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Flashcards in Radiology, Ethics and education Deck (40)
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1

A 19-year-old female is admitted with left upper abdominal pain and is diagnosed with pancreatitis.

Ranson’s

Ranson's criteria are used to predict prognosis in acute pancreatitis. They are based on variables measured on admission and again at 48 hours after admission. Bad prognosis on admission include

Age > 55 years
Blood glucose >11 mmol/L
WCC > 16
Serum lactate dehydrogenase (LDH) > 70
Serum aspartate aminotransferase (AST) > 60.
At 48 hours a bad prognosis is predicted by

Serum calcium 10
Haematocrit decreased by > 10%
Base excess > 4
PaO2

2

A 24-year-old male motorcyclist is admitted following an RTA with fractures to the pelvis and lower limbs.

RTS, ISS

The injury severity score (ISS) and the revised trauma score (RTS) are tools used to compare severity of injuries and outcome of interventions in trauma patients.

The ISS uses the AIS90 dictionary to score every injury; the abbreviated scale score in each of six areas are taken

Head
Abdomen and pelvis
Bony pelvis and limbs
Face
Chest
Body surface.
The squares of the three highest scores are then added together to give the ISS.

The revised trauma score combines coded measurements of

Respiratory rate
Systolic blood pressure and
Glasgow coma scale
to provide a general assessment of physiological derangement. The RTS is calculated from parameters recorded when the patient first arrives in the emergency unit.

3

A 72-year-old patient is admitted to the intensive care unit following abdominal aortic aneurysmal repair.

APACHE II

The APACHE II scoring system is used widely on intensive care units to evaluate chronic ill health. The 12 variables measured include

Temperature
Mean arterial blood pressure
Heart rate
Respiratory rate
PaO2
pH
Serum sodium
Potassium
Creatinine
Haematocrit
White cell count (WCC)
Glasgow coma scale.
It can be used for a variety of disease processes.

4

A 45-year-old male is admitted with marked jaundice, ascites and encephalopathy.

Child's

The Child-Pugh classification of liver function is used to quantify the degree of liver failure and is used in the selection of patients for liver transplantation. Variables measured include

Ascites
Encephalopathy
Serum albumin
Serum bilirubin and
Prolongation of prothrombin time.

5

A surgical team presented their data demonstrating an increased rate of post-surgical wound infection following gastrointestinal surgery compared with published standards from the Royal College of Surgeons.

Implement change
This group have collected and analysed their data and found a problem. Changes need to be implemented then re-audited.

Identify standards
The standards against which the audit should be compared need to be identified.

The audit cycle comprises an initial needs assessment where the requirements of the department/section/individual are determined and the actual audit itself determined.

Then what is to be audited is decided upon; it is important to identify the standards against which the audit will be compared. These can be national standards or clinical guidelines determined by the national bodies or comparisons can even be made within the department.

6

A vascular team intend to compare their future results for aortic aneurysm repair with national standards.

Data collection
They have specified the standards and can now collect their data.

Once the standards are set data collection is undertaken with selection of retrospective data followed by data analysis. Prospective clinical audit allows for accurate real time accrual of data that reflects current rather than historical practice whereas retrospective audit can act as a historical benchmark.

The results can then be presented, compared to the standards and from this recommendations for improvements/implementation of change are made.

Finally, to assess how effectively these recommendations have been implemented, a re-audit is suggested for some stage in the future.

7

A team wish to audit their departmental results on the use of anticoagulation in patients with atrial fibrillation.

Identify standards
The standards against which the audit should be compared need to be identified.

The audit cycle comprises an initial needs assessment where the requirements of the department/section/individual are determined and the actual audit itself determined.

Then what is to be audited is decided upon; it is important to identify the standards against which the audit will be compared. These can be national standards or clinical guidelines determined by the national bodies or comparisons can even be made within the department.

Once the standards are set data collection is undertaken with selection of retrospective data followed by data analysis. Prospective clinical audit allows for accurate real time accrual of data that reflects current rather than historical practice whereas retrospective audit can act as a historical benchmark.

The results can then be presented, compared to the standards and from this recommendations for improvements/implementation of change are made.

Finally, to assess how effectively these recommendations have been implemented, a re-audit is suggested for some stage in the future.

