Summative Past Papers 2 Flashcards
a) The extracellular compartment is one compartment in the body. What is the other?
b) Extracellular fluid can be further sub-divided into:
Body Fluid Compartments
- Intracellular compartment
- Extracellular
- Interstitial
- Intravascular
How much of the body is water?
How much of water is intercellular?
We are approximately 2/3 water
Cells contain 60% of all water in the body, with roughly one-third of the remainder, surrounding the cells.
Read the ‘Essence of dignity in medicine’ according to Chochinov: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1934489/
Give an example of an important consideration for each of the 4 components (Attitude, Behaviour, Compassion, Dialogue).
Essence of Dignity in Medicine - Chochinov
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Attitude
- Health care providers need to be aware that their attitudes and assumptions can influence the way they deal with and care for patients.
- Have I checked whether my assumptions are accurate?
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Behaviour
- Professional behaviours towards patients must always include respect and kindness
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Compassion
- Refers to a deep awareness of the suffering of another coupled with the wish to relieve it.
- Compassion speaks to feelings that are evoked by contact with the patient and how those feelings shape our approach to care.
- Compassion may be part of a natural disposition that intuitively informs patient care or it may develop slowly.
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Dialogue
- Might involve Acknowledging personhood - eg. “This must be frightening for you.”
- Knowing the patient - “What should I know about you as a person to help me take the best care of you that I can?”
- Life review/reminiscence
Graph showing decrease MI deaths over time per 100k for men vs women aged over 75, from 1990 to 2018.
a) Identify 3 trends.
(Similar to the graph below).
b) What are 3 modifiable risk factors/conditions of coronary heart disease for which there are interventions that have contributed to the decrease?
3 Trends
- Rates of MI deaths women 75+ have decreased from etc etc
- Rates of MI deaths men 75+ have decreased from etc etc
- Gap between men & women closing
Coronary Heart Disease - Modifiable Risk Factors/Conditions
- Hypertension (damages blood vessel wall) → Antihypertensive medications
- Hypercholesterolemia (↑ risk w/ high LDL levels; HDL = cardioprotective) → Statins
- Obesity → Dietary interventions & Increased physical activity level
- Excessive alcohol consumption → Alcohol addiction therapies - eg. rehabilitation + CBT
- Type 2 Diabetes → Diet control of BGLs & Insulin
How do we determine statistically significance from a study?
p value ≤ 0.05
If the confidence interval crosses 1 (e.g. 95%CI 0.9-1.1) this implies there is no difference between arms of the study.
Confidence interval (provide information about a range in which the true value lies with a certain degree of probability, as well as about the direction and strength of the demonstrated effect)
A 99% confidence interval is wider than a 95% confidence interval. In general, with a higher probability to cover the true value the confidence interval becomes wider.
Odds Ratio
- If the OR is > 1 the control is better than the intervention.
- If the OR is < 1 the intervention is better than the control.
What are 4 effective interventions for falls in the elderly?
Statistically significant interventions at the personal level
- Improved balance - tai chi
- Medication review
- Vitamin D supplementation
- Group and home based exercise
- Psychotropic medication withdrawal
- Cataract surgery
- Cardiac pacing
- Multi-faceted interventions (exercise program, falls prevention education and an OT home visit)
What are 4 groups of people prone to adverse events in hospital? Explain each.
An adverse event is an incident that results in harm to the patient. Adverse events commonly experienced in hospitals by patients over 70 include falls, medication errors, malnutrition, incontinence, and hospital-acquired pressure injuries and infections.
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The Elderly
- Older people are particularly vulnerable to experiencing adverse events due to inherent complexity in managing their care and a decline in physiological reserves.
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Children
- Medication errors are the most common adverse event experienced by pediatric inpatients. Often pediatric indications and dosage guidelines aren’t included with a medication.
- Vulnerable population group - mental development
- Overuse of antibiotics in children
- Treated as little adults
- Immunocompromised
- CALD
The health domains of vulnerable populations can be divided into 3 categories: physical, psychological, and social.
