Exam 2 and 3 - CEL, Comms, LEAPS Flashcards
1
Q
How do you incorporate spiritual history taking?
A
FICA
F - Faith or Belief
I - Importance/Influence
C - Community
A - Address/Action
2
Q
What are the pros/cons of a professional interpreter vs informal?
A
a) Professional Interpreter: PROS: - speed - accuracy - doctor confidence in communication - better informed consent process CONS: - time - cost - practically - not always trained in medical terminology
b) Informal interpreter: PROS: - convenience - availability - no cost - help with gaining patient trust CONS: - accuracy - understanding of medical terminology - increased appointment time - privacy may be compromised – patient might not disclose as much - difficult if they are a child
3
Q
What 5 locations should you take a pule from?
A
- Atrial
- Radial
- Brachial
- Femoral
- Carotid
4
Q
Where do you take an atrial pulse from?
A
Adult - 5th intercostal space, 8-10cm left of midline.
Child - 4th.3-5cm from midline
5
Q
What is the first pulse you check?
A
Radial
6
Q
How to you take a pulse?
A
Palpate a superficial artery and count number of beats felt.
7
Q
Where do you take the femoral pulse?
A
Mid inguinal crease between anterior supernal iliac crest and pubic bone.
Femoral artery
Can laterally rotate leg to get better angle.
8
Q
How do you describe heart rhythm?
A
i) regular regular – sinus rhythm = normal cardiac rhythm. (electrical impulse is the same as the normal rhythm)
ii) regular irregular – sinus arrhythmia (normal when HR is quicker during inspiration)
iii) irregular irregular – i.e. atrial fibrillation. Irregular intervals of sinus and contraction rhythms.
9
Q
How do you define heart rate?
A
i) bradychardia - 100
10
Q
What are the normal pulses, Systolic Bps and RRs of children?
A
a) 12 years
- Pulse: 60-120
- SBP: 90-150
- RR: 15-25
11
Q
Where COULD you take a temp from? What temperatures are normal?
Where SHOULD you take a temp from?
A
a) Oral
i) Mean – 36.8 +- 0.4
ii) upper limit of normal: 37.2 at 6am and 37.7 at 4pm.
b) Rectal
- up to 0.5 higher than oral
c) Axilla (armpit) – less accurate
- up to 0.5 lower than oral
d) Tympanic (ear)
Prefered sites:
a) Up to 2 yrs – digital axilla
b) child – digital tympanic
c) adult – digital tympanic
12
Q
When are the highest and lowest body temps during the day?
A
Highest – 4-6pm
Lowest – 6am
13
Q
How do you take BP?
A
Auscultatory method.
a) positioning: patient should be seated/lying comfortably. Cuff should be approximately at heart level.
b) cuff application – 2cm above cubital fossa crease and artery line marking should be inline with brachial artery.
c) While palpitating pule, pump cuff to estimate systolic reading (when pulse disappears)
d) note value and deflate completely
e) Diaphram of steth goes over brachial artery
f) inflate 20-30mmHg above previous estimate of SBP.
g) Deflate at rate of 2-3mmHg per second and listen for Korotcoff sounds.
i) KI – SBP = first sound heart
ii) KII – sound increases in intensity
iii) KIII – sound decreases
iv) KIV – sound becomes muffled
v) KV – DBP – sound ceases
14
Q
What are the parts of a stethoscope?
A
Two ear pieces, tubing and chest piece.
Chest piece has a diaphragm (amplifies high pitches) and bell (low pitches)
15
Q
How do you describe BP?
A
a) Normal140/90
i) mild: SBP 140-159 and DBP 90-99
ii) moderate: SBP 160-179 and DBP 100-109
iii) severe: SBP>180 and DBO>110
16
Q
What are some of the factors that can impact on blood pressure reading?
A
a) Patient activity:
i) Exercise/stress – increase
ii) Caffeine/Smoking – increase
b) cuff size:
Small will overestimate and low will under.
c) position of arm:
i) unsupported – increase
ii) If cuff to high – decrease. If too low – increase
iii) Tight clothing – underestimate
d) During the recording:
i) patient talking – increase
ii) moving – increase or decreasing depending on hight levels (see cii)
e) Errors in technique:
i) if correctly estimate SBP at first, might miss systolic reading. Auscultatory gap (10-20mmHg) can cause sound to disappear at rate lower than SBP and then reappear again.
ii) Quick deflation – decrease
ii) rounding off
iv) Repeat after a few minutes and check both arms. Normal for 5-10mmHg variation.
17
Q
What should the cuff size for children be for BP reading?
A
Bladder length – cover 80-90% of the circumference of the arm
Bladder width – length ratio should be at least 1:2
18
Q
What should the cuff size for children be for BP reading?
A
Bladder length – cover at least 80% of the circumference of the arm
Bladder width – cover at least 40% of the circumference of the mid upper arm.
19
Q
What is a postural drop?
A
Compare BP meadured from supine (on back) position vs standing after 2 mins. If SBP>20mmHd or DBP>10mmHg lower after 3 mins then this is a significant postural drop.
20
Q
How do you take peripheral perfusion?
A
pressing for 3-4 seconds on pulp of fingertip then remove to check capillary refill time (time taken for are to return to original pink colour).
Normal -
21
Q
Why are the normal vital signs for children so variable and why can’t you rely on them?
A
a) immature systems – won’t always mount an immunological or hypothalamic response to infection, so might not have fever with infections.
b) Compensation – BP change is a late response and may be serious, i.e. septic shock. They just compensate by increasing cardiac output when they have low circulating volume and increasing capillary tension.
c) Respiratory system less able to respond affectively – small and underdeveloped. Not good indicator of unstable physiology.
22
Q
How do you wash your hands with alcohol?
A
- Apply
- Rub palms
- Right palm over left dorsum with interlaced fingers and visa versa
- Palm to palm with fingers interlaces
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of thumbs
- Rotational rubbing of finger tups on palm
- Dry - safe
23
Q
How do you wash your hands with soap and water?
A
- Wet hands
- Apply
- Rub palms
- Right palm over left dorsum with interlaced fingers and visa versa
- Palm to palm with fingers interlaces
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of thumbs
- Rotational rubbing of finger tups on palm
- Rinse hands with water
- dry hands thoroughly with single use towel
- use towel to turn off faucet
- safe
24
Q
What are the 5 moments of hand washing?
A
- Before you touch a patient
- Before you perform a clean/aseptic procedure
- After touching a patient
- After touching a patient’s surroundings
- After body fluid exposure risk
25
How do you put on gloves?
1. Take out of box
2. only tough top edge of cuff
3. put on one glove
4. Take second out with bare hand, only touching edge of cuff.
5. Avoid touching skin on forearm by folding fingers into external surface
6. don't touch anything
26
How do you remove gloves?
1. pinch write and pee off, allowing it to turn inside out
2. - hold removed glove in gloved hand
- slide ungloved fingers under glove and remove by rolling down hand and fold into first glove
3. Discard
4. Hand hygeine
27
What are the ethical principles that can be applied to medical problems?
1. Treating people equally - ignores all other relevant principles
a) lottery
b) first come first serve
2. Prioritarianism (favouring the worst off)
a) Sickness first
b) youngest first
3. Utilitarianism
a) number of lives saved
b) prognosis/life years saved
4. Social Usefulness
a) instrumental value - future
b) reciprocity - past looking
28
What are the factors that affect perception of risk?*
- Trust vs lack of trust
- Voluntary/controllable vs coerced/uncontrollable
- natural vs man made
- not dreaded vs dresses
- chronic or catastrophic
- Familiar/awareness vs unfamiliar
- affects adults vs affects children
29
What are the stages of change in motivational interviewing?*
a) Pre-contemplation – raise doubt
b) Contemplation – tip the balance - address ambivalent
c) Determination – help them determine the best course of action (or preparation/decision making)
d) Action – help them take steps toward plan – ‘Action Plan’
e) Maintenance – prevent relapse
f) Relapse – renew stage of change
30
What are the broad determinants of health?*
- individual and psychological make up (effects everything)
- Broad features of society (culture, cohesion, media, politics)
- Environmental Factors (remoteness, natural)
- Socioeconomic characteristics
- knowledge, attitudes and beliefs (health literacy)
- health behaviours (lifestyle)
- psychological factors (stress, trauma)
- safety factors (OH&S, risk factors)
- biomedical factors (birth weight, BP, weight)
= health and wellbeing overtime
31
What is the Health Belief Model?
Likelihood of an individual taking action related to a given health problem is based on the interaction between four different types of belief:
1. Perceived susceptibility to a problem (perceived threat)
2. Perceived seriousness of consequences (perceived threat)
3. Perceived benefits (outcome expectations)
4. Perceived barriers (outcome expectations)
32
What communication strategies are used in motivational interviewing?
OARS
O - ask open ended questions
A - provide affirmation
R - reflective listening
S - summarizing statement
33
What are some important factors in motivational interviewing?
- collaboration
- evocation
- autonomy
- exploration
- non-judgmental
- express empathy
- develop discrepancy
- roll with resistance
- support self efficacy
34
How do you evoke change talk?
- Disadvantaged of the status quo
- advantages of change
- optimism for change
- intention to change
Evoking change talk about importance:
Scale 0-10
- tell me why you chose that number?
