Year 2 SAP Outcomes-3.pdf

Hello! The following "Tabs" are the Learning Outcomes for Year 2 SAP (2022/23) coupled with the relevant notes. In the comments section, you will find some of the questions asked for SAP which could be very helpful. Please take the notes with a pinch of salt as there are likely errors within in (we...

Hello! The following "Tabs" are the Learning Outcomes for Year 2 SAP (2022/23) coupled with the relevant notes. In the comments section, you will find some of the questions asked for SAP which could be very helpful. Please take the notes with a pinch of salt as there are likely errors within in (we did not recheck it after finishing Year 2). Hope this becomes useful! p.s. Year 2 is very content heavy, all the best, it is going to be a little tough :/ Notes prepared by Yuen Qi, Tze Xin & Fiffy (& a little bit of Insha) Learning Outcome Questions for revision Notes Delivery Discipline(s) Describe the process of Why are priorities important? Self Study Public health setting national health care - ensure best outcome for all patients priorities and the role of - prevent discrimination or disregard for legal rights economic evaluation - allocation based on clinical needs Why are setting priorities How are priorities set important? - NICE guidelines (evaluate evidence of treatmets and looks at QALY per cost) - Economic evaluations when it comes to resource allocation 1. Cost-minimisation (when output is equal, the cheapest therapy is preferred) 2. Cost-effectiveness (choosing the cheapest treatment which provides a "unit" of therapeutic good) 3. Cost-utility (QALY, costs vs mortality/ mobidity) 4. Cost-benefit (intervention taken when financial value of benefit > financial value of cost) Apply the principles of clinical Invasive: invasive ductal carcinoma, Paget's, inflammatory breast cancer Taught Diagnostics, Reasoning reasoning in formulating a Non: ductal carcinoma in situ, lobular carcinoma in situ differential diagnosis between the different presentations of DCIS breast disease - abnomral cell growth confined to ducts - lump, nipple discharge What are the main sites of - can be invasive if not removed metastasis for breast cancer? LCIS - abnormal cell growth confired to lobules - increased risk of future invasive cancer IDC - abnormal cells that infiltrate into breast tissue - can metastasise Inflammatory carcinoma - rare, invasice - red, swollen breast Paget's disease - eczematous rash around nipple/areola Main sites of metastasis (bone, brain, liver, lungs) Describe the risk factors for What are the non-modifiable 1 in 7 women have a risk for breast cancer Taught Pathology breast cancer and its risk factors for breast cancer? epidemiology Increased levels of sex hormones (estrogen, prosgesterone, testosterone) > increase breast What are the modifiable risk cancer risk factors for breast cancer? Risk factors Non-Modifiable - female - early menarche, late menopause - older age - radiation - PMG/FH of breast cancer Modifiable - Not breast feeding - Older age of first pregnancy (>30yo) - Nulliparous - HRT - Obesity Describe the mechanism of List the cancer drug, drug Alkylating agent Taught Pharmacology action, pharmacokinetic example, cancer they are MOA - cross linking DNA, inhibit DNA replication and RNA transcription characteristics, and clinical used in and the MOA E.g. - cyclophophamide use of anti-cancer drugs Use - ovaries, breast, blood, lymph, nerves (child) Cisplatin (platinum) MOA - DNA platination, cross linking Use - testicular, ovarian, bladder Doxorubicin (antibiotic) MOA - inhibit topoisomerase II, overwinding DNA, prevent recombindation of DNA double strands, stops DNA replication Use - bone & breast SE - urine turns reddish Methotrexate (antimetabolites) MOA - folate antagonist, block cell proliferation in S phase, prevent DNA repair/synthesis Use - inflammatory, acute lymphoblastic leukemia Vincristine MOA - Anti-mitotic, binds tubulin > microtubular depolymerisation > impair mitosis Use - leukemia (+ lymphoma, Hodgkins) Gefitnib MOA - inhibit tyrosine kinase EGFR > prevent cell growth & proliferation Use - non-small cell