agencies and professionals work together to assess needs and risk, and develop effective plans
o Agencies and professionals share information
o Professionals are competent and confident
o Agencies work with members of the community

Question 60

Prevent spread of general childhood infection

Answer 60

• Isolation on ward for RSV +ve NPA in bronchiolitis, or i.e., until 3 -ve cultures for diphtheria over 48 hours
• Hand washing – in between patients
• PPE – gloves and gowns for infectious patients
• Chemoprophylaxis – i.e., for TB, diphtheria, meningitis
• Vaccination
• Increase public awareness
• Contact tracing

Question 61

Prevent spread meningococcal disease and bacterial meningitis

Answer 61

o Notify public health team, on basis of clinical suspicion of meningitis
o ^ public awareness of Sx
o Trace contacts in last 7 days prior to onset
> Live together, share rooms, eat together, intimate kissing, HC workers exposed to droplet secretions
> Offer Abx (rifampicin/cipro – NNT 200)
> Consider immunisation – if correct serotype
> The above aims to decrease NP carriage of the strain and decrease risk for others

Question 62

Definition of outbreak

Answer 62

an epidemic limited to localised increase in disease incidence. Connected in space and time (2+ cases meningitis/legionella), sudden increase within defined area over short period (i.e., salmonellosis), some only one case (smallpox, plague, EVD)

Question 63

Definition of epidemic

Answer 63

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

Question 64

Definition of pandemic

Answer 64

epidemic over a wide area, crossing international borders

Question 65

Ways to prevent spreading infection

Answer 65

Education/training

disseminate national policies

investigation of outbreaks

screening pt’s (MRSA)

barrier nursing (quarantine infected)

sharps disposal

sterile instruments

Abx prescribing policy

hand washing

Question 66

Epidemiology of SIDS

Answer 66

• Sudden infant death syndrome (SIDS) is the unexplained death, usually during sleep, of a seemingly healthy baby less than a year old
• 1 per 3,636 is current SIDS rate in UK for live births
• 196 deaths per year, 0.28 deaths per 1000 life births
• 86% of SIDS happen in first 6 months of life

Question 67

Protective factors of SIDS

Answer 67

sharing a room with baby, sleeping supine, flat firm mattress, breastfeeding, feet to foot position, baby’s head uncovered, not letting baby get too hot or cold

Question 68

Risk factors of SIDS

Answer 68

male, sleeping on front, sleeping on sofa with baby, low birth weight, young mum, smoking during pregnancy or after baby born, twins, premature

Question 69

Relevant guidance for parents re: SIDS

Answer 69

• Dial 999 for ambulance if your baby: stops breathing or turns blue, is struggling for breath, is unconscious or seems unaware of what’s going on, will not wake up, has a fit for the first stop, even if they seem to recover

Question 70

Epidemiology of childhood asthma in the UK

Answer 70

• 1 in 11 children and young people in UK living with asthma
• UK has one of highest prevalence, emergency admission and death rates for childhood asthma in Europe
• Outcomes worse for children living in the most deprived areas
• 1 million children in the UK are receiving treatment for asthma.
• In early childhood, asthma is more common in boys than in girls, but by adulthood, the sex ratio is reversed.
• Asthma accounts for 2-3% of primary care consultations, 60,000 hospital admissions, and 200,000 bed days per year in the UK.

Question 71

Childhood asthma impact on primary care

Answer 71

-	In primary care, asthmatics should be seen at least once a year for their asthma review. Patients most likely attend during an attack
o	Hx and physical examination
o	Review asthma control 
o	Review potential triggers
o	Review treatment/adherence 
o	Review inhaler technique 
o	Education and PAAP 
-	Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden and impact on QoL

Question 72

Screening for congenital dysplasia of the hip?

Answer 72

• After 1 or both hips. More common in left hip.
• More common in girls and firstborn children.
• About ½ in every 1000 babies have DDH that needs to be treated
• w/o early treatment, may lead to: problems moving, limp, pain, OA of hip and back
• Hips check as part of NIPE within 72 hours and then 6 weeks. Barlow’s and Ortolani test. If hip feels unstable at NIPE > USS by 2 wks
• Also sent for USS between 4 and 6 weeks if, even with normal clinical examination:
  o Childhood hip problems in family (parents, brothers, sisters)
  o Breech after 36 wks or in last month of pregnancy
  o Baby born in breech after 28 weeks
  o If twin sibling has risk factor, other baby should have USS
• Screening so important to receive early diagnosis and treatment to allow normal development
  o Pavlik harness
  o Surgery if diagnosed after 6 months or if harness not helped – reduction surgery

Question 73

Availability and provision of services for patients with visual impairment and deafness impairment and deafness

Answer 73

For adults and children, parents of children, and carers

• Those with sight problems might need help with:
  o Managing sight loss
  o Mobility training to get out and about safely
  o Managing about the house and preparing food
  o Reading and writing (talking books/newspapers)
  o Special equipment like talking clocks or lighting
• Those with hearing problems might need help with:
  o Managing hearing loss
  o Lip reading or sign language training
  o Communication support (interpreters, voice to text equipment)
  o Special equipment like visual doorbells and alarms
  o Telephone equipment such as text phones or amplified headsets

services can be accessed by asking GP to make a referral or by contacting local social services. Carers are also entitled to assessment of their needs

o Local blind association - support, clubs, transport help, counselling, grants, talking books, specialist services for children
o Local deaf association - voice to text services, middleman for local lip speakers/interpreters
o Royal national institute for deaf people (RNID) - services similar to local services
o Country libraries - talking books, delivery service
o Worker’s education association (WEA) - classes in lip reading, sign language, deaf awareness

Question 74

Community management of diabetic eye disease

Answer 74

• Everyone with diabetes who is 12 years old or over is invited for eye screening once a year
• Controlling blood sugar, BP and cholesterol
• Attending all screening appointments
• Stop smoking
• Eat well and move more
• Laser treatment

Question 75

Potential significance of a squint

Answer 75

• Can lead to further problems:
  o Persistent blurred or double vision
  o Lazy eye (amblyopia)
  o Embarrassment of low self-esteem

Question 76

Outline the referral pathway for a squint

Answer 76

• If suspected in primary care, direct referral to optometrist or orthoptist to exclude refractive error and strabismus
• Refer to local paediatric eye service
• Urgently if serious underlying condition suspected – limited abduction, diplopia, headaches, nystagmus
• Encourage compliance with Tx, particularly occlusion Tx
• In secondary care, may be offered corrective glasses, occlusion Tx, penalization therapy (blurred normal vision with atropine), eye exercises, surgery (extra-ocular muscles), botox into extraocular muscles

Question 77

Outline global patterns of visual loss

Answer 77

• Globally, at least 2.2 billion people have a near or distance vision impairment. In at least 1 billion – or almost half – of these cases, vision impairment could have been prevented or has yet to be addressed.
• The leading causes of vision impairment and blindness are uncorrected refractive errors and cataracts.
• Majority of people with vision impairment and blindness are over the age of 50 years
• Low and middle income x4 times higher prevalence than high-income
• Population growth and ageing thought to increase risk of people acquiring vision impairment
• With regards to near vision, rates of unaddressed near vision impairment are estimated to be greater than 80% in western, eastern and central sub-Saharan Africa, while comparative rates in high-income regions of North America, Australasia, Western Europe, and of Asia-Pacific are reported to be lower than 10%

UK rates of blindness ~ 2:1000, whereas rates in Africa + Asia up to 10:1000

• Causes of WORLDWIDE AVOIDABLE blindness: Cataract > glaucoma > ARMD > Corneal opacity > trachoma > childhood (eg Vit A deficiency)
• Causes of BLINDNESS in DEVELOPED COUNTRIES – Congenital causes > Cataract > ARMD >Glaucoma > Diabetic
• AVOIDABLE blindness in LEDCs: Cataract > Glaucoma > Corneal opacities > Trachoma (Chlamydia trachomatis) > Childhood blindness > Onchocerciasis (‘river blindness’ cause by parasitic worm Onchocerca volvulus

o WHO Vision: 2020 – aims to eliminate these 6 causes of avoidable blindness by 2020

Question 78

Why start immunisations at 2 months?

Answer 78

o Maternal antibodies (transplacental IgG) can prevent the vaccine from working

Question 79

What is examined for on NIPE?

Answer 79

cataract, retinoblastoma, murmurs, DDH, cryptorchidism

Question 80

Assess the possibility of neo-natal and childhood deafness

Answer 80

• Hearing check list
  o Birth – startles and blinks at sudden noise (i.e., door slam)
  o 4 months – quietens or smiles to sound of voice, even if can’t see. May turn towards sound
  o 7 months – turns immediately to your voice
  o 9 months – listens attentively, babbles
  o 12 months – responds to own name and familiar words

Question 81

Causes of childhood deafness

Answer 81

• 32 million children live with disabling hearing loss
• 60% of childhood hearing loss is preventable
• Prenatal period
  o Genetic factors – hereditary and non-hereditary hearing loss
  o Intrauterine infections – rubella, CMV

-	Perinatal period
o	Birth asphyxia 
o	Hyperbilirubinemia
o	LBW
o	Other perinatal morbidities and their management 

• Childhood and adolescence
  o Chronic ear infections (chronic suppurative otitis media)
  o Collection of fluid in the ear (chronic non-suppurative otitis media)
  o Meningitis and other infections
• Factors affecting any age
  o Cerumen impaction
  o Trauma to ear / head
  o Loud noise/ loud sounds
  o Ototoxic medicines
  o Work related ototoxic chemicals
  o Nutritional deficiencies
  o Viral infections and other ear conditions
  o Delayed onset or progressive hearing loss
• Infections – mumps, rubella, meningitis, measles, ear infections

Question 82

Process of screening for hearing loss in infants

Answer 82

o Neonatal screening standard across UK and now internationally
> Evoked otoacoustic emission – tests cochlear function using click from earphone
> Automated auditory brainstem response – measures full ear function, using auditory stimulus and measuring EEG waveform

Question 83

Effective approaches to the prevention of deafness?