- what could happen that would increase it?
Evoking change talk about confidence:
Scale 0-10
- tell me why you chose that number?
- what could happen that would increase it?
35
What are the main points for a brief intervention?
5A's
- Ask
- Assess
- Advise
- Assist
- Arrange - regular follow ups
36
What is the attack rate of a disease?
No. of people at risk who develop illness/total number of people at risk
37
Herd immunity?
A situation in which a sufficient proportion of a population is immune to an infectious disease (through vaccination and/or prior illness) to make its spread from person to person unlikely
38
What are the 4 major factors of CD's?
1. Characteristics of the Infectious Organism
2. Characteristics of the Host (individual who is infected)
3. Characteristics of Transmission
4. Influence of the Environment
39
What are the types of transmission of CDs?
- Air-borne
- Water-borne
- Blood-borne
- Vertical (i.e. syphilis)
- Sexual
- Faecal-oral
- Vector Borne
40
What are the steps to investigate a CD?**
A. Obtain background info:
1. Prepare for field work
2. Establish the existence of an outbreak, consider severity, potential for spread, public concern and availability of resources
3. Verify diagnosis
B. Define the problem
4. Define and identify the cases - case definition and line listing
5. Describe and orient the data in terms of time, place and person (descriptive epidemiology) - PLOT EPIDEMIC CURVE
C. Formulate a hypothesis
6. Develop hypothesis (agent, host, environment, trait) = chain of transmission
D. Develop a study to test hypothesis, collect data and observations, evaluate results.
7. Evaluate hypothesis (analytical studies must have control group)
E. Determine if H is true/modify (8), formulate conclusion (9) and report results (10).
8. Refine hypothesis and carry out additional studies
9. Implement control and prevention methods
10. Communicate findings
41
What is a CD outbreak and what are the main questions to ask to establish if an outbreak exists?
• Cases of disease in excess of expected number for a given
time, place and/or group
• Smaller scale than an epidemic
* Main questions:
* What is the disease?
* What is the source?
* How is it being spread?
* How can the outbreak be stopped?
42
What is involved in verifying diagnosis (Q4) for CDs?
Confirm through:
a) clinical (probable)
b) lab (confirmed)
Establish definition - standard set of criteria
43
What is involved in 'Define and identify the case' for CDs?
• Identify cases & case-finding: Notifications, GPs, Labs, Schools etc
• Gather information -Demographics, clinical details, exposures (eg. Food history)
- Questionnaires (hypothesis generating interviews)
* Line listing- Person, place and time
* Plot an epidemic curve
44
What is involved in 'Describe and orient the data in terms of time, place and person' (5) for CDs?
Time - epidemic curve
- Point source (i.e. food poisoning from a
- Extended source - often food contamination
- propagative - i.e. virus
45
What factors are involved in the emergence and re-emergence of diseases?
- microbial adaption and change
- human susceptibility to infection
- climate and weather
- change in human demographics and behaviour
- eco development and land use
- breakdown of public health measures
- poverty and social inequality
- war and famine
- intent to harm
46
Types of emerging infections classification, what do they mean and what are some examples?**
1. Newly emerging - not previously recognised in humans (SARS, H1N1, HIV, Ebola)
2. Re-emerging and Resurging infections - existed in past but are now increasing in incidence of geographical/human host (MDR TB, cholera, malaria, Dengue)
3. Deliberately emerging infections (anthrax)
47
What are neglected tropical diseases?
They are called neglected because they have been largely wiped out in the more developed parts of the world and persist only in the poorest, most marginalized communities and conflict areas.
- double burden of disease
- > 1 billion people have one or more NTD
Examples: leprosy, trachoma, dengue fever
48
What are some emerging, re-emerging and NTDs?
Emerging:
- Aids
- Legionnaires
- Hendra virus
- SARS
- MRSA infection
- pandemic influenza
- Clostridium difficile
- H1N1 (swine)
Re-Emerging:
- Malaria
- Pertussis
- Cholera
NTDs:
- leprosy
- trachoma
- dengue fever
49
What is involved in 'Implement control and prevention methods' (9) for CDs?
a) Source
- treat cases
- isolate cases
- food recall
b) Transmission
- environment measures
- hand washing
- hygiene
c) Host
- immunisation
50
What is involved in CD surveillance? ('secondary prevention')
Ongoing systematic data collection
• Determine background level of the disease
• Examine trends over time
• Examine difference between locations & populations (so determine risk factors)
• Identify outbreaks and epidemics
• Monitor effects of interventions (eg. Immunisation)
51
What are the surveillance types?
a) Passive
• Notifiablediseases
• Notificationrequiredbylaw
• Need to be monitored for public health purposes (immunisation, contact tracing, investigation of outbreaks)
• Completeness depends on disease (severity, rarity, accurate diagnosis)
b) Active
• Finding cases in potential epidemic situations
c) Sentinel
• Cost effective
• A sample of places or people -GPs/Specific hospitals
• Early warning; less serious diseases
d) Enhanced
Gathering more detailed information from cases (from the notification system)
52
What are the facts about H5N1?
- Avian Flu
- affects poultry flocks in an increasing number of countries
- Aggressive infection - quickly kills whole flocks
- Can infect humans - mainly only people living/working with poultry
Over 200 people infected
- more than half have died (mortality rate >60%)
- Cannot yet easily spread from person to person
- affected China, Vietnam, Indonesia etc
53
What are the 3 attributes that a flu virus needs to become a pandemic? (i.e. Avian flu)
- novel
- causes significant illness/death
- spreads easily
1) A novel (new) virus which humans have no immunity
2) The virus causes significant human illness and death
3) The virus can spread easily from person to person (Avian flu does not have this)
54
Why are flu pandemics recurring events?
- virus continues to mutate
55
What is the global burden of CDs?
- About 15 million (26%) of 57 million annual deaths
- Burden most heavy on developing countries – infants and children
- Developed countries – Indigenous and disadvantaged people
- 2nd leading cause of death world wide
- More than half the world’s population is at risk of these diseases
56
CASE: Measles in Australia and globally
- elimination of endemic measles due to good uptake of MMR in 1999
- Average = 100 per year due to imported cases
- two doses of MMR to Aus children at 12 and 18 months
- contagious - 1 person = 12-18
- Aus - campaigns to prevent measles being brought in to the country by unvaccinated travellers
- AMA guidance is that vaccination rates below 93% are unsafe
- Rachel and Lola - deaf
- NOTIFIABLE DISEASE
GLOBAL:
Disney land - 95 infected
Worldwide many countries got >1000 cases per 5 month period from 2013
- one of the leading causes of vaccine-preventable death in children world wide
57
What do you do with notifiable diseases?
You contact the local Public Health Unit to inform them you have seen a likely case of measles.
The Public Health Unit staff’s role now is to work with both you and the patient to:
• find out how the infection occurred
• identify other people at risk of
infection
• implement control measures (such as immunisation and restrictions on attending school or work)
• provide any other advice as needed
58
CASE: Pertussis in Australia
- early 2015, baby Riley died of whooping cough in Perth
59
CASE: TB in Australia
- Tuberculosis (TB) is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent
- huge in south africa
- Stop TB partnership
In Aus, • The Western Australian Department of Health is notified and the Western Australian Tuberculosis Control Program take over the management of the outbreak. The Department of health staff begin tracing and screening close contacts – this includes immediate household members, extended family and friends and workplace contacts (staff and patients)
60
CASE: Chlamydia in Australia
Australian re-emerging infection
83,000 cases diagnosed in 2012
61
What are some of the homeostatic results of intense exercise?
- Breathing rate increases (Respiratory rate, increase tidal volume, minute volume ventilation)
- Heat and sweat
- Heart - cardiac output, heart rate, stroke volume
- get flushed - blood flow increases to the skin
- feel hot (cognitive sensation of heat)
- dehydration, body mechanisms come into play to try and conserve water. ADH - antidiuretic hormone
62
Describe at least one example of a neural control system and one example of a hormonal control system
Neural – hypothalamus and temperature
| ADH = anti-diuretic hormone. Increased levels of ADH result in greater reabsorption and decreased water excretion.
63
What are the three muscle metabolic systems in exercise?
1. Phosphocreatine-Creatine system - very high E and very quick - 8-10 seconds. moles of ATP/min = 4
2. Glygocen-Lactic Acid System (anaerobic) - alot faster than aerobic. 1.3-1.6 mins. ATP/min = 2.5
3. Aerobic system - mitochondria - glucose, fatty acids, amino acids. Unlimited time as long as nutrients last (so high carb diet is better). ATP/min = 1
64
What are the steps in the catabolism of carbs?
xxx
65
What are the steps in the catabolism of proteins?
xxx
66
What are the steps in the catabolism of fats?
xxx
67
What are the physiological changes in the respiratory system during
exercise?
High respiratory and heart rate. Oxygen debt, also RR is high because heart rate is still very high and they are linked.
Training doesn’t have that big of an effect on the oxygen-diffusion capacity of our lungs. This is because its not really the limiting factor in delivery of oxygen - the heart is.
68
What are the physiological changes in the cardiovascular system during
exercise?
