Student generated Short Answer Questions – 2008

SEMESTER 1

Abdominal Distension and Ascites: Short Answer Question (7 marks)Students’ original questions

Q1a) List 6 causes of abdominal distension. (3 marks)

Fat, Fluid, Foetus, Tumour, Flatus, Faeces

b) Name the anatomical space fluid occupies in ascites? (1 mark)

Peritoneal

c) Please give 3 simplified mechanisms for the development of ascites, NOT causes or pathologies. (3 marks)

sodium and water retention hypoalbuminaemia portal hypertension lymph perculation/ overwhelmed removal of lymph.

Q2 Give three mechanisms that are involved in development of ascites and a pathological cause for each. (1 mk for mechanism; 1 mk for cause: 6 total).

Eg. Mechanism: Decreased lymph removal leading to lymph percolation into peritoneal cavity Cause: Physical obstruction of cisterna chyle.

Mechanism: Hypoalbuminaemia leading to decreased colloid pressureCause: Cirrhosis leading to decreased hepatic synthetic function.Cause: Nephrotic syndrome/kidney failure leading to proteinuria.

Mechanism: Increased venous hydrostatic pressure in the hepatic portal systemCause: Right heart failure leading to venous congestionCause: Cirrhosis leading to portal hypertensionCause: Schistosomiasis leading to portal venous obstruction

Mechanism: Na+ and water retention as a result of renin-angiotensin system activationCause: Left heart failure leading to renal hypoperfusion.Cause: Fluid retention in peritoneal cavity leading to reduced plasma volume.

Q3 Give two clinical signs that you can elicit to differentiate ascites from other causes of abdominal distention. (2 mks)

-fluid thrill (1 mark) -shifting dullness (1 mark)

Anaphylaxis: Short Answer (13 marks)

Mary, aged 9, was with her parents when she developed an allergic reaction from a meal of shellfish. She presents at the emergency department at 2:00pm and the triage nurse documents the following history:

History of presenting complaint:- Onset: shortness of breath immediately following a meal of shellfish at 1:30pm,

within ‘minutes’ she fainted and then regained consciousness once lying down.PMH

- Insignificant, no history of asthma or allergiesMedications

- nilFamily History

- Father: hayfever and is allergic to peanuts.

Over the next four hours Mary develops further symptoms. Her breathing becomes more laboured and by 5pm she has developed an audible wheeze. She also develops a diffuse itch and urticaria

a) Mary experienced an early, sudden reaction which was followed, hours later, by another wave of symptoms. Compare this late phase reaction to the early phase and explain what has occurred. (4 marks)

Primary early response: 5-30 minutes Immediate degranulation and release of mediators e.g. histamine from IgE

sensitized mast cells (1/2 mark) Histamine → vasodilation & ↑ permeability of blood vessels (1/2 mark) →

peripheral hypovolemia → syncope (1/2 mark) Ach → smooth muscle contraction → bronchial spasm → shortness of breath (1/2

mark)

Late phase response: 2- 8 hours later release of newly formed mediators (1/2 mark) & recruitment of leucocytes (1/2 mark) Prostaglandins & leukotrienes → similar effects to Histamine & ACh oedema, mucus secretion, bronchospasm, epithelial damage

1 mark for coherent and logical comparison between the two phases.

b) Mary’s reaction can be described as a hypersensitivity reaction. Draw lines to match the correct mechanism and example for each of the types of hypersensitivity reaction. (4 marks) ½ mark per correct answer

Type of

HypersensitivityMechanism Example

IProduction of IgG, IgM → binds to antigen on target

cell or tissue → phagocytosis or lysis of target cell b activation of

complement; recruitment of lymphocytes

Glomerulonephritis, serum sickness, Arthus reaction

IIActivated T lymphocytes→

release cytokines and macrophage activation, and T cell-mediated cytotoxicity

Anaphylaxis, Allergies, Bronchial spasm

IIIProduction of IgE antibody

→ immediate release of vasoactive amines and

other mediators from mast cells; recruitment of

inflammatory cells (late-phase)

Goodpasture syndrome, Autoimmune haemolytic

anaemia

IVDeposition of antigen-antibody complexes →

complement activation → recruitment of leukocytes

→ release of enzymes and other toxic mediators

Contact dermatitis, Multiple sclerosis,

Transplant rejection

Answers 132, 213, 341, 424

c) During the emergency management of Mary you will check that her airway is clear, that she is breathing and that she has a pulse. You will probably consider treating her with adrenaline. What other actions should be performed in the emergency management of an anaphylactic patient? (2 marks)½ mark per correct answer

Establish venous accessLie flat – return fluid from peripheryIntubate – to secure airwayAdminister OxygenAdminister glucoseAdminister Corticosteroids: hydrocortisoneAdminister IV fluid Monitor BP

d) Adrenaline administration is important in the therapeutic response to anaphylaxis. Complete the table below regarding the actions of adrenaline in the body that are relevant to reversing the anaphylactic response. (3 marks) ½ mark per correct answer

The following are effected by the administration of

adrenaline:What is the adrenoreceptor involved in the response?

What is the effect on this organ? How does this

reverse the anaphylactic response?

Blood Vessels Alpha 1 or alpha 2(has effects on both)

Vasoconstriction increases blood flow to vital organs

Bronchi Beta 2 Bronchodilation improves respiration

Mast Cells Beta 2 Reduces release of histamine reducing further symptoms or reduces severity of anaphylaxis

Arrhythmias: Short Answer Question (11 marks)

Initial presentation:Mr Carthy, a 64 year old man with a history of long-standing hypertension and diabetes mellitus type 2 presents c/o SOB and fatigue.

O/E:HR 120 bpmBP 100/70 mmHgRR 24 bpm

Lead 2 ECG Trace

Questions: 1. (a) What is the ventricular rate of the ECG provided? (1 Mark).

120bpm.

(b) Is this a ventricular or supraventricular rhythm? (1 Mark).

Supraventricular.

Carotid sinus massage may be applied in the emergency room to better differentiate the arrhythmia.

2. Explain how carotid sinus massage affects the ventricular response? (2 Marks).

CSM increases vagal tone which slows conduction through the atrio-ventricular node and increases atrio-ventricular block.

Additional information: Mr Carthy is diagnosed with atrial flutter, admitted to hospital and commenced on digitalis and amiodarone. He feels better but has developed an irregularly irregular heart rate of 110 bpm.

Lead 2 ECG Trace

3. (a) What is the rational for treatment with these pharmacological agents? (2 Marks)

These agents slow the ventricular rate by increasing vagal tone and delaying conduction through the AV node. This slows the ventricular rate, allowing adequate time for ventricular filling.

(b) List 2 common side effects each for digoxin and amiodarone. (2 Marks)

Digoxin: Anorexia, nausea, vomiting, diarrhoea, blurred vision. Amiodarone: Benign corneal microdeposits, nausea, vomiting, skin pigmentation (blue-grey), constipation, pulmonary alveolitis or fibrosis, hyper/hypothyroidism, photosensitivity, transient elevation of hepatic transaminases, headache, dizziness, fatigue, tremor, ataxia, sleep disturbances (nightmares or vivid dreams), taste disturbances (metallic taste, loss of taste).

4. (a) What is the rhythm now based on the ECG strip of Lead 2 provided above? (1 Mark).

Atrial fibrillation

(b) What other therapy may be indicated and why? (2 Marks).

Patients with intermittent or persistent AF are at an increased risk of embolic stroke due to the increased risk of mural thrombi formation. For this reason patients should also receive anticoagulation.

Cardiovascular/Chest Pain: Short Answer Question (8 marks)

(a) Cardiovascular disease (CVD) is the leading cause of death and disability among Australians, accounting for 21.9% of the total disability-adjusted life years lost in 1996. Cardiovascular events including myocardial infarction (MI), transient ischaemic attacks (TIA) and stroke are preventable and GPs are well placed to implement screening and prevention procedures that will reduce the human and economic burden of these diseases.

Briefly define the 3 forms of prevention: Primary, Secondary and Tertiary / Continuing Care. Also provide one example for each, with respect to Cardiovascular disease.

Prevention type Definition (1 mark each) Example (1 mark each)Primary Prevention

Prevention of diseases or disorders in the general population by encouraging community-wide measures.  Primary prevention maintains good health and reduces the likelihood of disease occurring.

BP screening blood cholesterol/triglyceride

screening healthy diet low in fat good level of physical activity smoking cessation weight reduction adequate management of

diabetes Education Health promotion

Secondary Prevention

Detection of the early stages of disease before symptoms occur and the prompt and effective intervention to prevent disease progression.

treatment of hypercholesterolaemia/hyperlipidaemia with statins

treatment of hypertension treatment/control of diabetes

mellitus

Tertiary Prevention / Continuing Care

Prevention or minimisation of complications or disability associated with established disease.

angioplasty/stenting CABG (Coronary Artery

Bypass Grafting) cardiac rehabilitation treatment of CHF (esp with

beta-blockers)

(b) Describe the mechanism of action of the ‘statins’ in the treatment of cardiovascular disease (2 marks)

Inhibit the actions of hydroxymethylglutaryl coenzyme A (HMG CoA) reductase used in endogenous cholesterol synthesis → ↓ hepatocyte cholesterol concentrations → ↑ expression of hepatic LDL receptors → ↑ LDL uptake → ↓ plasma LDL

Also causes an ↑ in HDL and ↓ triglycerides (↓ synthesis of triglyceride rich lipoproteins)

Other effects include: ↑ endothelial function (↑ [NO]) possible anti-inflammatory effects ↓ thrombus formation possible antioxidant effects ↓ vascular smooth muscle growth

COPD SAQ

A 62 year old exotic dancer presents with worsening symptoms of COPD. You overhear a colleague complaining that he shouldn’t have to spend so much time treating a man who has “smoked himself half to death”.

a) Discuss how a doctor’s perceptions of self-induced disease may compromise quality of care. Use the ideas of self-induced disease, responsibility, lifestyle, autonomy, and transference to guide your answer. (5 marks)

The major ethical issue with assigning personal responsibility for health and illness is finding an acceptable way to attribute and quantify causality. While it may be easy to assign blame to a patient suffering from apparently self-induced illnesses, it is more difficult to determine exactly how much a patient’s lifestyle has contributed to the development of disease and exactly how responsible a person is for their actions, given their culture, socioeconomic status, genetic heritage, education, and life experience. Assigning absolute responsibility would deny the possible roles of genetic, environmental, and social influences on health. However, to deny the influence of personal choice is a deterministic view which completely discounts autonomy.