8

In relation to assessment of a patient's capacity to make decisions, which one of the following statements is correct?
(Please select 1 option)
A patient who has given power of attorney to a carer no longer has capacity to make decisions about medical care
A person who is unable to believe or understand what you are telling them about a particular treatment may have capacity to refuse the treatment
Assessment of capacity of an elderly person to refuse life-sustaining treatment must be made by a psychogeriatrician
For a person to have capacity, they must be able to retain the information that you give them about the decision they are being asked to make
Once a patient has been found to be mentally incapacitated, capacity can safely be assumed to be impaired in the future

For a person to have capacity, they must be able to retain the information that you give them about the decision they are being asked to make

Capacity to make decisions may fluctuate: a person who has capacity to make one decision may not necessarily have capacity to make another, and a person who lacks capacity to make a decision now may regain the capacity to make that decision as the situation changes.

For a patient to be said to have capacity to make a particular decision, the patient should understand the information they are given about the decision at hand and be able to retain the information long enough to weigh it in the balance and come to a decision for themselves. The assessment of capacity to make a decision does not necessarily have to be made by a psychiatrist or psychogeriatrician although, where there are any doubts about the capacity of a person who is making an important decision, it may be helpful to seek a specialist view.

Many patients make decisions that appear to doctors to be irrational, but this in itself is not an indication of lack of capacity.

Under the Mental Capacity Act 2005, an individual will be able to appoint a person to act as their attorney (Lasting Power of Attorney, LPA) if and when the individual becomes mentally incapacitated in the future. LPAs will be able to make some decisions about health and welfare on behalf of the patient, but only when the patient has lost the capacity to make those decisions for him or herself.

9

Lipoma

The diagnosis is a lipoma.

There is a 3 cm mass related to the anterior surface of the parotid. This mass is barely visible because it has a similar appearance to the overlying fat in the superficial tissue.

There is a fine line related to its anterior surface.

The feature of note is that there are no solid elements and it is of homogeneous low attenuation. It is, therefore, probably benign.

10

Carotid body tumour

The diagnosis is a carotid body tumour.

There is an intensely enhancing mass between the divisions of the internal and external carotid arteries.

These appearances are classical of a carotid body tumour.

11

Klippel Trenaunay syndrome

The diagnosis is Klippel Trenaunay syndrome.

There are elongated, enlarged bones with soft tissue swelling and phleboliths within the soft tissue. This condition is common in the lower limbs.

12

Haemophilia.

The diagnosis is haemophilia.

There is overgrowth of the epiphyseal plates due to associated synovial hyperaemia with gross degenerative changes secondary to the multiple bleeding episodes.

13

Lipoma

The diagnosis is a lipoma.

There is a 3 cm mass related to the anterior surface of the parotid. This mass is barely visible because it has similar appearances to the overlying fat in the superficial tissue. There is a fine line related to its anterior surface.

The feature of note is that there are no solid elements and it is of homogeneous low attenuation. It is therefore benign.

14

Ischaemic colitis

The diagnosis is ischaemic colitis.

There is an abnormal thickening of the distal transverse colon with a paucity of bowel gas in the descending colon. This segment of colon is involved as it is a watershed area at the anastomosis between the superior and inferior mesenteric arteries around the region of the splenic flexure. Here the marginal artery may be small or absent.

A CT scan may confirm the clinical diagnosis

15

Gall bladder carcinoma

The diagnosis is Gall bladder carcinoma.

There is gross dilatation of the intra-hepatic biliary tree with narrowing of the common hepatic duct and only proximal filling of the cystic duct due to a large mass replacing the gall bladder.

16

A 40-year-old complains of pain in the neck following a whiplash injury in road traffic accident. He is aware of marked soreness in the neck and has limited movements.
What is the most significant diagnosis on this film?

Fracture of the facet joint

There is a fracture of the posterior facets of C5 with posterior displacement of the spinous process.

On reviewing the lateral cervical spine, the anterior and posterior line of the vertebral bodies should be in alignment as should be the posterior lamina line connecting the fused portion of the spinous processes.

A line drawn through the posterior laminae is normal and contiguous until it reaches C5 where there is posterior displacement of the posterior lamina line. This is subtle but very important as this requires further investigation and possible surgical fixation.