Vasodilation to get more blood to muscle and heat out of skin, AND more blood to muscles. Increased HR, increased Stroke Volume, Increased BP.
EFFECTS OF TRAINING - HEART CHAMBERS ENLARGE AND MUSCLE
HYPERTROPHIES, so heart pumping effectiveness increases due to greater stroke volume, so heart rate can decrease.
69
What is Exertional hyponatremia?
Exertional hyponatremia – low sodium concentration in blood which typically results from an athletes ingestion of more water or low solute drinks and not replacing sodium lost through sweating.
70
What happens if your body temp boas above 40?
>40, temp becomes destructive to tissue cells, especially brain cells.
71
What is the normal temp range during exercise?
37-40
72
What is the difference between heat stroke and heat exhaustion?
Heat stroke - >40 degrees
73
What do you do when someone has heat stroke?
1. call for an ambulance
2. resuscitate following the Basic Life Support Flow Chart (ANZCOR Guideline 8)
3. place the victim in a cool environment
4. moisten the skin with a moist cloth or atomizer spray and fan repeatedly
5. apply wrapped ice packs to neck, groin and armpits.
ANZCOR suggest a 3-8% carbohydrate electrolyte fluid [any commercially available “sports drink”] for the treatment of exertion related dehydration (CoSTR 2015, weak recommendation, very low quality evidence)8. If carbohydrate electrolyte fluid is unavailable, water is an acceptable alternative.
74
What do you do when someone has heat exhaustion?
1. lie the victim down in a cool environment or in the shade
2. loosen and remove excessive clothing
3. moisten the skin with a moist cloth or atomizer spray
4. cool by fanning
5. give water to drink if fully conscious
6. call for an ambulance if not quickly improving.
75
What is anaphylaxis?
An acute allergic reaction to an antigen (e.g. a bee sting) to which the body has become hypersensitive. Multisystem involvement. Extreme end of the allergy spectrum.
76
What are potentially life threatening symptoms of anaphylaxis?
1. Difficult/noisy breathing
2. Swelling of tongue
3. Swelling/tightness in throat
4. Difficulty talking and/or hoarse voice
5. Wheeze or persistent cough
6. Persistent dizziness and/or collapse
7. Pale and floppy (in young children)
77
What are less severe symptoms of allergic reactions that can precede anaphylaxis?
- Swelling of face, lips and/or eyes
- Hives or welts
- Abdominal pain, vomiting (these are signs of anaphylaxis for insect allergy)
- Several factors can influence the severity of an allergic reaction. These include exercise, heat, alcohol, and in food allergic people, the amount eaten and how it is prepared.
78
In what way in anaphylaxis a mixed shock?
low blood volume and pressure
79
What are immunological and non-immunological triggers for anaphylaxis?
1. Immunological - a) IgE - food, bites, stings and sometimes drugs
b) non IgE = complement, immune complexes, autoimmune, coag activation - viruses
2. Non-immunological - mast cell degranulation, cold air/water, exercise, some drugs
Food = eggs, cows milk, peanuts, tree nuts, wheat, fish, shellfish, soy, sesame. Bugs = bee stings,
wasps, ants etc.Drugs: penicillin, anaesthetic etc. Other: latex,
80
How should you monitor a child with anaphylaxis?
Pulse rate, BP, pulse oximitary, ECG, respiratory rate. Remember in children, BP can be fairly constant, but one of the early signs is the RR going up and anxiety.
81
What is the mechanism of action of adrenaline? Where does it act according to your concept map?
Vasoconstriction. Part of our sympathetic nervous system – neurotransmitter is noradrenaline. Bronchodilator which helps for breathing. Increase heart rate,
82
Explain the adverse effects and precautions for adrenaline, based on what you know about autonomic effects of the sympathetic nervous system for each organ system.
Increase heart rate, vasoconstriction, high BP, feeling anxious, headaches and burred vision, tachycardia, chest pain, shortness of breath, sweating, nausea and vomiting. Inhibits mast cells.
83
What are the pharmacological agents used in anaphylaxis?
Frontline therapy = adrenaline (if they don’t respond to first shot, give a second one within 5 mins) Also Oxygen, saline.
Other = adrenaline infusion in ED, glucagon, vasopresin (vasoconstrictor), metarinol, salbutamol (if they are wheezing)
84
What do you need to do for a rural transfer?
People, equipment you have available and transfer – timing and safety.
TRANSPORT/PEOPLE: Need 2 personnel to go with ambulance to another setting. Some rural ambos are volunteers and are not trained enough. Also important they have medical staff left at the first medical place.
EQUIPMENT: oxygen, drugs, speak to specialist colleagues (can do this on phone)
- transfer with oxygen (have already given adrenaline and have inserted IV line in case of emergency.
- communication is important, i.e. with parents/guardians, and with transport people and people at place you a re transferring them to.
- many places have transfer protocols
- you are dealing with an anxious child, so you need to tell parent to be calm so the child can be more relaxed. Parent accompanies child in the ambulance to help.
85
Why do children have a higher pulse?
Cardiac output = HR x Stroke Volume.
| Stroke volume is markedly reduced in kids, so to maintain cardiac output they have a high HR.
86
Why do children have a higher RR?
Tidal volume is significantly less, therefore need to take more breath for sufficient gas exchange.
87
As vital signs can't always be relied on for children, what else can you look for as a warning sign?
behavioral changes such as anxiety, restlessness, lethargy
88
How do you communicate with children
- it’s going to dependent the age of the child. Babies are totally reliant on the parent so you rely on the parent to give a history and to consent an examination. Around 12 month mark they become a bit more mobile, but they still have their parental figures for comfort and security.
- Approach them in a friendly way.
- Kids love toys.
- Eye level.
- But sometimes they are so distressed, so may need parents help – i.e. to hold the child still or to let the child sit on their lap while you examine them.
89
What is an action plan for a mild allergic reaction?
* For insect allergy, flick out sting if visible. Do not remove ticks.
* Stay with person and call for help.
* Locate EpiPen® or EpiPen® Jr adrenaline autoinjector.
* Give other medications (if prescribed)....................................................... • Phone family/emergency contact.
90
What is an action plan for anaphylaxis?**
1 Lay person flat. Do not allow them to stand or walk. If breathing is difficult allow them to sit.
2 Give EpiPen® or EpiPen® Jr adrenaline autoinjector.
3 Phone ambulance*: 000 (AU) or 111 (NZ).
4 Phone family/emergency contact.
5 Further adrenaline doses may be given if no response after
5 minutes, if another adrenaline autoinjector is available.
91
In what ways are epidemics such as Ebola and Zika driven by pathologies of society?
- the way populations move and migrate. Migrant populations don't have great access to health care
- hybrid viruses that appear in food processing factories and increase the chances of human-animal interactions
- increased interactions between humans and forest animals - indigent populations are forced deeper into forested areas to look for food.
- economic exploitation - results in under resourced and weak health systems
92
What are some of the political challenges faced by refugees in the process?
- process can be long – 10 months on average
- in Thailand, they are not issued with a passport but with a travel document. The only way they can return is with a passport from their host country.
- only small amounts of cultural orientation – 3-5 days
- no medicare, PBS etc
93
What are some of the common diseases/conditions that refugees might have?
- Food insecurity and nutritional deficiencies - especially vitamin D and iron
- Infectious - TB, malaria (1/3 refugee children have had malaria before arriving in Aus), HIV,
H.pylori, tinea; parasites including schistosomiasis, strongyloides, giardia; immunisation status
- Haematological- anaemia assoc. with chronic infection, iron deficiency, haemoglobinopathies
(thalassemia, sickle cell disease)
- Dental - varies (but only 1/3 report toothache despite being severe)
- Failure to thrive - multifactorial; psychological factors can have significant impact; nutritional
compromise prior to arrival
- physical problems associated with journey itself
- physical problems due to torture/abuse/violence
FAMILY HISTORY MIGHT NOT BE KNOWN
94
What are some social determinants that may be relevant to refugees?
- absence of home - no safety, place for rest, play for play
- inadequate education
- language skills
- individual health literacy
95
What are some of the local health services available to refugees?
- AseTTs - provides services to people who are humanitarian entrants or are from a refugee type background and who have experienced torture or trauma
- PMH Refugee Health Clinic
- HEHS
- UNHCR – The UN Refugee Agency
- ASRC – Asylum Seeker Resource Center
- AFRAM – AMSA for Refugee and Asylum Seeker Mental Health
- Refugee Council of Australia
- Carad – The Center for Asylum Seeker Refugees and Detainees
96
What is the role of the PMH Refugee Health clinic?
The PMH Refugee Health Clinic aims to coordinate and manage the complex care needs of recently resettled refugee and asylum seeker children under 16 years of age. Holistic.
Specialist services include:
1. Medical staff (Paediatric consultants, GP, Refugee Health Senior Registrar)
2. Nurses (Refugee Liaison Nurse, Community Health Nurse and Clinic Nurse)
3. Social worker
4. Dietician
5. School teacher liaison
6. Dental Registrar
7. Psychology liaison
97
What is the role of the HEHS?
The Humanitarian Entrant Health Service (HEHS) provides a holistic health assessment service for all refugees and humanitarian entrants who are resettled in Western Australia under the Commonwealth Government’s Humanitarian Program and Special Humanitarian Program.