- Physical → high-risk mothers and infants, the chronically ill (elderly/comorbidites) and disabled, and persons living with HIV/acquired immunodeficiency syndrome.
- Psychological → chronic mental conditions, such as schizophrenia, bipolar disorder, major depression, and attention-deficit/hyperactivity disorder, as well as those with a history of alcohol and/or substance abuse and those who are suicidal or prone to homelessness.
- Social → those living in abusive families, the homeless, immigrants, and refugees.
Rank different study types in terms of most effective in proving causality to least.
- RCT
- Prospective cohort study
- Case controlled
- Cross-sectional
- Case series
- Case report
What are the parameters in a study we can use to assess causality?
- p value
- Confidence interval
- Odds Ratio
- Relative Risk
- Risk Difference
Also consider the Bradford-Hill Criteria for Causation → can be useful in establishing epidemiologic evidence of a causal relationship between a presumed cause and an observed effect.
What are 4 Notifiable conduct behaviours of doctors?
Notifiable Conduct Behaviours - Doctors
- Practised while intoxicated by alcohol or drugs.
- Engaged in sexual misconduct - ie. sexual relationship with patient.
- Placed the public at substantial risk of harm because of an impairment.
- Placed the public at substantial risk of harm because they have practised their profession in a way that departs from accepted professional standards.
An ‘impairment’ means the person has a physical or mental impairment, disability, condition or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect the person’s capacity to practise the profession.
A ‘reasonable belief’ is considered to be direct knowledge, not just a suspicion of the incident or behaviour that led to a concern. This is most likely to occur from an observation, not from speculation, rumours, gossip or innuendo.
What are three things you would use to determine capacity in a patient?
4 people who have reduced capacity?
Factors to Consider when Determining Patient Capacity
Assessing!decisionVmaking!capacity:!
- Ability to make a choice
- Ability to understand information
- Ability to understand consequences
- Understand risks/benefits
- Understand alternatives
Who has reduced capacity?
- Minors
- Mentally ill
- Cognitive impairment
- Dementia
Capacity: refers to an assessment of the individual’s psychological abilities to make rational decisions, specifically the individuals ability to understand, appreciate and manipulate information in order to from rational decisions. Capacity is determined by a physician, usually a psychiatrist.
Competency: a legal term referring to individuals having sufficient mental and cognitive capabilities to execute a legally recognised activity. Eg. making a medical decision, making a will. Determination of incompetence is a judicial decision, decided by the court in task-specific manner.
Patient consents but refuses the next day what are your ethical and legal responsibilities?
Withdrawal of Consent
Ethical Basis
- Behaviour of doctors
- Competent pts are entitled to refuse treatment or withdraw consent.
- Pt autonomy: decision-making capability
Legality - Right to Refuse treatment
- If patients are competent and have capacity, they are entitled to refuse medical treatment or withdraw their consent to tx.
- Should be clearly informed of the consequences of refusal/withdrawal
- Patients should always make decisions independently - NOT under DURESS
- This right to refuse treatment exists regardless of whether the decision is rational, irrational or illogical.
- A refusal can be spoken, written or implied.
- Clearly document in records
- NOTE: Refusal of treatments can be via Advanced Care Directives
What are the Stages of Labour and their characteristics?
Foetal lie is longitudinal and the head isn’t engaged and is in the fundus – what is the likely presentation?
Fundus = The part of a hollow organ that is across from, or farthest away from, the organ’s opening. Depending on the organ, the fundus may be at the top or bottom of the organ. For example, the fundus of the uterus is the top part of the uterus that is across from the cervix (the opening of the uterus).
Foetal Presentation
- Most common presentation vertex (head first) and delivery face down
- Breech presentation occurs when the baby is lying bottom or feet first
- Around 3/100 babies are breech at term
- C-Section common
Mum wants to give healthy daughter vitamins but she has good food intake what are 3 things you would say?
