Important ‼️ Flashcards
Name the two types of feedback mechanisms in the endocrine system (1 mark). Explain how these mechanisms work using a particular hormone as an example (2 marks for each example). ADD ANSWER
A: Positive and negative feedback (1 mark)
Negative feedback: Cortisol levels are controlled by a negative feedback mechanism that increases or decrease release of CRH and ACTH to maintain homeostasis (2 marks, full explanation)
Positive feedback: Oxytocin release is stimulated by childbirth or breastfeeding which both causes additional release of the hormone which only stope when birth or breastfeeding is complete. (2 marks, complete explanation)
This type of question can include different hormones to explain the types of mechanisms.
Negative and positive feedback mechanisms have to be named to get 1 mark.
As long as negative feedback is linked to a hormone (0.5marks), the system by which increases and decreases in the named hormone (1 mark) is controlled plus this is to maintain homeostasis (0.5marks) full marks can be achieved in multiple ways.
Oxytocin is really the only example that can be used as an example of positive feedback (0.5 marks). The physiological process that cause / inhibit release ned to be given (childbirth and breastfeeding (1 mark) and cessation of these stops hormone release (0.5marks)
Define half-life
Time taken for the plasma concentration to fall by half, once distribution equilibrium has been achieved
Describe the metabolic effects of glucocorticoids (4 marks)
Glucocortocoids tell catecholamines to exert the lipolytic effect (1 mark) and also tell glucagon to exert calorigenic effects (1 mark). These steroid hormones also causes increased gluconeogenesis (1 mark) and cause increased storage of glycogen in liver and in muscle (1 mark). Glycogen is a polysaccharide whereas glucose is a monosaccharide.
Therapeutics ILO (4 marks): Apply evidence-based management for person living with type 2 diabetes
Provide an evidence-based management plan for Parveen based on her presentation in relation to type
2 diabetes.
Type 2 diabetes
Assessment: HbA1c 58 mmol/mol is not in target of 53 mmol/mol - high-priority (1 mark)
Actions: discuss potential reasons for this with patient, has diet changed for example, has he been adherent to medication (if not explore underpinning reasons), already on dual therapy for diabetes mx of metformin and sitagliptin so can consider prescribing another antidiabetic moving to triple therapy and also discuss a reasonable HbA1c target - does not need to be 53, could be 55-56 mmol/mol for example, needs to be achievable for this person. (1 mark)
Consider adding in SGLT-2 inhibitor - dapagliflozin or empagliflozin 10mg OD due to current eGFR, - consider other symptoms he is presenting with (increased breathlessness - could be indicative of lots of things, one being heart failure - more investigations required to confirm - link back to year 2 learning and possible risk factors this person presents with i.e. hypertension and diabetes), SGLT-2 inhibitor has proven CV benefits.
Probe students to find out what investigations they might want to do to address symptoms of breathlessness and fatigue - full blood count/iron studies (? Anaemia or more sinister pathology), NT-pro-BNP/ECG (? Heart failure), lung function tests, thyroid function tests (will learn more in week 7 about hypothyroidism) (1 mark)
Could consider GLP-1 agonist but CV benefit from SGLT-inhibitor may be better in this case
If student suggests pioglitazone
- unsuitable for
moment as contraindicated in heart failure and need to explore what is going on re: presenting symptoms of breathlessness and fatigue.
Monitoring: SGLT2 inhibitors can cause DKA so ensure patient is aware of what to look for (prescribe blood glucose monitor with ketone monitor if doesn’t have already), inform about signs and symptoms of DKA (nausea, vomiting, anorexia, abdominal pain, excessive thirst, difficulty breathing, confusion, unusual fatigue or sleepiness - advise to get immediate medical help if these occur), review HbA1c and eGFR in 3 months to see if HbA1c reduced and if check eGFR has not deteriorated (1 mark)
Students may also mention checking the Parveen is attending eye and foot screenings, has had annual jab (all relevant points)
These next aspects will be expected to be included in prescribing SLEs in year 3 and 4 and other year 4 assessment.
Hypertension
Assessment: BP not in target range of 140/90 mmHg
Actions: discuss this with patient and explore reasons why (adherence to medication), discuss that this may be an isolated incident and explore bringing him back in 1-2 weeks to retake BP measurement. Ask if has home BP machine and ask to monitor twice daily at same time for 1 week (send in readings to practice so you can assess). If consistently higher than target, optimise ramipril to 10mg.
Monitoring: Ask if has home BP machine and ask to monitor twice daily at same time for 1 week (send in readings to practice so you can assess).
