Population health and ethics

Question 1

Age of consent to medical procudere?

Answer 1

• 16+ for medical purposes
• if <16yo:
  – minimental (mmc): >25 points
  – mm 18-25: order second assessment (pschyatrist or other) -> able or not

You can perform a Gillick’s test. It is about 3 major domains:
home independece, finnancial independence and decision making abillity

! There’s no bottom line for age for mature minor

Question 2

In case of adult inable to consent. Who decides?

Answer 2

Try to find advanced care directive
If not available, find a decision maker. In order of priority:
1. Legal guardian (Attorney or someone that has written power to do decisions);
2. Partner
3. First degree relatives: parents, siblings, children
4. Primary carers - a nurse, if in nursing home staff; a principal of school, a teacher
5. The doctor after aplying for guardianship (through phone in emergencies or submit a form and send to guardianship tribunal).

Question 3

When to disclosure information?

Answer 3

If the patient represent harm to himself or others.
In cases of suspicion of child abuse or neglect

Question 4

What’s Conspiracy of silence? Is it allowed?

Answer 4

Either the patient asks you to give relative misleading information and vice-versa.
It is prohibited

Question 5

About interdisciplanary problems with healthworkers. What to do?

Answer 5

If a doctor is envolved and there’s a breach that you clearly saw/witnessed: report to AHPRA or MBA

If other professional, report to the head of the concerned department

Question 6

Genetic testing for Huntington’s disease - indication?

Answer 6

Predictive genetic testing for Huntington disease only for people aged 18 years or older who have at least one blood relative with definite diagnosis of HD.

If competent minor (16-18): not perform the test, only genetic counselling.

Question 7

General screening tests routine:
DM, Colon cancer, cholesterol,

Answer 7

Every patient should have FOBT at least every two years after the age of 50. Consider sigmoidoscopy every 5 years from the age of 50 for those with moderate family history (2nd degree)

All adults aged 45 and over should have 5 yearly checks of serum cholesterol for the screening of hypercholesterolemia.

Fasting blood glucose should be done every 3 years in all patients above 40 years of age.
Every 3 years FROM 30 YEARS should be considered in following high-risk groups:
All people with a history of the previous cardiovascular event including acute myocardial infarction and stroke.
2-All the women with a history of gestational diabetes mellitus.
3-Women with polycystic ovary syndrome.
4-Those on antipsychotic drugs.
5-Those with impaired glucose tolerance test.
6- BMI > 30;
7- family history of DM 2
Annually if prediabetes or Aboriginal from 18y on

Question 8

Screening - AAA and Brain aneurysm

Answer 8

BA - if history or family history of Polycystic kidneys disease

AAA - US from 50 if positive family history

Question 9

What are the characteristics of fourth nerve palsy and its impact on vision?

Answer 9

Fourth cranial nerve (CN IV) palsy:
Binocular vertical diplopia 👓
Subjective tilting of objects (torsional diplopia)
Affected eye often extorted due to superior oblique muscle involvement (intorsion) 🔄
Challenges with down-gaze vision, like navigating stairs. 🏞️

Question 10

Describe sixth cranial nerve (CN VI) palsy and its clinical findings.

Answer 10

CN VI palsy:
Isolated weakness of abduction of the affected eye 👀
Horizontal binocular diplopia 🎯
Examination findings:
Esotropia (inward deviation)
Worsened with gaze towards the affected lateral rectus muscle
Limited abduction on the affected side
Predisposing factor: Poorly controlled diabetes 🩺🍭

Question 11

What is the age of majority in Australia, and when can a minor consent to medical treatment? (Gillick competent rule)

Answer 11

Age of majority in Australia: 18 years 🇦🇺
A child over 16 years can consent to medical treatment.
Gillick competence rule allows minors under 16 years (but not younger than 13 years) to consent if they:
Live independently from parents (emancipated minor) 🏡
Demonstrate sufficient understanding to grasp proposed treatment, risks, and benefits 🤔
If these criteria are met, minors can consent to treatment without parental or guardian involvement.

Question 12

How should minors be approached for medical consent?