Use of CAMs
- Will investigate if vitamin/mineral deficiency actually present - If not = Unnecessary treatment (Futility)
- ‘vitamins can only be of assistance if the dietary vitamin intake is inadequate’
- Dietary advice
- We can obtain all the vitamins we need, and in the correct amounts, from a balanced diet together with appropriate sun exposure for vitamin D
- ‘vitamin supplements should not replace a balanced diet’
- High dose vitamin supplements do not contain the co-factors and regulatory factors found in food so aren’t always as effective.
- Fears/concerns as to why she wants to use them when not indicated
- Complimentary medicines can have side effects and toxicity like any medicine can
- may produce significant drug interactions with prescribed and OTC medications
- If a patient wants to take a vitamin supplement recommend a product with doses close to the RDIs
Age of Daughter - Mature Minor can override mothers wishes.
Registered Medicines
- include all prescription medicines and most pharmacy OTC medications
- assessed for quality, safety and efficacy
Listed Medicines
- include most complementary medicines e.g. herbal, mineral and vitamin products
- The majority of oral vitamin preparations available in Australia are Listed medicines.
- assessed for quality and safety but not efficacy
Listed Medicines
- Listed medicines are considered to be of lower risk than Registered medicines
- Listed medicines are assessed by the TGA for quality and safety, but not efficacy
- This means that the TGA has not directly assessed any Listed medicine to see if it works
Phases of the Ovarian cycle?
What are 4 clinical signs warranting urgent investigation in patient with tingling and numbness on outer foot/leg?
Neurological Red Flags - Warranting Urgent Ixs
- Urinary incontinence
- Disturbance of Gait
Consider early MR scan and referral
- History of Cancer
- Cauda equina symptoms- Bilateral Symptoms!
- Significant neurological deficit
- Severe pain = not controlled with meds
- Relentless progressive symptoms
- Temperature/night sweats
Assess whether it is an UMN or LMN lesion - eg. Babinski’s test
82 year old fell broke and broke his hip and now has Acute Kidney Injury.
What are 3 likely causes?
Causes of Acute Kidney Injury
- Hypotension - eg. overmedication or medication change
- Blood or fluid loss (such as bleeding) - hypovolemia
- NSAIDs over-use
- Septic shock
- Interstitial nephritis from drug allergy
3 mechanisms held responsible for the development of AKI include prerenal, renal (intrinsic), and postrenal (postobstructive) failure.
Femoral neck surgery in the elderly individuals is usually associated with the former 2 mechanisms. Prerenal AKI may result from hypovolemia especially with acute tubular necrosis (prolonged dehydration or hemorrhage at perioperative period), pulmonary embolism, acute myocardial infarction, hearth failure, anesthetics, and sepsis, while renal AKI may be due to renal artery occlusion (embolism or thrombus), drugs (aminoglycosides, amphotericin B, nonsteroidal anti-inflammatory drugs (NSAIDs), proton-pump inhibitors, radiocontrast agents), and pyelonephritis.
What type of infectious organism is Giardia lamblia?
Giardia duodenalis, also known as Giardia intestinalis and Giardia lamblia, is a flagellated parasitic microorganism, that colonizes and reproduces in the small intestine, causing a diarrheal condition known as giardiasis.
GI Protozoa - Flagellate
Clinical Signs
- diarrhoea
- dehydration
- Steatorrhea (fat in stool- greasy)
- weight loss
- retarded growth
- failure-to-thrive
Pathogenesis
- Trophozoite adhesion to SI epithelium.
- Chemical epithelial damage from host & parasitic factors.
- Villous atrophy (↓ SI SA) & physical blanketing = malabsorption.
- (-)s pancreatic enzymes & interferes w/ bile salt metabolism.
- Disruption of epithelial tight jns = lymphocyte infiltration into lamina propria & epithelium = villous atrophy & crypt deepening.
What are the 3 main causes of Down Syndrome?
How does Trisomy 21 differ from Robersonian translocation - particularly in regards to inheritance?
Picture of the pterion: label the 4 bones, what vessel is underneath, and what bleed would it be if it’s injured?