lung cancer Trastuzumab MOA - monoclonal antibody, HER-2 receptor Use - breast cancer Tamoxifen MOA - Selective estrogen receptor modulator (SERM), estrogen agonist + antagonist Use - early metastatic breast cancer in pre-menopausal women Describe the approaches that Health economics - clinical effectiveness vs cost effectiveness. Self Study Public health can adopted to decide between options in a health care priority setting Describe the processes and 1. NHS England Ethical Framework Self Study Public health policies that can be used to 2. Set population & patient priorities allocate healthcare resources 3. NICE guidelines - evidence based, cost-effective and their impacts 4. QALY (pain, mobility, mood) Define gender identity and Gender identity Self Study Social science gender expression, and apply - sense of who we are and how we see/describe ourselves these concepts to gender - "binary" identities (male or female) variance and gender - "non-binary" (agender, gender divserse, gender non-conforming) dysphoria Gender expression - the way in which a person expresses their gender identity - through appearance, dress & behaviour - or gender roles (which rely on gender stereotypes) Gender dysphoria - describes a sense of unease that a person had - due to mismatch between biological sex & gender identity Effects of gender dysphora - often have a desire to live a life that matches their gender identity - changing their appearance, behaviour or treatements (hormone/surgery) - may lead to depression/anxiety - signs: low self-esteem, becoming withdrawn, socially isolated, depression, anxiety, taking unesscaery risk Describe the factors that - local cultue (feeding in public) Taught Social science influence maternal neonatal - family support feeding decisions - media (misleading information about baby formula) - school curriculum - health promotional materials (awareness of health benefits) - professionals, GPs, midwives Describe pelvic fistula Fistula - abnormal connection between 2 organs or vessels that do not usually connect Taught Anatomy & histology formation and its consequences Common Pelvic fistulas 1. Colocutaneous (external) colon→ skin 2. Colovesicle (internal) colon→ bladder - Diverticulitis, colon cancer - faeces → bladder → sepsis 3. Anal (external) - Can be caused by drainage of rectal abscess Common Obstetric fistulas 1. Vesicouterine 2. Vesicovaginal 3. Rectouterine 4. Rectovaginal Formation of anal fistula 1. Infection/trauma - pus/abscess 2. Burst of anal cushion - tunnel formation 3. Perianal area - pus discharge Formation of vaginal fistula - common after OnG injury - common during childbirth + unrelieved obstructed labour (large baby) 1. Reduce blood flow - tissue dies 2. Obstetric fistula formation Cosequences of anal fistula - fecal incontinence (anal opening/sphincter) - general symptoms (fever, pain, malaise, infection) - local (redness, sore, itch, pus) - nerve damage Consequences of vaginal fistula - urinary incontinence Describe the difference Triple assesment for Breast symptoms (NICE) Taught Diagnostics, Pathology between benign and 1. Clinical - age + examination malignant breastlumps and 2. Imaging - USG + mammogram how they are diagnosed - mammogram: 2 xrays of each breast (compressed uncomfortably between 2 plastic plates), not for young patients with dense breast - USG: determine whether lump solid/cystic, dimension, presence of other masses 3. Pathology - FNAC + core needle biopsy + open biopsy (biopsies) - definitive diagnosis - GOLD standard: core needle 4. Palpate regional lymph nodes Describe the signs and PC Taught Diagnostics, Pathology symptoms of breast disease 1. Breast pain (pregnant, cyclical mastalgia, mastitis, abscess) 2. Niiple discharge (pregnant, duct papilloma, duct ectasia, mastitis, breast abscess, DCIS) How can one describe breast 3. Breast lump (breast cancer, cyst, abscess, fibroadenoma, fibrocystic changes, lipoma) lumps? 4. Skin changes (eczema, carcinoma, Paget's disease) Early signs 1. 5S - symmetry, size, shape, swelling, scars 2. 