SAQ paper Qs Flashcards
(149 cards)
1
Q
Describe three main steps by which a fracture is likely to heal normally and for each step describe the normal cellular response.
A
- Will heal by secondary healing
- Inflammatory phase: bleeding from torn vessels, clotting cascade activated and inflammatory cells (platelets, PMNs, macrophages) brought into the area. Haematoma forms in fracture gap. Immediate from injury, peaks at 48 hrs, subsides by one week
- Reparative phase: mesenchymal stem cells become fibroblasts, osteoblasts, and chondroblasts at the fracture site. Callus formed by intramembranous ossification at cortical bone ends (hard callus) and by chondrogenesis at the periphery (soft callus). Endochondral ossification converts callus to woven bone. Starts within first few days and lasts a few weeks
- Remodelling phase: woven bone replaced by lamellar bone, and excess callus resorbed. Begins a few weeks after injury and lasts years
2
Q
What are the risk factors for delayed fracture healing?
A
- Diabetes
- Smoking
3
Q
Osteoporosis drug therapies?
A
- Bisphosphonates: inhibit osteoclast activity, this maintains bone density and reduces risk of fracture
- Calcium + vitamin D supplement: calcium is a major mineral found in bone and is important for maintaining healthy bones, vitamin D needed to help body absorb calcium
- Denosumab: monoclonal antibody that targets the RANK ligand
- Teriparatide: form of PTH, stimulates cells that creates new bone
4
Q
Risk factors for osteoporosis?
A
- Female
- Elderly
- Sedentary behaviour
- Post-menopausal (reduced oestrogen levels)
- Calcium deficiency
5
Q
Key symptoms that point to diagnosis of inflammatory spine disease?
A
- Early morning stiffness
- Gradual onset
- Better with NSAIDs
- Better with exercise
- Low back pain may radiate
- Fatigue
- Pain waking the patient
6
Q
What two radiological features would you expect in an MRI in axial spondyloarthropathy?
A
- Sacroiliitis: sacroiliac joint fusion, sacroiliac joint erosion, sacroiliac joint oedema
- Shiny on corners of vertebral bodies
- Vertebral body squaring
- Bamboo spine
7
Q
Outline complications of ankylosing spondylitis that are outside of the musculoskeletal system.
A
- Atypical lung fibrosis
- Anterior uveitis
- Aortitis
- Amyloids
- Achilles tendonitis
8
Q
Describe sources that a doctor could use to get information on the different medication that a patient may be taking
A
- Ask relatives
- Contact the GP
- Contact their local pharmacist
- Check patient’s own list of medication
- Examine previous hospital notes if applicable
9
Q
What are the four ethical principles?
A
- Autonomy: the right for patient to make their own decision
- Non-maleficence: do no harm
- Beneficence: act in the patient’s best interest
- Justice: ensure fairness
10
Q
Describe measures that can be taken to minimise drug interaction issues in elderly patients.
A
- Get an accurate drug history, including details on why patient takes certain medication and whether they still need it or not
- Give priority to non-drug alternatives (eg. Psychological, lifestyle change)
- Ask patients if they have noticed any side effects
- Check with pharmacist regarding medicines information
11
Q
Describe the main physiological processes involved in the sensation and transmission of pain from one part of the body to the brain.
A
- Initial pain is sensed by nociceptors (free nerve endings in skin, muscle, other tissues)
- Pain is transmitted by primary sensory neurons to the dorsal horn of the spinal cord
- Type A-delta fibres (myelinated) for fast, acute pain and type C fibres (unmyelinated) for slow, throbbing/dull pain
- In the dorsal horn, the primary sensory neuron will synapse with a second neuron of the spinothalamic tract
- This second order neuron immediately decussates and passes up to the thalamus
- In the thalamus, second order neurons synapse with third order neurons leading to the sensory cortex to register pain and mediate emotional components
12
Q
Describe pharmacological interventions the GP should consider to manage a patient with chronic back pain.
A
- Use of NSAIDs
- Combine NSAIDs with proton-pump inhibitor (PPI) such as omeprazole
- If NSAID not sufficient for pain then consider an opiod (dihydrocodeine)
- Anti-depressant such as amitriptyline
13
Q
Mother worried about vaccine, she asks “is it 100% safe?”, how should a doctor answer this truthfully?
A
- All vaccines carry some degree of risk, but evidence for this vaccine suggests that it is safe
14
Q
Describe four ways in which Wakefield’s paper was ethically problematic.