Pterion
Bones
- Frontal
- Sphenoid
- Temporal
- Parietal
Artery at risk = Middle meningeal artery
Causes an Extradural Haemorrhage = Bleeding between Dura and cranium
4 boundaries of the inguinal canal?
Boundaries of the inguinal canal
Anterior wall – aponeurosis of the external oblique, reinforced by the internal oblique muscle laterally.
Posterior wall – transversalis fascia.
Roof – transversalis fascia, internal oblique, and transversus abdominis.
Floor – inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis), thickened medially by the lacunar ligament.
Middle ear picture, fill in the table and label the tympanic membrane, ossicles and cochlear plus their functions.
Functions
- Semicircular canals
- Cochlear
- Eustachian tube
- Stapes
- Incus
- Malleus
- Tympanic membrane
- External acoustic meatus (ear canal)
Tympanic Membrane = The tympanic membrane is also called the eardrum. It separates the outer ear from the middle ear. When sound waves reach the tympanic membrane they cause it to vibrate. The vibrations are then transferred to the tiny bones in the middle ear.
Ossicles = tiny bones in the middle ear, that form a chain connecting the ear drum (Tympanic membrane, TM) and the inner ear. When airborne sound vibrates the TM, the ossicles perform an “impedance match” allowing sound energy to be transferred into the fluid filled inner ear, rather than just bouncing off. Transmit and amplify sound and to convert sound waves into pressure waves in the perilymph and endolymph.
Cochlear = The cochlea (auditory inner ear) transforms the sound in neural message. The function of the cochlea is to transform the vibrations of the cochlear liquids and associated structures into a neural signal.
Mechanism of long-term use of naproxen causing gastric ulcer?
Naproxen = Traditional NSAID
- Traditional NSAIDS (e.g. aspirin, diclofenac, ibuprofen, naproxen) inhibit both COX 1 and COX 2
- The mucosal barrier (bicarbonate and mucus) protects the underlying tissue from the acid and enzymes in the lumen of the stomach/duodenum
- Prostaglandins formed by COX 1 (e.g. PGE2) help maintain this protective barrier
- increase bicarbonate ion secretion
- increase mucus secretion
- increase mucosal blood flow
- reduce gastric acid secretion
- Inhibition of COX 1 by NSAIDS may reduce the effectiveness and integrity of the Gastric Mucosal Barrier (effect of selective COX 2 inhibitors?)
- This may expose the underlying tissue to the acid and enzymes in the lumen of the stomach and duodenum
- Longer term NSAID use may result in mucosal damage, bleeding and peptic ulcers
- stomach (gastric) ulcer
- duodenum (duodenal) ulcer
Mechanism of low-dose aspirin causing prolonged bleeding?
Aspirin:
- In platelets the enzyme cyclooxygenase 1 (COX 1) converts arachidonic acid to thromboxane A2
- Thromboxane A2 induces platelet aggregation and vasoconstriction
- Aspirin irreversibly inhibits COX 1, inhibits the production of thromboxane A2 and reduces platelet aggregation
- Platelets do not have a nucleus and cannot regenerate COX 1
- Vascular tissue can regenerate COX1 and COX2
- Low dose aspirin (50-150mg) is used clinically to inhibit platelet aggregation
- A patient with low BMI (<17), reduced food intake, and in starvation:
- Mechanism of starvation leading to the ketoacidosis and ketonuria
- 3 methods of compensation of metabolic acidosis
- Clinical signs of ketoacidosis
- What happens to intracellular K+ in DKA
- What are the two underlying mechanisms of K+ shift in DKA
Insulin promotes potassium entry into cells. When circulating insulin is lacking, as in DKA, potassium moves out of cells, thus raising plasma potassium levels even in the presence of total body potassium deficiency.
4 ways adaptive immunity is distinguished from innate immunity?
- Clinical features of generalised anxiety obtained from history
At least 3 of the following key symptoms are required to make a diagnosis in addition to a predominant picture of chronic, excessive worry for 6 months that causes distress or impairment:
- Muscle tension
- Sleep disturbance
- Fatigue
- Restlessness or sense of “on edge”
- Irritability
- Poor concentration
- Generalised anxiety disorder differential diagnosis
Panic disorder
Fate of thrombi PORER?
