SAQ 2017 Flashcards
16 year old woman brought to GP by father presenting with 6 month history of abdominal fullness on eating, alleviated by vomiting, with reduced food intake. She was unhappy with her weight and felt fat. BMI of 16. You suspect an eating disorder.
3 organic causes of symptoms (3 marks)
Malignancies, GI disease, endocrine disease (e.g. diabetes mellitus, hyperthyroidism), chronic infections and chronic inflammatory conditions
Alcohol or substance abuse
Bulimia:
3 other tests to do(3 marks)
Include: Signs found in: vomiting, starvation
• ECG
• U&Es-hypokalaemic, hypocholeraemic alkalosis; hyponatraemia, hypomagnesaemia, raised urea (dehydration)
• FBC- normocytic anaemia, leucopenia
• LFTs- abnormal LFTs
• Serum glucose and lipids- hypoglycaemia, hypercholesterolaemia, hypercarotenaemia
• TFTs- reduced T3
• Amylase- raised serum amylase
• DEXA scan for identification of osteopenia and osteoporosis
• Others- raised growth hormone and cortisol
What is the criteria for diagnosis of anorexia nervosa?
All of the following:
- Low BMI <17.5kg/m2
- Self-indulged weight loss (poor calorie intake, vomiting, exercising)
- Overvalued ideas: dread of fatness, low target weight
- Endocrine disturbance (hypothalamic-pituitary-gonadal axis, resulting in amenorrhoea, raised cortisol, growth hormone etc)
Pre pubertal- failure to make expected weight gains; delayed pubertal events
What is the diagnostic criteria for Bulimia?
All of the following:
- Binge eating
- Strong cravings for food
- Methods to counteract weight gain (vomiting, laxatives, fasting, exercise etc)
- Overvalued idea: dread of fatness, self-perception of being too fat, low target weight
4 physical signs you would expect with anorexia
- Emancipation
- Cardiomyopathy
- Amenorrhagia; infertility; reproductive system atrophy
- Constipation; abdo pain
- Cold intolerance; lethargy
- Bradycardia; hypotension; cardia arrhythmias, heart failure
- Lanugo: fine, downy hair on trunk; loss of head hair
- Peripheral oedema
- Proximal myopathy; muscle wasting
- Osteoporosis; fractures
- Seizures; impaired concentration; depression
Down’s Screening / Amniocentesis
35 year old woman is 15 weeks pregnant and is concerned about Down syndrome due to her age.
What screening should be offered to her?
Quadruple test (too late for combined test). Measures serum markers.
Low AFP, low oestriol, high HCG, low PAPP-A, thickened nuchal translucency
She is given a risk of 1/70 following screening. Amniocentesis is offered to diagnose.
What 4 possible complications of amniocentesis that should be mentioned when obtaining consent?
- Miscarriage
- Injury from the needle
- Infection
- Rhesus disease
- Talipes (club foot)
What drug should she be given on the day of the procedure?
Why?
Rhesus immunoprophylaxis- Anti-D
fetomaternal transfusion is a risk in amniocentesis and CVS
Name 3 other chromosomal abnormalities and their names
Edwards (trisomy 18)
Patau’s (trisomy 13)
Fragile X (trinucleotide repeat disorder)
6 year old child presents to A&E with a 2 day history of high fever. Arrives with a decreased consciousness level.
What should be the initial management of child with decreased consciousness (3 marks)
ABCDE IV access Get bloods Fluid bolus Broad-spectrum antibiotics- cefotaxime or ceftriaxone
On examination there is a non-blanching purpuric rash.
Give 2 causes of a purpuric rash in a child of this age. (Age 6) (2 marks)
Meningococcal septicaemia Acute lymphoblastic leukaemia Congenital bleeding disorders Immune thrombocytopenic purpura Henoch-Schonlein purpura Non-accidental injury
Meningococcal septicaemia: Blood gases: Acidotic Low CO2 Low bicarbonate Low BE
What is the abnormality shown on the blood gases? (1 mark)
What is the cause of this abnormality?