A
- He falsified information claiming it had been approved by a research ethics committee
- The procedures involved were invasive and not clearly justified
- The justification for the research was not clear
- Wakefield had an undisclosed conflict of interest
15
Q
Name the five components of the biopsychosocial model that can be used to help understand the treatment of chronic back pain
A
- Sensory (nociception)
- Pain
- Suffering
- Illness (pain behaviour)
- Social/cultural
16
Q
In chronic low back pain, the patient may progress through three phases, give examples of the typical features that may be seen in each phase
A
- Phase 1 (up to 2 months): belief that pain is controllable, anxiety
- Phase 2 (2 to 6 months): varying between increased and decreased activity, depression may occur
- Phase 3 (6 to 24 months): reduced activity, side effects of pain medication may occur, belief that pain is uncontrollable, depression is common
17
Q
Name four viral infections that can be spread by mosquitoes.
A
- Yellow fever
- Dengue fever
- Zika
- Japanese encephalitis
18
Q
Give two examples of methods of control for mosquito-borne viral infections and explain how these are effective
A
- Mosquito nets: act as barrier to prevent biting
- Use of insecticides: toxic to mosquitoes/kills them
- Genetic modification of mosquitoes: causes failure to reproduce
19
Q
Risk factors for sciatica?
A
- Obesity
- Age
- Occupation
- Sedentary lifestyle
- Diabetes
20
Q
Characteristics of pain for sciatica?
A
- Radiating pain down back of leg
- Made worse by some movements
- Numbness and tingling
21
Q
Findings on examination for sciatica?
A
- Reduced straight leg raise
- Sensory loss
22
Q
Risk factors for osteoarthritis?
A
- Age
- Occupation (eg. Active lifestyle)
- Obesity
- Gender (more common in women)
- Family history
23
Q
Characteristics of pain for osteoarthritis?
A
- Dull ache
- Worse during exercise and at end of day
- Chronic pain
- morning stiffness (less than 30 minutes)
24
Q
Findings on examination for osteoarthritis?
A
- Pain on movement
- Reduced range of movement
- Crepitus
- Joint is not hot
25
Describe the reference population used in calculating a T-score
- young, gender-matched population with peak bone mass
| - (Age 20-29)
26
For osteoporosis, describe two dietary interventions that can be made and the specific advice that the GP would give for each of them
- Calcium: increase calcium intake by eating more dairy products
- Vitamin D: oily fish, fortified cereals
- Moderate protein intake: red meat, chicken
- High alcohol intake: reduce
27
Elderly woman blames herself for falling ill because she went out shopping on a rainy day without fully drying her hair, what is the historical theory of health and illness to which this patient’s lay beliefs correspond?
- The humoural theory
28
Patient has pyrexia, chills, and a sore throat, what is the most likely diagnosis?
- Upper respiratory tract infection
29
List four myths about flu immunisation/vaccination which may influence a patient to refuse the flu jab
- Vaccines are ineffective
- Vaccination overwhelms the immune system
- Vaccines commonly cause serious side effects
- Influenza is not serious
30
Other than people with chronic conditions, name four other different groups of people who are encouraged to receive the flu immunisation
- Older people
- Pregnant women
- Children (age 2-17)
- Morbid obesity
- Living in a long-stay residential care home
- Carers
- Front-line health workers
31
Describe the legal elements of capacity
- Being able to understand information
- Retain information
- Process information
- Communicate one’s decision
- Relate to a specific moment in time
32
A patient is not deemed to have capacity, a family member phones the doctor and wishes to be given information about the patient, how should the doctor address the patient’s confidentiality in this scenario?
- If the patient lacks capacity, then the doctor must act in the patient’s best interest (beneficence)
- In determining the patient’s best interest, the doctor is under a duty to consult with the patient’s next of kin
33
Describe the four features of the anger stage of the grieving process
- Frustrated expression of bottled-up emotion
- Person may recognise anger as irrational, but unable to control it
- May drive away support
- Most anger expressed by those who are socially isolated
34
Describe four musculoskeletal symptoms that can be elicited from a history in making a diagnosis of rheumatoid arthritis
- Morning stiffness (>1hour)
- Pain of more than 3 joint areas
- Hand involvement
- Symmetry
35
What is the long-term significance of periarticular erosions?
- Poor functional outcome in comparison to those without erosions
36
When addressing concerns about safeguarding, describe four ethical issues that clinical teams should consider when sharing clinical or personal information
- The patient’s consent to disclose
- The patient’s capacity
- The patient’s autonomy
- The relationship between the patient and their carer
- Consequences of disclosure (best interest of patient)
37
Describe two roles that an occupational therapist has
- Addressing a safe home situation (recommends alterations to house)
- Need for equipment (eg. Ramps, rails, handles etc.)
- Care package
38
Describe two roles of social worker
- Personal budget questionnaire
| - Care and support planning
39
What structure in the brain responds to the inflammatory cytokines, whose production is stimulated by pathogens?