Answer 12

Approach a minor as a consenting adult if:
Age is 13 or older 🧒🔞
Living independently from parents 🏡
Demonstrates full understanding of the situation, treatment options, risks, and benefits 🧠💡

Question 13

What are the legal obligations when a mature minor discloses sexual assault?

Answer 13

When a mature minor discloses sexual assault, the doctor should:
Inform the minor about mandatory reporting requirements and limitations on doctor-patient confidentiality 🚨🤐
It’s important to remember that no matter how mature or independent a minor may be, they are legally considered children until they reach 18 years of age, and reporting abuse or assault is mandatory. 👶🚫🔒
Note: Different rules apply when a mature child voluntarily engages in sexual relationships. No mandatory reporting is required if the child is 13 years or older in such cases. 🚫🔞

Question 14

What is the recommended treatment for carefully selected ischemic stroke patients who present within 4.5 hours of symptom onset?

Answer 14

Fibrinolytic (thrombolytic) therapy is the treatment of choice if not contraindicated.
Recombinant tissue plasminogen activator (rTPA) such as alteplase is approved for this purpose in Australia. 🩸
Blood pressure management is crucial before thrombolysis. Lower it to 185/110 mmHg or lower using medications like glyceryl trinitrate and labetalol. 🩺
Thrombolysis should not be initiated if the blood pressure cannot be lowered to this level. ⚠️
Acute lowering of blood pressure is harmful, except in cases of extremely high blood pressure (systolic > 220mmHg, diastolic > 110 mmHg). 🚫🩸

Question 15

When is endovascular thrombectomy recommended for ischemic stroke, and what are the eligibility criteria?

Answer 15

Endovascular thrombectomy is highly effective within 6 hours of symptom onset when stroke is due to occlusion of a large vessel (e.g., internal carotid artery, proximal middle cerebral artery, basilar artery). 🧲
Eligible patients may overlap with those who receive intravenous alteplase, and both treatments can be used in the same patient.
Endovascular thrombectomy is also appropriate when alteplase is contraindicated (e.g., patient on anticoagulant) or when patients present too late for alteplase (between 4.5 and 6 hours after stroke onset). 🕒

Question 16

What are the uses of carotid endarterectomy (CEA) and aspirin in the management of ischemic stroke?

Answer 16

CEA is considered for secondary prevention of ischemic stroke and TIA in selected patients. It prevents further ischemic events but doesn’t affect the outcomes of the patient’s current condition. 🚫🩸
Aspirin (300mg initially and 100mg subsequently) is the common medication for initial treatment of ischemic stroke, given as soon as possible (within 48 hours), unless contraindicated in hemorrhagic stroke. If thrombolysis is performed, aspirin should be delayed for 24 hours. 💊🕒

Question 17

What are the clinical signs and possible causes of common peroneal nerve injury after knee surgery?

Answer 17

Clinical signs include foot drop due to ankle dorsiflexor weakness (deep peroneal nerve) and sensory loss over the outer aspect of the leg (common peroneal nerve and its superficial branch). 👣🚶‍♂️
Injury commonly occurs during knee surgeries due to nerve compression or trauma. 💥🔪
The nerve wraps around the fibular head and is superficial in this region, making it susceptible to injury. 🦵

Question 18

What are the key differences between common peroneal nerve injury and other potential nerve injuries in the lower leg?

Answer 18

(Option A) L4 nerve root damage: Weak knee reflex and partially impaired ankle inversion but doesn’t explain the full clinical picture. 🦵👩‍⚕️
(Option B) L5 nerve root damage: Similar presentation to common peroneal nerve injury but history of knee surgery makes the latter more likely. 🩹👍
(Option D) Tibial nerve damage: Impaired ankle jerk, weak or absent plantar flexion, and weak ankle inversion. Sensory impairment affects different areas. 🤕👣
(Option E) Sciatic trunk damage: Located above the knee, unlikely to be affected by knee surgery. Produces a different clinical picture involving both common peroneal and tibial nerve injuries. 🦵🧐

Question 19

Weakness of foot dorsiflexion and eversion. Which nerve is most likely to have been damaged?

Answer 19

Common peroneal nerve

Question 20

What are the common medical conditions and procedures that may lead to reduced driving ability, and what are the recommended non-driving periods for private and commercial drivers in these situations?