Answer 83

• Strengthen – maternal and child healthcare programmes, including immunisation and organizations of people with hearing loss
• Train – HCP’s in hearing care
• Regulate and monitor – use of ototoxic medicines and environmental noise
• Implement – infant and school-based hearing screening
• Make accessible – hearing devices and communication therapies
• Raise awareness – to promote hearing and reduce stigma
• Sensorineural deafness can be prevented by:
  o Vaccination – vs. measles, meningitis, rubella, and mumps
  o Screening – for syphilis + other infections in pregnant women
  o Antenatal/ perinatal care – strive to improve
  o Avoid ototoxic drugs – unless prescribed by qualified HCP – monitor dosing
  o Jaundice babies – refer for appropriate treatment
  o Reduce noise exposure – in occupational and recreational setting by using correct PPE and engineering noise control
• Conductive hearing impairment – early detection > medical +/or surgical intervention – this prevents language/speech delay in young children
• Affordable and properly fitted hearing aids for all who need them

Question 84

Outline the ‘Healthy Child Programme’ of screening and surveillance

Answer 84

• Health visiting and school nursing services
• Pregnancy and first 5 years
• 5 -19 years
• Families with babies offered 5 mandated HV reviews before child reaches 2 and a half
• HV – 0-5, school nurse – 5-19
• Extended 19 – 24 for those in care system with additional needs or a disability
• Ready to learn at 2, ready for school at 5

Question 85

Benefits of ‘Healthy Child Programme’

Answer 85

• Lead to:
  o Strong parent-child attachment and positive parenting
  o Keep children healthy and safe
  o Health eating, ^ activity, reduction in obesity
  o Prevention of serious + communicable diseases
  o ^ initiation and continuation of BF
  o Readiness for school and improved learning
  o Early recognition of growth disorders and RFs for obesity
  o Early detection of developmental delay

Question 86

Prevention of dental decay in children?

Answer 86

• Reduce consumption of food + drinks that contain sugars
• Brush teeth twice daily with fluoride toothpaste - supervised
• Take child to dentist when first tooth erupts, at about 6 months and then on regular basis
• Targeted community fluoride varnish programmes
• Water fluoridation programmes
• Toothbrushes and paste by post

Question 87

Prevention of smoking / negative effects from smoking in children?

Answer 87

• Adult-led interventions in schools – health effects of smoking, part of curriculum
• Stop-smoking interventions – behavioural, e-cigarettes, NRT with behavioural support for children aged over 12, don’t offer varenicline or bupropion for those under 18
• Pregnant women – CO testing, opt-out referral for stop-smoking interventions if smoking or just stopped, secondhand smoke, NRT and behavioural support

Question 88

Preventing accidents in children?

Answer 88

• Education, enforcement and engineering
• Environment – fireguards, safety gates
• Education
• Empowerment – accident prevention initiatives influenced by community
• Enforcement – products we buy meet reasonable level of safety performance
• Supervision – high surfaces, water,
• Floor free of toys to prevent falls
• Securely fitted safety harness on pram, pushchair, highchair
• Never unattended on high surfaces
• Medicines and chemicals in locked cupboard
• Appropriately sized toys for child’s age – preventing choking

Question 89

Preventing obesity in children?

Answer 89

• 28% of children 2-15 are overweight or obese
• Associated with poor emotional health (stigmatisation, bullying, low self-esteem), school absence, high cholesterol, high BP, pre-diabetes, bone + joint problems, breathing difficulties, ^ risk of becoming overweight adults, risk of ill-health and premature mortality in adult life
• Schools register with Change4Life – teach PSHE topics
• National Child Measurement Programme – whole school approach healthy weight, support children who are identified as overweight, talking to parents
• Increase activity throughout school day
• Schools – healthy eating policies
• School policies on bullying – obesity and weight as possible causes
• Schools having support for those affected by bullying
• 11-16 – Rise Above to build resilience
• NHS website – tips for healthy eating, Eatwell Guide, 5-a day, Change4Life
• Soft drinks industry levy
• Taking 20% of sugar from products
• 1 hour of physical activity every day
• School food healthier
• Clear food labelling

Question 90

Prevention of SIDS?

Answer 90

• place your baby on their back to sleep, in a cot in the same room as you, for the first 6 months
• keep your baby’s head uncovered – their blanket should be tucked in no higher than their shoulders
• if wearing your baby in a sling or carrier, do not cover their head with the sling material or with a muslin
• place your baby in the “feet to foot” position, with their feet at the end of the cot or moses basket
• do not let your baby get too hot or cold
• do not share a bed with your baby
• never sleep with your baby on a sofa or armchair
• do not smoke during pregnancy or breastfeeding, and do not let anyone smoke in the same room as your baby

Question 91

Discuss access to fertility services

Answer 91

• In 2012, UN declared reproductive freedom and access to contraceptive serves an additional human right
• Infertility is defined as a woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility.
• Should be offered further assessment and investigation along with partner. Earlier referral where the woman is:
  o Aged 36 or over
  o Known clinical cause of infertility or Hx of predisposing factors for infertility
• Do not offer medical or surgical intervention to women with unexplained infertility. Offer IVF to women with unexplained fertility after 2 yrs of regular UPSI
• A full cycle of IVF, with or without ICSI should comprise 1 episode of ovarian stimulation and transfer of resultant fresh and frozen embryos
• In those aged under 40 who have not conceived after either:
  o 2 years of regular UPSI
  o 12 cycles of artificial insemination
• Offer 3 cycles of IVF with or without ICSI. If she reaches 40 during a cycle, complete that cycle and offer no more
• In women aged 40-42 who have not conceived after either:
  o 2 years of regular UPSI
  o 12 cycles of artificial insemination
• Offer 1 cycle of IVF with or without ICSI, if the following three criteria are met:
  • No Hx of IVF treatment
  • No evidence of low ovarian reserve
  • Documented discussion of additional implication of IVF and pregnancy at this age

Question 92

Process of antenatal care

Answer 92

Assessment of gestational age should be based on USS rather than LMP

• All appointments include measuring BP and testing urine for proteinuria. Nulliparous women have 10 appointments, parous women have 7
• Booking appointment – before 12wks – may need double appointment:
  o Initial measures of weight, BMI and BP
  o Offer screening for:
• Anaemia
• Red cell allo-antibodies
• Hep B virus
• HIV
• Rubella
• Syphilis
• Asymptomatic bacteriuria
• Sickle cell and thalassaemia if using the national Family Origin Questionnaire
• No evidence to support routine screening for GDM

o Offer dating scan for 10-13wks. This is required is mother wants Downs Syndrome screening

o Offer Down’s screening – make sure pt. knows she is not obligated, and current screening has 90% detection rate and 2% false positive rate

o All women should be offered anomaly scan at 18-20 wks

o Ask about Hx of mental illness

o Routine breast and pelvic examinations are not recommended – no benefit. Where appropriate, the Q of FGM should be raised sensitively

• 12 wk
• gender
• 16 wks
  o Review results of earlier tests, discuss them and institute a changed pattern of antenatal care. Offer oral iron to women with Hb of <11g/dL
• 18-20 wks
  o If woman agrees to anomaly scan
• 25 wks
  o Nulliparous women. As well as BP and urine screen, includes first measurement and plotting of symphysis-fundal height ** all appt’s from this point should routinely include measurement and plotting of SF height **
• 28 wks
  o In addition to routine, another opportunity for screening for anaemia and RBC allo-antibodies. Treat Hb <10.5 g/dL and offer anti-D prophylaxis for rhesus -ve women. Offer pertussis vaccination
• 31 wks
  o Nulliparous women – review of any screens performed at 28 wks
• 36 wks
  o Check for position of foetus, with ECV offered to those in breech
• 38 wks + 40 wks
• 41 wks
  o If woman has not yet given birth, offer membrane sweep/ inducton of labour

Question 93

Describe the screening process for chromosomal abnormalities

Answer 93

• Screening methods:
  o 2 method of screening – serum and USS (nuchal translucency). Used in combined test
• Blood sample can be taken from mother between 10w and 14w + 1d
  • Serum screen measure free b-hCG (raised) and pregnancy associated plasma protein A (PAPP-A) (lowered)
• USS can be carried out between 11w + 2d and 14W + 1d

o	If a woman books later in pregnancy or nuchal translucency is not technically possible, the quadruple test (less accurate) can be performed between 14w2d and 20w:
	Free b-hCG (raised)
	Alpha fetoprotein (lowered)
	Inhibin A (raised)
	Unconjugated estriol (uE3) (lowered)

o Once screening test has been performed, the chance of the foetus having Down’s is calculated, taking into account maternal factors such as age, weight, family origin. The test is positive if probability > than the nationally agreed cut off – in the UK, this is 1/150

 If woman has had previously affected pregnancy or open NTD reported, result is classified as ‘screen positive’ regardless of screening markers’ so that further testing can be discussed with the woman

o Nuchal translucency screening
- Increased nuchal translucency reflects foetal heart failure – typically seen in any serious anomaly of the heart or great arteries, and strongly associated with a chromosomal abnormality. The greater the extent of FNT, the greater the risk of abnormality. 20% false positive rate if thresholds are set to detect 85% if used alone

Question 94

Measures of pregnancy outcome?

Answer 94

o Whilst outcomes and performance in maternity are generally good, there is a high degree of unexplained variability around the country and consequently room for improvement. Of these key indicators:

• Perinatal mortality rates range from 6/1000 in Southeast Coast to 9.1/1000 in West Midlands
• C-section rates range from 15% in Shrewsbury, Mid Staffordshire, and parts of Nottinghamshire to 36% in parts of London
• Home birth rates range from 1.2% in the Northeast to 3.8% in the Southwest
• Stillbirth rates are unchanged since the 1990s and are amongst the highest in Europe

Question 95

Definition of stillbirth, stillbirth rate, neonatal death, neonatal death rate, perinatal mortality, LBW, maternal mortality and maternal mortality rare?