- Hypothalamus
40
List two inflammatory cytokines that cause fever
- TNF alpha
| - Interleukins (IL-1)
41
Describe how paracetamol helps to reduce fever
- Paracetamol is a COX enzyme inhibitor
- It is thought to be selective for COX-3
- COX enzymes stimulate the production of prostaglandins
- Paracetamol helps to prevent PGE2 synthesis which is the main compound that alters the homeostatic temperature set point in the hypothalamic neurons that regulate body temperature
- In fever, the temperature set point is elevated by the production of PGE2
- PGE2 synthesis is stimulated by cytokines (IL-1, TNF-alpha) which are produced by the action of bacteria/viruses on the immune system
- By blocking PGE2 synthesis, paracetamol brings down the temperature set point to normal
42
Give four red flag symptoms that a GP should inquire about in a patient whose pain has changed
- Night pain
- Persistent pain
- Weight loss
- Night sweats
- Persistent excessive tiredness
- Progressive neurological symptoms
- Fever
43
Describe the most definitive diagnostic radiological investigation in a patient with back pain and red flag symptoms, explain your reasoning
- MRI scan of spine
- Better resolution of the bone marrow and bone lesions compared to plain x-ray
- MRI detects abnormal signal from abnormal cells, so can see lesions more clearly
44
What imaging technique should be used as the first line investigation for a patient with a soft tissue injury and give a clinical reason for this
- Ultrasound
| - Because dynamic investigation (ie. Imaging during function, patient contracts relevant muscle)
45
Describe the difference between the functions of tendons and ligaments
- Ligaments join bone to bone
- Ligaments maintain joint stability by providing a stop point, or prevent a movement
- A tendon is attached to the end of muscle fibres at one end and bone at the other
- A tendon allows movement whereas a ligament is designed to prevent it
- Tendons transmit muscle power generated by contraction to the bones to allow movement to occur
46
If patient is lactose intolerant, why can they not digest lactose?
- The patient cannot produce the enzyme lactase
47
List two treatment options for a patient who is lactose intolerant
- Avoid lactose-containing foods
| - Enzyme-replacement therapy (taking lactase before meals)
48
Describe three key principles of a palliative care approach
- Provides relief from pain
- Intends neither to hasten or postpone death
- Integrates the physical, psychological, and spiritual aspects of patient care (holistic)
- Offers a support system to help the family cope
49
Name four of the most common symptoms associated with the late stage of dying
- Pain
- Restlessness
- Increased respiratory secretions
- Drowsiness
- Skin colour changes
50
Which group of drugs is most commonly used for the management of severe pain in palliative care?
- Opiods
51
What class of hormone is cortisol?
- Steroid hormone
52
In which anatomical structure is cortisol synthesised and what is the precursor molecule from which it is made?
- Synthesised in the zona fasciculata of adrenal cortex/gland
- Precursor molecule is cholesterol
53
Hormones act by binding to receptors to transduce their signal into cells, describe how cortisol transduces its signal
- It is a lipid soluble hormone which diffuses into cells
- To bind to its receptor inside the cell in the cytoplasm
- The receptor/hormone complex moves into the nucleus to bind to DNA and activates or repress gene expression
54
List four positive social factors that keep people healthy in old age
- Owning a house
- Having had a car
- Having been married
- Having control and autonomy in decision making
- Social networks
- Enjoying the outdoors
55
Describe three gender differences in health behaviour that may impact the health a couple
- Females have better social networks
- Females are better able to discuss health with medical professionals
- Females experience of motherhood and caring generates responsibility for their own health
56
What is the single biggest factor that is likely to affect the life expectancy of a couple?
- Social class
57
What are the main findings on clinical examination that would support a diagnosis of fibromyalgia?
- Widespread pain
- Tender trigger points
- Widespread myofascial tenderness
58
What two blood tests should be requested and what would the results be for a diagnosis of fibromyalgia?