- Propagation
- Thrombi that do not resolve by fibrinolysis tend to “grow” due to the deposition of additional platelets and fibrin and red blood cells
- Such growth is typically accompanied by the formation of a downstream “tail”
- Embolisation
- Thrombi may detach from the vessel wall and give rise to emboli carried downstream by the blood
- Large thrombi may form fragments and may embolise
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Organisation
- Ingrowths of granulation tissue from the vessel wall forms a firm link between the thrombus and the vessel wall
- Like in a healing wound, granulation tissue will slowly transform into a fibrous scar
- A small “bump” inside the vessel may be the only residue of such an organised thrombus
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Recanalisation
- The blood vessels in the granulation tissue organising the thrombus may fuse into larger channels that bridge the thrombus, allowing the resumption of blood flow (decimalisation)
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Resolution
- Fibrinolysis mediated by plasmin accounts for the dissolution of most thrombi
- Since the endothelial cells lining the veins produce more plasminogen activator, venous thrombi are lysed more readily than cardiac and arterial thrombi
5 complications of thrombus?
Complications of thrombosis
Infarction (arterial or venous occlusion)
Oedema (obstruction of venous outflow)
Emboli (detachment, migration and impaction at distant sites)
Infection (good culture medium)
Inflammation of the vessel wall (arteritis or phlebitis)
DALY?
One DALY represents the loss of the equivalent of one year of full health. DALYs for a disease or health condition are the sum of the years of life lost to due to premature mortality (YLLs) and the years lived with a disability (YLDs) due to prevalent cases of the disease or health condition in a population.
What is the Formula to calculate population growth over a time period?
Formula to calculate population growth over a time period (birth rate - death rate + immigration rate)
What is Relative poverty?
Relative poverty describes circumstances in which people cannot afford actively to participate in society and benefit from the activities and experiences that most people take for granted. It is conventionally defined as 40, 50 or 60 percent of national median disposable income.
Biopsy from breast lump with nuclear pleomorphism, hyperchromicity but still intact basement membrane and myoepithelial cells, what is the diagnosis?
Carcinoma in situ
What produces hCG?
Trophoblast layer
Human chorionic gonadotropin (hCG) is a hormone for the maternal recognition of pregnancy produced by trophoblast cells that are surrounding a growing embryo (syncytiotrophoblast initially), which eventually forms the placenta after implantation.
- Which vitamin/mineral supplementation has greatest evidence for reducing birth defects? (folic acid)
Folate (folic acid) = B9
What occurs in a phase 2 reaction?
Add group to make drug more water soluble - conjugate
EEG Rhythms?
EEG characteristics for each level of conciousness:
Patient has normal hearing and auditory reflexes but difficulty interpreting and identifying sounds after an injury what is common cause?
Auditory processing disorder (APD) = King-Kopetzky syndrome = neurodevelopmental disorder affecting the way the brain processes auditory information. Individuals with APD usually have normal structure and function of the outer, middle, and inner ear (peripheral hearing). However, they cannot process the information they hear in the same way as others do, which leads to difficulties in recognizing and interpreting sounds, especially the sounds composing speech. It is thought that these difficulties arise from dysfunction in the central nervous system.
Acquired APD can be caused by any damage to or dysfunction of the central auditory nervous system and can cause auditory processing problems.
Glasgow coma score of 3, what is the most likely score for each contributor?
Glasgow coma score of 6 what is the first thing needed to be addressed?
GCS = 6 → Maintenance of airway
Boy suffers deep laceration to medial thigh in motor vehicle accident. No motor loss but sensory loss over medial calf and foot. What nerve is damaged?
Femoral nerve
(Obturator nerve = medial compartment - hip adductors, gracillis)
Nerve root to aspect lateral foot?
S1
Normal inspiration on X ray?
- Anteriorly the sixth rib intersects the diaphragm at the mid-clavicular line
8-10 posterior ribs