2D - dimpling, discharge 3. Rashes 4. Skin changes - Excoriation of nipple - Nipple retraction - Paget's disease - Orange peel appearance (peau d'orange) Describing breast lumps (4S, 4T, 3C) 1. 4S (site, size, shape, symmetry) 2. 4T (temperature, tenderness, tethering, trans-illumination) 3. 3C (colour, consistency, compressibility) 4. Pulsatile Apply the principles of clinical LUTS in Men Taught Diagnostics, Reasoning reasoning in formulating a 1. Storage: Frequency, Urinary incontinence/Urgency, Nocturia (FUN) differential diagnosis between 2. Voiding: Weak stream, Intermittent, Straining, incomplete Emptying (WISE) the different presentations of 3. Post-micturation: Dribble, Sensation of incomplete emptying genitourinary symptoms Causes What are the risk factors for 1. Storage: BPH, neurological, UTI, cancer (bladder/prostate) LUTS in men? 2. Voiding: BPH, antimuscarinic drugs, neuropathy, neurogenic bladder, stricture, phimosis Risk factors 1. High DHT 2. Obese/ comorbidites 3. Increase prostate size Examination 1. IPSS (7 symptoms, 1 lifestyle) 2. Urinary frequency volume chart (3 days) 3. PSA 4. Urine dipstick 5. Serum creatinine LUTS in Women 1. Stress UI 2. Urgent UI 3. Mixed 4. Overflow Apply an understanding of Folic acid supplements (400ug) Taught Embryology & development neural development and - Prevent neural tube defects dietary supplements when - Take 1 month before conception + first trimester describing the formation and prevention of neural tube defects Describe the impact of Genetic: chromosome/structure Taught Embryology & development maternal and environmental Diet factors on embryological and Environment: smoke/alchol, antibiotics, vitamin fetal development Infections: TORCH Apply an understanding of Turner Syndrome Taught Embryology & development reproductive development - females with XO when describing - genitialia don't mature abnormalities and disorders of sex development Klinefelter Syndrome - males with XXY - small genitalia, no/low sperm count (asoospermia) Turner’s syndrome in females – absence of X chromosome – ovary degeneration Extra X chromosome in Males – small testes Uterine duplication (Didelphys) (failure in fusion of Mullerian ducts) Undescended testes (cryptorchidism) Hypospadias - Failure in fusion of urogenital folds Pseudohermaphroditism is caused by abnormal sex hormone levels during development Genetic females (XX) with male external genitalia Genetic males (XY) with under-developed external genitalia Describe common maternal - to identify how much breastmilk baby has drank Taught Infectious disease, Pathology breast feeding problems - sore cracked nipples (wrong position/attachment) - oral thrush (clean mouths before feed) - breast engorgement (full of milk, alternate breast > prevent mastitis) - mastitis - inverted nipple - inadequate milk supply  Menopause causes HAVOCS Taught Pathology H ot flushes A trophy of vagina V aginal dryness O steoporosis C oronary artery disease S leep disturbance Symptoms 1. Night sweats 2. Mood changes 3. Dry vagina 4. Decrease libido 5. Hot flashes 6. Headache 7. Breast shrinks Clinical implications 1. Osteoporosis (reduced bone density - weak bones) - reduced estrogen levels causes increased bone resorption - less bone formation 2. GUTI - incontinence, sexual dysfunction 3. Increased risk of fracture 4. Risk of CVS disease Describe techniques for Initial general - folic acid, sexual intercourse, stop smoking, reduce obesity Taught Physiology assisting pregnancy in Ovarian stimulation - metformin, clomifene citrate infertility, sub-fertility, and mitochondrial disease Surgical correction of blockage The main difference between Gonadotrophic drugs (act of testes/ovaries) an IUI and IVF treatments Clomiphene citrate (anti-estrogen - strops pituitary inhibition) are: IVF is a process involving egg stimulation, retrieval, Intrauterine insemination fertilization, and transfer; - inject sperm sample into iterus whereas, an IUI injects sperm - natural/stimulated cycle into a uterus to decrease the sperm's travel time to the egg. IVF - drain follicular fluid to obtain egg - 5 day embryo implanted with progesterone - intracytoplasmic sperm injection & frozen embyros Surgical