Answer 95

• Stillbirth – death of a baby before or during birth after 24 weeks of gestation in the UK (WHO definition is 28 wks)
• Stillbirth rate – number of stillbirths per 1000 total births
• Neonatal death - death of a baby within the first 28 days of life
• Neonatal rate – number of neonatal deaths per 1000 total births
• Perinatal mortality – stillbirths plus early neonatal deaths (under 7 days)
• Low birth weight – weight at birth under 2500g
• Maternal mortality – death of pregnant woman or within 42 days of delivery, miscarriage, or termination, providing the death is associated with pregnancy or its treatment
  o Can be subdivided into direct (obstetric complications), indirect (a disorder exacerbated by pregnancy) or late deaths (>42 days after end of pregnancy)
• Maternal mortality rate – number of maternal deaths per 100,000 maternities

Question 96

Still birth, neonatal and maternal mortality rates in UK?

Answer 96

o Stillbirth rate - 3.9 per 1000 (2020)
o Neonatal rate – 2.7 per 1000 (2020)
o Maternal mortality – 7 per 100,000 (2017)

• Neonatal deaths and stillbirths in developed countries are falling. This is the result of changing patterns in reproductive health, socioeconomic progress and the quality of obstetric and neonatal facilities

Question 97

Still birth, neonatal and maternal mortality rates globally?

Answer 97

o Stillbirth rate – 13.9 per 1000 (2020)
o Neonatal rate – 17 per 1000 (2020)
o Maternal mortality – 211 per 100,000 (2017)

No good historical data on neonatal mortality and stillbirth rates are available for developing countries. Perinatal deaths are seen as a natural occurrence in many societies, which consider the birth of a child accomplished only when the baby has survived the initial period. Vital registration systems usually do not record and report stillbirths.

Question 98

Most common cause of direct maternal death?

Answer 98

• Increase in maternal deaths due to sepsis – now the most common cause of direct maternal death. PPH is most common cause of death worldwide and new initiatives in poorer countries are called for, e.g., anti-shock garments and balloon tamponade.

Question 99

Outline the UK cervical screening programme?

Answer 99

routine three-yearly recall between 25-49, then 5 yearly until 65

o Women over the age of 65 are only screened if they have not been screened since the age of 50 or have had recent abnormal tests

o If cytology normal – test repeated at 12 months
 If repeat test is now hrHPV -ve > return to normal recall
 If repeat test is still hrHPV +ve and cytology still normal > further repeat 12 months later
 If hrHPV -ve at 24 months > return to normal recall
 If hrHPV +ve at 24 months > colposcopy (x3 hrHPV +ve)

o Smear is taken with a brush rotated against the squamocolumnar junction for liquid-based cytology

• Inadequate
  o Repeat immediately after treating infection if required. Repeat sample within 3 months if technically inadequate. If persistently inadequate (2 consecutive samples) refer for colposcopy

Question 100

Outline the HPV vaccination programme?

Answer 100

o Boys and girls 12-13 (born after 1 September 2006)
o Protect against cervical cancer, some mouth and throat cancers, some cancer of anal and genital areas, and genital warts
o 1st dose – year 8
o 2nd dose – 6-24 months after 1st dose

Question 101

Summary of syphilis?

Answer 101

o Acquired
> Primary (2-3wk, local infection) > (6-12wk, generalised infection)
> Early latent (asymptomatic <2yr) > late latent (asymptomatic >2yr)
> Tertiary (CVS, neurosyphilis or gummatous syphilis)

o Congenital
> Early (<2yr) or late (>2yr)

79% MSM. Often co-infected with HIV. Tertiary stage rarely seen in UK.

Primary - 2-6wks, chancre, enlarged regional LNs

Secondary - 6wks - Night-time headaches, malaise, fever and aches. Generalised polymorphic rash affects palms, soles and face

Tertiary- neurological (dorsal column loss, dementia, meningovascular involvement), CVS (aortitis, AR, aneurysm, angina), Gummata (in any organ, freq. bone and skin)

o Penicillin first line. In early syphilis beware of Jairsch-Herxheimer reaction – acute febrile illness with headache, myalgia, rigors and resolves in 24 hrs

Question 102

Summary of gonorrhoea?

Answer 102

gram negative diplococcus infects mucous membranes of urethra, endocervix, rectum, pharynx and conjunctiva. 2-5d incubation typically. Co-infection with chlamydia increases gonococcal organism loads (increases transmission)

o Prevalence increasing, men>women (63% MSM). Deprivation and black ethnicity associated factors

Urethral discharge, dysuria

Children - Acute conjunctivitis, bilateral, <48 hours after birth, Can cause ophthalmia neonatorum, pneumonia, Vaginal discharge and vulval erythema

o Treat with IM ceftriaxone

Question 103

Summary of chlamydia?

Answer 103

gram-negative bacteria

o Most commonly diagnosed bacterial STI in UK. Most preventable cause of infertility worldwide. Sequalae include PID, ectopic, tubal infertility, epididymitis/epididymo-orchitis in men. Most consistent risk factor is young age (<25)

discharge, dysuria, contact bleeding, urethritis, epididymal tenderness

• Treat > doxycycline BD 7/7

Question 104

Summary of herpes simplex?

Answer 104

o Subdivided into:
> HSV type 1 is oral, causes cold sores (herpes labialis)
> HSV type 2 is genital – penis, anus, vagina
> Both can infect either or, due to oral sex or auto inoculation

o Twice as common in women than men, most prevalent 20-24 yo. Prevalence has doubled over time
RF - HIV -ve

Multiple painful ulcers, neuropathic pain in genitals/buttocks/legs

Recurrent - latent in sensory ganglia near skin,

o Advice saline bathing, topical lidocaine, and follow up appointment. Acyclovir not recommended as standard as can cause resistant strains of HSV. ?aciclovir, famciclovir, valaciclovir

Question 105

Summary of HPV and genital warts?

Answer 105

o Cutaneous manifestation of infection with HPV

90% warts caused by HPV 6 and 11 (low risk for CIN). Types 16 and 18 high risk CIN.

• Incubation period 3w-8m. lesions may appear, usually painless but may itch, burn, bleed. Lesions are usually papilloma and pink, red or brown, may be single or develop multiple

o Many treatments – topical and ablative.

Question 106

Opportunities for early diagnosis of HIV

Answer 106

o Everyone should be offered a HIV test when attending:
> GUM clinic
• Especially if they test +ve for anything
• Contact tracing for anyone testing HIV +ve
• All MSM (annually)
• All female sexual contacts of MSM
• All contacts of anyone from country of high prevalence
> Antenatal services
• Part of booking appt.
> TOP services
> Drug dependency programmes
• Or anyone who reports IVDU
> Diagnosis of TB, HBV, HCV, lymphoma
> All men and women known to be from country of high prevalence (>1%)

o	Routinely performed in
>	Blood donors
>	Dialysis pt’s
>	Organ transplant donors and recipients
>	Needlestick injury workers

Question 107

Principles of safer sex

Answer 107

o Use condoms
o Regular testing
o Contraceptive advice
o Consent and legal age of consent are two different things
o User error – people don’t know how to use condoms properly

Question 108

Summary of eczema?

Answer 108

o Most frequent children, but can present any age
o No difference in sex or ethnicity
o ^ if parents affected
o ^ in urban areas, smaller families and higher SES > supporting role of environmental factors in development
o dry, pruritic skin, and is typically an episodic disease of flares (exacerbations, which may occur as frequently as two or three times each month)
o atopic family
o complex interactions of genetic predispositions, environmental triggers, and immune dysregulation with disturbed epidermal barrier causing dry skin (gene filaggrin), increased IgE production with role of allergy

Question 109

Summary of psoriasis?

Answer 109

o epidermal hyperproliferation, abnormal differentiation of epidermal keratinocytes, and inflammation with immunologic alterations in the skin.
o Chronic plaque, pustular, flexural, guttate, nail
o Any age, but 2 peaks at 20-30 and 50-60 (guttate more common under 30)
o M=F
o More common in white people
o raised, inflamed lesions covered with a silvery white scale. This is most common on the extensor surfaces of the knees, elbows, scalp, and trunk.

Question 110

Summary of acneiform eruptions?

Answer 110

o Acne vulgaris is a chronic inflammatory skin condition affecting mainly the face (99% of cases), back (60% of cases) and chest (15% of cases).
o blockage and inflammation of the pilosebaceous unit (the hair follicle, hair shaft and sebaceous gland). It presents with lesions which can be non-inflammatory, inflammatory or a mixture of both.
o Non-inflamed lesions are known as comedones which may be open (blackheads), closed (whiteheads) or microcomedones (clinically invisible).
o Inflammatory acne lesions include papules and pustules (5 mm or less in diameter) — in more severe disease these can develop into larger deeper pustules and nodules.
o Altered follicular keratinocyte proliferation leading to formation of follicular plugs (comedones).
o Androgen induced seborrhoea (increased sebum production) within the sebaceous follicles which usually occurs around puberty.
o Proliferation of bacteria (such as Propionibacterium acnes) within sebum in hair follicles.
o Inflammation of the pilosebaceous unit.
o An estimated 650 million people are affected by acne worldwide.
o Prevalence varies widely in different geographical areas with Western industrialized countries having much higher rates
o Most are aged 12-24 years
o Acne is more common in males during adolescence but in adulthood, incidence is higher in women.
o Acne is one of the most common skin conditions in the United Kingdom leading to 3.5 million visits to primary care every year

Question 111

Summary of viral warts?