HEHS aims to identify health issues which may affect the well-being of newly arrived refugees and to detect and treat infectious diseases of public health importance. The health screen includes obtaining a thorough history (including medical, psychological, obstetric and nutritional conditions) and screening for communicable diseases.
- voluntary
- no cost
98
What is health literacy?
(a) Individual health literacy: the knowledge, motivation and competencies of a consumer to access, understand, appraise and apply health information to make effective decisions about health and health care and take appropriate action.
(b) Health literacy environment: the infrastructure, policies, processes, materials and relationships that exist within the health system that make it easier or more difficult for consumers to navigate, understand and use health information and services to make effective decisions about health and health care and take appropriate action.(shared decision making)
99
What is the difference between a refugee and asylum seeker?
Refugee – a person who has been forced to leave their country in order to escape war, persecution, or natural disaster.
Someone who has a:
- well founded fear of persecution
- is outside the country of their nationality
- is unable or unwilling, owing to such fear, to avail themselves to the protection of that country
- OR doesn’t have a nationality
- And is outside the country of their former habitual residence
- is unable or unwilling, owing to such fear, to return
Asylum seeker – a person who has made a claim that they are a refugee and are waiting for the claim to be accepted or rejected.
100
What are internally displaces persons?
like refugees but they remain in their country. They are not covered by refugee convention. Therefore they are at even greater risk than refugees – they have less aces to resources and support from the international community.
101
What are some of the experiences of a refugee that could have a psychological impact and what are some of those impacts?
Experiences:
Threats of violence, killings, assaults, disappearances, lack of access to basic needs to survival, death, separation from family, forced displacement, prohibition of traditional practices, exploitation of women, brutality, violation of human rights, invasion of personal boundaries, rape, impossible choices.
Results:
- anxiety
- PTSD
- feelings of helplessness and loss of control
- relationship changes
- grief
- depression
- loss of trust, faith, meaning, identify and futire
- guilt
- shame
102
How do you use interpreter services?
- Introduce yourself and the interpreter to the client.
- Maintain eye contact with the patient throughout the session.
- Speak to the patient in the first person.
- Always speak to the patient directly and not the interpreter.
- Speak clearly and avoid using jargon.
- Speak in short intervals allowing time for the interpreter to interpret what you have said.
- Do not talk with the interpreter and exclude the patient. Everything that is said during the interview must be interpreted. Except if you need further info, clarification etc.
- Summarise discussion and provide opportunity for the patient to ask questions.
103
What are developmental milestones?
Developmental milestones are behaviors or physical skills seen in infants and children as they grow and develop. Rolling over, crawling, walking, and talking are all considered milestones. The milestones are different for each age range. There is a normal range in which a child may reach each milestone.
104
What are the guidelines for breast feeding?
Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary
foods at 6 months of age (180 days) while continuing to breastfeed.
Benefits include protective effect against infant gastrointestinal infections, motor development is enhanced by exclusive breastfeeding for six months, lactational amenorrhoea in mother.
105
On a growth chart, what is considered normal growth?
- “Normal” growth is within ± 2SD (some nutritionists now recommend ± 1.6 SD) of the mean.
Key point: longitudinal observations (growth velocity) and growth comparison between weight, height (or supine length if
106
Where are RBCs removed and why?
Removed by spleen, liver and BM - phagocytksed
They are removed due to reduced flexibility, altered membrane surface or rupture.
107
What is the structure and function of erythrocytes?
- biconcave disc – gives them greater SA which increases rate of gas exchange AND makes them more flexible which helps them flow through narrow openings of capillaries.
- 6-8um diameter
- no nucleus, mitochondria or ER
- Functional component - Hb
108
What is the structure and function of haemoglobin?
Hemoglobin consists of four subunits, each with a cofactor called a heme group that has an iron atom center. The iron is the main component that actually binds to oxygen, thus each hemoglobin molecule is able to carry four molecules of O2.
109
What are the red cell indices equations?
```
MCHC = Hb/PCV
MCV = PCV/RBC
MCH = Hb/RBC
```
110
Describe the different sites of haemopoiesis according to age
- Embryo – yolk sac
- Foetus 2-7 months – liver, spleen, lymph nodes
- 7 months gestation – BM
- Birth – 5 years – all bones
- Adult – axial skeleton. Membranous bones, vertebrae, sternum, ribs, ilia.
111
List the requirements for normal bone marrow function
- Requires Haemopoietic Stem Cells (“seed”):
- Special cells which can develop to produce all blood cells
- These cells can multiply in vivo
- Can be stored in vitro, and can be used in transplants
- Grown in vitro to assess colony forming units and growth
Requires a suitable supportive environment (“soil”):
- Network of structural and supportive cells
- Nurturing environment, rich in nutrients and cytokines,
directing development pathways
Nutrients including iron, B12, B6, folate, amino acids, energy
- supportive cells- stromal cells, cytokines
- Cytokines:
- Erythroid- includes ERYTHROPOIETIN
- Granulocytes- includes G-CSF, GM-CSF
- Lymphocytes- Interleukins
- Platelets- THROMBOPOIETIN
112
Define anaemia
The condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased.
113
List three broad pathological mechanisms that can lead to anaemia
- Impaired production of red cells e.g.
- haematinic deficiencies, malnutrition
- Bone marrow failure or replacement
- inherited disorders of globin production - thalassemia
- anaemia of inflammation
- depressed erythropoietic activity eg renal failure
- Blood loss
(NOT ACUTE) – i.e. due to helinths
- Excessive red cell destruction e.g.
- intrinsic red cell defects inherited or acquired. eg
haemoglobinopathies, enzymopathies,
membranopathies
-
extrinsic defects
114
Describe standard patterns of Mendelian inheritance
1. Autosomal dominant: 50 percent chance of having an affected child with one mutated gene (dominant gene) and a 50 percent chance of having an unaffected child with two normal genes (recessive genes).
2. Autosomal Recessive – need two carrier parents
3. X-Linked Dominant: X-linked dominant traits do not necessarily affect males more than females (unlike X-linked recessive traits). The exact pattern of inheritance varies, depending on whether the father or the mother has the trait of interest. All daughters of an affected father will also be affected but none of his sons will be affected (unless the mother is also affected). In addition, the mother of an affected son is also affected (but not necessarily the other way round).
4. X-Linked Recessive - X-linked recessive inheritance is a mode of inheritance in which a mutation in a gene on the X chromosome causes the phenotype to be expressed in males (who are necessarily hemizygous for the gene mutation because they have one X and one Y chromosome) and in females who are homozygous for the gene mutation, see zygosity.
115
Describe types of genetic alterations
Changes at sequence level leads to:
a) altered transcription and RNA processing
b) altered translation
c) altered post-translational modification and folding
116
Describe the steps involved in the clinical transfusion process
- Donor Selection
- Whole Blood Donation
- Donation testing
- Separate into components
- Plasma fractionation
- Labelling
- Store and handle
- Informed consent from recipient
- Pretransfusion sample collection according to procedures
- Group and screen recipient
- Compatibility testing
- Transfusion /administration packed cells according to procedure
- Monitor for reaction
117
Describe the potential effects of mutations on normal cell function
Effects in general on mature protein:
- amount of protein produced
- subcellular localization
- interaction with other subunits, cofactors
- biological function
- degredation
- accumulation
118
What is the difference between major and minor thalassemia?
Major – just means so severe that you will need transfusion. I.e. excess relative alpha chains due to decreased production of B.
Someone with major thalassemia could have two parents with minor as minors tend to be asymptomatic. Majors tend to present with severe anemia within 1st year of life, characteristic blood changes (ineffective erythropoiesis – increased but products are bad) and elevated HbF – characteristic of major thalassemia – no other disease does this. They need regular transfusions to survive. Example – relative excess of alpha globin chains. Will result in hemolysis, ineffective erythropoiesis and membrane binding of IgG and C3.
Minor is characterized by mild anemia, reduced mean cell volumes and mean cell hemoglobin concentrations, and elevated concentrations of the normal minor adult component of hemoglobin
119
Why is salt reduction so important?
- Reducing dietary salt intake lowers blood pressure for most people.
- The leading risk factor for the global disease burden is raised blood pressure, estimated to cause 9·4 million deaths every year
- Salt reduction has been identified as one of the most cost-effective interventions for reducing the burden of NCDs
120
Why is iodine essential?
it is a constituent of thyroid hormones, which play an important role in physical and mental development
121
What is iodine deficiency one of the leading causes of?
Iodine is one of the leading causes of preventable mental retardation and brain damage in the world. The problem is more pronounced in pregnant women and young children.
122
What are the causes of iodine deficiency?
- **low level of iodine in the soil
- poor consumption of seafood like fish
- increased consumption of goiterogens like cabbage, cassava etc
123
Who is most at risk of of iodine deficiency?
- children
- pregnant ladies
- lactating mothers
- adolescents
124
Where is iodine deficiency most common?
- mountainous area
| - areas having frequent flooding
125
What is the geographic distribution of iodine deficiency?
Australia:
Re-emerging in Australia UK and NZ, with children in NSW and Victoria mildly iodine sufficient. And longstanding problem in Tasmania.
Global:
Most at risk:
Parts of south America in particular and North America, China, some parts of Africa.