The compatibilist view is the compromise between these two extremes. When doctors assign blame to patients with perceived self-induced disease, there is a risk of transference, creating negative feelings toward the patient, which may compromise the quality of care.

(1/2 mark for proper integration of each word and 1/2 mark for proper understanding of each concept.)

**{According to Mal Parker, it would be good to: say a bit more on HOW negative feelings could compromise care. also consider expanding it a bit by saying that to the extent that responsibility is

attributed, up to the max of absolute responsibility, the possible functioning of the other factors is diminished ….

give an example of self-induced illness in order to demonstrate that you understand the concept. The example from the case could be used.}

b) Discuss the concepts of negative sanctions and positive incentives in the context of community resources and self-induced disease (5 marks)

A shortage of community resources increases the appeal of negative sanctions, where you deny care or other benefits to patients who indulge in harmful behavior. This is also problematic as it gives doctors the power to administer social justice. The practice of denying certain procedures, particularly organ transplant, on the basis of physiological criteria secondary to harmful behaviour, is somewhat more accepted. Positive incentive programs, where patients gain benefits in recognition of healthy lifestyles, are less ethically problematic and are aimed at reducing the burden of disease by reducing disease prevalence rather than denying care.

Emphysema: Short Answer Question (10 marks)

Gary is a 54 year old male who presents with shortness of breath worsening over the past 6 months. He has a 40 pack-year history of smoking. You suspect he has emphysema.

(a) List one (1) sign found on clinical examination of the chest in a patient with emphysema for each of: (1/2 mark for each box, max of 2 marks)

Inspection Hyperinflated chest/Barrel chest, use of accessory muscles, intercostal/subcostal/supraclavicular recession (one of), tachypnoea

Palpation decreased chest expansion, displaced apex beat, (no marks if missing words decreased or displaced)

Percussion Hyper-resonant, decreased liver dullness

Auscultation Crackles, decreased breath sounds,

(b) Below is a vitalograph, as seen in a normal healthy person. Draw the tracing you would expect to see from Gary. (2 marks)

[drew the graph myself, so there aren’t any copyright issues]

1 mark for decreased FVC1 mark for decreased FEV1/FVC ratio

(c) Outline the process that leads to cor pulmonale in patients such as Gary. (3 marks)

Destruction of alveolar walls -> Loss of pulmonary vascular tissue and/or pulmonary hypoxic vasoconstriction -> increased pulmonary vascular resistance -> pulmonary HT -> increased afterload-> RV hypertrophy -> RV failure

(d) 10 years later Gary is diagnosed with small cell carcinoma. After being informed of his prognosis, he refuses further treatment. What factors must be taken into consideration while deciding if his refusal is valid. (3 marks)

Competent, informed, voluntary (1/2 mark for listing, each and ½ mark for a brief explanation)

Eczema/Psoriasis: Short Answer Question (6.5 marks)

Tracey is an 18 month old child whom you diagnosed with eczema 3 months ago. Her parents have been regularly bathing Tracey and applying a bland emollient 2-3 times a day since your diagnosis.

(a) What are the common clinical findings in a toddler with eczema? (2 marks)

- Asthma, allergic rhinitis, conjunctivitis (general atopy)- Involvement of antecubital and popliteal fossae, neck, face, wrists, ankles.- Lichenification (chronic skin thickening and increased skin markings)- Erythematous thickened plaques – may weep- Excoriations and scratch marks- Generally dry skin- Pruritis- Irritability- Growth retardation/failure to thrive

Despite Tracey’s parents’ dedication to the treatment regime, Tracey has not had the response to treatment you would like and you consider prescribing a topical steroid cream in addition to the emollient.

(b) Describe how steroids work in relation to eczema? (3 marks)

Atopic eczema is due to a disregulation of T-cell function (or something similar - 1 mark). Corticosteroids bind to glucocorticoid receptors in the cytoplasm and the activated receptor moves into the nucleus which stimulates or inhibits protein synthesis (1 mark). This reduces immune responses generally by reducing cytokine and interleukin production (1/2 mark); production of phospholipase A2 is reduced (thus reducing acute inflammation) (1/2 mark); and decreases release of histamine from basophils (1/2 mark).

(c) List three (3) side effects of steroids (1 ½ marks. ½ mark each)OsteoporosisAdrenal suppression/atrophyIncreased susceptibility to infectionPsychosis/euphoria/depressionDecreased uptake and utilization of glucose OR abnormal carbohydrate metabolism OR hyperglycaemiaDecreased protein synthesis and increased breakdown OR muscle wastingFat redistributionImpaired wound healingImpaired growth in children

Encephalitis: Short Answer (8 marks)

Susan, a 25 year old female presents to your surgery complaining of fever, headache and cold sores. On examination you find she has papilloedema. During your examination, you observe a clouding of consciousness and she begins to convulse. You send her immediately to the ED

1) Name 2 pathological processes that could account for her presentation

Infection, Neoplasia, Inflammation, Ischaemia, Obstruction

Diagnoses such as meningitis, encephalitis are NOT acceptable

2) List 3 Investigations that will aid in your immediate management and diagnosis of Susan, AND JUSTIFY (no marks will be given for Ix only)

BSL to rule out hypoglycaemia/hyperglycaemiaHead CT to rule out space occupying lesion, subarachnoid haemorrhage, infarct etcBlood MCS to rule out septic infectionLP to check CSF for white cells, bacteria, inflammatory cellsFBC to rule out infectionLFT to rule our liver induced encephalopathy

NOT acceptable isCT (no specific place), MRI, EEG – unsure whether or not to accept ECG, shows no cardiac signs, but are routinely done.

Epigastric Pain: Short Answer Question (8 marks)

You are an intern sleeping in the emergency ward one night, when Bill, a 54 year old man, is rushed in with severe epigastric pain and vomiting.

1 (4 marks)

List four (4) anatomical structures and an associated pathological process for each that give rise to epigastric pain.

Structure Pathological processExample: myocardium Ischaemia/infarctionstomach Ulceration/inflammation/infection/carcinoma/volvulusduodenum Ulceration/inflammation/infection/obstruction/carcinomapancreas Inflammation/obstruction/infection/carcinomaoesophagus Perforation/ulceration/chemical irritation/distension gallbladder obstruction/infection/inflammationAorta Ruptured Dissection/aneurysm musculoskeletal system Trauma/inflammation/fracture Skin Infection/inflammation/traumapericardium Inflammation

2 (2 marks)

Describe the mechanism of referred pain.

Good answer Pain arising from the visceral organ radiates to the dermatome level which receives

visceral afferent fibres from the organ concerned. (1) The brain maps somatic sensation more effectively than visceral sensation and the

irritation is interpreted as occurring in the skin rather than from the viscera. (1)

Poor answer (worth half marks) Pain arising from the internal organs is mapped better by the brain. Reason: too vague. Have not demonstrated complete understanding of the mechanism.

3 (2 marks)

Bill is in too much pain to talk. A quick examination shows absent bowel sounds, he looks pale, sweaty and has a weak, thready pulse. He starts vomiting blood. You suspect peptic ulcer perforation, and realising that this is a medical emergency, you begin to think about immediate management.

Explain why treatment can be provided without consent in this case

o Patient is unable to give consent (1/2)o The procedure is necessary, and not simply convenient (1/2)o The necessity must be to save the life of the person, or save a limb or function of

a part of the body that may cause long term harm to the patient. (1/2)o The patient is in grave danger, and treatment is urgent in terms or hours or days

(1/2)

Functional Bowel Disease: Short Answer Question

Ms Sraczka, a 36 year old single mother of 2 young children, presents with a 2 week history of abdominal discomfort, feeling bloated & complains of some "loose bowel motions". She is new to your practice as she has recently relocated from Tasmania. You suspect she may have irritable bowel syndrome.

a) What are 3 broad differential diagnoses you should consider in this patient?

Lactose intolerance. Infectious Coeliac disease Inflammatory bowel disease Colorectal cancer related to familial polypoid syndrome – FAP / HNPCC

b) List 4 aspects of your management plan for a patient with irritable bowel syndrome.

Counselling and education regarding the disorder. Restriction diets to identify triggers of symptoms Keep a log book Dietary advice eg high fibre diets Identification of and dealing with stressors

Regular follow-ups Regular hydration Pharmacologic therapy eg Anti-spasmodic agents, Stool-bulking agents, Anti-

diarrhoeal agents, Anti-depressant drugs, Antiflatulence therapy, Chloride channel activators.

Further investigations e.g. stool microscopy, colonoscopy

Gallstones: Short Answer Question (6 marks)

What are 3 common clinical presentations of gallstones? For each one, briefly explain their pathogenesis and how they would present.

a) Bilary Colic- temporary obstruction of the cystic or common bile duct. Colicky pain generally felt in the epigastrium.

b) Acute Cholecystitis- obstruction to gallbladder which induces blockage of secretions, progressive dilation which may impact on vascular supply. Obstruction to the bile secretions may also cause infection, and inflammation. Bilary colic pain is felt, as well as a right upper quadrant localized pain due to parietal peritoneal involvement. Fever.

c) Acute Cholangitis- a gallstone is lodged in the common bile duct. Generally presents with a triad of fever, jaundice and bilary colic.  