Answer 111

o Warts are common worldwide and affect approximately 10% of the population. In school-aged children, the prevalence is as high as 10% to 20%. They are more common among immunosuppressed patients and meat handlers
o caused by an infection with the human papilloma virus (HPV). The virus causes an excess amount of keratin, a hard protein, to develop in the top skin layer (epidermis). The extra keratin produces the rough, hard texture of a wart
o red/black dots – papillary capillaries
o common in school aged-children, dermatitis (due to defective skin barrier), immunosuppression
o proliferation of keratinocytes and hyperkeratosis due to infection with HPV
o spread by direct skin-to-skin contact or autoinoculation
o resolve spontaneously
o topical Tx – wart paints, pastes with salicylic acid, podophyllin
o cryotherapy w/ liquid nitrogen
o electrosurgery

Question 112

Summary of epidermoid and pilar cysts?

Answer 112

o Epidermoid cysts are typically filled with keratin and lipid-rich debris
o An epidermoid cyst is a cyst where the cyst sac forms from cells that normally occur on the top layer of the skin (the epidermis). A pilar cyst is a cyst where the cyst sac forms from cells similar to those that are in the bottom of hair follicles (where hairs grow from).
o Epidermoid cysts most commonly occur in adults, particularly when young-to-middle aged. They occur twice as frequently in men than in women
o Genetic disorders – Gardner syndrome, Pachyonychia congenia type 2, basal cell naevus syndrome
o A firm, flesh-coloured or yellowish round papule or nodule fixed to the skin surface but typically mobile over deeper layers, Diameter 1–3 cm, central punctum, foul-smelling chest debris expressed
o Small uncomplicated – no Tx
o Surgical excision

Question 113

Summary of Seborrheic keratosis?

Answer 113

o a harmless warty spot that appears during adult life as a common sign of skin ageing.
o extremely common. It has been estimated that over 90% of adults over the age of 60 years have one or more of them. They occur in males and females of all races, typically beginning to erupt in the 30s or 40s. They are uncommon under the age of 20 years.
o Seborrhoeic keratoses can arise on any area of skin, covered or uncovered, with the exception of palms and soles
o Seborrhoeic keratoses have a highly variable appearance.
 Flat or raised papule or plaque
 1 mm to several cm in diameter
 Skin coloured, yellow, grey, light brown, dark brown, black or mixed colours
 Smooth, waxy or warty surface
 Solitary or grouped in certain areas, such as within the scalp, under the breasts, over the spine or in the groin
o They appear to stick on to the skin surface like barnacles.
 Cryotherapy (liquid nitrogen) for thinner lesions (repeated if necessary)
 Curettage and/or electrocautery
 Ablative laser surgery
 Shave biopsy (shaving off with a scalpel)
 Focal chemical peel with trichloracetic acid

Question 114

Summary of dermatofibroma?

Answer 114

o a common benign fibrous nodule usually found on the skin of the lower legs
o mostly seen in adults. People of every ethnicity can develop dermatofibromas.
o Ordinary dermatofibromas are more common in women than in men
o presents as a solitary firm papule or nodule on a limb.
 tethered to the skin surface and mobile over subcutaneous tissue.
 The overlying skin dimples on pinching the lesion – the dimple or pinch sign.
 Colour may be pink to light brown in white skin, and dark brown to black in dark skin; some appear paler in the centre.
 Dermatofibromas do not usually cause symptoms, but they are sometimes painful, tender, or itchy.
o Reassurance
o Surgical removal – recurrence common

Question 115

Summary of lipoma?

Answer 115

o A lipoma is a non-cancerous tumour that is made up of fat cells. It slowly grows under the skin in the subcutaneous tissue. Very common
o tend to develop in adulthood and are most noticeable during middle age. They affect both sexes equally, although solitary lipomas are more common in women whilst multiple lipomas occur more frequently in men.
 A dome-shaped or egg-shaped lump about 2–10 cm in diameter (some may grow even larger)
 It feels soft and smooth and is easily moved under the skin with the fingers
 It may have a rubbery or doughy consistency
 Lipomas are most common on the shoulders, neck, trunk and arms, but they can occur anywhere on the body where fat tissue is present.
o No Tx
o Surgical removal if interfering with moving muscles – excision, squeeze technique, liposuction

Question 116

Summary of common vascular lesions?

Answer 116

o Vascular naevi - present at birth or appear in early childhood. They are classified according to the size and type of vessel
o Angiomas - a benign tumour formed by the dilation of blood vessels or the formation of new ones by the proliferation of endothelialcells.
o Telangiectases - Prominent cutaneous blood vessels can be physiological or pathological.
 Blood vessels feeding a tumour such as basal cell carcinoma
 A common sign of rosacea
 A diagnostic feature of the CRST variant of systemic sclerosis
o Malignant vascular tumours – Kaposi, angiosarcoma, intravascular B-cell lymphoma

Question 117

Summary of benign melanocytic lesions?

Answer 117

o Proliferation of melanocytes may result in congenital or acquired benign melanocytic naevi. ^ melanin in epidermis, ^ melanocytes in basement membrane, nests of melanocytes at epidermal/dermal junction
o Congenital melanocytic naevi, café au lait macules, acquired melanocytis naevi (moles), halo naevi, Spitz naevi, Spindle cell tumour of Reed, atypical naevi, naevi of special sites, freckles, solar lentigo

Question 118

Summary of actinic keratosis?

Answer 118

o Actinic keratosis is a precancerous scaly spot found on sun-damaged skin, also known as solar keratosis. It may be considered an early form of cutaneous squamous cell carcinoma(a keratinocyte cancer).
o affect people that have often lived in the tropics or subtropics and have predisposing factors such as:
 Other signs of photoageing skin
 Fair skin with a history of sunburn
 History of long hours spent outdoors for work or recreation
 Defective immune system.
 A flat or thickened papule, or plaque
 White or yellow; scaly, warty, or horny surface
 Skin coloured, red, or pigmented
 Tender or asymptomatic
o Actinic keratoses are very common on sites repeatedly exposed to the sun
o Actinic keratoses are the result of abnormal skin cell development due to DNA damage by short wavelength UVB.
o They are more likely to appear if the immune function is poor, due to ageing, recent sun exposure, predisposing disease, or certain drugs.

Question 119

Summary of Bowen’s disease?

Answer 119

o Intraepidermal squamous cell carcinoma (SCC) is a common superficial form of keratinocyte cancer
 Sun exposure: intraepidermal SCC is most often found in sun-damaged individuals.
 Arsenic ingestion: intraepidermal SCC is common in populations exposed to arsenic.
 Ionising radiation: intraepidermal SCC was common on unprotected hands of radiologists early in the 20th century.
 Human papillomavirus (HPV) infection: this is implicated in intraepidermal SCC on fingers and fingernails.
 Immune suppression due to disease (eg chronic lymphocytic leukaemia) or medicines(eg azathioprine, ciclosporin).
o Up to 50% of patients with intraepidermal SCC have other keratinocytic skin cancers, mainly basal cell carcinoma.
o Ultraviolet radiation (UV) is the main cause of intraepidermal SCC. It damages the skin cell nucleic acids (DNA), resulting in a mutant clone of the gene p53, setting off uncontrolled growth of the skin cells.
o Human papillomavirus (HPV) is another major cause of intraepidermal SCC. Oncogenicstrains of HPV are the main cause of squamous intraepithelial lesions (SIL)

Question 120

Summary of BCC?

Answer 120

o most common skin cancer in humans, which typically appears over the sun-exposed skin as a slow-growing, locally invasive lesion that rarely metastasizes.
o approximately 75,000 basal cell carcinomas of the skin are diagnosed each year. A full time GP is likely to diagnose at least one person with basal cell carcinoma per year. Death from basal cell carcinoma is exceptionally rare. The main advantage from early diagnosis is less extensive treatment.
o Cause is multifactorial – DN mutation in patched (PTCH) tumour suppressor gene, exposure to UV radiation, spontaneous and inherited gene defects
o Slow-growing, skin coloured/pink, spontaneous bleeding or ulceration
o Nodular, superficial, morphoeic, basosquamous

Question 121

Summary of SCC?

Answer 121

o Approximately 25,000 squamous cell carcinomas of the skin are diagnosed each year. A full time GP is likely to diagnose at least one person with squamous cell carcinoma every 1–2 years. Death from squamous cell carcinoma is rare. The main advantage of early diagnosis is less extensive treatment. More likely to metastasize
o Precursor – actinic keratoses, Bowen’s, keratocanthoma
o Irregular keratinous nodule or firm erythematous plaque, frequently ulcerates

Question 122

Counsel patients on appropriate sun protection behaviours with the correct use of sunscreens (protecting for both UVA and UVB)

Answer 122

• The sun protection factor, or SPF, is a measure of the amount of ultraviolet B radiation (UVB) protection.
• More specifically, it refers to how well the product reduces the burning effect of the sun on your skin. For instance, if you usually begin to burn after 10 minutes in the sun, applying an SPF 15 sunscreen will protect you for 15 times longer than that, meaning you are protected for up to 150 minutes. Products need to be applied every two hours and after being in water to help maintain protection, and if you’re intending to spend longer in the sun then you should choose a higher SPF to begin with
• The star rating measures the amount of ultraviolet A radiation (UVA) protection. You should see a star rating of up to 5 stars on UK sunscreens.
• Sunscreens that offer both UVA and UVB protection are sometimes called broad spectrum.
• Babies – at least SPF30
• UVA - These are present at all times during daylight hours, and while you might not immediately see their effects, they’re very powerful – they can penetrate clouds and even glass. They penetrate the skin more deeply than UVB to cause long-term damage (including all types of skin cancer) and play a major part in the ageing process, such as causing wrinkles, sun spots and leathery skin.
• UBV - These are the rays that are mostly responsible for sunburn and skin reddening. They don’t penetrate as deeply as UVA rays, but they’re just as damaging. They play a large part in the development of skin cancers including melanoma.