Answer 20

In cases of various medical conditions or procedures, it is essential for patients to receive appropriate advice regarding their ability to drive safely. 🚗🩺
Patients themselves are responsible for informing the Road Safety Department about their medical condition, and failing to do so can result in legal consequences. 🚨📋
The table below outlines common medical problems and procedures and the recommended minimum non-driving periods, including advisory periods for private and commercial drivers. ⏳🚗🚚

Question 21

what are the recommended non-driving periods for private and commercial drivers in these situations?

Answer 21

Ischaemic heart disease:

Acute myocardial infarction: 2 weeks (private) or 4 weeks (commercial)
Percutaneous coronary intervention (e.g., angioplasty): 2 days (private) or 4 weeks (commercial)
Coronary artery bypass graft: 4 weeks (private) or 3 months (commercial)
Disorders of the rate, rhythm, and conduction:

Cardiac arrest: 6 months (private and commercial)
Implantable cardioverter defibrillator (ICD): 6 months (private), after cardiac arrest (commercial)
Generator change of an ICD: 2 weeks (private)
ICD therapy associated with symptoms of haemodynamic compromise: 4 weeks (private)
Cardiac pacemaker insertion:

2 weeks (private)
4 weeks (commercial)
Vascular disease:

Aneurysm repair: 4 weeks (private) or 3 months (commercial)
Valvular repair: 4 weeks (private) or 3 months (commercial)
Other cardiovascular conditions:

Deep vein thrombosis: 2 weeks (private and commercial)
Pulmonary embolism: 6 weeks (private and commercial)
Heart/lung transplant: 6 weeks (private) or 3 months (commercial)
Syncope (due to cardiovascular event): 4 weeks (private) or 3 months (commercial)
Epilepsy:

First seizure OR isolated seizure: 6 months (private) or 5 years (commercial)
Recently diagnosed with epilepsy: 12 months (private) or 10 years (commercial)
Chronic epilepsy + uncontrolled seizure in the past: 12 months after the last seizure (if on treatment) (private) or 10 years (commercial)
Seizure only in sleep OR treated with surgery: 12 months after the last seizure (private) or 10 years (commercial)
Reducing the dose of one or more antiepileptic drugs: 3 months after dose reduction (if no other seizure occurs) (private)
Seizure in a person whose epilepsy was previously well controlled: 4 weeks if a provocative cause can be identified or 3 months if a provocative cause cannot be identified (private and commercial)
Vertigo:

Benign paroxysmal positional vertigo: 3 months (private) or 6 months (commercial)
Meniere’s disease: Conditional license if there are alarming symptoms to alert the driver of the attack (private and commercial)
Stroke / intracranial hemorrhage:

Intracranial surgery: 6 months (private) or 12 months (commercial)
Stroke (ischemic or hemorrhagic): 4 weeks (private) or 3 months (commercial), conditional licensing depends on residual defects
TIA: 2 weeks (private) or 4 weeks (commercial)
Subarachnoid hemorrhage: 3 months (private) or 6 months (commercial)
Visual acuity / visual fields:

Visual acuity: No driving license if acuity in the better eye or with both eyes together is worse than 6/12 (private) or no driving license if acuity in the better eye is worse than 6/9 (commercial)

Question 22

What are the recommended non-driving periods for patients after a stroke or transient ischaemic attack (TIA), and what assessments are necessary before they can resume driving?

Answer 22

Patients who have experienced a stroke or transient ischaemic attack (TIA) are generally considered unfit to drive until certain criteria are met. 🚗🩺
After a stroke:
Private vehicle drivers should not drive for at least 4 weeks.
Commercial vehicle drivers should not drive for at least 3 months.
These non-driving periods apply even if the patient has no detectable neurological deficit.
Before resuming driving, patients must undergo an assessment to evaluate for residual impairments that could impact their ability to drive safely. 🚦📋
Particular concerns include sensory and/or visual inattention (neglect) and hemianopia. 🚫👁️
Patients with significant neurological, cognitive, or perceptual impairments (especially inattention) should be referred for a driving assessment supervised by an occupational therapist.
Patients with hemianopia should be referred for assessment by an ophthalmologist.
After a TIA:
Private drivers are advised not to drive for 2 weeks.
Commercial drivers are advised not to drive for 4 weeks.