SAQ – Hypertension

Scenario- Mr Richard Cranium, a 66 year old patient of Anglo-Saxon descent, presents requesting a ‘check up’ at your GP practice.

1. What are the major cardiovascular risk factors? Indicate which of the risk factors are modifiable and which are non-modifiable (3 marks)

Non-modifiable = (3 for 1.5 marks)Age (>50), sex (male), family history                  

Modifiable = (3 for 1.5 marks)Hyperlipidaemia (aetiology not primarily genetic), hypertension, diabetes mellitus, smoking, obesity, high fat diet, physical inactivity.

Whilst seated, Mr Cranium’s BP: right arm = 145/95. No significant differences on left arm or on standing.

2. Do these measurements justify a clinical diagnosis of hypertension? Explain your answer(4 marks)

No (0.5 mark). Epidemiologically, there is no specific cut-off at which blood pressure begins to cause pathology of the vascular, cardiac and renal systems (0.5 marks). Clinically, the diagnosis of HTN is made when there is seated systolic (>140) and/or diastolic (>90) elevation (0.5 marks) on two or more visits (0.5 marks). These BP measurements were chosen as points at which risk is significantly increased and there are established benefits of treatment (1 mark).

There is the consideration of white coat hypertension as well, and taking more than one BP measurement aims to reduce the influence of this syndrome.( 1 mark)

3. Name the two aetiological classifications of hypertension and indicate which one is more common. (1.5 marks)

Essential HTN (0.5) and secondary HTN (0.5 marks). Essential is more common (0.5 marks) (95% and 5% of HTN cases respectively).

4. What are the two major neurohormonal systems that contribute to the maintenance of MAP? Briefly describe the general mechanism of each(5 marks).

Autonomic nervous system(1 mark): The sympathetic nervous system maintains vascular tone (vasoconstriction) and elevates heart rate (increased chronotrophism), thereby maintaining TPR and CO respectively. The parasympathetic nervous system decreases vascular tone and heart rate. (1.5 marks for mechanism)

Renin-Angiotensin system (1 mark): Activation increases MAP. Decreased renal perfusion causes the macula densa of the juxtaglomerular apparatus to secrete renin. Renin cleaves angiotensin I to angiotensin II (primarily in the lungs). Angiotensin II acts as a potent vasoconstrictor which increases TPR and MAP. Angiotensin II also activates the adrenal secretion of aldosterone, which causes renal sodium and water retention.(1.5 marks for mechanism)

Lymphadenopathy: Short Answer Question (7 marks)

Part A

Mr X, an 74 year old retiree, presents to your GP clinic with a lump in his neck.   You know Mr X. well although he is often reluctant to keep up his regular visits and has refused invasive diagnostic procedures and lifestyle advice on several instances in the past.   You suspect the swelling is within a lymph node.

a) Name 3 different anatomical structures (of different tissue types) in the neck and relevant diagnosis (not pathological processes) for this structure.

Specific Anatomical Structure Relevant Diagnosisexample: Carotid Artery example: Carotid AneurysmAny lymph node (eg Cervical lymph node) -Malignant lymphadenopathy (metastaic or

secondary-Infectious lymphadenopathy-Lymphoma

Thyroid gland GoitreThyroglossal duct thyroglossal cystSalivary gland Stone or caliculiSkin Lipoma

Sebaceous cystCystic hygroma

Parathyroid gland MalignancyPharyngeal pouch

Any neck muscle (eg SCM) Muscular spasmAny neck nerve Neurofibroma

b) What relevant questions should also be asked of Mr X. to test your hypothesis? (2 Marks)

smoking hx, alcohol hx, previous history of cancer, fever, night sweats and weight loss dentition, recent URTI, time course,pain, recent travel

Poor answers: age, gender, occupation, any questions relevant to signs found in a clinical exam

c) Describe prominent differences in clinical features between infectious and malignant lymphadenopathy (1 Mark)

Infectious - tender, mobile, soft, regular borderMalignant - non tender, fixed, hard/rubbery, nodular border

Part B

To narrow down your long list of differentials, you would like to take a biopsy. Describe the difference between material and obvious risk? (1 Mark)

Material Risks - Patient needs to be informed to the level that a reasonable person (as patient) needs to make a reasonably informed decision OR to the level that the doctor reasonably knows the patient needs.   A risk that a reasonable person would attach significance to.

Obvious Risks – don’t need to inform unless law requires it, or if patient requests information, “obvious” different for a doctor if compared to a non-doctor

Myeloma: Short Answer Question (6 marks)Bob is a 59 year old building contractor who presents with back pain following a minor fall. He tells you he hasn’t felt well for a while now; his appetite is less than usual, he has a dry mouth and has been unusually constipated. You take a thorough history and perform a physical examination. By the end of your consultation, you are concerned that Bob may have multiple myeloma.

Complete the following table by listing 3 investigations and one anticipated finding from each investigation which would be consistent with a diagnosis of myeloma.

1 point is assigned for each investigation from the following list, and 1 point for the expected finding. Students do not need to list every potential finding for the investigation: 1 acceptable answer per investigation is sufficient.

Investigation (3 marks) Anticipated Findings (3 marks)Serum protein electrophoresis Monoclonal or ‘M’ bands/spikes

(accept: immunoelectrophoresis)Bone marrow aspirate Infiltration by plasma cells OR plasmacytosis Skull X-ray ‘Pepper-pot’ or lytic bone lesionsSpine X-ray Crush/wedge fractures

Lytic lesionsDiffuse osteopenia/osteoporosis

Urine electrophoresis(accept: 24 hour urine collection with electrophoresis)

Bence Jones proteinsFree light chains

FBC N or ↓ WBCN or ↓ RBC or HbN or ↓ platelet count

Serum globulins(accept: total protein)

Elevated(accept: elevated IgG, IgM, IgA, IgE)

ESR ElevatedBlood film Rouleaux formation

Normochromic normocytic anaemia Serum urea nitrogen Elevated Serum creatinine ElevatedSerum calcium ElevatedSerum uric acid ElevatedAlkaline phosphatase Usually normal MRI of spinal cord Cord or root compression (present in myeloma pain

syndromes)

Nausea and Vomiting: Short Answer Question (5 marks)

Mark 37, presents suddenly with diffuse abdominal pain, which he describes as colicky, as well as persistent vomiting since dinner.

a) List 2 likely diagnoses and briefly describe their mechanisms for causing vomiting: (3 marks)

Mechanical obstruction

Hernia - herniation of loop of bowel → small intestinal obstruction → gastric outflow interruption + reverse peristalsis → emesis other possibilities include: Gastric outlet obstruction: peptic ulcer disease, malignancy, gastric volvulus , Small intestine: adhesions, hernias, volvulus, Crohn's disease, carcinomatosis

Dysmotility

Gastroparesis due to diabetes – decreased motility of stomach → decreased emptying of stomach contents → contraction of stomach → vomitingother possibilites include: medications, postviral, postvagotomy ; Small intestine: scleroderma, amyloidosis, chronic intestinal pseudo-obstruction, familial myoneuropathies

Peritoneal irritation

Appendicitis: inflammation → pain detected by sensory afferents → transmission to higher cortical centres → action on the vomit centre → efferent fibres to somatic and visceral receptors → vomit

Infections

Food poisoning: ingestion of preformed toxin from bacteria (eg Bacillus cereus, Staphylococcus aureus, or Clostridium perfringens → toxin induces stimulation of visceral afferents from stomach → send signal to chemoreceptor trigger zone → efferent fibres to somatic and visceral receptors → vomit

Other possibilities include: Norwalk or rotavirus, Hepatitis A or B, Acute systemic infections

Hepatobiliary and pancreatic disorders

Acute pancreatitis: inflammation → pain detected by sensory afferents → transmission to higher cortical centres → action on the vomit centre → efferent fibres to somatic and visceral receptors → vomit

Other possibilities include: Cholecystitis or cholelithiasis

Topical gastrointestinal irritants /Drugs

Alcohol ingestion → systemic emetogenic properties → travel in blood → acts on chemoreceptor trigger zone → action on the vomit centre → efferent fibres to somatic and visceral receptors → vomit

Other possibilties include: NSAIDs, chemotherapy, opioids

Miscellaneous

Myocardial infarction: severe crushing chest pain → sensory afferents transmit pain to higher centres in cortex → action on the vomit centre → efferent fibres to somatic and visceral receptors → vomit

Other possibilites include: hypercalcaemia, kidney stones, pyelonephritis, diabetic ketoacidosis, uraemia, radiation therapy, adrenal crisis, parathyroid disease, hypothyroidism, paraneoplastic syndrome

b) List 2 common antiemetics (1 mark)

H1 receptor antagonists (e.g. cyclizine) Muscarinic antagonists (e.g. hyoscine) 5-HT3 receptor antagonists (e.g. ondansetron) D2 receptor antagonists (e.g. metoclopramide)

c) Choose one of the drugs listed above (listed in part b) and briefly describe its main mechanism of action (1 mark)

Hyoscine: Inhibits muscarinic receptors (in the vestibular nuclei) -> loss of stimulation of chemoreceptor trigger zone -> decrease stimulation at vomiting centre (also inhibits receptors directly in vomiting centre).

Cyclizine: Inhibits H1 receptor (in the vestibular nuclei) -> loss of stimulation of chemoreceptor trigger zone -> decrease stimulation at vomiting centre; (alternative response - also inhibits receptors at nucleus of solitary tract, which in turn inhibits stimulation at vomiting centre)

Metoclopramide: Direct inhibition of D2 (dopamine) receptor in chemoreceptor trigger zone -> decrease stimulation at vomiting centre

Ondansetron: Direct inhibition of 5-HT3 (serotonin) receptor in chemoreceptor trigger zone -> decrease stimulation at vomiting centre; (also inhibits stimulation of visceral afferents from stomach/pharynx which in turn inhibits stimulation in the CTZ).