~ 1/3 worlds population live in areas with some iodine deficiency
126
What are the clinical consequences of iodine deficiency?
- Abortion
- mental retardation
- growth retardation
- goiter - a swelling of the neck resulting from enlargement of the thyroid gland
- nodular goiter and hyperthyroidism
- lower intelligence
- goiter and hypothyroidism
- increased infant mortality
127
Why is salt used as a preventative measure of iodine deficiency?
- Salt is eaten in consistent amounts by a large proportion of the target population;
- iodine from iodized salt is well absorbed;
- iodized salt does not affect the sensory properties of food;
- salt production is usually limited to a few producers;
- and the cost of iodization of salt is very low and the technology relatively simple
128
What is the conflict between iodine deficiency and salt consumption?
Iodine deficiency - Iodine is one of the leading causes of preventable mental retardation and brain damage in the world.
Salt - Reducing dietary salt intake lowers blood pressure for most people, which is the leading risk factor for the global disease burden.
BUT may not be a conflict. Just put more iodine in salt.
129
What are some of the man made barriers to combatting iodine deficiency with salt in some countries?
- some countries have many small and independent salt producers - can't regulate them effectively
- some countries have trade barriers
130
What are some other solutions to the iodine problem?
– could possibly introduce it to other foods, but hard to regulate individual foods and get all of the companies involved.
– Could put it in water.
– Could add more iodine to salt so that we could reduce salt consumption.
– Add it to animal feed or soil
– Supplements for pregnant women
131
What are some of the sources of lead?
- industry emissions
- paint
- leaded fuel (phased out in WA)
- water pipes –PVC plumbing and old pipes
- electrical solder
- cigarettes
- shooters (lead bullets)
- melting car batteries
- home renovations**
- Community wide:
- mining
- processing
- transporting
132
What are some of the consequences of too much lead in the environment?
- bird deaths
- poisoining
- death
- neurological impacts
- behavioral disorders
133
What are the signs and symptoms of lead poisoning?
Signes and symptoms:
a) neurological:
- headaches
- irritability
- reduced sensations
- aggressive behavior
- difficulty sleeping
b) Other:
- abdominal pain
- poor appetite
- Constipation
- anemia
c) Additional symptoms for children:
- loss of developmental skills
- behavior, attention problems
- hearing loss
- kidney damage
- reduced IQ
- slowed body growth
134
How is lead absorbed?
Ingestion or inhalation
135
What can increased absorption of lead lead to?
- anemia - lead is ingested through gut via same cation pumps used for iron absorption.
- hypocalcaemia
- malnutrition
136
What is the half life of lead in the body?
- 25 days in blood
- 40 days in soft tissues
- 25 years in bone
137
What is a concerning level of lead?
- level of concern = 10 ug/dL
- BUT lower levels can cause measurable intellectual loss
- Use Chelation if > 45ug/dL
138
Why are children more at risk of lead poisoning?
- high absorption – 4 times more than adults
- high exposure - crawling, hand to mouth activity, pica
- high susceptibility:
- peak at 1.2-2 years
- a the critical point of brain development – more sensitive
- immature blood-brain barrier
- can have behavioral disturbances such as ADHD
- In Nigeria, Zamfara provine – lead is used to help extract gold from local mines. 450 children died in area in last year. Government slow and ineffective response
139
Why are the consequences of lead poisoning more severe for children?
- The developing brain has a greater sensitivity to lead exposure
- Children absorb four times more lead than adults
- Exposure is more likely in young children from hand-to- mouth activity
- Concurrent iron deficiency further increases gut lead absorption
140
What are some sources of fine particles? (pollutants?)
- power plants
- heavy duty diesel engines
- cars and trucks
- space heating
- rail
- forest fires etc
141
In relation to diagnostic and screening tests, what is sensitivity?
- The sensitivity of a test measures how well a test performs in detecting a disease in people who have the disease
- The probability (usually expressed as a %) of those with the disease correctly detected by the test
- The true positive ‘rate’
- High sensitivity means few people are missed
- ‘detection rate’
- Accuracy
- LOW SENSITIVITY – false negatives, false reassurance, delayed treatment, costs without benefits
- THEREFORE, choose test with high sensitivity if the costs of false negatives are high
142
In relation to diagnostic and screening tests, what is specificity?
Specificity:
- The specificity of a test measures how well a test performs in determining that disease is not present in people who do not have the disease
- The probability (usually expressed as a %) of those without the disease correctly excluded by the test
- The true negative ‘rate’
- High specificity – rarely test positive when a person does not have the disease
- Accuracy
- LOW SPECIFICITY – false positives, unnecessary anxiety, unnecessary investigative procedures, costs will increase with no compensating benefits
- THEREFORE, choose test with high specificity if the costs of false positives are high
143
In relation to diagnostic and screening tests, what is positive predictive value?
- probability that a patient has a disease if he or she has a positive test
- the extent to which being categories as a positive test actually predicts the presence of the disease
- the close to 100% the better the test is at ruling in the disease
- Dependent on PREVALENCE of the disease in the population.
144
In relation to diagnostic and screening tests, what is positive predictive value?
- probability that a patient does not have the disease if he or she has a negative test
- the extent to which being categorized as a negative test actually preducts the absence of disease
- the probability of being disease-free given a negative result
- the close to 100% the better the test is at ruling out the disease
145
In relation to diagnostic and screening tests, what are likelihood ratios?
- alternate method of assessing performance of diagnostic test
- express how many times more/less that a test result is to be found in diseased compared with not diseased people
- The higher the LR for a positive test, the better the test is at diagnosing disease
- The lower the LR for a negative test, the better the test is at diagnosing non-disease
- Rule of thumb – diagnostic tests with positive LRs >10 and /or negative LRs
146
In relation to diagnostic and screening tests, what is pre-test probability?
Pretest Probability is defined as the probability of a patient having the target disorder before a diagnostic test result is known.
147
In relation to diagnostic and screening tests, what is post-test probability?
the proportion of patients testing positive who truly have the disease.
148
In relation to diagnostic and screening tests, what are ROC curves?
- In statistics, a receiver operating characteristic (ROC), or ROC curve, is a graphical plot that illustrates the performance of a binary classifier system as its discrimination threshold is varied. The curve is created by plotting the true positive rate (TPR) against the false positive rate (FPR) at various threshold settings. The true-positive rate is also known as sensitivity
- X = False positive rate, Y = true positive
- The more the curve lies to the left of central, the better the test (i.e. false positive test is low for a given true positive. As True positive increases, False positive will also increase.
149
What are some of the negative consequences of screening?
- cost
- injury
- stigmatization
- false positives/false negatives – psychological consequences
- over diagnosis
- harm due to actual test – i.e. ionizing radiation for mammograms.
- discrimination by insurance companies, employers, schools etc in genetic testing
- Results of genetic testing – abortion, sterilization.
150
What are some of the ethical dilemmas with genetic screening?
- should disclosure be made to insurance companies etc? I.e. confidentiality
- should genetic testing be done on babies for the purpose of predicting issues with future pregnancies, even though that baby doesn’t stand to benefit?
- Should people testing positive for certain disordered be counseled not to have children?
151
What is the criteria for screening?
- Important health problem
- Disease should be understood
- latent period or early symptomatic stage
- Available facilities for diagnosis
- Test is simple, safe, accurate (sensitivity, specificity) and validated (suitable) test or examination
- Reliability: (precision)
- Acceptable to the population to be screened
- Suitable cut-off level defined
- Yield: Amount of disease detected in the population, relative to the effort - Prevalence of disease/positive predictive value
- Effective treatment or intervention for patients identified
- Clinical management of the condition and patient outcomes should be optimised in all health healthcare providers prior to participation in a screening program
- RCTs should evidence that is reduces morbitiy
- Clinically, socially, and ethically acceptable
- Benefits>harms
- Costs justifiable
152
What are some tips for obtaining a history from a child?
- same physical level
- establish rapport before touching them
- child's terminology
- explain procedures before you do them - prepare child for strange noises etc
- use affirmative and positive language
- keep talking - calm and reassuring
- engage help of parent/guardian
- use drawings, dolls, parent etc
- let them play with instruments
- ise pimple language
- wear bright badges, cary toys
- always listen
- stickers for praise etc
- let parent/guardian know what you are going to do in advance so they can prepare for adverse consequences
153
Identify strategies to facilitate communication with older people.
1. allow extra time for older patients.
2. Minimize visual and auditory distractions.
3. Sit face to face with the patient – vision/hearing loss
6. Speak slowly, clearly and loudly.
7. Use short, simple words and sentences.
8. Stick to one topic at a time.
9. Simplify and write down your instructions.
11. Frequently summarize the most important points.
13. Schedule older patients earlier in the day.
16. Make signs, forms and brochures easy to read.
17. Be prepared to escort elderly patients from room to room.
19. Use touch to keep the patient relaxed and focused.
154
Discuss strategies to effectively communicate information from a medical history to patients and their families.
1. acknowledge families support
2. speak to them and give them time to raise issues or concerns
3. where possible, provide them with a room where they can be alone
4. Identify a key worker whom they can contact
5. First give info to patient to check whether you have their permission to discuss it with outers
6. ask patient who in family can be given what info
7. summary in notes of what you have talked about with them
- DON’T examine (unless child) or do procedures in front of relatives.
