pqs Flashcards
A 76-year-old man is admitted to hospital with sudden-onset paralysis and paraesthesia affecting his left side. He has a background of vascular dementia, coronary artery disease and chronic obstructive pulmonary disease (COPD). The speech and language therapy (SALT) team have deemed that he has an unsafe swallow, and have recommended insertion of a nasogastric (NG) tube. His wife refuses the procedure, stating that he gets great enjoyment from his food and feeding him through a tube would make him miserable. She is his lasting power of attorney (LPA). What is the most appropriate initial course of action?
assess the pt capacity
what class of medication is associated with increased mortality in dementia patients
Antipsychotics is the correct answer for this patient with Alzheimer’s dementia. Examples of antipsychotics include typical ones like haloperidol and atypical like clozapine. In patients with dementia, who have an increased susceptibility to side effects, antipsychotics can heighten the risk of cardiovascular events such as strokes and heart disease. These medications may also exacerbate metabolic conditions including weight gain and diabetes, and increase the likelihood of infections, particularly pneumonia. Furthermore, antipsychotics are known to cause sedation, accelerate cognitive decline, and cause movement disorders. These effects cumulatively elevate the risk of falls and related injuries in a patient group already at heightened risk. Consequently, antipsychotics are most closely associated with a significant rise in mortality in individuals with dementia.
what must be stated in both figures and words for controlled drugs
Controlled drugs - it is the quantity supplied which needs to be stated in both figures and words, rather than the dosage
A 73-year-old woman is admitted to hospital with abdominal pain and jaundice. She is confused and unable to understand the need for a CT scan of her abdomen. A clinic letter from an appointment three weeks ago in surgical outpatients indicates that she had seemed fit and well at that time and had consented to elective gallbladder removal. Contacting relatives has been difficult as her next of kin, who holds lasting power of attorney, is on holiday. It is clinically urgent that she undergoes imaging.
How should the healthcare team proceed?
use mental capacity act 2005
when to stop warfarin with STOPP START
STOPP criteria states that it has no proven added benefit when given for longer than 6 months for uncomplicated DVT.
A 76-year-old man is accompanied by his daughter to the memory clinic. He has been having difficulty recalling names, frequently loses his train of thought mid-sentence, and has had an incident of disorientation in his local area. A brain MRI shows global atrophy with more pronounced changes in the temporal lobes.
He scores 20/30 on the Montreal Cognitive Assessment. Despite being on donepezil therapy for six months, his daughter observes only minimal improvement. The clinical team wants to add a new medication.
What is the mechanism of action of the new medication?
Memantine - NMDA receptor antagonist
This man is suffering from the most common form of dementia, Alzheimer’s dementia. He presents with classic symptoms of inability to remember faces, cognitive decline and spatial disorientation. The MRI scan confirms the diagnosis and the patient has initially been started on donepezil, an acetylcholinesterase inhibitor. However, the team has decided the patient would benefit from the addition of a second-line medication, which in this case is memantine. NICE guidelines suggest using memantine in patients with severe or moderate dementia not responsive to initial treatment like in this case. While there is no cure for Alzheimer’s it is important to slow the progression of the condition.
Which drug is really bad for Parkinsons patients
Haloperidol is a first-generation (typical) antipsychotic that works primarily by antagonising D2 dopamine receptors in the brain. In Parkinson’s disease, there is already a deficit of dopamine in the basal ganglia, and administering haloperidol would further block the remaining dopamine activity, potentially causing a severe deterioration in motor symptoms and possibly precipitating neuroleptic malignant syndrome. The use of haloperidol in patients with Parkinson’s disease could lead to increased rigidity, severe akinesia, and a significant worsening of their condition.
Acute confusional state: if treating the underlying cause and environmental modification not working then what is sometimes used
haloperidol
Alzheimers on head CT
Alzheimer’s disease causes widespread cerebral atrophy mainly involving the cortex and hippocampus
First line for mild to mod Alzheimer’s
Donepezil is an acetylcholinesterase inhibitor, which along with with galantamine and rivastigmine, are first line for management of mild to moderate Alzheimer’s dementia.
What to avoid in Lewy Body
Halperidol - Avoid neuroleptics in Lewy body dementia- may cause irreversible parkinsonism
Controlled drug prescriptions must have
Controlled drug prescriptions - the address of the patient must be included on the prescription
A 21-year-old female is rushed to the emergency department following a road traffic accident. On examination she has a Glasgow Coma Score of 3, her blood pressure was 89/64 mmHg and her heart rate was 132/min.
The paramedics state she has lost around 2 litres of blood. As a team, you decide she requires a blood transfusion.