Pass answer:

a) Lists 2 diagnoses without mechanism or poor mechanisms, eg hernia – obstruction → vomiting (1 mark for diagnosis and okay mechanism) food poisoning → bacteria secretes toxin → vomiting (½ mark for diagnosis)

b) Does not list 2 antiemetics/ uses trade names, eg maxolon (0 mark), ondansetron (½ mark)

c) Provides poor or nonspecific mechanism maxolon acts on dopamine receptors in the brain and inhibits vomiting (½ mark acts on... needs to say inhibits, etc)

Newborn: Cyanosis: Short Answer Question

PART A

Sally is diagnosed with Rubella by her GP. Routine blood tests show that she is also 7 weeks pregnant. Sally knows of the risks associated with Rubella and the effects on the unborn baby. She wonders if she should terminate the pregnancy.

Briefly discuss the ethical arguments regarding termination of pregnancy.

Conservative:The foetus is a potential person (1mark), thus has a right to life (1mark), and abortion infringes upon this right.

Liberal:A right to life requires an inherent interest (1mark), since a foetus has no concept of continuing life it does not have an interest (1mark), and therefore no right to life.

PART B

Seven months later, Sally gives birth to a baby boy, Jo. The night registrar on the medical ward is called to the maternity ward as she is distressed because Jo turned on feeding.

(a) [Picture of foetal circulation]This is a diagram of a foetal heart.

Label (a)(ductus venosum)

Ductus Venosum (1 mark)

What is the function of (b) (foramen ovale)

Allows oxygenated blood from the placenta to bypass the non-functional lungs in the foetus. (To get the 1mark, the student needs to mention the oxygenated blood via the placenta, and that it allows for the bypass) (1 mark)

What does (c) become upon birth (ductus arteriosum)

Ligamentum arteriosum (1mark)

(b) For each system listed, provide a pathological process for cyanosis in the newborn

System Pathological ProcessCardiovascular system Right to left shunt (0.5 mark) shunting of

deoxygenated blood away from the pulmonary circulation (0.5 mark) increased deoxyhaemoglobin in the systemic circulation (0.5 mark) cyanosis

Respiratory system Decreased Ventilation/Diffusion (0.5 mark) Decreased Oxygenation of Haemoglobin (0.5 mark) Increased Deoxyhaemoglobin (0.5 mark) Cyanosis

Haematological system Genetic defect of haemoglobin (0.5 mark) decreased affinity for oxygen (0.5 mark) increased levels of deoxyhaemoglobin (0.5 mark) cyanosis

(c) The newborn is diagnosed with Tetralogy of Fallot.List the four features of Tetralogy of Fallot

VSD (0.5 mark)Overriding aorta (0.5 mark)Right ventricular hypertrophy (0.5 mark)Pulmonary Stenosis (0.5 mark)

SAQ

1. Maggie, a 53 year old lady presents with unilateral leg pain. You are highly suspicious of a DVT. List 6 risk factors associated with DVT (3 marks).

Increasing age History of venous thromboembolism/DVT/pulmonary embolism Thrombophilia, specific examples also acceptable include:

o Protein C or S deficiency,o Factor V leiden,o antithrombin III deficiency,o hyperhomocysteinaemia,o antiphospholipid syndrome

Surgery Stasis of blood flow, specific examples also acceptable include:

o travel,o bed rest,o immobilization,o sedentary lifestyle,o bone fractures,o paralysis,

o leg ischemia or amputation. Trauma Hypercoagulopathy, specific examples also acceptable include:

o malignancy,o smoking,o exogenous oestrogen including oral contraceptive pill,o pregnancy.

Inflammatory disease processes Coronary artery disease Intravenous catheters Burns

2.What 2 findings specific for DVT might you elicit on physical examination that will assist in confirming your suspicion? (2 marks)

Asymmetrical calf swelling Asymmetrical thigh swelling Superficial venous dilatation Asymmetrical skin temperature Tenderness Redness Homans’ sign Mild fever Pitting oedema

3. Assuming a high clinical probability of DVT, what is the most appropriate diagnostic investigation and why? (2 marks)

Venous compression ultrasound.

Ultrasound and Doppler ultrasound are also acceptable answers.

Explanation: Two (2) marks awarded for an answer consistent with:

o A high specificity test is required to rule the diagnosis in.o Ultrasound is a high specificity test.

One mark awarded for venography because, although it is a high specificity test, it is not an appropriate investigation due to cost and technical requirements.

D-dimer is not an acceptable answer because it has a low specificity and high sensitivity and should therefore only be used in the setting of low clinical suspicion.

SAQ

Joe B, a 53 yr old computer programmer, presents to A&E on a Saturday morning with a productive cough, shortness of breath, and mild chest discomfort. You immediately notice his slightly pale, sweaty appearance

History: Joe has had the cough for 4 days, and this was preceded by a runny nose and sore throat. The chest discomfort began shortly after the cough, and occurs with breathing. He has been quite tired since the episode began, and had to take yesterday off work. He hasn’t been traveling lately. The rest of his history is unremarkable, and Joe appears to be otherwise healthy.

Question 1: (4.5 marks, ½ mark for each finding)

You include the following conditions in your differential diagnosis. What physical findings on a chest examination would make you suspect each of the following:-

Condition Elements of Chest ExaminationLobar Pneumonia(1.5 marks)

Dull to percussionBronchial breath soundsIncreased vocal resonanceCracklesReduced chest wall expansion on affected side

Pneumothorax(1.5 marks)

Reduced expansion on affected sideHyper-resonant percussion noteReduced or absent breath soundsReduced or absent vocal resonanceMediastinal displacement away from lesion

Asthma(1.5 marks)

Chest hyperinflationWheezingBilateral reduced chest wall expansionUse of accessory muscles

Question 2: (3 Marks)A chest radiograph is ordered. Opacity consistent with lobar pneumonia is seen in the region of the right lower lobe. Briefly explain the pathophysiologic process occurring within the lungs that accounts for this finding.

Proliferation of bacteria in the alveoli (1/2 mark) leads to a host inflammatory response (1/2 mark) which results in:-

1. Capillary leak, (1/2 mark)2. Exudation of protein-rich fluid (1/2 mark), and3. Neutrophil proliferation and extravasation into the alveolar spaces (1/2 mark).

This combination of capillary leak, purulent exudation and fluid accumulation appears asopacity on x-ray. (1/2 mark)

Question 3: (1.5 Mark total; 1/4 mark each)It is decided that Joe does not need to be admitted to the hospital. List six factors that, when present in a patient suspected to have pneumonia, would provide a strong basis for hospital admission (eg. Coexisting illness, age >65 years etc)

Curb-65 Criteria and PSI (PORT) Criteria: Confusion or altered mental status, Urea >7mmol/L, RR ≥ 30/min, BP S ≤ 90 mmHg or D ≤ 60 mmHg, age ≥ 65 years Nursing Home Resident Coexisting Illness Temp <35 or >40 , HR ≥ 125/min Arterial pH < 7.35, BUN > 30mg/dL,

Na+ < 130mmol/L, BGL > 250mg/dL, hematocrit < 30%, PaO2 < 60mmHg, pleural effusion

NB: Must state exact values to get the 1/4 mark. I.e can not say elevated urea, must say urea >7mml/L etc.

PUO: Short Answer (10 marks)

Milly, 27, presents to her local GP with a 3 week history of fever.

a) List 4 important questions you would ask in the history (2 marks)

Red flag signs : weight loss night sweats

Travel history Recent travel to areas of endemic illness i.e. Africa, South east

Asia Travelling with ill travel companions

PMH PMH of autoimmune disease FHx of autoimmune diseases PMH of unexplained fever

Associated sx Rash Myalgia/arthralgia

Pattern of fever i.e. tertian/quaternary/saddleback

Medications Sexual history Occupational history IV Drug use

b) List 3 broad causes of pyrexia (3 marks)e.g. infectious

Connective tissue disease/autoimmune Drug-induced Neoplastic Endocrine

c) Assuming an infectious cause describe the mechanism of fever in this patient. (5 marks)

Infectious agent -> release of monocytes/neutrophils (1) -> peripheral cytokine release (IL-1, IL-6, TNF) (1) -> centrally released PGE2 acts on hypothalamic thermoregulatory centre (1)-> elevated set point (1) -> peripheral response (shivering, raised BMR, vasoconstriction) for heat conservation and production (1) -> fever

POOR ANSWER: Infection -> inflammatory response -> increased blood flow -> fever

Short Answer Question

Jenny presents to your general practice with a chest infection, she has brought her daughter Zoe (7 months) with her. You notice that her vaccination schedule is not up to date.

Question 1.

List 5 vaccinations that are given by six months of age (abbreviations accepted).

Hepatitis B (hepB) Diphtheria, tetanus and acellular pertussis (DTPa) (pertussis without accellular is

accepted) Haemophilus influenzae type b (Hib) Inactivated poliomyelitis (IPV) (polio on its own is accepted) Pneumococcal conjugate (7vPCV) (streptococcus pneumoniae or

pneumococcus accepted on their own) Rotavirus

You talk to Jenny about getting Zoe's vaccinations up to date, however Jenny refuses as she says she read an article on the net about the immediate side effects Zoe can have to the vaccinations.

Question 2

List three (3) similarities and three (3) differences between refusal of childhood vaccination by parent/s and refusal of childhood treatment by their parent/s.  