Metabolic acidosis with respiratory compensation
Sepsis?? Check
Meningococcal septicaemia
What treatment would you give to family as prophylaxis (1 mark)
Rifampicin
Adults- 600mg every 12 hours for 2 days
Child- 10mg/kg every 12 hours for 2 days
What is Need, defined by NICE (1 mark)
The ability to benefit from an intervention
What is an example of a health related intervention that is supplied, but not needed or demanded. Explain why. (1 mark)
Routine Caesarean sections on women with a history of a previous Caesarean section
What is an example of a health related intervention that is supplied, needed but not demanded. Explain why. (1 mark)
Smoking cessation
Alcohol cessation,
Colorectal screening
Colorectal screening- People don’t demand it, but it is needed for detection of colorectal cancer
Define epidemiological health needs assessment (2 marks)
Person, place and time. Assess a problem, the size of it, the services available for this issue, the evidence base for effectiveness and cost-effectiveness. Then make recommendations.
Define corporate health needs assessment (1 marks)
Collects the views of stakeholders e.g. service users, GPs, other health professionals, and asks them what they believe the need is
Define comparative health needs assessment (1 mark)
Taking 2 populations and compare the services available in one with another. Shows the effectiveness of the intervention
Limitation of comparative health needs assessment (1 mark)
Hard to find a comparable population.
Poor data quality/ unavailable data
Neither group may be using the ideal service
Down’s w/ Depression
Sheltered accommodation 45 year old Down syndrome patient is presenting with a 6 month history of agitation, incontinence of urine, attacking other residents,
Suspected diagnosis of depressive syndrome
What three features in the history would clarify this diagnosis. Give an area and an example of each (3 marks)
- Low mood, which varies little from day-to-day and is unresponsive to circumstances
- Loss of interest or pleasure in almost all activities
Fatiguability on minimal exertion leading to diminished activity (anergia)
- Loss of interest or pleasure in almost all activities
Biological symptoms-loss of appetite, psychomotor retardation, early morning wakening
Cognitive symptoms- reduced memory and concentration, poor self-esteem, guilt, hopelessness, suicide or delf harm
Down’s with depression:
What two other differentials are possible? (2 marks)
In Down’s, early onset dementia, hypothyroidism, infection
Others-Medication induced low mood, infection, pain, hypothyroidism
Down’s with depression:
Two further investigations? (2 marks)
-FBC: Check for anaemia (low HB), infection (high WCC), high MCV (high alcohol intake)
- U+Es (hyponatraemia, renal function)
-LFTs and gamma GT ( also high alcohol intake)
Thyroid function tests (hyper- or hypothyroidism) and calcium (hypercalcaemia)
Other investigations if indicated- CRP/ESR, Vit B12 and folate,urine drug screen, ECG, EEG, CT
Down’s with depression:
What non-pharmacological interventions could help him? (3 marks)
- CBT
- Group therapy
- Physical activity
- Lifestyle changes- healthy diet, regular sleep times, avoid alcohol
Down’s w/ Epilepsy (Mental Capacity and deprivation of liberty)
Chap with Down’s, cerebral palsy and epilepsy supported by sister whole life. Sister can no longer support him.Steps to assess mental capacity (4 marks)
- Understand info
- Retain info
- Weigh up info to make a decision
- Communicate the decision by any means
What are the best interest principles? Not in exam but good to know
- Presumption of capacity – you have the right to make your own decisions and must be assumed to have capacity to do so unless it is proved otherwise.
- Right to be supported to make your own decisions – all practicable steps must be taken to help you make your own decision before anyone concludes you are unable to do so.
- Right to make eccentric or unwise decisions – you are not to be treated as being unable to make a decision simply because the decision you make is seen as unwise.
- Best interests – any decision made, or action taken, on your behalf if you lack capacity must be made in your best interests.
- Least restrictive intervention – anyone making a decision on your behalf must consider all effective alternatives and choose the less restrictive of your basic rights and freedoms in relation to risks involved.
What 3 things are required for a deprivation of liberty standard?
They lack capacity to consent to care and treatment arrangements.
They are under continuous supervision and control.
They are not free to leave.
What does a DoL safeguard ensure? (2 marks)
That steps are provided for a deprivation of liberty to be continually assessed and monitored, so that it remains in the best interests of a person. It can be challenged in the Court of Protection and a representative i.e. family member of the patient can attend.
How long does a DoL safeguard last? (1 mark)
Indefinitely, until it is decided it is not in the best interests of the patient.