17

A 78-year-old male dies and is found by his children the following morning (after having seen him alive the night before). His GP attends to certify him dead.
The patient had a known history of ischaemic heart disease and was treated in the local hospital where angiography performed nine months previously for angina had revealed some insignificant coronary artery disease of two vessels for which medical therapy was deemed most appropriate. He had also been diagnosed eight years previously with diabetes mellitus for which he took metformin and gliclazide.
He had seen the practice nurse two weeks ago for review of his diabetes. One month ago he had seen the diabetologists for his annual review and had seen the cardiologists approximately six months ago. He had last seen a partner in the practice six weeks ago for advice concerning driving licence registration.
The family are keen to have a death certificate issued and proceed to cremation. They do not want any post mortem examination.
Which of the following is true with regard to issuing of a death certificate in this scenario?
(Please select 1 option)
The certifying doctor may issue a death certificate
The death needs to be referred to the coroner
The diabetologist can certify the death
The partner in the practice may issue a death certificate
The practice nurse can certify the death

The death needs to be referred to the coroner

A death certificate may be completed if the practitioner has seen the deceased within 14 days of the death (28 days in NI). In this case the patient had been seen six weeks previously by the partner.

Consequently, and in view of the sudden death, the coroner should be informed, although he may decide that in the circumstances reported the doctor may be able to issue a death certificate stating ischaemic heart disease if he deems it appropriate, and on the balance of advice given to him.

18

You intend to undertake a study of patients who have undergone excision of minor lumps and bumps over the last five years.
Specifically you wish to compare postoperative infection rates and also whether there are any differences between the clinical diagnosis and the histological diagnosis between the differing grades of practitioner performing the procedure.
Which of the following statements are correct concerning this study?
(Please select 1 option)
Approval for the study must be obtained from the local ethics committee
If a study has already published with exactly the same concept then this constitutes plagiarism
If such a study has already been published then the investigators must obtain consent from the original authors to replicate their work
The study is flawed in its design and should not be performed
This is an audit and does not require ethical committee approval

Approval for the study must be obtained from the local ethics committee

This is not an audit.

There is no information provided to indicate that there are either any local or national guidelines relating to such a study. Furthermore, there is no information provided to indicate that there is a specific clinical problem to which an audit should be addressed.

Consequently, this is a research study and is a retrospective study. As such, it requires local ethical committee approval.

The study itself seems very reasonable and even if it were published elsewhere it would still be reasonable to perform in the investigator's practice as the outcomes may be completely different.

Using the same methods as another study is perfectly justifiable, if only to prove the veracity of the original publication.

No consent is required from the original authors if a similar study has already been published.

19

A 22-year-old female is admitted following severe injuries sustained in a road traffic accident.
She is communicative but in shock with low blood pressure and tachycardia. You realise that without a transfusion she will die but she informs you that she has recently become a Jehovah's Witness and that she adamantly refuses transfusion despite knowledge that she could die.
Her distraught parents tell you that she has only recently joined the Jehovah's Witnesses and implore you to transfuse her, as they insist that she does not know her own mind.
Together with other intervention which she permits, what is the most appropriate action regarding possible transfusion?
(Please select 1 option)
Declare her incompetent and transfuse
Do not transfuse even if it means that she will die
Get immediate psychiatric intervention to section her and then transfuse
Transfuse immediately, irrespective of the patient's wishes
Wait until she becomes unconscious and then get consent from her parents to transfuse

Do not transfuse even if it means that she will die

The patient appears competent and has elected to refuse the transfusion.

Despite the parents' protestation, you must respect the patient's wishes if, as seems likely here, she is making a reasoned judgement.

If the patient refuses the transfusion then even if she slips into unconsciousness you are not permitted to treat with transfusion, even if it is in her best interests.

20

A report is filed by the registrar to the clinical governance team concerning a patient who developed a DVT after having undergone hip replacement but did not receive any thromboprophylaxis.

Adverse incident reporting

Clinical Governance is the most recent of a series of initiatives mounted by the DoH in its quest to promote more uniform standards of high quality, evidence-based clinical care.