Question 23

When is the MMR vaccine typically administered in infants, and why?

Answer 23

MMR-containing vaccines are usually not recommended for infants under 12 months due to the presence of maternal antibodies to measles, which can interfere with immunization. ⏰👶
Evidence suggests that giving the first MMR dose at 11 months (but before 12 months) can provide sufficient immunity. 💉👶👍
Rubella infection offers lifelong immunity in immunocompetent individuals, but not against measles and mumps. 🩺🔒

Question 24

Can family members or friends be used as interpreters for patients with language barriers?

Answer 24

in general, using family, friends, or non-accredited individuals as interpreters is discouraged. 🚫❌
Such practices may raise legal and ethical concerns about the validity of consent obtained. 🧾⚖️
Exceptions can be made when the medical issue is minor and the patient explicitly wishes to use a close friend or family member as an interpreter. 🤝💬

Question 25

How can doctors access qualified healthcare interpreters in situations where one is needed?

Answer 25

When a language barrier arises, doctors should request an accredited healthcare interpreter. 📞👩‍⚕️
In cases where an on-site interpreter is unavailable, the Telephone Interpreting Service (TIS) is a convenient option for accessing interpreters. ☎️🌐
TIS is free for doctors providing care and can be claimed under Medicare for Australian citizens or permanent residents. 🇦🇺💳
If an unqualified interpreter is used in an emergency, obtaining a qualified interpreter as soon as possible is essential to ensure patient understanding. ⏳🏥
The patient’s preference for a supervisor’s presence during translation can be discussed when an interpreter is available. 🗣️👤

Question 26

How should a patient’s competence be assessed when they refuse treatment?

Answer 26

Competence assessment when a patient refuses treatment should involve various aspects, including: understanding, beliefs, cognitive capacity - Formal tests of cognitive capacity (such as the Standardized Mini-Mental Status Examination), psychological evaluation, and corroborative history. 🧠💬📝
A competent patient can understand and retain treatment information, believe the information, weigh it, reach a decision, and communicate that decision, even if the reasoning is flawed. 🤔📣👩‍⚕️

Question 27

How long is a referral valid when supplied by a general practitioner (GP)?

Answer 27

Referrals from a GP are typically valid for a single course of treatment for one year, but this period can vary if specified by the referring practitioner. 🩺👩‍⚕️📅How long is a referral valid when supplied by a general practitioner (GP)?

Question 28

When does the referral period for a specialist begin?

Answer 28

The referral period starts on the date of the first specialist visit, not on the date the referral was written. This is a common misunderstanding. 📆👩‍⚕️👨‍⚕️

Question 29

How long are referrals from a specialist valid?

Answer 29

Referrals from a specialist are typically valid for only three months after the first visit to the referred practice. 🩺👨‍⚕️📅

Question 30

What are the recommended driving restrictions after various medical conditions?

Answer 30

Coronary Artery Bypass Grafting (CABG):

Private vehicles: 4 weeks 🚗
Commercial vehicles: 3 months 🚚

Acute Myocardial Infarction (MI):

Private vehicles: 2 weeks 🚗
Commercial vehicles: 4 weeks 🚚

Stroke:

Private vehicles: 4 weeks 🚗
Commercial vehicles: 3 months 🚚

Transient Ischemic Attack (TIA):

Private vehicles: 2 weeks 🚗
Commercial vehicles: 4 weeks 🚚

Subarachnoid Hemorrhage:

Private vehicles: 3 months 🚗
Commercial vehicles: 6 months 🚚

Repair of AAA
PV: 4 weeks
CV: 3 months

Question 31

What are the recommended approaches and guidelines for smoking cessation during pregnancy?