Fainting epileptic woman
50 year old woman presents with her friend following ?seizure. Her friend reports that she felt confused, and then had twitching of her right eye, before collapsing to the ground shaking. This lasted 3 minutes before she started to regain consciousness. She is still confused.
You conclude that what occurred was an epileptic attack.
What 3 features from the history support epilepsy as a diagnosis? (3 marks)
Tonic-clonic movements
Post-ictal confusion
Loss of consciousness
What 2 non blood investigations would you do? (2 marks)
EEG
MRI
How long can she not drive? (1 mark)
6 months
She then has another seizure.
What is first line management for this patient? (3 marks)
Sodium valproate is used first-line for patients with generalised seizures
NEC
28 weeks gestation, following a placental rupture. Then when he was 2 weeks old he suddenly turned gray and non responsive.
Apart from NEC, what 2 conditions could cause this presentation? (2 marks)
Severe gastroenteritis Sepsis Hirschsprung's disease DKA UTI
Blood gases Acidotic Low O2 High CO2 Normal bicarb Normal BE What does the blood gas show? (1 mark)
Respiratory acidosis
Two bowel specific complications of NEC? (2 marks)
Death
Bowel perforation
Peritonitis
Short bowel syndrome
Three radiological findings suggestive of NEC (3 marks)
-Dilated bowel loops
-Bowel wall oedema
-Pneumatosis intestinalis (intramural gas)- gas cysts in wall
-Portal venous gas
Pneumoperitoneum resulting from perforation
-Air both inside and outside the bowel wall (Rigler sign)
-Air outlining the falciform ligament (football sign)
Two immediate non surgical interventions for NEC (2 marks)
ABCDE
Broad spectrum antibiotics
NSTEMI Otherwise fit and well 50 year old man with a long family history of ischaemic heart disease presents with NSTEMI. He is treated with a stent. He is started on Bisoprolol Atorvastatin Clopidogrel Lansoprazole
For the first three of these, explain why in laymans terms he is prescribed them, and two side-effects (6 marks)
Bisoprolol- Reduce blood pressure by reducing flow of blood to the heart
SE- Nausea, fatigue, hypotension, bronchospasms
Atorvastatin- Reduce cholesterol in the blood. Reduce risk of clotting.
SE- Joint pain, diarrhoea, indigestion, muscle pain, nausea
Clopidogrel- thins the blood to reduce risk of clotting.
SE- Thrombotic thrombocytopenic purpura, haemorrhage, headache, nausea, bruising.
Two weeks later, he is feeling exhausted on exertion and is trying to remain as fit as he used to be. He presents with 100/80 BP. The cardiology discharge form advised that you titrate bisoprolol to the highest dose.
What would you do? And why? (1 mark)
Stop the bisoprolol?
What non-pharmacological measure would you advise for him?(1 mark)
Lifestyle changes- Diet, exercise, reduce BMI, stop smoking
Heart failure treatment
88 year old chap with heart failure and renal failure. Consultant decided that they had tried every management to the maximal extent and that in the next few weeks the patient would die.
Four domains of the geriatric assessment, and a member of the MDT for each (4 marks)
Medical assessment
Doctor, nurse, pharmacist, dietician, SaLT
Functional assessment
OT,PT,SaLT
Psychological assessment
Doctor, nurse, OT, psychologist
Social and environmental assessment
OT, SW
Three things to consider in an advanced care plan (3 marks)
The main goal is to clarify peoples’ wishes, needs and preferences and deliver care to meet these needs.
- What you want to happen
- What you don’t want to happen
- Who you want to speak for you
?PCOS Menorrhagia
Woman presents with irregular cycle since a menarche of 12. She has a 32-40 week cycle, that she would like to be more regular.
Give two possible causes of irregular cycle (2 marks)
Dysfunctional uterine bleeding
PCOS
If she had hirsutism and weight gain, what two tests? (2 marks)
USS
Bloods- FSH, LH, testosterone, TFTs
What two non hormonal interventions to control dysmenorrhoea and menorrhagia? (2 marks)
Tranexamic acid
Mefenamic acid
Menorrhagia
What three management options would you advise? (3 marks)
Weight loss and exercise, Smoking cessation
Treat menstrual problems- COCP
Hirsutism- anti-androgen e.g. cyproterone.