You speak to the father before the transfusion who informs you that the whole family are Jehovah witnesses and he refuses to allow you to give his daughter a transfusion. On reading through her notes you can’t find any documentation of her wishes prior to the accident. However, her father informs you that she spoke to them in the last few months confirming her wish to refuse a transfusion, should she require one.
The correct answer is to give her the blood transfusion, this patient is presenting with a class 3 haemorrhagic shock and requires a urgent blood transfusion. Although she has expressed her wishes verbally to her family, the GMC consent guidelines state that ‘when an emergency arises in a clinical setting and it is not possible to find out a patients wishes, you can treat them without their consent, provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition. The treatment you provide must be the least restrictive of the patients future choices.’ (GMC good medical practice, Consent: The scope of treatment in emergencies)
You are a medical student working on a student selected component project analysing histopathology slides from patients with alcoholic liver disease. Your consultant is pleased with your hard work and invites you to present your findings at a national conference. You will need to present images you have taken, of the pathology slides used in your work. What is the most appropriate action to take so you can present these images?
consent is not needed for pathology as patients are not identifiable
what needs to be stated in words and figures
QUANTITY
can a doctor avoid serious vaccines due to needle phobia or lack of time
no - The GMC is quite clear that you should be immunised against common communicable disease unless it is contraindicated. This is so that your health does not pose risks to colleagues, patients or others.
notifiable deaths
what would invalidate an advanced directive
The advanced directive is entirely valid other than for two factors. Firstly, it is evident that when the directive was written the patient was not of sound mind as he then went on to attempt suicide and this is grounds to ignore it. Secondly, the patient is in England and under 18 and is therefore not legally binding. In Scotland this age is 16 and so the name of the hospital is an important part of the question.
A 50-year-old man is a patient on your ward. He has HIV and metastatic hepatocellular carcinoma. His HIV diagnosis is known to medical staff but it has been clearly documented in his medical notes that his family is not to be told about his HIV diagnosis. He has been given permission for the staff to discuss his cancer diagnosis and treatment, however. The man dies and his parents enquire about his medical history. What action is most appropriate?
discuss the cancer and omit the HIV diagnosis
A patient is furious about an aspect of their care you provided. Before you’ve had a chance to discuss the situation they demand you full name and GMC reference number. What should you do?
give it to them
plaster cast flying rule
Full plaster cast should not fly (if >2 hours durations) until 48 hours after cast applied, unless bivalved
do you need to inform the GMC about a noise complaint fine
‘You do not need to tell us about:
a A fixed penalty notice for disorder unless it is specified in paragraph 4
b payment of a fixed penalty notice for a road traffic offence,
c Payment of a fixed penalty notice issued by local authorities (for example, for offences such as dog fouling or noise)’
You are an F2 working in general practice. One of your patients has been coming to the practice regularly with no real complaint and is always requesting to see you for her consultations, in which she is very flirtatious and usually comes with no medical concerns. On the last consultation, she mentions wanting to go out for dinner with you and is very flirty and adamant that you oblige. What is the most appropriate course of action?
Inform the patient that you can’t and try to re-establish a professional boundary
What should you do if the GMC asks for patient records and the patient doesn’t give consent for this? The context is in an investigation against a doctor for negligence
Disclosures to comply with a statutory request made by a regulatory body such as the GMC can be made without the patient’s consent
You’re an F2 working in the Emergency Department. You’re on a night out with your housemates when you notice a group of work colleagues enjoying themselves in the same bar. You notice two of them (members of the ambulance service) are loudly telling the rest of their group about a patient they were deployed to, who suffered a subarachnoid haemorrhage during coitus with a man who wasn’t her husband, they’re not using the patient’s name. You remember this patient as she was extremely embarrassed when you clerked her and begging the staff to not tell her husband. What is the most appropriate action to take?
Go over to the people and tell them they are speaking loudly about sensitive information and people around them may know the patient and be able to identify them
A 19-year-old man is brought to the emergency department by the police after being found trying to convince passing-by men in the street that they are his doppelgänger.
He has a past medical history of schizoaffective disorder.
In the emergency department, a mental state exam reveals marked delusional thought process. An official capacity assessment is performed and he is deemed to not have capacity.
After a liaison psychiatry review, they recommend beginning regular antipsychotic treatment to avoid potential risk of harm to himself. However, the patient refuses this.
What legislation will most likely be used to treat this patient against his will?
The Mental Health Act 2007 overrides the Mental Capacity Act and enables people with capacity to be given treatment against their will
The mental capacity act is more for treating physical disorders
Should you tell the GMC about a caution you receive either here or abroad?
Yes, always
Can you consent to patient to a cosmetic procedure?
the surgeon performing the cosmetic procedure must consent the patient themselves rather than delegate the task to someone else.