Clinical Governance is a cornerstone of the quality agenda presented in the DoH's 1998 publication A First Class Service 1 where it is defined as: 'a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.'

The principal components of 'Clinical Effectiveness', which was the DoH quality initiative immediately preceding Clinical Governance, were:

Clinical guidelines to inform healthcare professionals about evidence-based practice for discrete clinical topics
Education and training to bring such information to the attention of clinicians and health service managers
Clinical audit to monitor practice and to promote change where indicated.
These three components may be viewed as the principal tools envisaged within the Clinical Effectiveness initiative for implementing high quality, evidence-based care. Now, with Clinical Governance, additional components have been added. Principal among these are:

Continuing professional development (CPD)
Clinical risk management
Formal appraisal of complaints from patients and their families
Revalidation of specialists
Accreditation of services against explicit standards.
Management, IT skills, teaching and ethics courses would be recognised as training rather than CPD.

With regard to the thromboprophylaxis after high risk orthopaedic procedures, the report could be recognised as a 'white card' event or adverse event reporting.

The construction of the patient information website would seem to be best suited to R and D activity.

21

A report is submitted concerning the planned construction of a clinic website providing patient and clinic information.

Research and development

22

A circular provides information concerning a one day course on management in the NHS for registrars.

Training

23

A registrar submits a report detailing the results of a comparative study of weight loss in subjects in the weight management clinic with and without clinical psychology support.

Research and development

24

A report indicates that 50% of type 2 diabetics are failing to meet the BHS recommended targets amongst a practice’s diabetic population.

Clinical audit

Clinical governance is the most recent of a series of initiatives mounted by the DoH in its quest to promote more uniform standards of high quality, evidence-based clinical care. The principal components of 'Clinical Effectiveness', which was the DoH quality initiative immediately preceding Clinical Governance, were:

Clinical guidelines to inform healthcare professionals about evidence-based practice for discrete clinical topics.
Education and training to bring such information to the attention of clinicians and health service managers.
Clinical audit to monitor practice and to promote change where indicated.
These three components may be viewed as the principal tools envisaged within the Clinical Effectiveness initiative for implementing high quality, evidence-based care. Now, with Clinical Governance, additional components have been added. Principal among these are:

Continuing professional development (CPD)
Clinical risk management
Formal appraisal of complaints from patients and their families
Revalidation of specialists
Accreditation of services against explicit standards.
Therefore, in the examples given,

The completion of a register is part of CPD for the health professionals
A business plan for the appointment of personnel is recognised as a staffing issue
The comparison of clinic outcomes with national standards is part of audit
Patients' complaints may concern quality of care, waiting times, staff or cleanliness.
Complaints may be verbal or written.

25

A register that details the attendance of health professionals at the weekly postgraduate seminars in hospitals.

Continuous professional development

26

A patient writes in concerning the hour that she waited beyond her actual appointment time.

Complaints procedures

27

A business plan is constructed for the appointment of a research nurse to the asthma clinic.

Staffing and staff management

28

A vascular team assessing the mortality of patients in ITU/HDU following surgery for abdominal aortic aneurysm have retrospectively collected data over the last five years on 133 patients.

Data analysis

The audit cycle comprises an initial needs assessment where the requirements of the department/section/individual are determined and the actual audit itself determined.

Then when what is to be audited is decided upon, it is important to identify the standards against which the audit will be compared. These can be national standards or clinical guidelines determined by the national bodies or even comparisons can be made within the department.

Once the standards are set, data collection is undertaken with selection of retrospective or prospective data followed by data analysis. The results can then be presented, compared with the standards and from this recommendations for improvements/implementation of change are/is made.

Finally, to assess how effectively these recommendations have been implemented, a re-audit is suggested for some stage in the future.

The vascular team having collected data on AAA procedures needs to analyse and then present their data. Finally, having presented their data, the a re-audit of post-operative pain control is now required to see if the recommendations have been implemented.

29

At a recent directorate meeting an ENT consultant has been nominated to undertake the next clinical audit.

Needs assessment

In the case of the ENT team nominated to take on an audit, they have to decide what needs to be audited.

30

A team presented their audit of post-operative analgesia for GI surgery approximately one year ago from which a number of recommendations were made and changes implemented.

Re-audit