sperm retrieval Mitochondrial disease - egg donation - pre-implantation diagnosis - pro-nuclear transfer Describe the causes and Sexual desire disorder - Hypoactive sexual desire is the persistent or recurrent deficiency (or Taught Physiology management of sexual absence) of sexual thoughts, and/or desire for or receptivity to sexual activity for at least 6 dysfunction months - Psychological: Anxiety, depression, stress, body image, etc - Vascular: hypertension, coronary disease, etc - Neurologic: multiple sclerosis, stroke, peripheral neuropathies - Endocrine: diabetes, thyroid, adrenal, hyperprolactinemia, etc - Gynecological: cancer, cystocele, endometriosis, etc Erectile dysfunction can be psychogenic or organic. In contrast with organic impotence, sleep- associated tumescence is preserved in psychogenic impotence. Organic causes: Endocrine, atherosclerosis, lifestyle (smoking, alcohol), drugs Orgasmic disorders - failure to achieve orgasm Sexual pain disorders - Dyspareunia is pain during penetration or after intercourse - Premature ejaculation - Delayed ejaculation - Retrograde ejaculation - Anejaculation - Aspermia (failure to produce sperm) - Priapism (erection >4hrs, may lead to ischemic injury) Erectile dysfunction - inability to initiate/sustain penile erection - Cause: psychological, vascular (arteries cannot dilate, hypertension) - Management - Consevative: lifestyle changes, CBT, disease screening, vacuum erection - Medical: PDE-5, testosterone - Penile implants Describe the causes, clinical Male Taught Physiology investigations, and screening - Semen analysis of infertility and sub-fertility - Head CT (pituitary tumours) Female - Serum progesterone (21 day) - AMH - FSH/LH - Estrogen (Day 3) - STI check - Pelvix ultrasound - Hysterosalpingogra, - Laproscopy/hysteroscopy Describe the factors that 1. Maternal age Taught Public health influence patient engagement 2. Number of living children in antenatal care 3. Place of residence 4. Financial 5. Occupation Describe the purpose and Purpose Taught Public health holistic impact of antenatal 1. providing information that can be easily understood care 2. providing informed choices regarding antenatal care 3. screen for maternal/fetal complications 4. assess maternal & fetal wellbeing 5. provide advice & education on normal pregnancy symptoms Impact 1. Provides assess to formal healthcare system 2. Increased chance of use of skilled attendant during delivery 3. Better health outcomes Screening Describe how the limitations - postcode lottery (how some poeple have access to better services due to the area of the Self Study Public health of local healthcare resources country they live in) can impact upon patient care - long distance travel - patients with same clinicall need may not have the same access to services - Healthcare staffing shortages, reduced patient care Apply the principles of clinical Hypogonadotrophic Infertility: Taught Diagnostics, Reasoning reasoning in formulating a hypogonadism A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual differential diagnosis between - problem with the production intercourse, in the absence of any known cause of infertility, should be offered further clinical the different presentations of of GnRH assessment and investigation along with her partner. fertility problems > Kallman's syndrome > Stress Causes: 1. Hypo-gonadotrophic hypogonadism Hypergonadotrophic - gonads produce no/less sex hormones hypogonadism - hypothalamus/pituitary problem > problem with the gonads - low GnRH/FSH/LH responding to the FH and e.g. Kallman, stress LSH produced > Turner Syndrome 2. Hyper-gonadotrophic hypogonadism (primary gonadal failure) > Klinefelter Syndrome - Impaired response of gonads to gonadotrophins (FSH/LH) - FSH & LH still produced, but gonads (ovaries/testis) not functioning e.g. Klinefelter, Turners, autoimmune 3. Normogonadotropic - obstruction/infection/vasectomy/varicocele 4. Normogonadotropic normoestrogenic anovulation - Normal estrogen, low FSH - PCOS & obesity in women Describe the behavioural Babkin Babkin Taught Embryology & development characteristics of the