You are a junior doctor on a cardiology ward. A 25-year-old patient is admitted to your ward after collapsing in court. They are the defendant in a trial and are accused of fraud. In the emergency department, they were noted to have ECG changes but troponin tests were not raised. They were admitted for angiography but sadly died before they had any further investigations.
Why must this patient be discussed with the Coroner?
Unknown cause of death, it does not matter that they were still waiting an investigation
You are the FY2 in a small hospice and you are asked to speak to a patient about her do not attempt cardiopulmonary resuscitation order (DNACPR). The patient is ninety eight years old with advanced heart failure and metastatic lung cancer. She previously agreed to a DNACPR, a decision that was supported by an number of healthcare professionals, but has now changed her mind and is asking for the order to be rescinded. She doesn’t want to die and would like CPR if her heart stops. How should you proceed?
Ask your registrar to speak to the patient and explain the DNACPR order will stay in place as resuscitation would be unsuccessful. If the patient is still unhappy offer to refer for a second opinion
chaperone conditions
next of kin with LPA vs consultant who has final say
The daughter of this patient has lasting power of attorney, which means she can make healthcare decisions for her mother. However, according to the GMC guidelines:
‘If a legal proxy or other person involved in the decision making asks for a treatment to be provided which the doctor considers would not be clinically appropriate and of overall benefit to the patient, the doctor should explain the basis for this view and explore the reasons for the request. If after discussion the doctor still considers that the treatment would not be clinically appropriate and of overall benefit, they are not obliged to provide it.’
stroke symptoms by region
dysphagia, dizziness, hoarse voice. Leans to left when walking, multidirectional nystagmus, dysphonia voice. Reduced pain and temperature over right side of body.
Most likely lesion location -
medulla oblongata
Lateral medullary syndrome/Wallenberg syndrome: acute ischaemic infarct of lateral medulla oblongata, LEFT SIDED in this case (leaning to left, loss of spinothalamic on RHS —> left sided lesion)
- Characterised by vestibulocochlear symptoms, vertigo, falling towards side of lesion, multidirectional nystagmus, diplopia
- Autonomic dysfunction: ipsilateral Horners, hiccups
- Sensory symptoms: loss of pain and temp over ipsilateral face, loss of pain and temp over contralateral body (due to spinal trigeminal nucleus)
- Ipsilateral bulbar muscle weakness: hoarseness, dysphagia, dysphonia, dysarthria
cerebellar infarction symptoms:
non specific - nausea, vomiting,dizziness and unsteadiness. OE: incoordination, ataxia and nystagmus.
DANISH - dysdiadochokinesis, ataxia, nystagmus, intention tremor, slurred speech/scanning dysarthria, heel-shin positive
pons lesions presentation:
pons lesions presentation:
can affect cranial nerves 5,6,7 and 8. Ipsilateral loss of pain and temp on face, ipsilateral loss of abduction of eye, ipsilateral facial weakness and ipsilateral deafness
parietal lesion presentation;
parietal lesion presentation; functions to integrate sensory input primarily with visual system, also involves sensation.
right-left confusion, agraphia, acalculia, aphasia and agnosia. Contralateral neglect, and memory and personality may be affected in a parietal-temporal region lesion
Following thrombolysis, aspirin should be
delayed for 24 hours, and a CT should be arranged to ensure there is no haemorrhage.
lateral medullary syndrome infarction
PICA
In patients with a history of anticoagulant use and suspected intracranial haemorrhage, it is crucial to
Administer 5 mg of IV Vitamin K and 4-factor prothrombin complex concentrate
indications for clot evacuation in subdural haematoma
In patients with subdural haematoma, surgery is needed if there is any focal neurology, if the patient is deteriorating or if there is a large haematoma, raised intracranial pressure or midline shift.
anti emetics in parkinson’s
Domperidone is the most appropriate anti-emetic to prescribe in this case. Domperidone has anti-dopaminergic activity, but does NOT cross the blood brain barrier.
NICE CKS guidelines also advise against the use of prochlorperazine in patients with Parkinson’s disease. Like metoclopramide, it acts as a dopamine antagonist and can exacerbate parkinsonism.
NICE CKS guidelines advise against the use of metoclopramide in patients with Parkinson’s disease. This medication is a dopamine antagonist that crosses the blood-brain barrier and can exacerbate parkinsonism.
The BNF advises that haloperidol is contraindicated in Parkinson’s disease. It is a potent dopamine receptor antagonist that can significantly worsen motor symptoms in people with Parkinson’s.
features of progressive supranuclear palsy -
balance issues leading to recurrent falls and vertical gaze palsy. It is classified as a Parkinson’s plus syndrome as it presents with parkinsonism with additional features.