Question 123

Explain the two-week-wait pathway and the role of the skin cancer multidisciplinary team to patients and their carers

Answer 123

• Suspected malignant melanoma:
  • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma if they have a suspicious pigmented skin lesion with a weighted 7-point checklist score of 3 or more.
  Weighted 7-point checklist:
  • Major features of the lesions (scoring 2 points each):
  o Change in size.
  o Irregular shape.
  o Irregular colour.
  • Minor features of the lesions (scoring 1 point each):
  o Largest diameter 7 mm or more.
  o Inflammation.
  o Oozing.
  o Change in sensation.
  • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) if dermoscopy suggests melanoma of the skin.
  • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma in people with a pigmented or non-pigmented skin lesion that suggests nodular melanoma.
• SCC
• Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with a skin lesion that raises the suspicion of squamous cell carcinoma.
• BCC
• Consider routine referral for people if they have a skin lesion that raises the suspicion of a basal cell carcinoma.
• Only consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with a skin lesion that raises the suspicion of a basal cell carcinoma if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size.

Question 124

Risk factors for VTE?

Answer 124

o Surgical patients
o Significantly reduced mobility
o Active cancer or cancer treatment
o Age >60
o Dehydration
o Known thrombophilia’s
o Obesity (BMI >30kg/m2)
o One or more significant medical co-morbidities (e.g., heart disease, metabolic, endocrine, or respiratory pathologies, acute infectious diseases, inflammatory conditions)
o Personal history or first-degree relative with a history of VTE
o Use of hormone replacement therapy
o Use of oestrogen-containing contraceptive therapy
o Varicose veins with phlebitis
o Pregnancy or <6 weeks post-partum
o Significantly reduced mobility for 3 days or more
o Hip or knee replacement
o Hip fracture
o Total anaesthetic + surgical time > 90 minutes
o Surgery involving pelvis or lower limb with a total anaesthetic + surgical time > 60 minutes
o Acute surgical admission with inflammatory or intra-abdominal condition
o Critical care admission
o Surgery with significant reduction in mobility

Question 125

Evaluate the possibility of fractures as an indicator of non-accidental injury including domestic violence

Answer 125

Children:
- metaphyseal fracture (so-called bucket handle fracture or corner fracture)
- rib fractures - especially posterior ribs
- skull fracture - non-parietal skull fracture
- scapular fractures
- sternal fractures
- outer third clavicular fractures
• bilateral fractures with fractures of differing ages
• digital fractures in non-ambulant children
• vertebral fractures or vertebral subluxation
• spiral humeral fractures
• separation of epiphysis

Elder abuse:
•	associated injuries
o	long bone fractures
o	rib fractures
o	bruises caused from abuse are
>	commonly over 5cm in size
>	located on the face, neck or back

DV:
o characteristic injuries or patterns
> injuries inconsistent with history
> long delay between injury and treatment
> repeat injuries
o characteristics of abused patient
> change in affect
> constantly seeking partner approval
> finding excuses to stay in treatment facility for prolonged period of time
> repeated visits to the emergency department
> significant time missed at work or decreased productivity at work
o characteristics of the abuser
> refuses to leave patient alone
> overly attentive
> aggressive or hostile
> refuses to let the patient answer their own questions
o barrier to reporting
> fear of retaliation
> shame
> difficulty reporting to male physicians
> fear of custody conflicts
• Minimally displaced forearm fracture – ulnar

Question 126

Outline the rehabilitation process and discuss the potential longer term functional, psychological and socioeconomic consequences of trauma for the patient

Answer 126

Rehabilitation may include support and guidance with:
• mental health and emotional difficulties
• increase movement, endurance and strength
• learning new ways to look after yourself with an injury or disabilities
• mobility, using aids or wheelchairs if needed
• Pain management
• guidance in returning to work, family activities and leisure
• arranging home care services, where applicable
• communication difficulties
• swallowing difficulties

• Roles of MDT:
o OT – assess cognition and functional ability – daily living skills (Washing, dressing, meal prep, work, leisure), assess environment, provide therapy programs, adaptations or aids
o SALT – assess and manage communication difficulties. Provide advice and treat difficulties with swallowing. Tracheostomy weaning plans
o Clinical psychologists – assess emotional and psychological needs, offer support in admission and sign post to services following discharge.
o Dietician – assess nutritional needs and provide advice on most appropriate route of nutrition – hep make suitable food choices, prescription of nutritional drinks or tailored feeding regimes.
o Rehabilitation medicine dr’s – provide support to medical team directly involved and the rehab team. Provide assessment, treatment, and guidance in management of complex rehab needs.
o Rehabilitation coordinators – ensure your rehab needs can be met at the point of discharge. They signpost your treating teams to appropriate services in hospital and community.
- Rehabilitation prescription - include a brief description of your injuries and how they are currently being managed. The Rehabilitation Prescription will also include an explanation of your rehabilitation needs and the services you are being referred to.

• Functional:
o Spinal rehab, Amputee rehab, Neuro rehab, MDT, Assessing pain management to enable physical rehabilitation activities to begin
o Neuromusculoskeletal assessment – physical impairments such as nerve injury, muscle imbalance, proprioception problems
o Upper and lower limb function – ability to move, walking aids
o ROM for each joint affected
o Balance + dizziness, Falls risk assessment, Visual/hearing problems
o Any difficulties with communication, speech, and language
o Ability to do transfers
o Trunk control and core stability
o Exercise tolerance
o Skin care, wound care, pressure area management
o Children > developmental attainment and functioning
o Swelling – circulation exercises, compression bandaging
o Scar management – look, touch, move
o Nutrition – post-surgical anorexia, pain meds, constipation, and nausea, increased calorific needs of healing

• Psychological
o Lack of engagement with rehab
o Problems beyond acute stress response
o Children – play or play therapy when offering psychological and emotional support
o Children – team should actively monitor for emerging emotional difficulties as child grows and develops
o Long-term psychological impact of change in body image as a result of injury
o Practitioner psychologist with appropriate expertise in physical trauma and rehabilitation

• Socioeconomic
o Realistic rehabilitation goals for life skills, work related training or education
o Providing equipment and adaptations (e.g., wheelchairs and seating)
o Increasing independence in ADLs
o Advice from job centres – disability employment advisers and access to work scheme
o Access to adult education settings
o Access to education for children and young people (e.g., SEND (special educational needs and disabilities) or new school placements)
o Give information about opportunities for daily meaningful activity (hobbies, social activities or voluntary work)
o Community practitioners offer emotional and psychological support to adults and families to help with adjustments

Question 127

Demonstrate knowledge of burns as a form of non-accidental injury

Answer 127

• Unexplained delay in presentation
• Unexplained burns
• Changing or evasive history
• History incompatible with injury
• History inconsistent with developmental age of child
• Sibling or child blamed
• Supervising adult not attending with child at A&E or unrelated adult presenting with child
• Lack of concern about treatment or prognosis
• Location of contact burn inconsistent with child touching hot item unintentionally
• Depth of burn greater than expected from described burning agent
• Multiple burns
• Other injuries or fractures noted
• Child sustained previous burn
• Previous history of accidental or non-accidental injury
• Trigger event such as misbehaviour, soiling or enuresis prior to burn
• Child disclosing abuse
• Forced immersion scalds are commonest- results in circumferential stocking and/or glove distribution and clearly demarcated upper edges/tide mark
• Frequently involve buttocks, legs, perineum and feet
• Are frequently bilateral and symmetrical
• The commonest reported cause of intentional non-scald burns are contact burns (i.e. from cigarettes, irons, hairdryers or domestic heaters)
• Clearly delineated burns or scars which carry the shape of the causative agent
• Non- accidental friction/carpet burns can be sustained on the trunk if a child is dragged across a floor

Question 128

Outline effective approaches to health promotion with relation to burns and scalds

Answer 128

• Apply safety regulations to housing designs and materials
mprove the design of cookstoves, particularly with regard to stability and prevention of access by children.
• Lower the temperature in hot water taps.
• Promote fire safety education and the use of smoke detectors, fire sprinklers, and fire-escape systems in homes.

First aid – STOP

• Strip hot clothes and jeweller
• Turn on cold tap – cool water for 10-20 minutes
• Organise medical assistance – NHS
• Protect – cling film or clean cloth (not dressing, cloth, cream, lotions). Give painkillers

Question 129

Explain the role of psychiatric assessment, assessment of suicide risk and continuing care in patients whom have taken an overdose

Answer 129

• A psychiatric assessment is most commonly carried out for clinical and therapeutic purposes, to establish a diagnosis and formulation of the individual’s problems, and to plan their care and treatment
• Purpose of suicide risk assessment:
  o Establish patient’s intent
   Useful to start off with day in question and obtain a narrative
  o Assess the seriousness and perceived seriousness of their attempt
  o Assess how they feel about the attempt at the time of assessment

• People who have deliberately self-poisoned should have a psychosocial assessment of their needs and risks by a specialist mental health professional while they are in hospital. The person’s subsequent management is based on this assessment. > precipitating events, reasons, assessing suicidal intent, any psychiatric disorder, risk of further self-harm/suicide, support

Question 130

Outline the organisation of health services for people with chronic neurological problems

Answer 130

• Stroke unit is an integrated medical ward with special skills in the management of acute stroke. > investigation of stroke, prevention of complications, secondary prevention, nursing care, rehab
• Stroke rehabilitation ward > PT, OT, SALT, Psychologist, social worker
• Mechanical aids and modification to the home are planned according to need
• Tailored community care package is planned prior to discharge

Question 131

Outline the prevention of spread of meningococcal disease including notification, chemoprophylaxis, and immunisation

Answer 131

• Notification is a legal requirement. Consultant for communicable disease control (CDC) or public health medicine (CPHM) responsible for policy design and implementation

o Early referral to hospital
o Prompt case reporting to CCDC/CPHM – with or without micro confirmation
o Investigated appropriately
o Contact racing and chemoprophylaxis
o Media communication appropriate and efficient
o Info given to GP, educational institutions/ authorities, NHS helpline and employers

• IV/IM benzylpenicillin should be given at earliest opportunity unless history of immediate penicillin allergy (i.e., within 48 hours of penicillin admin)
• Chemoprophylaxis should be offered to close contacts of contacts irrespective of vaccination status if:
  o Prolonged close contact in household settings during 7/7 before onset of illness
  o Transient close contact if directly exposed to large particle droplets/secretions from respiratory tract of case near to time of admission
• Rifampicin is drug of choice and licensed for this purpose. Ciprofloxacin is used if large numbers of people need prophylaxis.
• MenC conjugate vaccine part of childhood vaccination programme

Question 132

RFs of stroke?