155
What are some challenging medical situations?
- long waits
- busy environment that results in perceived rush
- patient can’t see doctor they want to see
- patient presents with long list of complaints
- internet self diagnosis
- distressing diagnosis/prognosis
- treatment as a result of life threatening diagnosis
- distressing/painful medical procedure
- patients/third parties disagree on health care strategies
- medical intervention or treatment that results in a poor outcome
156
What is the ABCDE strategy for breaking bad news?
```
Advance preparation
Build a therapeutic environment/relationship
Communicate well
Deal with patient and family reaction
Encourage and validate emotions.
```
157
What are types of coping strategies?
- Problem-focused coping (the individual solves the problem by addressing and removing the source of stress – e.g adequately preparing for an exam)
- Emotion-focused coping (individual regulates, reduces or channels, or eliminates aversive emotions associated with the stressful encounter – e.g talking to a friend after doing an exam that went badly)
- Avoidance coping (individual employs strategies that are designed to circumvent or avoid the stressful situation – e.g watching TV, reading etc; using alcohol or drugs to avoid a situation; denial).
158
What are the different types of grief?
a) anticipatory grief – as soon as you accept someone it going to die you begin to grieve
b) ‘Normal’ grief
c) Complicated grief – reactions that are debilitating, long lasting or impair ability to engage in faily activities
d) Disenfranchised grief – person feels their grief is invalid and insignificant, i.e. when death is stigmatized
e) Ambiguous grief
i) physically alive but emotional loss (i.e. dementia)
ii) person missing, but psychologically still alive for family
159
Name two theories of grief and what they mean
1. Dual process model of coping with bereavement. Consists of:
a) loss orientation – emotion-focused coping
b) restoration orientation – problem-focused coping
2. Task-Based model:
Engagement with four tasks:
a) to accept the reality of the loss
b) to process the pain of gried
c) to adjust to a world without the deceases
d) to find an enduring connection with the deceased in the midst of embarking on a new life
160
From a patient perspective, what themes have been identifies as important when receiving bad news?
- Characteristics of the person giving the bad news – safe, confident, friendly, sympathetic
- The amount of time available to the patient
- The type of information given and the language used – be open and honest
- the ongoing process of having a serious illness – they want to know what to expect in long term, follow up plants etc
- Support, both at the time of diagnosis and during the illness, ie from friends and family
- Physical setting when the news was given – privacy is very important
161
What are the 4 essential goals to be met when giving bad news?
Gathering information from the patient.
Providing relevant and
understandable information in accordance with the patient’s needs
and desires.
Supporting the patient by using skills to reduce the emotional impact and isolation
experienced by the patient.
Develop a treatment and management plan in collaboration with the patient.
162
What is the general epidemiology of lung cancer?
- Leading cause of death in Australia, but only 5th in diagnosis.
- tobacco smoke causes 90% of lung cancer in males and 65% in females
- 15% of of people with lung cancer will survive 5+ years
163
What are the risk factors for lunch cancer?
Risk factors:
a) lifestyle
- tobacco smoking
b) environmental
- passive smoking
- radon
- occupational
- air pollution
- asbestos
c) personal
- age
- family history
- previous lung diseases
Diagnosis:
- physical exam
- x ray
- examination of sputum sample
- ct scan/MRI of chest/other organs
- bronchoscopy
- biopsy
164
Why does smoking have a high burden of disease?
mostly due to premature death
165
Should lung cancer screening be introduced in Aus?
- evidence that screening persons aged 55 to 74 who have smoking history of 30 or more pack-years and who, if they are former smokers, quit within the last 15 years, reduced lung cancer mortality by 20% and all-cause mortality by 6.7%.
- Potential harms of LDCT (low-dose helical computed tomography CT)
- radiation exposure
- false positives and risks of follow-up interventions
- quality of life
- over-diagnosis
- Other issues to consider:
- definition of population at-risk
- timing and intervals of screening
- cost effectiveness
- In Australia – they are waiting on more result
166
Discuss tobacco as a risk factor for disease
1. Diseases caused by smoking:
- Cancer – throat, lunch, stomach, pancreas, kidney, ureter, colon, cervix, bladder etc
- stroke
- blindness, cataracts
- aortic aneurysm
- coronary heart disease
- pneumonia
- COPD
- reproductive effects on women
- atherosclerotic peripheral vascular disease
2. Diseases caused by secondary smoke:
a) Children:
- middle ear disease
- respiratory symptoms
- sudden infant death syndrome
- lower respiratory illness
- more with causative suggestion
b) Adults:
- stroke
- nasal irritation/cancer
- coronary heart disease
- lung cancer
- reproductive effects in women
- more with causative suggestion
167
Discuss GP advocacy in relation to smoking
- brief 3 minute advice by the GP is effective in increasing quit rates
- GPs advise only about 50% of the patients they have identified as smokers to quite
- Barriers to addressing smoking:
a) patient Facts
- sensitive topic, lack of concern, lack of knowledge of health effects and benefits of quitting, underestimating difficulty associated with changing behavior, reluctance to seek help, weight gain, stress, effects of withdrawal, peer pressure, feel failure
b) Clinician factors
- attitudes and beliefs about their effectiveness in facilitating change, skills and practice
c) practice setting
- lack of time, lack of organizational infrastructure.
168
What are some of the strategies for quitting?
- nicotine replacement therapy
- varenicline
- bupropion
- all these meds result in quit rates about double that in those who attempt without meds.
Reducing smoking over time doesn't seem to help
169
How is tobacco consumption controlled in Australia?
- all tobacco products in Aus required to be sold in plain packaging
- smoking inside pubs and clubs banned
- states ban smoking in cars carrying children
- tobacco industry sponsorship has been phased out
- graphic anti smoking adds
- advertising cigarettes banned
- tax
- advertising not to smoke and strategies to quite
170
What is the current picture of smoking in Australia?
In Australia, 15% of Australians over 14 were smokers in 2007.
Groups with high rates of smoking:
- low socioeconomic
- unemployed
- prisoners
- mental illness
- aboriginal and torres strait islanders
- remote areas
171
What is the current picture of smoking in Australia globally?
- tobacco kills nearly 6m people each year, >600,000 are non-smokers exposed to second-hand smoke nearly 80% of the world’s one billion smokers line in low and middle income countries
- consumption increasing globally, but decreasing in some high/middle income countries
172
What are some of the symptoms of lung cancer?
- new or changed cough
- haemoptysis - coughing upblood
- chest infection that won’t go away
- chest pain and/pr shoulder pain
- shortness of breath
- hoarse voice
- weight loss or loss of apetite
173
What are the treatment options for non-small cell lung cancer?
a) surgery if operable
- 11-12% of cases
- only chance of cure
b) Chemo
- palliative, never curative
c) Radiotherapy
– Lower dose palliative for symptom control (Eg. localised pain, brain metastases)
– High dose to lung if localised and inoperable for technical reason (attempt to cure)
174
What are the patient issues with lung cancer diagnosis?
1. Impact:
a) life
b) family
c) friends
d) work - when to stop working/centrelink
e) identity
Coping Strategies
Autonomy - loss of control over life
Challenges for doctor:
- did they understand the palliative nature of treatment from the start?
175
What are some of the treatment issues/challenges for doctors dealing with terminal lung cancer?
– Lower dose palliative for symptom control (Eg. localised pain, brain metastases)
– High dose to lung if localised and inoperable for technical reason (attempt to cure)
176
On which side of the patient does the doctor usually examine from?
The right side
177
Describe the patient positioning for a cardiovascular exam
Positioned at 45 degrees
178
Describe the patient positioning for a respiratory exam
Predominantly sitting at ninety degrees
179
Describe the patient positioning for an abdominal exam
Lying in a supine position
180
What are the four core elements of physical examination?
Inspection
Palpation
Percussion
Auscultation
181
What is palpation?
The process of pressing on areas of the body relevant to the area being examined, to look at:
- the underlying structures
- any tenderness
- swelling
- deformities
- or irregularities
Uses the whole hand, not the fingertips, when examining larger areas like the abdomen
Typically the initial exam is soft to elicit areas of tenderness, while the second time around is harder to detect deeper abdominal masses
182
Describe percussion
The process of hyperextending the middle finger of the left hand, and using a quick, sharp but relaxed wrist motion of the right wrist, to strike with the right middle finger
```
This is used to determine:
- size,
- density
- shape
of underlying structures of the thorax or abdomen in a physical exam
```
183
What is auscultation?
Using a stethoscope in a physical exam to listen to parts of the body i.e. pulse, lung function, gut function
184
What are the three things you should do prior to an examination?
1. wash your hands
2. introduce yourself to the patient
3. explain the examination ot the patient and obtain their consent to be examined
185
What are some specific findings to look for when inspecting a patient prior to examination?
```
Level of consciousness
Presence of emotional or physical distress
Colour
Posture
Initial visual assessment of weight
```
186
In which type of patient is general observation particularly important?
The paediatric patient
| Observe both child and parent
187
What should you always do before beginning a palpation exam on a patient?