Similarities DifferencesSufficient information for decision-making must be provided prior to both vaccination and treatment.  Discussion of specific parental concerns or specific concerns of the adult must occur.  A dismissive attitude to either the parent’s approach/beliefs or the adult’s reluctance or refusal will tend to reduce immunisation rates or treatment acceptance respectively. Assess competence of adult.  (Other adequate responses)

Refusal of immunisation of a child has potential implications for the welfare of others in the community, whose risk of disease may be increased with decreased immunisation rates. Risk perception differs between the two kinds of case, due to the relative absence of experience of diseases which can be vaccinated against (especially when vaccination rates are high) compared with most conditions affecting adults.  Refusal of vaccinations of children may lead to financial penilisation if parents do not notify a conscientious objection. (other adequate responses)

Similarities

Any mention of the following concepts: Providing information or that the patient should be fully informed Discussing concerns of adults Dismissive or paternalism reduces immunisation rates Assess competence

Other acceptable answers Respecting autonomy of patient

 Skin Cancer

1. Give one characteristic histological feature of the following skin cancer: SCC, BCC and melanoma. (3 marks)

SCC: keratin whorls, keratin pearls or localized keratin accumulation (1 mark), BCC: palisade arrangement of nuclei at the periphery of proliferating clusters of cells, picket fence arrangement of nuclei or darkly staining basaloid cells (1 mark). Melanoma: nests of melanocytes, melanocytes proliferating higher up in the epidermis (1 mark).

2. Give the three risk factors that associated with the development of skin cancer (1.5 marks)

Significant sun exposure in early life (0.5 mark), increasing age (0.5 mark), family history of skin cancer (0.5 mark). (Other answers accepted - see poor answer)

3. What is the main distinguishing feature between Breslow thickness and Clark level with respect to their use in skin cancer staging? (2 marks)

Breslow thickness is the absolute level of penetration of neoplasm, measured vertically in millimetres (1 mark). Clark level measures the depth of penetration with respect to the anatomical location in the epidermis/dermis. For example, dermal-papillary junction (1 mark).

Skin Cancer: Short Answer Question (18 marks)

You are a family GP in Gold Coast and one day, Tanya (19yo) walks in into your practice. Tanya comes to see you concerning a suspicious looking mole on her shoulder. “I do have a lot of moles but somehow this one looks bigger than before”, she says. You examine the mole, and take the following photograph.

1. Name 4 features of this lesion that would raise your suspicion of it being a malignant melanoma. (4 marks)

o It is asymmetrical

o Its border is irregularo It shows colour variegationo Its diameter is greater than >6mm

2. List 4 differential diagnoses of melanocytic nevi (2 marks)

Accept any of:o Melanomao Seborrheic keratoseso Lentigines (accept both simple lentigo & solar lentigo)o Ephelides (accept ‘freckles’)o Haemangiomas

3. (a) List 5 possible routes by which a cancer can spread from its primary site to other areas of the body. (5 marks)

Direct extension into surrounding tissue Via the lymphatics (lymphatic spread) Via the blood (venous or arterial; haematogenous spread) Transcoelomic (seeding of body cavities) In cerebrospinal fluid

(b) By which route does melanoma most often spread? (1 mark)

Via the lymphatics

Tanya’s case makes you think about the great number of Australians that die each year as a result of skin cancer and you wonder how their deaths might have been prevented. (6 marks)

4. (a) Explain the difference between a primary prevention strategy and a secondary prevention strategy.

Primary prevention strategies aim to reduce the incidence of a disease, i.e. prevent disease occurrence. Secondary prevention strategies aim to reduce the prevalence of a disease, i.e. by shortening the duration of a disease that has already developed.

(b) Give one example of a community-based primary prevention strategy and one example of a community-based secondary prevention strategy that could be used to try to reduce skin cancer mortality in Australia’s population.

A primary prevention strategyAccept any reasonable answer, e.g. -

o Advising schools that they should make children wear hats when playing outside

o Education campaigns advising people about correct sun safety.

A secondary prevention strategy: Accept any reasonable answer, e.g. -

o Education campaigns advocating regular self-examination and professional skin check ups

o Advising medical practitioners to conduct “opportunistic screening”, i.e. take the opportunity to perform skin checks on patients when examining them for something else

o A national screening program involving regular skin checks for all or for high-risk people

Spleen

(a) Wally L, aged 66, presents to your surgery with a 3-month history of fatigue, bleeding gums and a ‘throat infection that won’t go away.’ Mr L also complains of abdominal discomfort, pointing to the left upper quadrant. You notice that he looks rather pale.

One possible cause for Mr L’s abdominal discomfort is hypersplenism. Explain the normal functions of the spleen and how such functions may have caused Mr L’s symptoms and signs (2 marks)

(Normal function of the spleen: Removal/phagocytosis of old or abnormal erythrocytes/red blood cells and leukocytes/white blood cells from circulation (1/2 mark) and sequesters/stores/acts as a reservoir for platelets. (1/2 mark)

Overactive spleen can lead to excessive removal of erythrocytes Anaemia (1/2 mark), which may present with fatigue and pallor (1/2 mark).

Overactive spleen can lead to excessive removal of leukocytes Increased susceptibility to infections. (1/2 mark)

Overactive spleen may sequester more platelets Thrombocytopenia Increased risk of bleeding, especially in the mucosa. (1/2 mark)

(b) List two (2) pathological processes that may cause hypersplenism (2 marks)

Congestion, obstruction, malignancy, infection, autoimmune reaction, storage disease. (1/2 mark each, maximum 1 mark)

Travel Health: Short Answer Question (12 marks)

Maddox, a 22 year old male comes into your GP surgery.  He has recently returned from overseas & is complaining that he feels unwell.  

a) What are four (4) key questions you would ask Maddox about his travel history in order to develop an appropriate differential diagnosis? (2 marks)

Where did you travel? When did you travel:– departure date– return date?

Did you travel in:– urban areas– rural areas?

What was the purpose of your travel:– tourism– visiting friends or relatives– business– other?

What special activities did you undertake:– mountaineering– scuba diving– caving– other?

What vaccinations did you receive?

Were you taking malaria prophylaxis?If so:– which drug did you take– when did you start it– did you take it regularly as directed– are you still taking it?

Did you become ill while away? Did anyone accompanying you become ill?

During the consultation, you find that Maddox’s symptoms include fever and lethargy.  You suspect he may have malaria.  

b) Give four (4) other clinical features of malaria you would investigate (2 marks).

Confusion (cerebral malaria – fits and even coma)  hepatomegaly splenomegaly hepatoslenomegaly may be used instead of hepatomegaly/splenomegaly jaundice headache any sign/symptom of anaemia (anaemia itself cannot be used as an answer) myalgia

Maddox tells you that he did not take any prophylactic medications nor did he receive any vaccinations due to his beliefs that they are a big scam by the big pharmaceutical companies.  He does not intend to have his children vaccinated either.

c) Explain as the GP how you would consider the following ethical principles (autonomy, non-malificence, beneficence, justice) in relation to a parent choosing not to vaccinate their child.  (Maximum 8 marks) 

Autonomy:

Autonomy – right to self-determination and non-interference - allowing one to make their own decisions to refuse or consent to healthcare. (0.5 marks)

Doctors must respect the autonomy of their patients by avoiding paternalistic behaviours (for example coercion) (0.5 marks), but must strive to improve autonomy by ensuring their patients are fully informed (in this case, about the benefits of vaccination)(0.5 marks)

Children are considered to have a lesser capacity to practice their autonomy compared to an adult (0.5 marks). For this reason, a child’s parent or guardian is able to consent to or refuse to vaccination, on behalf of the child, if it is done with the child’s best interests in mind. (or, parents are commonly the substitute decision makers who are responsible for their children’s healthcare) (0.5 marks)

Parents generally do not have the right to refuse a treatment that is immediately life saving (0.5 marks). As a vaccine is not immediately life saving, the refusal of vaccination for a child often falls within the rights of a parent authorizing their autonomy. (0.5 marks)

Non-malifecence:

Non-malificence is the principal that dictates that above all, a doctor shall do no harm. (0.5 marks)

In this case the doctor must consider the potential harms of administering the vaccination (pain of injections) (0.5 marks) and the potential adverse effects of the vaccination (0.5 marks). In the case of vaccinations these potential harms are low (0.5 marks)

There is also a potential harm to the community if vaccination rates decline – there will be a decrease in herd immunity and decreased protection for the wider community (0.5 marks).

Beneficience:

Beneficience is the principle which drives doctors to do good to patients and to treat with the patient’s best interests in mind (0.5 marks).

By immunizing children against preventable diseases, doctors are able to practice beneficence by helping to prevent the burden of disease (1 mark)

By maintaining high vaccination rates, herd immunity is achieved thus benefiting the wider community (0.5 marks)

In a highly immunized population, a parent may deem that their child can receive the benefits of herd immunity without exposing their child to the potential adverse effects of the vaccination program (0.5 marks)

Justice:

Justice is involved with the determination of rights and responsibilities and ensuring that these are equally distributed amongst all members of society (0.5 marks)

Every individual in the community has a right to be protected from preventable infectious disease, this can be achieved through maintaining high levels of childhood vaccination (1 mark)

Vaccination is more cost effective than treating the acquired disease (good use of public funds) (0.5 marks)

An unvaccinated child may be discriminated against in the context of their education/societal opportunities (eg. denied daycare, removed from school during outbreaks etc) (0.5 marks)

WBC Abnormalities SAQ

You are a haematologist at the RBWH and a patient, Bob G, is referred to you by his GP after having a lymph node biopsied. The results show diffuse large B-cell lymphoma (stage 3). You explain to him the diagnosis and prognosis. After the staging procedures are complete you start Bob on CHOP-R therapy.

1. The staging demonstrates axillary and inguinal adenopathy. The bone marrow biopsy/aspirate is negative and there are no other extranodal sites of involvement. Of note, Bob presented without weight loss, night sweats or fever. What is the name of the most common staging system used in patients with NHL? What stage would you describe Bob’s lymphoma as being? (2 marks)

The Ann Arbor Staging System (1 mark)Bob’s lymphoma is stage 3A (1 mark)

2. Explain the benefits of multi-drug treatment compared to single agent therapy (3 marks)

Using more than one drug increases the efficacy of treatment because the patient experiences fewer side effects and more drug can be used/the ability of the drug to kill cancer cells is better when used in combination.