Answer 132

-	Modifiable risk factors for stroke:
o	BP
o	Smoking
o	DM
o	AF
o	High salt intake
o	High fat intake
o	Low potassium
o	Low vitamins
o	Excess alcohol
o	Obesity
o	Sedentary lifestyle
o	Hypothermia
o	Abnormal cholesterol 
-	Non-modifiable risk factors 
o	Increasing age
o	Male gender
o	Afro-Caribbean descent
o	FHx

Question 133

Primary and secondary prevention of stroke

Answer 133

• Primary - lifestyle changes to smoking, diet, exercise, weight, alcohol. Treating BP, consider statins if CVD risk >20%, anticoagulated if AF (exclude haemorrhage first), carotid endarterectomy if very stenosed and symptomatic
• Secondary – lifestyle measures, antiplatelet Tx (clopidogrel or aspirin and modified-release dipyridamole), statin, anti-hypertensives, anticoagulant if have AF (warfarin), optimise co-morbidities
• Single TIA – not drive 1 month but need not notify DVLA
• Multiple TIA – not drive for 3 months and must notify DVLA
• Stroke – not drive 1 month, need not notify DVLA – only notified if residual neurological deficit 1 month after episode (visual, cognitive, impaired limb)
• CHADS VASc stroke risk score used in primary prevention of stroke in AF

Question 134

The role of health economics in NICE technology appraisals

Answer 134

• NICE technology appraisal:
  o Technology appraisal is the recommendation on the use of new and existing medications and treatments within the NHS in England and Wales. This includes medicines, medical devices, diagnostic techniques, surgical techniques, and health promotion activities
  o Assess the evidence base for the clinical and cost-effectiveness of new and existing healthcare technologies with a view to providing a single, authoritative source of advice on these interventions and procedures
  o Technology appraisals are mandatory for CCGs to fund the technology
  o Technologies appraised include drugs, diagnostic tests, clinical devices, surgical and clinical procedures and health promotion interventions
• Cost effectiveness can be worked out using the Incremental Cost Effectiveness Ratio. This is the ratio of the change in costs of therapeutic interventions (compared with alternatives/no treatment) to the change in effects of the intervention (measured as clinical outcome or QALY)
  o ICER = (Cost A – Cost B) / (QALYs B – QALYs A)

Question 135

Outline the pharmacological treatment of dementia and discuss the role of health economics in NICE technology appraisals to determine access to these, and other, new treatments

Answer 135

o Acetylcholinesterase inhibitors
> Donepezil - £59.85 (5 mg, 28-tablet pack) – initial 5mg
> Rivastigmine - 1.5 mg rivastigmine capsules is £33.25 (28-capsule pack) – initial Tx – 1.5mg BD
> Galantamine - £68.32 (8 mg, 56-tablet pack) – initial 8mg
o Memantine - 10 mg memantine tablets cost £34.50 (28-tablet pack)

o If prescribing an AChE inhibitor (donepezil, galantamine or rivastigmine), treatment should normally be started with the drug with the lowest acquisition cost (taking into account required daily dose and the price per dose once shared care has started). However, an alternative AChE inhibitor could be prescribed if it is considered appropriate when taking into account adverse event profile, expectations about adherence, medical comorbidity, possibility of drug interactions and dosing profiles

Question 136

Describe and recognise risk factors for falls

Answer 136

• Medical – conditions affecting mobility or balance (arthritis, diabetes, incontinence, stroke, syncope, PD), muscle weakness, depression, alcohol misuse, postural hypotension, low body weight
• Environmental – loose rugs, mats, poor lighting, wet surfaces, loose fittings, steep stairs, cluttered, poorly fitting footwear, new environment
• Pharmaceutical – polypharmacy (4+), psychoactive drugs (BDZ’s), drugs causing postural hypotension
• Sensory/cognitive - poor balance, visual impairment, cognitive impairment, dementia, diabetic neuropathy, hearing impairment
• System (nursing homes) – poor staff education, poor staff:resident ratio

Question 137

Outline the role of and evidence for physiotherapy, osteopathy, and chiropractic therapy in the management of back pain

Answer 137

• Physiotherapy – restore movement and function to whole body after being affected by illness/injury. Look at part affected. spinal manipulation, mobilisation or massage, early activity, specific stabilization exercises, general exercises and stretches, ergonomic advice, postural guidelines
• Acupuncture now recommended by ACP
• Specific Treatment of Problems of the Spine (STOPS) approach > stratified care
• Osteopaths – gentle hands-on technique, look at health of body as a whole, working smoothly together
• Chiropractors – manipulation of the spine

Question 138

Outline the physical and psychosocial factors (including yellow flags) that can influence the persistence of disabling back pain

Answer 138

• Yellow flags:
  o Maladaptive/ passive pain coping behaviors – fear avoidance or catastrophizing
  o nonorganic signs or more generalized pain – suggest strong psychological component to pain, or intentionally false of exaggerated pain Sx
  o high baseline functional impairment – at work or ADL
  o general health status
  o presence of psychiatric comorbidities

-	other factors:
o	low general health status
o	high pain intensity 
o	higher work dissatisfaction
o	higher work physical demands
o	receiving worker’s compensation
o	presence of radiculopathy or leg pain

Question 139

Outline the social and medicolegal implications of a diagnosis of epilepsy

Answer 139

• social
  o feel isolated/alone
  o families – emotional, protective,
  o school – seizures or medication SFx, LD or neuro problems, meds = tired, difficult paying attention, forgetful, can’t focus,
  o work – if can’t driving then commuting a problem, any driving-related jobs cannot do, vocational counselling, training
  o stigma + discrimination – avoiding Tx
• medicolegal
  o intent for alleged criminal actions - most cases it is difficult or impossible to form intent for certain actions while suffering from a major incapacitating seizure even though ictal and post-ictal actions may appear to occur in an organized fashion
  o fitness to drive
  o child protection – epilepsy of parent affecting care, or NAI causing child to develop epilepsy
  o medical negligence – failure to diagnosis, failure to warm about effects, allergic reactions to meds, incorrect diagnosis, failure to convey important information (i.e., DBLA, baths, cooking)
  o tell DVLA - £1000 fine if don’t tell DVLA

Question 140

Describe the organisation of cancer services and networks in the United Kingdom

Answer 140

EUROCARE Study - the UK had one of the worst survival statistics in Europe

Thus an expert advisory group formed by the Chief Medical Officers called for the Calman-Hine Report (1995)

Resulted in (via NHS Cancer Plan 5 years later) the formation of Cancer Networks (34 in total) – 3 levels of care:
- 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
All above three use the MDTs which meet weekly to discuss new patient

Strategic Cancer Networks

Organisational model to implement the: NHS Cancer Plan 2000
They drove the Cancer Plan and Cancer Reform Strategy

Cancer Reform Strategy 2007:

Question 141

Outline the ways in which the quality of cancer services are measured at local and national levels

Answer 141

Primary care > cancer units > cancer centres

Cancer units - diagnose and treat common cancers, diagnose intermediate cancer and refer to specialists, provide drug therapy and other treatments

Cancer centres - provide cancer unit services and also provide cancer services for large areas and specialist diagnostics and treatment

Concentrating specialist care in cancer centres? (centralisation)

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

Question 142

Give examples of some of the possible psychological consequencies of cancer treatment for patients and their relatives

Answer 142

Therapy may change physical appearance:
> Loss of hair from chemotherapy
> Mastectomy - Can change self-image

Destruction of Assumptive World Theory:
> Benevolence theory = not everything in world is good
> That world is meaningful = bad thing happens to good person, so point of being good is shattered
> May change biography = who I am – can also directly change identity
> The assumption of invulnerability = nothing bad could happen to me
> Can’t rely on body anymore
> Can control fate = loss of control of fate

Family / friends death forces to confront own mortality

Worry about leaving people behind, especially children

Grief

Uncertainty: Put life on hold

Demanding physical health affects of chemotherapy > And intense regimes can be socially isolating as either in hospital or recovering

Stress of becoming carer or cared for > Family members more susceptible to depression, Financial concerns

Question 143

Prediction of LBW?

Answer 143

Small for gestational age is defined as a fetus that measures below the 10th centile for their gestational age. Two measurements on ultrasound are used to assess the fetal size:

Estimated fetal weight (EFW)
Fetal abdominal circumference (AC)

Customised growth charts are used to assess the size of the fetus, based on the mother’s:

Ethnic group
Weight
Height
Parity

Low-risk women have monitoring of the symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards to identify potential SGA

If the symphysis fundal height is less than the 10th centile, women are booked for serial growth scans with umbilical artery doppler.

Women are booked for serial growth scans with umbilical artery doppler if they have:

Three or more minor risk factors
One or more major risk factors
Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)

Women at risk or with SGA are monitored closely with serial ultrasound scans measuring:

Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
Amniotic fluid volume

Question 144

Complications and management of LBW?