Ask about any areas of pain/discomfort prior to the exam
You should continue to check pain/comfort levels throufhout the exam as well
188
Where should you expect to hear resonant / hyperresonant noises when percussing?
Resonant - Over a normal lung
Hyper-resonant - over hollow structures i.e. an air-filled bowel
189
Where would you expect to hear a dull noise when percussing?
Over dense/solid features like the liver, or consolidation in the lung
190
Where would you expect to hear a stony dull noise when percussing?
Over fluid filled areas. This would be an abnormal sound. You could hear it over the lungs if there is pleural effusion
191
Discuss Decline in infectious disease since 1900s
- more than 90% of decline in respiratory TB took place before antibiotics or vaccination – suggests that social and economic change had done most of the work
- 30 years of life expectancy have been gained since 1900
- 5/30 years are due to medical advances
192
How would you find out the major infectious diseases in WA?
a) notifiable diseases
b) non-notifiable infectious disease:
- research
- non-mandatory surveillance systems (i.e. ASPREN)
- lab surveillance
193
Why do notifiable diseases have mandatory reporting?
- Prompt public health management of the case and their contacts
• Early identification of disease outbreaks
• Evaluate the effectiveness of prevention programs, e.g. immunization, cancer screening
• Identify high risk groups for targeting prevention programs
• Health service planning
Comes up on Notifiable Infectious Disease Reports from WA Department of Health.
194
What is an Adverse event following immunization?
AEFI is an unwanted or unexpected event following the admin of a vaccine. It maybe be caused by the vaccine or may be coincidental.
It is notifiable – immunization provider who becomes aware of it must notify the Executive Director, Public Health.
195
What does prevalence depend on?
- incidence
- duration
- migration
196
What are the most commonly notified infectious diseases in Aus and WA?
Australia and WA:
1. chlamydia
2. pertussis
3. influenza
4. campylobacter
197
*What is R0?
Number of secondary cases which one case would produce in a completely susceptible population
R1 – number of infections grows exponentially (epidemic)
Measles: 16-18
SARS: 2-5
AIDS: 2-5
Flu: 2-3
198
*What does R0 depend on?
a) duration of the infectious period
b) probability of infecting a susceptible individual during one contact
c) the number of new susceptible individuals contacted per unit of time
199
What decreases R0 for flu?
a) duration of the infectious period
- early diagnosis (testing for symptomatic cases)
- antiviral Rx (prescription)?
- good nutrition
b) probability of infecting a susceptible individual during one contact
- staff – universal precautions
- patients – cough etiquette
- contacts – prophylactic Rx of high-risk
- setting – UV light, ventilation
c) the number of new susceptible individuals contacted per unit of time
- isolation of cases
- quarantine of contacts
- immunization of at risk groups
- mosquito nets
200
What could decrease R0 for TB?
a) duration of the infectious period
- early diagnosis (screening, case findings)
- timely, effective Rx (prescription)
- contact tracing + prophylactic Rx
- Rx is free of charge
b) probability of infecting a susceptible individual during one contact
- personal hygiene and social distancing while infectious
- respiratory isolation of sputum + cases
- safe disposal of clinical waste
c) the number of new susceptible individuals contacted per unit of time
- BCG vaccination
- good nutrition
201
What could decrease R0 for Chlamydia?
a) duration of the infectious period
- early diagnosis (screening, case findings)
- timely, effective Rx (prescription)
- contact tracing
- empirical Rx of patients with symptoms at time of presentation and before test results available
- empirical Rx of sexual contacts in regions of high STI endemicity
b) probability of infecting a susceptible individual during one contact
- condoms
- reduce co-ixisting ulcerative or inflammatory STIs or HIV
- early detection and Rx
- safe sex
- abstain from sex while infected
personal hygiene and social distancing while infectious
- respiratory isolation of sputum + cases
- safe disposal of clinical waste
c) the number of new susceptible individuals contacted per unit of time
- partner reduction
202
List the changes to immunological function in the elderly.
Elderly: Immunosenescence:
- suboptimal antibody responses to infections and vaccines
- low CD8 T cell responses
- cancer
B cell responses:
- decreased production of naïve B cells
- impaired germinal center function
- decreased access to plasma cell niches in bone marrow. Lots of fat deposits. Therefore relatively low number of naïve cells, and accumulation of memory and plasma B cells (but they are not necessarily controlled well, i.e. they could be monoclonal)
203
Identify barriers to accurate clinical assessment in elderly
patients.
Environmental factors
. Difficult or rushed access – doorways, waiting rooms
. Limited privacy
. High level of background noise
Patient factors
. Anxiety
more likely to tire easily and so find it difficult to concentrate and absorb too much
information at a time,
. Hearing loss and vision impairment
. Expressive language impairment
. Effects of medications – drowsiness, sedated Tendency not to disclose fully and focus on
one topic
. Impaired cognitive functioning & dementia
Clinician factors
• Poor attitude towards older people in general – perhaps related to own fear of ageing and death. May be age related – i.e younger doctors less aware.
• Limited value placed on changing communication style to accommodate needs - Doctors and other health professionals may need to be careful to ensure they do not use acronyms and terms that are too specific to their own generation. For example, how many students have grandparents who know how to use Facebook.
• Lack of experience/training
• Being judgemental and making assumptions/generalising
• Limited understanding of ageing and ageing related factors
• Using language that may be perceived as patronising or condescending
• Minimising the importance of issues relevant to the older people
• Having a limited understanding of communication issues
204
Demonstrate knowledge of cardinal signs of inflammation.
1. Rubor - redness
2. Calor – increased heat
3. Tumor - swelling
4. Dolor - pain
5. Loss of function (possibly)
205
Discuss nature of various causes of inflammatory reaction.
Causes of inflammation
. Infections and microbial toxins - bacterial, viral, parasitic
. Trauma - blunt and penetrating
. Physical and chemical agents - Burns, frostbite, irradiation, some environmental
chemicals
. Tissue necrosis
. Foreign bodies - splinters, dirt, sutures
. Immune reactions - also called hypersensitivity reactions
Ischaemia/Necrosis – borders will be inflamed
206
Describe haemodynamic changes in microvasculature of
acutely inflamed tissues.
. triggered by physical damage by bacteria
. Endothelial activation, expression of adhesion molecules
. Vasodilation and increased vascular permeability due to vasoactive amines
stored in granules in tissue mast cells, platelets and released in response to
trauma, Ab reactions, complement, cytokines
207
List the mediators of acute inflammation and describe their
mode of action.
. Lysosomal enzymes from leukocytes cause bacterial lysis
. Chemokines from leukocytes cause further chemotaxis of more leukocytes
. Cytokines from leukocytes cause endothelial activation, increase in
neutrophil numbers and activation
. Leukocyte mediators (AA metabolites, reactive oxygen species, nitric oxide) – cause chemotaxis, vasodilation, increased permeability and bacterial lysis but also collateral tissue damage
. Complement activation and formation of membrane attack complex
208
Describe the mechanism by which acute inflammation is
resolved.
- short half life of mediators
- TGF from macrophages
- IL-10
- Production of anti-inflammatory lipoxins
- Down-regulation of pro-inflammatory molecules
- Up regulation of anti-inflammatory molecules
- Apoptosis of pro-inflammatory cells
- etc
209
Describe the possible outcomes and consequences of acute
inflammation.
Resolution:
- clearance of injutious stimuli
- clearance of mediators and acute inflammatory cells
- replacement of injured cells
- normal function
Pus formation (abscess)
Fibrosis:
- loss of function
Chronic Inflammation:
- angiogenesis
- mononuclear cell infiltrate fribrosis
210
List the organisms that cause skin and soft tissue infections in various clinical settings.
Tinea:
- tinea pedis – feet
- tinea corpus – body, ring worm – T rubrum
- tinea cruris – warm, moist, creases
- tinea capitis – scalp
- tinea (or pitriasis) versicolor – Malassezia furfur
- tinea unguium – onchomycosis. Fungal nail infections. Nails thick, crumbly and discolored.
Paronychia- usually S. aureus
- soft tissue infection around fingernail
- acutely painful, red, swollen fingernail
Dactylitis – usually GAS, strep pyogenes
- sausage-shaped, painful swelling of fingers and toes
Bullous Impetigo – usually S. aureus
- fluid filled blisters
- pop and leave sores
Toxic Shock Syndrome
Folliculitis - usually S. aureus
- infection of hair follicles/apocrine glands
Furuncles - usually S. aureus
- a plague of boils
- deep inflammatory nodule
Carbuncle - usually S. aureus
- deep infection, contagious furnucles
Erysipelas - beta haemolytic strep (usually GAS)
- fiery red, indurated, tense plaque
- clearly demarcated borders
211
Explain the pathophysiology and clinical features of cellulitis.
Microbiological causes:
- causative pathogen rarely identified
```
Pathogenesis:
Predisposing factors:
- tinea pedis
- chronic venous or arterial ulcers
- primary skin diseases (eczema etc)
- minor trauma, recent surgery
- leg oedema, i.e. RH failure, venous incompetence, lymphedema.
- Immunodeficiency
```
Presenting symptoms and signs:
- acute bacterial infections of skin and soft tissues
- presents as a diffuse, spreading erythematous rash
- maybe fever and chills after rash
- abscesses, bullae/vesicles may form
- often lymphangitis, regional lymphadenopathy or lymphadentitis
212
What diagnostic tests are used for suspected cellulitis?