- ESR or CRP: will be normal
- Anti CCP: will be negative
- Creatine kinase: will be normal
- Vitamin D: will be normal
59
Give two available treatment strategies for fibromyalgia
- Increase exercise
- Education regarding self-management
- Amitryptiline (antidepressant)
- Cognitive behavioural therapy
60
A patient is from Lithuania and has two children, she is a cleaner in a nursing home, describe one psychological and one sociological reason that this patient may be reluctant to seek medical help
- Psychological: fear of diagnosis, lack of confidence in health service, fear of losing job
- Sociological: not registered with GP, cost of prescription, language barrier, lack of child care
61
Explain two non-pharmacological ways that the doctor could help this patient to give up smoking
- Refer to stop smoking clinic
- Discuss lifestyle change and positive attitude to stopping smoking
- Offer follow up appointment
62
Briefly describe the physiological pathway in the brain thought to be involved in nicotine addiction
- Nearly all dependence-producing drugs activate the mesolimbic and/or mesocortical dopaminergic pathways
- Nicotine, via attachment to nicotinic receptors, enhances the synthesis and release of dopamine from dopamine-containing neurons in the ventral tegmental area (VTA) of the hypothalamic region
63
Describe the physiology behind the mechanism of action of the oral contraceptive pill
- Synthetic oestrogens inhibit FSH release by negative feedback, suppressing follicular development
- Synthetic progesterone like compounds (progestins) block the oestrogen-mediated positive feedback surge in LH release, preventing ovulation, also changes the properties of cervical mucous so that it is hostile to sperm
- Endometrial layer development is less and not favourable for implantation
64
A 9 year old boy has recently been diagnosed with juvenile RA, his doctor involves him in all the discussions about his condition, outline three ways in which this patient can benefit from the way information has been communicated to him by his doctor
- If treatment and risks of poor adherence become relevant, then treatment adherence is better
- Better understanding of condition, treatment, risks, means that patient experiences less anxiety
- Child feels included in decision making and an active participant in his own health care
- Better understanding means better management of own health care
65
Describe three issues the doctor needs to consider in order to communicate, in the right way, the correct information to the patient
- Assess patients level of understanding
- Explain condition, treatment, risks in age-appropriate ways
- Be prepared to answer questions
- Involve parents in the discussion
- Involve other professionals if necessary (nurses, child psychologists, play therapists)
66
Why, in Paget’s disease, are both lytic and sclerotic lesions found on plain radiographs of the affected bone?
- Osteoclasts more active, greater bone resorption, you get lytic areas on x-ray
- Osteoblasts lay down bone more randomly, so you get sclerotic areas on x-ray
67
What is the biochemical marker of osteoblastic activity?
- Alkaline phosphatase
68
What class of drugs are the treatment of choice in Paget’s disease of the bone?
- Bisphosphonates
69
What is the mechanism of action of bisphosphonates?
- Reduces osteoclast activity
- Bisphosphonates taken up rapidly within the bone
- When osteoclast starts to activate they release enzymes and engulf the bone
- the bisphosphonate causes death/reduces function of the osteoclasts
70
When describing a radiograph, what do you do?
- Right or left side of body
| - What views?: AP and lateral
71
X-ray shows fracture of fibula above syndesmosis, medial malleolar fracture and talar shift, how should this injury be definitively managed and why?
- Open reduction
- Internal fixation
- Because unstable injury
72
According to DVLA guidance, what must the patient be able to do before being legally allowed to drive?
- When the patient can safely do an emergency stop
73
In law, how is a child defined by the children act 1989?
- A child is an individual under 18 years old
74
Discuss the principles of consent to treatment in an individual who is not an adult
- Gillick competence
- If child is deemed to have capacity then can give consent without parents/guardian
- Although, child would be unable to refuse treatment
75
Not including analgesia, outline the next two steps in the management of a suspected fracture and why
- Immobilise: to reduce risk of disruption of blood supply (to reduce osteonecrosis risk)
- Repeat x-ray in 10-14 days: because at this stage sclerosis (part of bone healing process) may be visible at the fracture line
76
A 32 year old female has developed RA, she is prescribed methotrexate 10mg and folic acid 5mg orally, how often should this patient take methotrexate?
- Once a week
77
With a patient taking methotrexate, name two blood tests which must be carried out regularly
- Liver function tests (LFTs)
| - Full blood count (FBCs)
78
Name two other important issues, other than drug interactions, which need to be addressed for patients prescribed methotrexate
- Alcohol intake: restrict it
- Need for folic acid to reduce side effects
- Common side effects: nausea
- Increased risk of infection
- The importance of regular blood tests
- Avoid pregnancy
79
Patient develops a UTI and is so symptomatic that she requires treatment before the sensitivities are available, what antibiotic should not be given and what is the reason?
- Trimethoprim
| - Because folate antagonist, therefore increased risk of pancytopenia (body has too few RBCs, WBCs, and platelets)
80
A 7 year old boy falls and has a deep scratch, pus is oozing out of it, what inflammatory cells are most likely to be present in the pus?
- Neutrophils
81
Describe the four changes that take place to facilitate the movement of cells of the immune system from the blood stream to the tissues, mentioning one important mediator for each
- Vasodilation: causes a change in laminar flow, mediated by histamine
- Margination: partly due to change in laminar flow, but also mediated by adhesion molecules (eg. Integrins) which allow cells to adhere to endothelium
- Emigration: the change in vascular permeability, mediated by histamine, bradykinins, and leukotrienes allows movement of fluid and cells from the vessel into tissues
- Chemotaxis: attracts cells to site where needed, mediated by complement components leukotrienes and cytokines
82
The four features of acute inflammation are redness, swelling, heat, and pain, what two nerve fibres are responsible for the sensation of pain?