Answer 144

Short term complications of fetal growth restriction include:

Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia

Growth restricted babies have a long term increased risk of:

Cardiovascular disease, particularly hypertension
Type 2 diabetes
Obesity
Mood and behavioural problems

The critical management steps are:

Identifying those at risk of SGA
Aspirin is given to those at risk of pre-eclampsia
Treating modifiable risk factors (e.g. stop smoking)
Serial growth scans to monitor growth
Early delivery where growth is static, or there are other concerns

When a fetus is identified as SGA, investigations to identify the underlying cause include:

Blood pressure and urine dipstick for pre-eclampsia
Uterine artery doppler scanning
Detailed fetal anatomy scan by fetal medicine
Karyotyping for chromosomal abnormalities
Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)

Early delivery is considered when growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results). This reduces the risk of stillbirth. Corticosteroids are given when delivery is planned early, particularly when delivered by caesarean section. Paediatricians should be involved at birth to help with neonatal resuscitation and management if required.

Question 145

risk factors for perinatal mortality

Answer 145

low socio-economic status
referrals
late registration
prematurity
low birth weight
intra-uterine growth restriction
maternal diseases like gestational hypertension and gestational diabetes intrapartum complications like abruption.

Question 146

outline strategies to reduce perinatal mortality in the UK and globally

Answer 146

neonatal resuscitation

thermal care for term newborns

routine antenatal care visits

nutritional interventions - folic acid, calcium supplementation,

antenatal treatment of maternal infections

treatment of DM and GDM

improved detection and management of IUGR

elective induction

Question 147

What are the aims regarding transition of care from child to adult in regards to their own health?

Answer 147

Aim for independence

Should have a named worker that coordinates transition, delivery etc

Person-centered approach= treat the young person as an equal partner

Support them physically, mentally, job employability

Start early- support should continue from 6 months before and after care

Question 148

Explain the principle of Multi-Disciplinary Team (MDT) approach to treatment of gynaecological malignancies

Answer 148

a gynaecological oncologist – a surgeon who specialises in gynaecological cancers

a gynaecologist – a doctor who treats problems with the female reproductive system

clinical oncologists – doctors who specialise in cancer treatments such as radiotherapy, chemotherapy and targeted therapy drugs

a gynae-oncology nurse specialist – a nurse who will be your main contact and will make sure you get help and support throughout your treatment

a plastic surgeon – a doctor who specialises in reconstructive surgery if you have vulval cancer

a radiologist – a doctor who looks at scans and x-rays to diagnose problems

a pathologist – a doctor who looks at cells or body tissue under a microscope to diagnose cancer.

a dietitian

a physiotherapist

an occupational therapist

a radiographer

a psychologist

a counsellor.

Question 149

Discuss issues in relation to female genital mutilation (FGM) in obstetrics and gynaecology

Answer 149

It is essential to educate patients and relatives that FGM is illegal in the UK. Discuss the health consequences of FGM.

It is mandatory to report all cases of FGM in patients under 18 to the police.

Other services should also be contacted:

Social services and safeguarding
Paediatrics
Specialist gynaecology or FGM services
Counselling

In patients over 18, there needs to be careful consideration about whether to report cases to the police or social services. The RCOG recommends using a risk assessment tool to tackle this issue. The risk assessment includes considering whether the patient has female relatives that may be at risk. If the unborn child of a pregnant woman affected by FGM is considered to be at risk, a referral should be made.

A de-infibulation surgical procedure may be performed by a specialist in FGM in cases of type 3 FGM. This aims to correct the narrowing or closure of the vaginal orifice, improve symptoms and try to restore normal function.

Re-infibulation (re-closure of the vaginal orifice) could be requested after childbirth. Performing this procedure is illegal.

Question 150

Discuss domestic violence issues in obstetrics and gynaecology in relation to safeguarding

Answer 150

Domestic violence is common among obstetric and gynaecology patients and is a leading cause of maternal mortality.

Reproductive coercion involves male attempts to control female fertility; long-acting contraception should be considered in these cases.

Past domestic violence and late booking for antenatal care are associated with abuse during pregnancy.

Healthcare providers should ask women about domestic violence directly and in private, assess victims’ safety, offer referrals to community-based organisations and document abuse in the hospital or office record (not necessarily in the hand-held record).

The highest standard of confidentiality is required to keep abused women safe; at times, this standard may conflict with complete information sharing.

Healthcare providers often feel frustrated and powerless when working with abused women. It is the woman’s decision when to leave her violent relationship and the clinician’s role to provide empathy and information about resources.

Question 151

Discuss welfare of the child issues in relation to subfertility

Answer 151

Section 13(5) of the Act is no exception. This prevents a woman from receiving treatment from a UK fertility clinic ‘unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father) and of any other child who may be affected by the birth’.

Also in 2005, as part of its review of the entire Act, which it commenced in 2004, the House of Commons Science and Technology Select Committee called for the abolition of Section 13(5) in its existing form

The latter of these indicated the government’s intention to retain the duty on clinics to consider the welfare of the child who may be born as a result of treatment, or any other child who may be affected, before offering treatment. However, it planned to remove reference to the child’s ‘need for a father’, a proposal that was consistent with other recent legislation passed by parliament, namely the Adoption and Children Act 2002 and the Civil Partnership Act 2004

The HFEA also recommends that patients using donated eggs, sperm or embryos should be encouraged to be open with their children from an early age about the circumstances of their conception

clinics should now only make further enquiries about their patients in cases where they think the child may be at risk of serious harm. Currently, fertility doctors are required to ask every patient’s GP to run medical and social checks on prospective parents, a system which can delay treatment.

The HFEA has also scrapped the need for clinics to consider social factors such as the patients’ ages, their commitment to having children and the stability of their relationship

Question 152

Assess the medical and social needs of an elderly person

Answer 152

care needs assessment

They will look at:

the emotional and social side of your life
your skills and abilities
your views, religious and cultural background and support network
any physical difficulties you may experience, or any risks
any health or housing requirements
your needs and wishes
what you would like to happen
information about your needs from your carer, if you want them to be involved in your assessment.

Fried et al (2001) suggested frailty, multimorbidity and disability as the main problems in older age;

The ‘three Ds’ are dementia, delirium and depression; in some cases, a fourth D – cognitive decline – is added (Harris, 2017);

The five ‘geriatric Ms’ are mind, mobility, medications, multi-complexity and ‘matters most to me’ (Tinetti et al, 2017);

The ‘geriatric giants’ identified by Bernard Isaacs in 1965 were impaired vision and hearing, incontinence, instability, and intellectual impairment; they have recently been expanded to include frailty and sarcopenia (Morley, 2016).

Question 153

Be aware of the community support groups available to patients with neurological conditions

Answer 153

Spinal Injuries Association (SIA)

The Stroke Association

The Neurological Alliance

Parkinson’s UK

The Muscular Dystrophy Campaign

MS trust

MS society

The Motor Neurone Disease Association

The Independent Neurorehabilitation Providers Alliance (INPA)

The Huntington’s Disease Association

Headway supports people with brain injury

GAIN offers support and information to those affected by Guillain-Barré syndrome, CIDP and other dysimmune neuropathies

Fighting Strokes lobbies for stroke care policy changes

Dementia UK

Child Brain Injury Trust

Brain Tumour charity

Question 154

Discuss the options available for complex discharge planning

Answer 154

Each hospital has its own discharge policy. You should be able to get a copy from the ward manager or the hospital’s Patient Advice and Liaison Service (PALS).

f the discharge assessment shows you’ll need little or no care, it’s called a minimal discharge.

If you need more specialised care after leaving hospital, your discharge or transfer procedure is referred to as a complex discharge.

If you need this type of care, you’ll receive a care plan detailing your health and social care needs.

You should be fully involved in this process.

A care plan should include details of:

the treatment and support you’ll get when discharged
who will be responsible for providing support and how to contact them
when and how often support will be provided
how the support will be monitored and reviewed
the name of the person co-ordinating the care plan
who to contact if there’s an emergency or things do not work as they should
information about any charges that will need to be paid (if applicable)

If you’re given any medication to take home, you’ll usually be given enough for the following 7 days. The letter to your GP will include information about your medication.

If you’re sent home with a medical device, make sure you know how to set it up and have been taught how to use it.

Question 155

Discuss the effects of polypharmacy in the elderly considering drug classes such as anticholinergics, antihypertensives and opioids.

Answer 155

Polypharmacy can worsen frailty, a term which refers to the collection of health problems an older adult may face. This includes delirium and cognitive impairment, falls and decreased functional ability. Drugs are a common risk factor for delirium

The common signs are a loss of appetite, diarrhea, tiredness or reduced alertness, confusion and hallucinations, falls, weakness and dizziness, skin rashes, depression, anxiety, and excitability

Older adults are more sensitive to adverse events associated with anticholinergics, including confusion, dry mouth, blurry vision, constipation, urinary retention, decreased perspiration, and excess sedation

Antihypertensives - postural hypotension, falls, frailty, Beta-blockers and alpha-blockers are generally not recommended in this population.

75% of older outpatients with CNS polypharmacy were opioid users [2]. This type of polypharmacy is of particular concern for older adults, since it has been linked with a higher risk of falls, cognitive impairment, accidental overdose, and mortality, increased risk of respiratory suppression and death when combined with medications that can slow brain activity, including benzodiazepines, antipsychotics, and gabapentinoids. These drug-drug and drug-disease interaction risks may be even greater for older adults with dementia who also may have difficulty communicating any adverse effects.

Question 156

Appreciate the limitations to successful rehabilitation.

Answer 156

Main barriers were:

Differences in staff and patients perspectives of goal-setting;

staff-related barriers - Staff lack of confidence to manage patient expectations.

patient-related barriers - Patients’ stroke related impairments.

organisational level barriers - Insufficient time and ineffective organisational systems.

Question 157

Recognise the importance of the multidisciplinary approach in the assessment and management of inflammatory arthritis

Answer 157

Input from a variety of team members can be required to help the patient maximize their physical, psychological and social function

General practitioners
GPs with a special interest
Consultant rheumatologists
Nurse specialists
Extended scope practitioners
Physiotherapists
Occupational therapists
Podiatrists
Chiropodists
Orthotists
Pharmacists

Question 158

Appreciate the impact of untreated inflammatory arthritis on function and quality of life

Answer 158

Rheumatoid arthritis (RA) has many physical and social consequences and can lower quality of life. It can cause pain, disability, and premature death.