neonate Babinski - hold infants hand between thumb and index finger Rooting - mouth opens and tongue drops to floor of mouth Sucking Stepping Babinski Palmar - baby's foot is stroked from heel toward the toes Plantar - big toe lifts up while the others fan out Galant Moro Rooting Tonic Neck - stroke infants cheek or corner of mouth - infant turns head towards it and opens mouth Behaviours > alertness Sucking > cuddliness - touching infants mouths > motor - respond by opening and making sucking movement > auditory response > consolobility Stepping > habitualisation - stepping motions when sole of foot touches hard surface Palmar grap - stroke palm with finger - hand tightens to a fist Plantar grasping - stroke ball of foot - infant curls toes in attempts to grab finger Galant - suspend infant vertically, support anterior chest wall - strkoe spine cause infant trunk/pelvis to flex towards stimulus Moro - in sitting position, allow head to momentarily fall backwards - symmetrically extend and abduct arms and open their hands Tonic neck - fencing position - head turned to one side, the arm on that side stretches out and the opposite arm bends up Behaviours (voluntary) - Alertness - Visual/audio response - Cuddliness - Habituation - Consolobility - Motor response Describe the ethical and legal Ethical Self Study Ethics issues involved in the 1. Any dependants? distribution of finite healthcare 2. Does he/she contribute to society? resources 3. Treatment cost + who pays for it? 4. Age of patient What are the points to 5. How desperate is the patient? consider when distributing 6. Can you relate to patient? finate healthcare resources? Legalities (Human Rights Acts 1998) 1. Everyone's right to life is protected (no discrimination against sex, race, religion, politics) 2. Lgal responsinilities from GMC - You must make good use of resources made available to you To consider 1. Cannot refuse/delay treatment if believed that patient's action/lifestyle contributes to their condition 2. Decision made regardless of personal connections 3. Fair healthcare resource distribution requires each person to be receiving sufficient healthcare that provides them with opportunity to live in good health Describe common sexually Chlamydia trachomatis - Urethritis, discharge, cervictitis, endometritis, proctitis - repeated Taught Infectious disease transmitted infections and infections lead to infertility their impacts on fertility and cervical cancer Neiseeria gonorrhoea Males: cloudy discharge Females: abnormal discharge, PID Neonates: opthalmia neonatrum (conjunctivitis) Trepnonema pallidum (syphillis) Primary - chancre formation (heals w/o treatment in 2-3 weeks) Secondary - maculopapular rash, candylmata lata @ anogenital region Tertiary - dementia, gummata (inflamX nodules or plaques) Congenital syphillis - Similar to secondary syphillis - CNS/developmental abnormalities - Hutchinson’s teeth , Mulbery molar, Saber shin HPV 16,18 - MOST related to cervical cancers Describe the risk factors for 1. Reduce intake Taught Nutrition malnutrition in neonates and 2. Increased requirements during pregancy 3. Lack of sunlight 4. Pregnancy 5. Veggies 6. Excess alcohol - Fetal alcohol syndrome 7. Excess intake During pregnancy -15 years of age -Twins or triplets pregnancy -Poverty -Cigarette/ alcohol/ drug abuse -Low education level -Chronic disease e.g. Diabetes -Overweight/ underweight Inadequate diet Features of Fetal Alcohol Syndrome Describe the main types, Spread Taught Pathology clinical features, and 1. Direct - local invasion of skin and muscles metastasis of breast cancer 2. Lymph - axillary, supraclavicular, tracheobronchial lymphadenopathy 3. Blood - lungs (SOB, pain, chronic cough), bone (pain), liver (jaundice, abdo pain), brain (blur vision, seizures, headache) Main organs affected by metastasis: brain, lung, liver, bone Describe the clinical 75% axillary Taught Physiology importance of lymphatic 20% parasternal - contralateral breast drainage of the breast 5% posterior intercostal May spread to diaphragmatic lymph nodes - abdomen Define primary and secondary Primary Taught Physiology