- Type A-delta fibres
| - Type C fibres
83
List four of the common primary risk factors for OA
- Age
- Female
- Obesity
- Muscle weakness
- Smoking
84
Describe two responsibilities towards the patient and two rights of the health professional according to the sick role
- The responsibility to apply their skill to benefit the patient
- The responsibility to have a high degree of professionalism
- The responsibility to be objective
- The right to examine patients physically
- The right to ask intimate questions
85
Describe four sources that the specialist rheumatologist registrar might consult to determine whether a patient could be treated with anti-TNF drug
- Check hospital prescribing guidance
- Look at NICE guidelines
- Literature search (BNF)
- Ask a consultant for advice
86
In carrying out a literature search, give two issues that the specialist rheumatology registrar should consider in formulating their search strategy
- Patient diagnosis
- Study type
- Relevant outcome
87
When considering the results of the search, briefly describe which study types are considered to provide the highest quality evidence and why?
- Systemic review of randomised control trials
- Then individual randomised control trials
- These are considered the best because RCTs limit bias, and confounding
- Cochrane evidence base?
88
For a neck of femur fracture, what surgical procedure is required?
- (Left/right) hip hemi-arthroplasty
89
How would a doctor assess whether a patient is competent to consent?
- Test ability to retain and comprehend information
- Test ability to make a decision
- Test ability to communicate a decision
90
Patient has osteoporosis, what medication should be prescribed?
- Bisphosphonates (alendronic acid)
- Denosumab (only if patient is intolerant to bisphosphonates)
- Calcium + vitamin D
- Teriparatide: form of PTH, stimulates cells that create new bone
91
Give a brief definition of stress
- Stress is what we experience when the demands of a situation exceed our resources to cope with the situation
92
State two immunological/physiological changes that are apparent in the immune response of stressed individuals
- Individuals have a lower T-helper cell (CD4) count
- Less rapid spread of CD4 cells
- Reduced natural killer cell activity
- Altered cytokine activity that leads to a reduction in wound healing
93
Give three examples of how doctors can overcome language barriers with patients and give advantage and disadvantage of each
- Family members: free, might not tell truth, bias, breach of confidentiality
- NHS interpreters: trained and skilled, expensive
- Information leaflets in different languages: freely available, one-way communication/patient may not be able to read
- Members of staff: free and convenient, breach of confidentiality
94
Patient is in a falls clinic, name three systems that would be examined in this patient and explain what is being looked for
- MSK: muscle strength, gait and balance, weight bearing joints
- Neurological: cognitive function, proprioception, reflexes
- Vision: doctor should consider visual acuity
- Cardiovascular: check heart rate/rhythm, postural blood pressure
95
Provide four of the most common reasons why transgender people do not report transphobic crime
- Mistrust of police
- Don’t want to waste police time
- Poor past experience with authorities
- Fear of being ‘outed’
- Feeling that nothing can be done
96
The doctor suspects an ulnar nerve lesion, what sensory abnormality is likely to be present on examination?
- Mid-ring finger and little finger (dorsal and palmar aspects)
97
Describe two movements that the GP would ask the patient to perform to assess the function of the ulnar nerve
- Adduction and abduction of fingers to test small muscles of hand
- Little and ring finger flexion
98
Provide an example of a disaccharide found in food and name its constituent monosaccharide parts
- Sucrose: glucose + fructose
- Maltose: glucose + glucose
- Lactose: glucose + galactose
99
Explain two principles of confidentiality that the doctor needs to practice, in order to respect the patient’s right to confidentiality
- The doctor owes the patient a legal and professional duty of confidentiality
- Information held in confidence should not be released to a third party without the patient’s consent (except in exceptional circumstances)
100
What are four likely psychological features of the depression stage of bereavement?
- Regret
- Hopelessness for future
- Helplessness
- Social isolation
- Heavily loaded with emotions
101
Girl with a stepmother, what is the sociological name for this type of family?
- Reconstituted family
102
In a reconstituted family, outline three emotional issues that may arise
- Grief arising from bereavement or divorce
- Anger arising from bereavement or divorce
- Resentment to step-parents
- Tension may occur over child custody and child support
103
The GP wants to speak to the girl alone, outline two legal principles that underpin the GPs ability to do this, in spite of her age (15 years old)
- The young person’s best interest allows them to receive treatment without parental consent
- The young person has to be able to understand the professional advice
- The young person cannot be persuaded to inform their parents
104
Fred and Wilma got married at the age of 25, they have two daughters and a son, they are still happily married, although the world is very different for their children, name four social trends which are likely to be different for Fred and Wilma’s children when it comes to partnering and parenting
- Higher average of first time mother
- Higher average of first time marriage
- More births outside of marriage
- More reconstituted families
- More same sex partners
- More co-habitation (living with each other when not married)
105
Fred and Wilma’s daughter, Stacie, had two children, divorced, and then married Ed, who had a son from his first marriage, explain two types of difficulty which may arise within this type of family
- Anger and grief after bereavement for both parents and children
- Tension over child support and child care
- Resentment towards step parents
- Resentment towards step siblings
- Higher risk of child abuse
106
What does the term ‘triple shift, double burden’ usually refer to in the context of families?