An appropriate-level answer will mention and/or explain the concept of synergy – that is, the word ‘synergy’ is not necessary but a demonstrated understanding of decreased toxicity/lower drug doses for similar efficacy/complimentary mechanisms of action is:

Drug regimens for cancer chemotherapy are designed to optimize the antineoplastic effects of drug combinations (0.5 mark), while minimizing their (systemic) toxicity (0.5 mark). The regimens often use drugs that work synergistically, i.e. they have different toxic effects due to different mechanisms of action, maximizing cytotoxic effects on tumour cells while sparing host tissue(1 mark); thus multi-drug therapy can therefore be successful with lower dose (1 mark).

3. CHOP-R includes the following drugs: cyclophosphamide, hydroxydoxorubicin, vincristine, prednisone, and rituximab.

a. Give the mechanism of action for vincristine and indicate the cell cycle phase where it acts. (2 marks)

Vincristine binds to tubulin (0.5mark) and blocks tubulin polymerization (0.5mark). It acts on the M phase of the cell cycle (1 mark)

b. Name three adverse effects of prednisone in this patient (3 marks)

Cushingoid syndrome (telangiectasia, bufallo-hump, moon faces, paper-like thin skin/bruising), hyperglycaemia, osteoporosis, lymphopenia, cataracts, glaucoma, behavioural changes, hypertension. (This list is not exhaustive – medically correct answers should all suffice) – 1 mark for each good answer

SEMESTER 2

Dementia: Short Answer Question (9 marks)

Bill (73) and Joan (71) see you for a routine follow-up visit for Bill's blood pressure. Both have been patients of yours for the past two years after selling their property and moving to Brisbane from Roma due to declining health. Bill was diagnosed with Alzheimer's disease shortly after seeing you for the first time and has been progressively deteriorating. Joan is frail and suffers from rheumatoid arthritis and osteoporosis. Their closest family is their son, who lives on the Gold Coast, 40 minutes from their unit. Today, both look a little more dishevelled than usual and Joan is quite teary. She mentions that Bill has gone "walkabout" three times this week and is now finding it difficult to dress himself. She mentions that she is having difficulty helping him. Her arthritis makes her slow with zips and buttons and Bill gets angry with her. 

a) Using the table below, list and describe three features of Alzheimer's dementia and describe at least two different ways in which the features would impact on Bill and on Joan.

Feature   Impact on Bill Impact on Joan Example:Depression (severe is rare due to loss of insight)

Example:Feelings of apathy, or burdensomeness leading to decreased self-esteem and development of/perpetuation of automatic negative thoughts. Increased risk of suicide during periods of lucidity.

Example:Sense of guilt, frustration, sadness, helplessness or incompetence. Potentially leading to a depressed mood herself.

Memory loss - inability to learn, retain and process new information

Frustration and annoyance at self, sense of isolation.

Increased need to supervise and assist Bill, leading to increased workload, stress and decreased available time for her own activities.

Decline in language - difficulty in naming and in understanding what is being said

Reduced ability to communicate leading to embarrassment, confusion, anger and frustration. Failure to understand directions, instructions and requests may result in dangerous activities (failure to follow safety directions, medication dosage regimes).

Difficulty communicating effectively with her husband may contribute to a sense of isolation and altered feelings toward him and subsequent feelings of guilt. Frustration with simple conversations becoming repetitive and tiring.

Apraxia - Impaired ability to carry out skilled motor tasks

Decreased independence, reduced self esteem, embarrassment and frustration at not being able to complete simple tasks such as doing up zips, buttons and shoelaces. Loss of the ability to drive, resulting in increasing social isolation and withdrawal.

Required to assist with any skilled motor tasks or will have to do them herself, increasing her daily workload. Her own illnesses may impair her ability to help and external assistance/devices may be required adding costs and a sense of helplessness, dependence and burdonsomeness.

Agnosia - Failure to recognise objects

Depending on severity, may result in confusion when attempting simple activities

May need to keep dangerous items out of easy access locations for fear that

such as setting the table or eating, or may lead to potentially dangerous situations with hot/sharp items, small appliances and tools, chemicals and medications.

Bill will accidentally harm himself or others (‘child proofing’ the house). May lead to anger, frustration and arguments over simple items Bill cannot find or recognise, adding more stress to their relationship.

Progressive loss of executive function

Inability to work or participate in control of household management tasks. Continued attempts to do so may result in unpaid bills, risk of financial abuse, inadvertent purchases.

All responsibility for household function lies with her. This may be a new role for her within the marriage. She may also fall victim to forms of financial or other abuse.

Behavioural change - agitation, aggression, wandering, persecutory delusions

Physical danger to himself or others through wandering or aggressive behaviour. May result in further social isolation. Delusional episodes may be mistaken for psychosis leading to inappropriate medications. Disinhibition may cause behaviour that results in community stigma and further isolation or victimisation.

Changes in Bill's personality may lead to fear of physical harm, sadness over the loss of the previous relationship or social embarrassment and feelings of guilt. Wandering episodes may lead to the need to improve the security of the house and yard or 24 hour observation, increasing stress and workload.

Loss of insight Inability to relate to those around him due to not being aware of how his actions are affecting them. May contribute to loss of friendships and long term relationships without understanding why, leading to sadness, anger or depression. He may refuse treatment or medication believing nothing is wrong with him.

Joan may take comments or actions made by Bill personally, yet still be fully aware that they are due to his inability to moderate his behaviour. She may find it difficult to get Bill to cooperate with medical and allied health staff or to adhere to treatments, increasing her stress and anxiety.

Depression (severe is rare due to loss of insight)

Feelings of apathy, or burdensomeness leading to decreased self-esteem and development of/perpetuation of automatic negative thoughts, lethargy, concentration problems and lack of motivation. Increased risk of suicide during periods of lucidity.

Sense of guilt, frustration, sadness, helplessness or incompetence. Fear of suicide of her husband. All potentially leading to a depressed mood herself.

Marking Guide:

A poor answer would be very factual and literal.  The answers would be an extension of the definition of the features and not an application of the definition to the biopsychosocial aspects of Bill and Joan's lives.  The student may not define the feature initially and use the

impact boxes to describe the feature, without actually describing the impact in terms of the effect on Bill or Joan.

Feature   Impact on Bill Impact on Joan 1 mark 1 mark 1 markMust show understanding of the feature listed. This may be through the description of the feature, as in the sample answer or by demonstrating an obvious understanding of the feature through its impact. For example, apraxia without further explanation and an impact of inability to remember... would only gain ½ a mark for the feature because the feature listed is technically correct, but the student does not understand what it is.

Must describe at least two ways in which the feature will impact on the patient. Each is worth ½ a mark.

This should focus on aspects of emotional, psychosocial, practical or economic impact (effect) on the patient. A description of what the feature is (eg. difficulty performing skilled motor tasks) only gains ½ a mark.

Must describe at least two ways in which the feature will impact on the carer. Each is worth ½ a mark.

This should focus on aspects of emotional, psychosocial, practical or economic impact on the carer. An extension of a description of what the feature is (eg. will have to help in performing skilled motor tasks) only gains ½ a mark.

A good answer will place the impact in the context of Joan’s disease and social support.

Depression

Mr Ben Zo, a 29 year old lawyer presents to you this morning saying that he is tired all the time. He complains that he is having trouble concentrating at work and feels irritable. Despite feeling tired during the day, he is finding it increasingly difficult to sleep at night and is requesting “something to help him to sleep”. On further questioning, he denies any history of traumatic life events, recent bereavements or changes to personal circumstances. You believe Mr Ben Zoe is depressed.

(a) List four psychiatric diagnoses that you would consider for this patient (excluding Major Depressive Disorder) (4 marks)

Bipolar disorder (depressive phase) Substance abuse (alcohol, amphetamines, drug withdrawal) Generalised anxiety disorder Psychosis Dysthymic disorder Seasonal affective disorder

(b) You seek to identify if Mr Zo is at risk of suicide. List three (3) distinct risk factors that you consider relevant in assessing his suicide risk that haven’t already been elicited on history (3 marks)

3 marks for three responses. One mark for:

Suicidal ideation – thoughts, plans or intents Previous suicide attempts Feelings of hopelessness, helplessness and/or worthlessness

Half marks for (Note – this is the decision of the question checker from Mental Health) Family history of mental illness (eg mood disorder, suicide or substance

abuse) Access to means (eg drugs, firearms History of psychiatric illness (eg depression, bipolar disorder, alcoholism or

other substance abuse, schizophrenia, personality disorders…) Previous threats of suicide Social isolation or rural background Previous history of substance abuse Physical illness such as chronic pain, recent surgery and chronic or terminal

disease

No marks for: male gender, older age, recent bereavement, separation or divorce, recent retirement or loss of job

Doctor’s Health: Short Answer (4 marks)

The medical profession is often regarded as a particularly demanding and taxing lifestyle.

a) Name 2 common problems that Doctor’s may be susceptible to due to the nature of the profession.

Name 2 common problems that Doctor’s may be susceptible to due to the nature of the profession. Alcohol and other substance abuse Depression Suicide Relationship difficulties Disenchantment with medicine leading to stress and burnout.

b) List 2 barriers that may prevent Doctor’s seeking help regarding their problem.