Investigation:
- swab blister fluid
- results may be misleading
213
How is cellulitis treated?
Treatment:
- antibiotics directed at S aureus and B-haemolytic strep
- flucloxacillin
- 1st gen cephalosporins
- clindamycin
- IV if significant fever or systemic upset, facial cellulities lymphangitis, obesity
- HITH therapy used commonly
214
Use the written record to present the findings from interview and examination in a clear, logical manner to build a clear picture of the person, illness, disease and underlying pathology.
Basic Framework for a Problem Orientated Medical Record:
```
. Date and time, who you are
. Patients name, DOB or age (ensure sticker is on the page)
. PC
. HPC
. PMH
. Family history (FH)
. Medications (Med)
. Allergies
. Alcohol/Smoking
. Social and occupational history
. Systemic Enquiry (SE)
. Physical examination
. Summary (short paragraph)
. Formulation and problem list
. Sign and print your name and position, contact number (pager/mobile).
```
215
Apply the Symptoms, On examination, Assessment and Plan (SOAP) approach to presenting information.
S - Symptoms
O - On examination
A - Assessment
P - Plan
Symptoms:
Describes the patient’s current condition in narrative form. This section usually includes the patient’s chief complaint, or reason why they came to the physician.
i.e. SOCRATES
On examination:
Actually examine them
Documents objective, repeatable, and traceable facts about the patient’s status. Includes:
- Vital signs
- Findings from physical examinations, such as posture, bruising, and abnormalities
- Results from laboratory
- Measurements, such as age and weight of the patient
Assessment:
The Physician’s medical diagnoses for the medical visit on the given date of a note written. I.e. consolidated all of the above info into an assessment.
```
Plan:
This describes what the health care provider will do to treat the patient – ordering labs, referrals, procedures performed, medications prescribed, etc.
- For diagnosis (Dx)
- For Monitoring-type information (Mx)
- For Treatment (Rx)
- For the education of the patient (Ex)
```
216
Explain the requirements for a patient to be treated by hospital in the home services.
To be eligible, patients must:
. Be referred from a GP, specialist, medical practitioner, St John Ambulance or nurse in a community setting, Health Direct, Residential Aged Care Facility (RACF), clinic, hospital or ED.
. Be living at home or in a residential aged care facility.
. Require short term acute and sub-acute care that can be delivered safely in the home.
. Not require an emergency response and be safe to wait up to four hours.
. Be aged 13 and over.
. Be no more than 22 weeks pregnant.
. Be able to communicate effectively, directly or through an interpreter.
. Be medically and mentally stable.
. Be Medicare eligible.
. Have given their consent.
217
Describe the function of lymphatics.
The lymphatic system has multiple interrelated functions:
. It is responsible for the removal of interstitial fluid from tissues
. It absorbs and transports fatty acids and fats as chyle from the digestive system
. It transports white blood cells to and from the lymph nodes into the bones
. The lymph transports antigen-presenting cells, such as dendritic cells, to the lymph nodes where an immune response is stimulated.
218
/What are the different skin types?
1. Pale white skin, blue/hazel eyes/red hair
- always burns, does not ran
2. Fair skin, blue eyes
- burns easily, poorly
3. Darker white skin
- tans after initial burns
4. Light brown skin
- burns minimally, tans easily
5. Brown Skin
- rarely burns, tans dark easily
6. Dark brown of black skin
- never burns, always tans darkly
219
What are the risk factors for melanomas?
- increased sun sensitivity (pale skin, bond or red hair, numerous freckles, tendency to burn or tan poorly)
- history of painful or blistering sunburns during childhood or adolescence (2 or more episodes before age 20)
- intermittent intense sun exposure
- dysplastic naevi
- others (genetics, OVC, xeroderma pigmentosum etc)
220
What is the ABCDE rule of melanomas?
- A- asymmetry
- B- border irregularity
- C- colour variation NB - black is not essential and may not be present in some melanomas,
e.g. amelanotic nodular melanomas
- D- diameter greater than 6 mm. However melanoma can be diagnosed when less than this
diameter
- E- evolution and/or elevation eg. lesions may enlarge and a flat lesion may become raised in
a matter of weeks
221
What is a nodular melanoma?
- About 15% of melanomas present with a clinically predominant expansile nodule (nodular
melanoma) and are symmetric nodules with a single colour that is often pink or red. They
are often misdiagnosed as non-melanoma skin cancer.
- Nodular melanomas account for at least half of thick melanomas and are likely to make a
disproportionately high contribution to mortality.
- Their appearances can be summarised by the acronym EFG (Elevated, Firm and Growing
progressively)
222
What are the tissues from which skin tumours can arise?
- epidermal origin
- melanocytic origin
- skin adnexal origin
- soft tissue origin
223
/What are benign neoplasms from each of these tissue types?
- Epidermal origin
o Seborrhoeic keratosis, wart, squamous papilloma
- Melanocytic origin
o Lentigines, naevi (junctional, compound, dermal)
- Skin adnexal origin
o Syringoma, trichofolliculoma
- Soft tissue origin
o Dermatofibroma, hemangioma, neural tumours, lipomas
224
What are the types of malignant skin tumours?
- basal cell carcinoma (most common)
- squamous cell carcinoma (second)
- Malignant melanoma (most lethal)
225
What is the pathogensis of melanomas?
- Starts with acquired melanocytic naevi (moles) – benign tumours
- a point mutation in the BRAF gene is usually the initiating genetic mutation
- dysplastic nevus: lesions evolve with age – the initial lesion being macular with nests of proliferating melanocytes confined to the dermoepidermal junction
- rapid growth phase: with time, nests extend into the dermis and lesions become elevated
- vertical growth phase: with further maturation junctional activity, is ceased and the naevus becomes intradermal
- metastatic melanoma – dissociates from primary tumor and grows at distant sites.
226
What are the key elements of malignant melanomas?
- Melanocytes proliferating in basal layer
- Architectural disturbance
- Cytological atypia and many mitotic figures
- Spread upwards into epidermis (= pagetoid spread)
- Spread downwards into dermis with nests of melanocytes of variable size and shape; nests may
be confluent
Inflammatory reaction of surrounding tissue with angiogenesis and fibroplasia
- Melanocytes within lymphovascular spaces
227
What are some of the features on the pathology report that affect prognosis?
- Thickness (Breslow thickness) – prognosis for localized disease (stages I or II) principally determined by tumor depth. I.e.
228
Understand the principles of open disclosure.
- openness and timeliness of communication
- acknowledgement of the incident
- expression of regret/apology
- recognition of the reasonable expectations of the patients and their support person
- support for staff
- confidentiality
229
What to do when things go wrong:
- discuss in full/frank manner
- face to face meeting ASAP – shouldn’t be rushed
- spend time, offer support and concern
- empathy and compassion
- give them time to ventilate their feelings about the outcome and anxieties regarding future treatment and care
- use layman’s language
- avoid defensiveness and laying blame
- don’t admit negligence or liability
- give factual account
- arrange any appropriate referral for further treatment
- as treating doctor, it is your responsibility to ensure they are closely followed up
- you should not agree to pay for further treatment
- document event in detail in a factual manner
- don’t include additional comments with personal interpretation of possible reasons for outcome
- advise your MDO of any adverse outcome that may lead to a claim
- access your MDO’s 24hr hotline for additional guidance on individual situation.
230
Which disciplines may be involved in the management of melanoma?
- Initially GP or whoever she first went to see
- WA Melanoma Advisory Service
- Plastic Surgeon
- Dermatologist
- Pathologists – histology etc
- May remain under dermatologists follow up
231
State the optimal sun exposure in Perth to balance the benefits of sun exposure and risk of solar damage to the skin.
- Summer: if UV>3, most people get enough incidental exposure by spending just a few minutes outdoors most days of the week.
- Winter/Autumn: if UV
232
Explain the current screening requirements for skin cancer in Australia.
. In the absence of sufficient evidence for an associated reduction in mortality from melanomas or other skin cancers, Cancer Council Australia does not recommend population-based screening by a doctor for skin cancer.
. Cancer Council Australia encourages people to become familiar with their skin, including skin not normally exposed to the sun, and consult a doctor if they notice any change in shape, colour or size of a lesion, or the development of a new lesion.
. Cancer council Australia recommends that people at high risk of developing skin cancer consult their doctor if they notice any changes and be checked at regular intervals as recommended by their doctor.
. Cancer Council Australia recommends employers, under work health and safety responsibilities, focus their attention on the introduction and maintenance of effective sun protective control measures, including education and the importance of early detection, over skin cancer screening programs.
233
What is the clinical reasoning cycle?
1. Consider the patient situation - consider facts, context, objects or people.
2. Collect cues/info
a) review current info
b) gather new info
c) recall knowledge
3. Process Info
4. Identify problems/issues
5. Establish goal/s
6. Take Action
7. Evaluate Outcomes - has the situation improved?
8. Reflect on process and new learning - contemplate what you have learnt and what you could have done differently
234
Which is the preferred site for measuring temperature in infants up to 2 years of age?
Digital Axilla
For people >2, use digital tympanic