Answer 31

First-line Treatment:

Pregnant smokers are recommended to start with behavioral counseling and support as the first-line treatment. 🤰🚭
Smoking should be addressed at every GP (General Practitioner) visit during pregnancy due to its serious health impact.
Counseling’s Effectiveness:

Counseling in pregnancy has been shown to produce a 4%-6% increase in the quit rate compared to no counseling. 📈
Nicotine Replacement Therapy (NRT):

NRT should be considered if the patient is unable to quit without it and should be used under the supervision of a qualified health professional. 👩‍⚕️
Intermittent, short-acting forms of NRT (e.g., lozenge or mouth spray) are recommended to deliver a lower total daily nicotine dose, but this may result in under-dosing and reduced effectiveness.
If patches are used, they should be removed at bedtime.
Dosing and Duration:

Guidelines recommend using the smallest effective dose of nicotine, but larger doses or combination therapy may be required to relieve cravings and withdrawal symptoms.
A full course of at least 8 weeks of treatment is supported.
Risks and Benefits:

The risks and benefits of NRT during pregnancy should be explained to the patient without causing undue concern.
There is no evidence of increased rates of miscarriage, stillbirth, admission to the neonatal intensive care unit (NICU), or neonatal death between NRT and control groups.
Although there is currently insufficient evidence to determine whether NRT is entirely safe in pregnancy, available data and expert opinion suggest it is less harmful than continuing to smoke.
Prescription Medications:

The Australian Smoking Cessation Guidelines recommend against using varenicline and bupropion for smoking cessation during pregnancy and breastfeeding. 🚭🚫

Question 32

What are the available vaccines in Australia for measles, mumps, rubella, and varicella, and what are the current vaccination guidelines for children?

Answer 32

Available Vaccines:

In Australia, the available vaccines for measles, mumps, rubella, and varicella (chickenpox) are MMR (measles, mumps, rubella) and MMRV (measles, mumps, rubella, varicella). 🇦🇺💉
Vaccination Guidelines:

Current guidelines recommend a two-dose regimen of MMR vaccine for children in Australia.
The first dose is typically administered at 12 months of age - MMV, and the second dose is given at 18 months of age - MMRV . 🧒📆

Question 33

What are the recommendations for statin therapy and target lipid and blood pressure values in patients with Coronary Heart Disease (CHD)?

Answer 33

Statin Therapy:

Statins should be initiated in all patients with Coronary Heart Disease (CHD), regardless of their current lipid profile, as it is associated with decreased mortality. 🩺💊
Lipid Profile Monitoring:

Patients on statin therapy should have their lipid profile checked every 3-6 months to monitor their response to treatment. 📊
Target Values for Patients with CHD:

Low-density lipoprotein cholesterol (LDL-C) should be maintained at < 1.8 mmol/L.
High-density lipoprotein cholesterol (HDL-C) should be kept > 1.0 mmol/L.
Triglycerides (TG) should be controlled to < 2.0 mmol/L.
Non–high-density lipoprotein cholesterol (NHDL-C) should be < 2.5 mmol/L.
Target Blood Pressure:

The target blood pressure for patients with CHD is ≤ 130/85 mmHg. 🩸📏

Question 34

What are case-control studies, and what is their role in epidemiological investigations?

Answer 34

Case-control studies are observational and look back retrospectively to compare individuals with a disease or outcome (cases) and those without (controls).
They aim to determine the relationship between exposure to a risk factor and the disease.
Case-control studies provide insights into the association between risk factors and diseases. 🔄🔬

Compare patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcomes (controls), and looks back to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. These studies are designed to estimate odds

Question 35

What are cohort studies, and how do they contribute to epidemiological research?

Answer 35

Cohort studies are prospective (forward-looking) in nature and involve tracking subjects over time.
They identify a population group and compare those exposed to a risk factor with those who are not exposed.
Cohort studies can determine incidence and establish causal relationships, but they require a long enough follow-up period for the incidence to appear. 📆👥

Cohort studies are used to investigate the cause of disease, and establishing links between risk factors and health outcomes.

Question 36

What situations warrant a court application for healthcare consent due to potentially life-changing effects?

Answer 36

A court application is necessary when medical procedures may have life-changing effects, such as:
Sterilization of mentally disabled young persons.
Abortions.
separating conjoined twins.
Removal of life support.
Removal of organs for transplants.
Gender re-assignment.
Bone marrow harvest.
Life-saving emergency surgeries are exceptions to this rule. ⚖️🏥