- Triple shift: women doing paid work, house work, and child care
- Double burden: work and family
107
Patient’s sleep is disrupted because of his job, identify four health conditions that this patient could be at an increased risk of developing due to this prolonged sleep disruption
- Stress
- Anxiety
- Depression
- Extreme fatigue
- Headaches/migraines
- Heart burn
108
The sleep-wake cycle is an example of a circadian rhythm, describe the role of the Suprachiasmatic Nucleus (SCN) and the Pineal gland in the sleep-wake cycle
- The SCN becomes activated by changes in light levels detected via the optic chiasm
- In turn, the SCN sends a signal to the pineal gland
- Once activated, the pineal gland produces melatonin (sleep hormone) which reduces arousal in the brain and leads to sleep
109
Describe one other type of biorhythm and provide an example
- Infradian rhythms: where each cycle happens less frequently than every 24 hours (eg. Menstrual cycle)
- Ultradian rhythms: where each cycle happens more than once in 24 hours (eg. Hormone release, heart rate, bowel activity)
110
Describe four risk factors for developing an addiction to prescribed opiates
- Current or past history of substance misuse including alcohol
- Family member with history of substance misuse
- Poor social support
- Co-morbid psychiatric disorders
111
The GP thinks this patient may be at risk of addiction, describe four ways in which this risk could be reduced and managed
- Addiction should be discussed with all patients considering long term opioid treatment
- Opioids should only be used after other medications have been tried
- Advice from specialists in pain medicine and addiction medicine should be readily available
- Injectable opioids play no role in the management of persistent pain
- Opioid therapy should be monitored regularly and adjusted appropriately
112
From a history and examination, name three elements, which make a diagnosis of septic arthritis unlikely and explain why for each element (patient can weight bear, can flex knee comfortably, has temp. of 38, BMI of 35, has swelling anterior to his left patella)
- Able to weight bear: in septic arthritis would be unable to weight bear
- Can flex knee comfortably: in septic arthritis would be unable to flex
- Swelling is anterior to patella: in septic arthritis swelling is extra-articular
113
What is the most likely diagnosis? (patient has red swelling on knee and feeling unwell)
- Infected bursitis (prepatellar bursitis)
114
From the history, identify an undiagnosed co-morbidity that would predispose him to this condition
- Diabetes
115
List the people who are able to verify that death has occurred
- Any medical practitioner with a license to practice
116
List three physical signs that death has occurred
- There is no respiratory effort (examine for one minute)
- There are no heart sounds (examine for one minute)
- There are no palpable pulses (examine for one minute)
- The pupils are fixed and dilated (do not respond to light)
- There is no response to pain stimuli
117
The patient who died was Muslim, describe two cultural issues that make the request for a post mortem difficult to accept by his family
- Muslims believe that dissection of the body is wrong (the body should be kept whole because it belongs to God)
- Muslims believe that the body should be buried as soon as possible so that the risk of decay is minimised
- Muslims believe that cleansing of the corpse should be done by family members
118
Describe how calcium is removed from the muscle cell to start muscle relaxation
- Calcium needs to be removed from sarcoplasm (cytoplasm of striated muscle cells)
- Sarco Endoplasmic Reticulum Calcium ATPase (SERCA) pumps two calcium ions out of sarcoplasmic reticulum via active transport
- Plasma Membrane Associated Calcium ATPase (PMCA) actively transports calcium ions across sarcolemma membrane into extracellular space
- Calcium is also removed via Na/Ca pump by facilitated diffusion across the sarcolemma membrane into extracellular space
119
Name two processes that are carried out to prevent wrong-side surgery from occurring and explain why they are effective
- Never-event list: for organisations to raise awareness to prevent event
- Consent process: patient agreeing to the procedure, including the site
- Side marking: patient agreeing to the site/side and marking with a pen, correlate the consent form and the clinical information
120
Describe two types of measures taken in theatres to reduce the risk of post-operative bacterial infection
- Antibiotic prophylaxis
- Aseptic techniques
- Ventilation
121
Describe three modifiable factors (ie. other than normal ageing) that would be asked about in a history and explain how they cause falls
- Alcohol: causes confusion, clumsiness
- Drugs and their interactions: dizziness due to hypertension
- Behaviour: not using the bath/shower without a mat, standing on an uneven chair
- Environment: trip hazards, lighting etc.