List 2 barriers that may prevent Doctor’s seeking help regarding their problem. Stigma about psychiatric illness Lack of supervision Colleagues turn a blind eye “ there but for the grace of God go I” Misplaced loyalty esp. from student days Personality style eg the obsessional person sees admission of the need for

help as evidence of being intrinsically flawed Concerns about the confidentiality with which a colleague may treat

information they give them Pressure from self/ colleagues/ family to perform and achieve financially and

professionally Fear of being unable to continue to work and maintain lifestyle/service debts Knowledge about treatment limitations/ side-effects Sense of omnipotence, unrealistic expectations of self

Drug Abuse SAQ

1. What are four diagnostic features of psychosis (2 marks)

Delusionso Persecutoryo Of referenceo Grandioseo (Paranoid – strictly speaking this is persecutory + grandiose)o Autochthonous (Primary)o Secondary

Formal thought disorder Hallucinations (eg 3rd person auditory) Thought alienation

o Insertiono Withdrawalo Stoppingo Broadcasting

Passivity phenomenao Thoughto Willo Action

2. List 2 pharmacological treatment agents used in psychosis, one side effect of each and basic mechanisms of action of each (3 marks)Typical Antipsychotics –

Side Effects Dopaminergic Extrapyramidal Side Effects

(acute dystonias, akathsia, parkinsonism, tardive dyskinesia) Endocrine side effects – increased prolactin levels Anti-histamine sedation, antimuscarinic effects dry mouth, blurred vision, urinary retention postural hypotension, weight gain Jaundice Agranulocytosis, Leucopenia neuroleptic malignant syndrome (NMS) Chlorpromazine only also causes photosensitivity Prolongation of QTc interval (ECG effect)

Examples Chlorpromazine Thioridazine (?no longer available – taken off the market in UK) Haloperidol

Mechanism Of Action Primary – antagonist at Dopamine D2, Secondary – antagonist at

o Dopamine - D1, D3o Noradrenaline - alpha1o Histamine - H1o Acetyle-choline - (muscarinic) M1o Serotonin (5-HT) - 5HT2. and probably others

Atypical Antipsychotics –

Not a uniform class. Much more variation between drugs…

Side Effects Extra-pyramidal side-effects

– much less common but do occur, probably more with Risperidone, Amisulpride

– Dystonias – dyskinesias– akathisia, and other

Weight Gain & metabolic syndrome esp. with olanzapine

QTc prolongation Hypersalivation

Esp. with Clozapine Agranulocytosis

Esp. with Clozapine, requires monitoring as condition of treatment

Sedation More marked with quetiapine & Clozapine Less marked with the others

Agitation sometimes with aripiprazole

Mechanism Of Action Mechanism of action not as well known and not the same between drugs. There is a theory that the newer drugs block 5-HT2A receptors & others

at the same time as they block DA receptors and that somehow this serotonin-dopamine balance confers its characteristics.

Also theory of “limbic-selectivity”

Aripiprazole is known to be dopamine D2/3 partial agonist.

Examples Clozapine Risperidone Olanzapine

3. What are 4 of the criteria for drug dependence (2 marks)

Tolerance Withdrawal symptoms Difficulty controlling use, e.g. taken in larger amounts or for longer period

than intended or unsuccessful attempts to cut down Strong desire or compulsion to use Great deal of time getting, using, or recovering Important activities given up or reduced Continued use despite physical or psychological problems

4. List 4 risk factors for illicit drug use (2 marks)

o Adolescenceo Childhood physical sexual assault / poor quality family relationshipso Early age of first useo Geneticso Knowledgeo Lack of social bondingo Low socio-economic status

o Maleo Peer use / pressureo psychiatric conditionso Availability of drugso financial meanso lack of parental supervisiono parental exampleso physiologic vulnerabilityo Personality factors

Anti-social behaviour Conduct disorder Impulse control problems

Epilepsy: Short Answer Question (10 marks)

Question:Tara is a 20 year old female University student who comes to see you for a routine check up at your GP clinic. You look up her history and note that Tara was diagnosed with Epilepsy when she was sixteen (16) and is currently on Valproate. As you are talking to Tara you notice that she seems quiet and subdued.

a) Discuss four (4) ways in which epilepsy can negatively impact on a Tara’s lifestyle

Stigma: Reinforces lack of self confidence and self esteem and therefore also anxiety and depression states among epileptics. This leads to feelings of not fitting in (especially children), difficulties in establishing friendships and other social contacts and marginalization.

Relationships: Stigma and marginalization can result in difficulty establishing relationships.

Loss of driver’s license: Almost always associated with some loss of freedom. Simple things like going to work, visiting a doctor or going shopping may become very difficult (especially in rural settings).

Employment: Certain occupations cannot be carried out by epileptics. The difficulty in commuting to work may lead to loss of employment. Remember that employment not only provides financial rewards but also a state of purpose. Therefore it is not uncommon for the unemployed to question their self worth.

Sport & Leisure: Although encouraged, certain sports may require that a second party be present (eg swimming).

Travel: Provisions for a supply of medication when travelling abroad must be made. Travelling may raise further anxiety as to the consequences of a seizure while abroad.

Education: Some evidence suggests that epileptics collectively achieve at a lower level than their peers. Biological factors such as memory disturbances play a significant role as do other factors such as teacher/parental expectations, misconceptions, high rate of absence from school, social isolation, and anxiety.

Housework: Activities such as climbing a ladder or using a power tool carry a higher risk of injury.

Pregnancy: Seizures during pregnancy and side effects of medication (teratogenesis, increased rate of babies born with birth defects, decreased effectiveness of OCP) are all issues of concern to epileptic women of reproductive age.

b) An individual may cope with stigma in many ways. Following the example in the table list three further ways an individual may cope with stigma, and explain these coping styles.

Coping style Explanation

Eg Accept the stigma The patient may incorporate the stigma into their identity and be open and positive about the stigma.

1 Correct the attribute to remove stigma

Through treatment and therapy the patient may be able to remove the attribute causing the stigma

2 Compensate Finding ways to complete ordinary tasks despite the condition and the stigma

3 Find a secondary gain Using the condition or the stigma associated with it to access new areas and aspects of life

Develop a new identityFinding a special, usually religious meaning behind the stigmatised attribute, and embracing this as a new identity

SecrecyThe patient may conceal the condition as far as possible and may experience intense fear of others discovering their condition

WithdrawalWithdrawal from normal social relationships and becoming isolated due to excessive stigma from the condition

Frequency/Urgency and Polyuria: Short Answer Question (6 marks)

Mr Hugh Rethra, a 67 year old man, presents to your general practice with urinary frequency and urinary urgency. You perform a physical examination including a DRE. You diagnose Benign Prostatic Hypertrophy

(a) What is the difference between urinary frequency and polyuria (specific volumes are not required)? (1 mark)

Urinary frequency is urination a short intervals without increase in daily volume of urinary output, whereas polyuria is the passage of a large volume of urine in a given period.

(b) List four (4) differential diagnoses that may cause urinary frequency in this patient (2 marks)

Bladder infection (cystitis) * Urethritis (infection of urethra)* Infection of ureters* Pyelonephritis (kidney infection) *Or urinary tract infection Bladder Neoplasm Kidney neoplasm Urinary tract neoplasm Diabetes mellitus Diabetes insipidus Excess fluid intake Diuretic use Calculus of bladder# Calculus of kidney# Calculus ureter#

Calculus urethra# # Or urinary tract calculi Urethral stricture Chemical irritation Caffeine intake Alcohol intake Urethral stricture Neurogenic bladder (poliomyelitis / parasympatholytic drugs / tabes dorsalis multiple sclerosis / spinal cord lesion / diabetic neuropathy) Psychogenic bladder Anxiety Urinary tract obstruction / Bladder outlet obstruction External genital lesion Pelvic mass Extrinsic bladder compression Upper motor neuron lesion Detrusor instability Prostate enlargement / obstruction e.g. prostatic cancer Prostatitis Nephritis Hyperthyroidism Hyperparathyroidism Urinary tract clots Anticholinergic drugs Smooth muscle depressants Haemorrhoid Diverticulitis Appendicitis

(c) Explain why Mr Smith is at increased risk of urinary tract infections. (1 mark)

BPH -> Urinary Tract ObstructionAscendingReduced/absent voiding due to UTOBacterial growth and colonisation = infection

(d) A transurethral resection of the prostate is indicated. You are in the process of obtaining consent. Briefly explain the two categories of material risk in QLD. (2 marks)

A risk is material if, in the circumstances of the particular case:

1. Proactive duty: a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it. (1)

2. Reactive duty: the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance (1)

Parkinson’s Disease: Short Answer Question (8 marks)

Timmy Tremble, aged 63 years, presents to your GP practice, with an exacerbation of his symptoms. He was previously diagnosed with Parkinson’s disease 5 years ago, and was well-controlled on Levadopa until recently.

(a) List four classical features (signs / symptoms) of Parkinson’s disease. 2 marks (pass: 1.5)

rigidity 0.5 marks resting tremor (at 4-6 Hz) 0.5 marks postural instability / gait disturbance 0.5 marks akinesia / slowness or clumsiness in movements 0.5 marks [1]

(b) Describe the pathophysiology underlying Parkinson’s disease, specifically relating to the basal ganglia and their influence on the motor pathways. You may wish to use a diagram to aid in your explanation. 4 marks (pass: 2)

Idiopathic Parkinson’s disease is characterised by decreased dopamine synthesis (0.5 marks) due to progressive degeneration of neurons in the pars compacta of the substantia nigra (0.5 marks), resulting in a functional deficiency of dopamine in the striatum of the basal ganglia (0.5 marks).

Under physiological conditions, dopamine stimulates the direct pathway (which facilitates movement) through the basal ganglia, whilst inhibiting the indirect pathway (which inhibits movement) (0.5 marks). The functional dopamine deficiency leads to dysregulation of the basal ganglia via down regulation of the direct pathway and up regulation of the indirect pathway (0.5 marks).

This leads to a decreased signal via the thalamus to the motor cortex (0.5 marks), resulting in decreased activation of the corticospinal tract (0.5 marks).

The overall result typically manifests as slowed responses and less spontaneous movement (0.5 marks). [2,3]

A basic map of the basal ganglia and the pathways involved may assist in explaining the underlying pathophysiology: e.g.