Infection

Inflammation causes narrowing of BV

Premature heart disease. People with RA are also at a higher risk for developing other chronic diseases such as heart disease and diabetes.

Obesity. People with RA who are obese have an increased risk of developing heart disease risk factors such as high blood pressure and high cholesterol. Being obese also increases risk of developing chronic conditions such as heart disease and diabetes. Finally, people with RA who are obese experience fewer benefits from their medical treatment compared with those with RA who are not obese.

Employment.

Question 159

When to consider DNACPR decision?

Answer 159

if cardiac/resp arrest is likely and they are unlikely to survive

CPR may be successful but clinical outcomes would be very poor

last few hours/days spent in place they want to be

Question 160

What are the issues regarding capacity and CPR?

Answer 160

if they have capacity - they can refuse CPR

if they don’t - Dr must act in their best interest or a legal proxy can make decision

Question 161

What are the levels of critical care?

Answer 161

0 = requires hospitalisation, can admit onto a normal ward

1 = just got discharged from a higher level of care

2 = 1 nurse to 2 patients = requires term support, renal support, CV support, neuro support

3 = requires specialist 1 to 1 care, e.g., ventilatory support, tracheostomy

Question 162

What are the ASA grades?

Answer 162

1 = normal healthy patient

2 = mild systemic disease, e.g., smoker, alcoholic

3 = severe systemic disease which is not a constant threat to life, e.g., DM/HTN

4 = severe systemic disease that is a constant threat to life e.g., MI/sepsis

5 = moribund = not expected to survive without the operation, e.g, ruptured AAA

6 = organ donation - brain dead, organs used for donation

Question 163

What drugs should be stopped prior to surgery?

Answer 163

COCP 4w prior to surgery
Clopidogrel 7 days prior to surgery
Warfarin 5 days prior to surgery

Question 164

What is a major trauma centre?

Answer 164

All services available to manage seriously injured adults/children or both

Question 165

What is the triage system?

Answer 165

1 = immediately seen (red)
2 = very urgent (orange) seen within 5-10 minutes 
3 = seen urgently within an hour (yellow)
4 = seen within 2 hours (green)
5 = seen within 4 hours (blue)

Question 166

What is the traumatic care pathway?

Answer 166

First responder > emergency care > acute hospital > clinical rehab > community rehab

Question 167

What are the rims of a major trauma centre?

Answer 167

Reduce avoidable deaths

Reduce injuries through prevention programmes

Improve quality of life/functionality

Question 168

Difference in impairment vs disability vs handicap?

Answer 168

Impairment - disturbance to function either physical or physiological, e.g. amputation

Disability - restriction to activity due to impairment, e.g., can’t walk

Handicap - disadvantage faced which restricts them from being seen as a normal being by other people, e.g., going to the shops

Question 169

General criteria for palliative care referral?

Answer 169

Incurable disease

Prognosis of <1 year OR prognosis of >1 year but complex needs

Malnutrition signs, e.g., cachexia

Need support in at least 3 ADLs

Multiple co-morbidities

Progressive deterioration

Symptoms cannot be alleviated

Question 170

Gold standard framework for palliative care?

Answer 170

7 C's
1 - communicate
2 - coordinate
3 - control symptoms
4 - continuity
5 - continue learning
6 - carer support
7 - care in dying process

Question 171

End of life care strategy 2008?

Answer 171

1 - engaging with local communities
2 - identifying those at the EoL
3 - identifying the needs and wishes of patients
4 - coordinating care
5 - rapid access to care if condition changes
6 - last days of life and care after death

Question 172

WHO principles of palliative care?

Answer 172

FANS - family, activity, natural death and symptoms relief/spiritual views

Question 173

4 phases of Colin Murray Parkes Phases of grief?

Answer 173

1 - shock or numbing
2 - yearning or searching
3 - disorganisation or dispair
4 - recovery

Question 174

What factors affect grief sensitivity?

Answer 174

Meaningfulness of relationship

Manner of the death - sudden or knew it was coming

Age of griever

Religious beliefs

Resilience

Question 175

What is pathological grief?

Answer 175

Extended grief reaction

If Sx are present for >2 months = major depressive disorder

Feeling stuck in a phase

Question 176

What is income support JSA, personal income dependence payment, statutory sick payment?

Answer 176

Income support - 16-59 yrs, if they work <16 hours a week and not receiving JSA

JSA (job seeker allowance) - actively looking for a job, from 18 to retirement age up to pension

Personal independence payment - replaced disability living allowance, if they have a physical or mental disability, from 16-64 years

Statutory sick pay - can’t work for more than 4 days in a row, paid up to 28 weeks

Question 177

What are the 4 types of euthanasia?

Answer 177

Active - person actively ends life

Passive - withheld treatment

Voluntary - ask to be killed

Involuntary - someone decides for them (murder)

Question 178

What are the pros and cons of euthanasia?

Answer 178

Pros

• autonomy - respect patient’s decision
• allows them to die with dignity
• pragmatic - EoL care is very similar to euthanasia

Cons

• non-malificience - causes murder
• slippery slope - may feel like a burden to society
• goes against doctor’s duty to do no harm
• may have been coerced by their condition

Question 179

Marie Curie nurse vs Macmillan’s nurse?

Answer 179

Marie Curie - can be district or community based caring for palliative/terminal illness

Macmillan’s nurse - caring for people with cancer in community or hospital

Question 180

What is palliative care?

Answer 180

Active holistic care of patients with advanced progressive illness

Question 181

What is the effectiveness gap?

Answer 181

Tx not satisfactory or successful due to lack of efficacy or acceptability or side effects

Question 182

RFs of substance misuse in elderly?

Answer 182

Loneliness
Bereavement
Retirement
Long-term prescriptions
Homelessness
Depression

Question 183

What is notification of assessment vs notification of discharge?

Answer 183

NOA - social worker needs to be allocated to the patient

NOD - informs social services that the patient is medically and therapy fit for discharge but now social service is delaying discharge

Question 184

When considering discharge of a falls patient, what should the assessment entail?

Answer 184

Joint ROM
Strength
Ability to carry out daily activities
Toileting
Kitchen duties

Question 185

What specialities involved in falls management?

Answer 185

Pharmacist, OT, podiatry

Question 186

Rules regarding epilepsy and informing the DVLA?

Answer 186

Any unprovoked seizure with no structural abnormality and normal EEG = ban is 6 months otherwise it is 12 months

Established epilepsy - must be seizure free for 1 year - must be seizure free for 5 years to get a till-70 license

Don’t drive whilst withdrawing AED and for 6 months post medication

Question 187

What is disability discrimination act 1995 and the equality act 2005?

Answer 187

DA 1995 - protect those with a disability

EA 2005 - states that discrimination within the workplace is not allowed

Question 188

Order of most common neurological conditions

Answer 188

Essential tremor
Epilepsy
PD
MS

Question 189

Scale to determine someones risk of an overdose?

Answer 189

SAD PERSONS 
Sex - male
Age - <19 and >45 
Depression or hopelessness
Previous attempts or psychiatric care
Excessive alcohol or drug use
Rational thinking loss
Separated/divorced/widowed
Organised or serious attempt
No social support
Stated future intent

<6 outpatient
6-9 emergency psych evaluation
>9 inpatient

Question 190

Most common inherited cause of vision loss?

Answer 190

Retinitis pigmentosa

Question 191

Most common cause of vision loss in UK

Answer 191

Age related macular degeneration

Question 192

Most common cause of vision loss worldwide

Answer 192

1st - cataracts, 2nd - glaucoma

Question 193

Blindness in children - high vs low income

Answer 193

high income - optic nerve lesions

low income - measles, vit A def, rubella, corneal scarring

Question 194

When to offer a statin 20mg primary prevention

Answer 194

QRISK > 10
T1DM
QRISK > 10 and T2DM
EGFR <60

Question 195

Pathophysiology and stages of diabetic retinopathy

Answer 195

Hyperglycaemia causes endothelial dysfunction, abnormal metabolism within walls and increased retinal blood flow

1 - background - blot haemorrhages, micro aneurysms and hard exudates > annual screening

2 - pre-proliferative - cotton wool spots, venous looping, > blot haemorrhage, photocoagulation burns > refer to hospital eye service in less than 13 weeks

3 - proliferative - neovascularisation, fibrous tissue forming at the retinal disc > fast track to hospital eye service within 2 weeks and annual screening

4 - maculopathy - hard exudates, check visual acuity - refer to hospital eye services within 13 weeks

Question 196

How many wks to wait before administering MMR following most diseases?

Answer 196

At least 4 weeks

Question 197

Common causes of viral meningitis and how to diagnose?

Answer 197

EBV, enterovirus, adenovirus

PCR/culture of stool, CSF, urine

Question 198

What is doctrine of double effect?

Answer 198

Doing something morally good is acceptable even if it has a morally bad side effect given that you did it with intention of providing the good side effect

Question 199

Criteria of EoL care for a child

Answer 199

Life-threatening condition for which curative treatment may be feasible but can fail (e.g. malignancy)

Conditions where premature death is inevitable e.g., CF

Conditions which are progressive without curative treatment and where treatment is palliative

Irreversible but non-progressive conditions which can cause severe disability leading to health complications, e.g., severe head injury

Question 200

Rules of Gillick competence and Fraser guidelines

Answer 200

Gillick competence = <16 deemed competent to consent to treatment

If below 18 = don’t have the right to refuse Tx, even if parents support refusal

The doctor/court can overrule the refusal if it is in the best interest of the patient

Fraser guidelines - for contraception < 16

Question 201

Common medical causes of bruising in children?

Answer 201

VWD
Haemophilia
ITP