- Muscle weakness: lower limb deformities, poor biomechanics
122
Name two conditions that may affect the biomechanics in Mrs Smith’s feet, bearing in mind her age (80) and history (RA with joint deformities, systemically well)
- Dropped arches
- Osteoarthritis of any foot joint
- Hallux rigidus (stiff big toe)
- Subluxation of MTP joint (partial dislocation)
123
Name four routes of administration or forms of drug, apart from oral, which should be considered in a full drug history
- Rectal (eg. Suppositories)
- Sublingual (eg. Spray, dissolvable tablet)
- Topical (eg. Spray, cream)
- Inhaled/nebuliser
- Eye drops
124
An 87 year old man is confused. He urgently requires a urinary catheter, the patient does not appear to understand the doctors explanation. Explain the legal considerations that allow the doctor to proceed with the task
- Capacity: a patient is presumed to have capacity to consent to treatment under the Mental Capacity Act 2005 (MCA)
- Under the MCA: a patient lacks capacity if they are unable to understand the information, retain it, process it, and communicate the decision
- Consent: this patient lacks capacity as he is unable to understand the explanation and therefore cannot consent to the procedure
- Best interests: as this patient lacks capacity, the doctor is under duty to act in the patient’s best interests. The doctor is under duty to consult with family to determine the best interests
- Emergency: if urgent treatment is required, the doctor can provide treatment proportionate to achieving the aim (ie. Preventing the patient from coming to harm)
125
A 12 year old boy falls on outstretched hand causing a fracture of the distal end of his right radius, if the fractured bone goes through the normal healing sequence, describe the typical histological features that a pathologist will see in the tissue at the following time points (less than 24 hours after fracture, one week after fracture, three weeks after the fracture)
- Less than 24 hours after fracture: rupture of blood vessels causes the formation of a haematoma (blood clot) which fills the fracture gap
- (the blood clot provides a fibrin (protein involved in clotting blood) mesh which seals the fracture site and provides a scaffold for the influx of inflammatory cells, fibroblasts and support for new capillary growth (granulation tissue))
-
- One week after fracture: soft callus forms (osteoclast and osteoblast activity stimulated)
-
- Three weeks after fracture: bony callus (new bone formation, woven bone formation)
- (remodelling occurs, reduces size of the callus until the shape and outline of the fractured bone are re-established as lamellar bone, the healing process is complete with the restoration of the medullary cavity)
126
What are the systemic complications that can be associated with bone fractures or damage to associated soft tissues?
- Shock syndrome
- Myoglobinuria (myoglobin in the urine): can occur if there has been significant muscle injury (or rhabdomyolysis)
- Bone marrow embolisms: can travel to lungs
- Fat embolisms: seen in severe multiple fractures, can cause cerebral ischaemia and/or pulmonary insufficiency
127
Describe two characteristics of the condition (prostate cancer) that make it suitable for population screening and two characteristics of the test for population screening
- Characteristics of the condition:
- The condition is important (common and disabling)
- The epidemiology and natural history are well understood
- There is a recognisable pre-symptomatic phase
-
- Characteristics of the test:
- The screening test is reliable
- The test is acceptable to the population
- Easy to perform, sensitive, specific, and low cost
- The treatment should be effective and available
- Case-finding should be a continuous process and not just done once
128
Patient talks to GP and decides that the harms of having the PSA test do not warrant testing at that time. Two years later, patient presents with new-onset back pain which is unrelieved with analgesia, GP recommends a PSA test. What is the reason for the GP ordering this test now and not two years ago?
- The test is now used as a diagnostic test to look for metastatic prostate cancer
- Benefits of the test outweigh the harms
129
Describe two red flag symptoms which this patient with back pain might describe
- Systemically unwell
- Constant progressive mechanical back pain
- Widespread neurological issues
- Persisting severe restriction of lumbar flexion
- Pmx: malignancy, corticosteroids
130
Describe four of the potential social reasons for why a patient might stop their injections
- Side effects of drugs
- Value of prophylaxis not communicated well by clinical team
- Over-demanding drug regime, if patient has co-morbidities (lots of other drugs)
- Dissatisfied patient seeks second opinion
- Lack of health literacy
131
With respect to the sociological understanding of the sick role, give two aspects in which this patient (not taking injections) is not acting on their responsibilities
- Obligation to get well as soon as possible
| - Obligation to seek and respond to professional help
132
Patient has their cast removed, the fracture has healed well, patient asks “do I need physiotherapy or any exercises?”, what two clinical factors will the orthopaedic team base their answers on for this patient?
- Referral to physio/prescribed exercises depends on the function of the patient (are they stiff?, can they weight bear?, are they mobile?)