(c) Parkinson’s disease is a chronic illness. Describe four challenges faced by people who have a chronic illness. 2 marks (pass: 1.5)

Gaining access to appropriate well coordinated services Availability of after-hours care including home visits Problems with transport and mobility Communication problems Financial disadvantage Stigma / self-esteem issues Management of co-morbidities or complications: depression, falls, Relationship strains – carers, family and friends Long-term management of medications e.g. adherence and side effects [5]

Headache Questions SAQ

A 35 year old female presents to a GP with increasing tiredness, a stiff neck and difficulty in concentrating over the last 48 hours. Combined with this has been an increasing sensitivity to bright light and loud sounds. She says she has experienced these symptoms in the past as they usually precede a bad headache most often located to one side of her head which is throbbing in nature and aggravated by physical activity.

a) Give three differential diagnoses for the presenting complaint

Cluster headache Brain tumor Temporal (giant cell) arteritis Sinusitis Subarachnoid hemorrhage Pseudotumor cerebri Transient ischemic attack Tension headache Venous thrombosis Idiopathic intracranial hypertension (IIH) Hypoxia Hypoglycemia Dialysis Pheochromocytoma Raeder's syndrome Glaucoma Hypnic headache Dissection of the carotid or vertebral artery Antiphospholipid antibody syndrome Cerebral vasculitis Moyamoya disease CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and

leukoencephalopathy) MELAS (mitochondrial encephalopathy, lactic acidosis, and strokelike episodes)

syndrome

b) Name three non-pharmacological treatments of this acute condition

Rest or sleep in a dark and quiet room Relaxation techniques may be of benefit Avoid triggers Dark room Warm or cold packs to head Spinal manipulation Rebreathing into paper bag

Relaxation techniques Neck massage Avoidance of triggers such as:

o alcohol o hunger o foods (eg chocolate, cheeses, MSG, nitrate-containing foods) o irregular sleep patternso organic odourso sustained exertiono altered stress levelso flashing lights/glares

managing environmental shifts such as: o time zone changeso high altitudeo barometric pressure changeso weather changes

Avoid movement/activity (including reading and watching TV) Rehydration with IV fluids if vomiting persistent

c) Name three pharmacological treatments of this acute condition

Paracetamol NSAID

o Ibuprofeno Naproxeno Diclofenaco ketoprfen

Metoclopramide Domperidone Sumatriptan Naratriptan Zolmitriptan. Ergotamine Dihydroergotamine Aspirin Opioids Triptans Narcotics

o Codeineo Pethidine

Prochlorperazine

Kidney Failure: Short Answer Question

 A 59 year old obese male with chronic renal failure is noted by the registrar to be in a delirious state. This morning on ward rounds, he mentions that he wishes to make an advance health directive (AHD) to cease dialysis, if his condition deteriorates further.

(a) Is he currently in a legal position to write an AHD?  Select one of the following.

      a)      yes

b)      no

 Answer B

 

(b) Describe 2 of the advantages of AHDs: (2 marks)

They extend self-determination beyond competency Avoids quality of life decisions having to be made by others Help reduce anxiety of patients over end-of-life issues Help reduce anxiety of health practitioners over end-of-life issues )

(c) List 2 circumstances in which an AHD may be overruled: (2 marks)

Terms are uncertain or contradictory. Contrary to good medical practice. Inappropriate because circumstances have changed. Inappropriate because of advances in medical science. )

Meningitis: Short Answer Question (9 marks)

A 17 year old male presents to your general practice with headache, photophobia, neck stiffness and a temperature of 39.2°C. You suspect bacterial meningitis.

a) Apart from meningitis , give two possible differential diagnoses (2 marks)

Malaria, encephalitis, septicaemia, subarachnoid haemorrhage, tetanus

b) Name three (3) organisms which commonly cause bacterial meningitis (3 marks)

Haemophilus influenza, Neisseria meningitidis (or meningococcus), Streptococcus pneumoniae (or streptococcus), Listeria monocytogenes, Escherichia coli, Staphylococcus aureus, Group B streptococcus

c) The diagnosis of bacterial meningitis caused by some organisms is notifiable under the public health act of 2005. What public health measures are taken after diagnosis is made? (4 marks)

Notify public health Contact tracing Clearance (or chemoprophylaxis) Vaccination if appropriate

Psychosis: Short Answer Question (8 marks)

Ms P, aged 22, presents to you in the E.D. one evening with an apparently minor laceration on her left forearm. She has been brought in by a concerned friend, and is acting a little strangely but you think this might just be anxiousness at being in the E.D., and annoyance at the length of time she has been waiting to be seen. However, it crosses your mind that she might need psychological assessment.

1. List 4 features of psychosis (2 marks, ½ mark each)

Disruption of the Form and Flow of Thought and SpeechFlight of ideas (disconnected ideas, incoherent speech, loose associations)Pressured speech (rapid and unrelenting speech)Thought blocking (speech halted for variable intervals)Clanging (rhyming speech without meaningful content)Echolalia (sing-song repetition of recently heard words or phrases)Neologisms (idiosyncratic or newly coined words)Alogia (paucity of speech, mutism)Disruption of the Content of Thought and PerceptionDelusions (false beliefs about reality that are not amenable to revision by fact)Persecutory delusions (others intend the person harm)Delusions of grandeur (person is famous or all powerful)Delusions of reference (events or others' actions are directed at the person)Thought broadcasting (the person's thoughts can be sensed by others)Thought insertion (others' thoughts are invading the person's mind)Loss of insight (unawareness of the person's illness)Hallucinations (typically auditory > visual in schizophrenia; visual > auditory in organic psychoses)Disruption of EmotionsBlunting of affectInappropriate affectLabile affectDisruption of behaviorRitual behaviorAggressivenessSexual inappropriatenessPosturing or grimacingMimickingWithdrawal

2. Psychotic disorders may be functional (without known biologic cause) or organic (resulting from medical or neurologic illness or cause). List 2 features (signs or symptoms, but not investigation results) (1 mark each) that might point to psychotic symptoms being the result of organic disease. For each of these listed features, describe how they point towards organic disease (1 mark for each)? (NB: Schizophrenia, depression, schizophreniform disorder, and similar psychiatric conditions are not classed as organic illnesses for the purposes of this question.) (4 marks)

Clues to the possible organic basis of psychosis include the following: substantial memory loss, clouding of consciousness, absence of a family or personal history of psychiatric illness, presence of a serious underlying medical or neurologic condition, acute onset of symptoms, visual rather than auditory hallucinations, and presence of myoclonus or asterixis. (Andreoli & Carpenter’s Cecil Essentials of Medicine, 7th ed, p 1060)

Explanations could include: Memory loss is more common in patients with dementia, and is a common

feature of delirium (see Kumar & Clark, 6th ed, p 1309-10) Short term memory loss could be the result of intoxication or alcohol abuse

(Korsakoff's syndrome). People with a family history of psychiatric conditions, are more likely to have the

condition themselves than those without a similar history. (e.g. for schizophrenia, see Kumar & Clark, 6th ed, p 1307)

A serious known underlying medical condition would obviously make this a more likely cause – delirium is common in hospital patients (see above ref & Harrison’s 17th p 1724)).

Acute onset can suggest delirium, particularly in hospital patients (see K&C ref) Auditory hallucinations are a common symptom of schizophrenia, but visual

hallucinations are much more common in delirium. myoclonus can be seen in association with pathology in cortical, subcortical, or

spinal cord regions, associated with hypoxic damage (especially following cardiac arrest), encephalopathy, and neurodegenerative disorders. Reversible myoclonus can be seen with metabolic disturbances (renal failure, electrolyte imbalance, hypocalcemia), toxins, and many medications. (Harrison’s 17th, p2500).

Asterixis is an indication of hepatic encephalopathy. (Harrison’s 17th, p 1979). Clouding of consciousness can be caused by diffuse metabolic processes (e.g.

organ failure) and focal, structural processes (e.g. stroke). (Harrison’s 17th, p 1721).

Anything else that on the face of it makes sense.

3. Choose 2 features in Ms P’s history and explain how they might lead you to a particular diagnosis. Each feature can contribute to a different diagnosis, or they can both point to the same diagnosis. (2 marks)

She presents late at night which might point to alcohol or drugs being the cause She has an obvious traumatic injury. There could be others, perhaps a head

injury, which could cause strange behaviour. She might simply be anxious and tired, with the laceration being the only real

problem. She might be depressed and the laceration is the result of self-harm, particularly

since it is her left arm. Anything else that seems coherent

SAQ –Renal Failure

Dave the Wiggle is a long-term patient of your clinic with a progressively defining eGFR. It has been under 60 for greater than 3 months, and his latest result indicates an eGFR of 40.

(a) Give two modifiable and two non-modifiable risk factors for this condition. (2 marks; 0.5 marks each)

modifiable risk factors: Hypertension Diabetes Mellitus Smoking Obesity Other answers:

o Excessive dietary protein, o Hyperlipidemia, o Abnormal calcium/phosphorus homeostasis

Non-modifiable risk factors: ’in age or advancing age Family history of kidney disease Race (ATSI, African) Other answers:

o Previous episode of acute renal failure; o Structural abnormalities of urinary tract; o Autoimmune disease; o Genetics; o Intrinsic paucity in nephron number

(b) The kidney is involved in many functions of the body and some of these are listed in the table below. What is the complication that results from a failure of this function in chronic kidney failure? (0.5 marks each) Outline a mechanism for this effect (1 mark per mechanism). An example is shown below.

Function of Kidney Complication associated with chronic renal failure

Mechanism

Eg. Erythropoietin (EPO) synthesis and release

Anaemia KF dec EPO production and release dec red blood production overall decreased RBC mass anaemia.

Vit D synthesis/activation Osteomalacia KF → decrease in 1,25-dihydroxycholecalciferol → decrease in activation of vitamin D to active form → decreased intestinal absorption of calcium and phosphate → decreased mineralisation of bone (osteomalacia)

Acid/Base balance Metabolic Acidosis KF → decreased excretion of protons (H+, K+, NH4

+)(loss of buffering systems) → increased retention of H ions in the blood → ↓pH → metabolic acidosis