Assessment: lives with hypertension and CKD- high priority
Actions: discuss what this means with patient (greater risk of further damage to kidneys if BP not controlled) and possible risks of developing CVD in next years increased risk, discuss recommendation to commence atorvastatin 20mg OD, need to measure LFTs before commencing (should have been started on diagnosis of CKD)
Monitoring: assess LFTs within first 3 months of commencing statin, lipid profile annually
Assessment: BMI not in target range - medium priority
Actions: discuss this with patient, case outlines reasons for possible increase in weight, talk about exercise regimes that might work for him but recognise that this may happen after further investigations for heart failure/other pathology, also that empagliflozin can lead to
2-3kg weight loss, discuss some weight loss can contribute to better glucose control and reduction of BP and mx of CKD
Monitoring: check weight at next annual review
CKD
Assessment: Currently stage 3a, stable since last review, need to prevent progression of CKD - medium priority
Actions: discuss need for good BP control as discussed previously. Offer lifestyle advice, information and education on CKD. Advise on kidney health and need to avoid nephrotoxics (speak to pharmacist if buying OTC products), reminder of drugs that cause AKI (SADMAN - SGLT2 inhibitors, ACE inhibitors, diuretics, metformin, ARBs and NSAIDs), and what to do if unwell (stop meds for 48 hours and then restart when better if experiencing diarrhoea and vomiting - seek medical advice if unsure)
Monitoring: minimum twice yearly eGFR based on disease staging
Lifestyle and Wellbeing
Assessment: Check mood - medium priority
Actions: lives with long term conditions and evidence shows risk of low mood, ask about mood and use PHQ-10 tool if needed
Monitoring: Check mood at all reviews
Assessment: Reduce cardiovascular risk - high priority
Actions: discuss exercise as above and weight loss to reduce CV risk as well as benefits to controlling blood glucose and BP
Monitoring: check weight and BP at next review and ask about how she is managing exercise
Part 2
(1 mark)
Assessment: HbA1c 58 mmol/mol is not in target of 53 mmol/mol - high-priority
Actions: discuss potential reasons for this with patient, has diet changed for example, has he been adherent to medication (if not explore underpinning reasons), already on dual therapy for diabetes mx of metformin and sitagliptin so can consider prescribing another antidiabetic moving to triple therapy and also discuss a reasonable HbA1c target - does not need to be 53, could be 55-56 mmol/mol for example, needs to be achievable for this person. (1 mark)
Consider adding in SGLT-2 inhibitor - dapagliflozin or empagliflozin 10mg OD due to current eGFR, consider other symptoms is presenting with (increased breathlessness - could be indicative of lots of things, one being heart failure - more investigations required to confirm - link back to year 2 learning and possible risk factors this person presents with i.e. hypertension and diabetes). SGLT-2 inhibitor has prove CV benefits
Investigations to address symptoms of breathlessness and fatigue - full blood count/iron studies (? Anaemia or more sinister pathology), NT-pro-BNP/ECG (?
Heart failure), lung function tests, thyroid function tests (will learn more in week 7 about hypothyroidism) (1 mark)
Could consider GLP-1 agonist but CV benefit from SGLT-inhibitor may be better in this case.
If student suggests pioglitazone
- unsuitable for moment as
contraindicated in heart failure and need to explore what is going on re: presenting symptoms of breathlessness and fatigue.
Monitoring: SLT2 inhibitors can cause DKA so ensure that patient is aware of what to look for (prescribe blood glucose monitor with ketone monitor if doesn’t have already), inform about signs and symptoms of DKA (nausea, vomiting, anorexia, abdominal pain, excessive thirst, difficulty breathing, confusion, unusual fatigue or sleepiness - advise to get immediate medical help if these occur), review HbA1c and eGFR in 3 months to see if HbA1c reduced and if check eGFR has not deteriorated (1 mark)
Students may also mention checking the Parveen is attending eye and foot screenings, has had annual jab (all relevant points)
Other detailed points to mention:
Hypertension, CKD, Lifestyle and wellbeing - indicative answer on BB to cover
What are the risk factors for breast cancer, and, what are the red flags that may present for breast cancer? (4 marks)
Risk Factors (not limited to):
• Our age
• The natural rate that the cells multiply in that tissue
• The extent to which DNA polvmerase, oxygen free radicals. and APOBEC enzymes have caused mutations in the tissue’s cells (the amount of damage will gradually increase as we age)
• Our sex, our lifestyle (smoking, alcohol intake, physical activity), and behaviors (which will be hugely impacted by our cultural background, physical location, and personal choices and opportunities)
• Our cells’ exposure to carcinogens, hormones (e androgen in prostate cancer). and factors that cause inflammation (including obesity, viral infections, comorbidities such as diabetes)
• Our inherited genetic (expression of estrogen receptor alpha, androgen receptor,
HER2) and epigenetic makeup (determined by our ancestors’ and our own life style).
0.5 for each - maximum of 2 points relating to risk factors
Primary Care - Identification of red flag symptoms, early diagnosis and referral (2 marks - 2 correct red flags from list below)
https://www.lasepharmacy.hee.nhs.uk/dyn/ assets/ folder4/cancer-factsheets/006 red flags factsheet 140323 v007.pdf
https://www.bopa.org.uk/cancerhub-red-flag-factsheets/
Breasts - please refer to the breast cancer factsheet
Patients with any of the following symptoms should be referred to their GP for review
• Unexplained lumps under the armpits
• Unexplained discharge or crust from
one niodle or sunken appearance
• Unexplained lumps, bumps, dimples or growing veins in breast tissue
• Unexplained skin changes - texture (orange peel), red or hot, appearance of sores, thickening
As an independent prescriber, you have been asked to prescribe the following four medicines for a patient who requires them today and the doctor isn’t available. You have experience in prescribing medicines for diabetes but have never prescribed the other medicines they receive.
1. Janumet® 50/1000 (Sitagliptin 50 mg and metformin 1000 mg) -
ONE tablet twice dailv
2. Ramipril 5 mg tablets - ONE daily
3. Tamoxifen 20mg - ONE daily
4. Goserelin 3.6mg S/C iniection - ONCE monthly
What is the ethical issue in this scenario and what options do you have?
Ethical issue - there is a need for the medication now and you are the only available prescriber but you don’t have experience prescribing in this area. You should only prescribe in areas where you are competent to do so.
Option 1 - Ask the patient to return when Dr is available. Establish how urgently the prescription is needed. When would the Dr be available? Would this delay cause harm to the patient? This would inconvenience the patient and the delay could harm the patient.
Option 2 - Prescribe the medication. Are you able to access appropriate references sources, patient medical notes and consult with the patient to ensure the medication continues to be appropriate? Assess your competence to review the appropriateness of issuing a repeat prescription for the medication.
Option 3 - Identify another prescriber. Contact the out of hours GP and ask if they will write the prescription. This may also inconvenience the patient.