- Patient may not be mobile due to muscle dystrophy due to not using the muscles as they have been immobile
133
A 31 year old female is investigated for recurrent miscarriages, it is found that she is anticardiolipin positive and a diagnosis of SLE is suspected. Name three other symptoms that, if present in the history, would confirm the diagnosis
- Skin rashes
- Pleuritic pain (chest pain)
- Fatigue
- Hair thinning
- Headache
134
What laboratory investigations would be performed to support the diagnosis? Give one example for each investigation and explain what abnormality would be expected (biochemistry, haematology, immunology)
- Biochemistry…
- CRP: raised levels
- U and E: renal impairment indicating renal involvement
-
- Haematology…
- FBC: thrombocytopenia (low platelets)
- ESR: raised levels
-
- Immunology…
- ANA: anti-double stranded DNA, Ro, La antibodies may be positive
- Complement: C3 and C4 levels low
135
She is followed up in rheumatology clinic on a regular basis and each time they ask for a specimen of urine for testing, what routine screening test is being performed and what abnormality is being looked for and why?
- Screening test: urinalysis (dipstick, midstream)
- They are looking for proteinuria
- Proteinuria indicated renal damage (nephritis) which is a complication of SLE
136
How many standard deviations below peak bone mass does a patient have to be in order to be diagnosed with osteoporosis?
- 2.5
137
What population characteristics do you need to know in order to calculate incidence and prevalence?
- Number of new cases
- Number of people currently with disease
- Total population at risk of having that disease
- At a given point in time or over a period of time
-
- (incidence = the number of new cases in a specified time divided by the number of people in the population at risk)
- (prevalence = the number of people with a disease at a given time divided by the population at risk of having that condition)
138
The national chlamydia screening programme has been initiated in order to reduce this disease in the English population. What level of disease prevention is this?
- Secondary prevention
139
A patient presents with tingling in the fingers in both hands, which is exacerbated by reading and which wakes her at night. The GP suspects carpal tunnel syndrome. Entrapment of what nerve leads to this common presentation?
- Median nerve
140
Indicate the classical distribution of paraesthesia that would be found on examination
- Palmar aspect, thumb, 1st, 2nd, and half ring finger
141
On examination, the symptoms are exacerbated by wrist flexion. Explain why this is the case
- The nerve is trapped already
- Because of this, on wrist flexion, you are reducing further the space in the carpal tunnel and therefore increasing the compression on the nerve
142
What two different non-surgical options are available to treat the condition in this patient?
- Steroid injection
- Analgesia (eg. Paracetamol, NSAIDs)
- Treat underlying cause (eg. RA)
- splint
143
What are the three main differences between innate and adaptive immune responses?
- Innate…
- Fast (occurs within minutes)
- Low specificity
- Does not have memory function
-
- Adaptive…
- Takes several days to develop
- Highly specific
- Memory cells are produced
144
Describe how the adaptive immune response is activated and the two major cell types involved in the process
- Macrophages and dendritic cells process and present antigens to cells of the adaptive immune system
- They present antigen to T cells, so initiating all T-cell-dependent immune responses
- Activation of T-helper lymphocytes then stimulates the activation of B lymphocytes to produce antibodies specific to the antigen presented to the T-helper lymphocyte
145
The GP starts her on steroids. Which other symptoms should be asked about to determine the starting dose of prednisolone and what is the starting dose?
- Headache, visual loss, claudication
| - 15-20mg prednisolone per day
146
A 49 year old male had an aggressive inoperable brain tumour for two years. Due to his escalating care needs he was eventually admitted to the local hospice where his family were made to feel special and able to enjoy happy times together in his last few months. He left a widow and four children. Give four reasons why admission to a hospice may be preferable to remaining at home
- Provides care needs/dignity
- Caters for drug administration needs
- Limiting emotional stress for children and relatives
- Patient’s wishes
147
During his last few months of life the patient was prescribed morphine. Describe how morphine works
- Morphine attaches to opioid receptors
- Morphine reduces membrane excitability and hence action potential firing frequency
- Opioids act on the dorsal horn as well as the peripheral terminals of nociceptive afferents neurons
- Thus preventing pain signals travelling up the spinal column
- Morphine also increases release of enkephalins and 5-HT (serotonin) onto dorsal horn neurons via stimulation of the periaqueductal grey matter (PAG) and the raphe nucleus
148
How might the side effects of morphine undermine the quality of life in end stage cancer treatment?
- Undermining physical wellbeing
- Constipation
- Nausea
- Confusion
- Sedation
149
Describe four late complications that can arise from a fracture
- Non-union
- Delayed union
- Joint stiffness
- Avascular necrosis
- Osteomyelitis
- Deformity