amenorrhoea and disorders - no menses, no secondary characteristics by 14 years old of the menstrual cycle - no menses, w. secondary c. by 16 yo Secondary - no menses for 3-6 consecutive months Apply an understanding of Congenital anomalies Taught Embryology & development embryonic and fetal - Physical structural defect - single, multiple developmental abnormalities - Non-structural defect - inherited metabollic defects, functional, behavioral deficits to their clinical identification Causes of congenital anomalies - Unknown (50%) - Maternal (age, disease, drugs, nutritional status, parity, low socioeconomic status) - Environmental (radiation, infections TORCH, exposure to chemicals) Benign breast lump Lipoma - slow-growing fat tumour - between skin & muscle layer - well-circumcised, soft, smooth, non-tender, can be lobulated Fat necrosis - inflammation of fat cells - palpable mass - common after trauma - painless mass Breast cyst - develop from terminal duct lobular unit - fluid-filled, well-circumcised, palpable - can be painful - common in pre-menopause women (30-40) Breast cyst vs Breast abscess - Abscess more tender & has infective symptoms Fibrocystic changes - collection of fibrous tissue in breast - age 30-50 - pain & size increase during menstrual period - blue-domed appearance - commonly presents after trauma Fibroadenoma - most common (esp in 20s) - develop from breast lobule - excess frowth of glandular & connective tissue in breast - well-circumcised, high mobile - painless - follows estrogen levels in the body - does not develop to cancer Learning Outcome Notes Delivery Discipline(s) Describe the treatment of chronic 1. Nutrition by mouth Taught Nutrition, Pathology undernutrition - food first approach - patient can eat, does not have loss of appetite - provide dietary advice to patient 2. Oral nutritional supplements (ONS) - patient cannot meet nutritional requrement through oral diet - for high risk patient 3. Enteral nutrition - GIT feeding - patient who cannot take food orally but GIT is functional - or neurological disorders, cannot swallow, head/neck cancer 4. Parenteral nutrition (PN) - IV route - can supplement oral intake if patients are able to - TPN (total parenteral nutrition): all nutritional requirements given by IV Describe the range of eating disorders, Anorexia nervosa Taught Nutrition, Reasoning including anorexia nervosa and bulimia, - low weight due to and how they present 1. preoccupation with body weight 2. fear of fatness 3. pursuit of thinness - dieting behaviours + social withdrawl + obsession - characteristics: 1. 16-70 yo 2. BMI affects health seeking behaviours Influence of lay referral may differ - extent & influence of the relationships - the predominant views towards professional health care 5 Zola's Triggers to seek medica help - Perceived interference with social or personal relations - Perceived interference with vocational or physical activities - Occurrence of interpersonal crisis - 'Sanctioning' - A kind of temporalizing of symptomatology Describe the role of healthy lifestyle in 1. Poor diet Taught Nutrition, Public health disease prevention 2. CVD 3. Excessive alcohol 4. Inactive lifestyle 5. Smoking Apply the principles of clinical reasoning 1) Basic history – Medical, Family, Drug, Social, Smoking and Alcohol etc Taught Diagnostics, Reasoning in formulating a differential diagnosis § Can ask focused questions such as between the different presentations of - Dietary habits, bowel habits, Abdominal pain, Skin colour changes, Bladder habit malnutrition 2) Junior Marsipan risk assessment requires HR, BP. ECG and temperature taken (table below) 3) Be aware of refeeding syndrome § Potential shifts in fluid and electrolytes in malnourished patients after receiving artificial refeeding (ex. Hypophosphatemia) 4) Weight concerns § NICE definition of malnourished - BMI 10% in the past 3-6 months - BMI 5% in past 3-6 months Causes of unintentional weight loss: o Poor appetite – Alcoholism, Depression, Cancer, Chronic infections (TB/HIV) o Good appetite – Diabetes, Hyperthyroidism, Malabsorption syndrome (Crohns, disease, Chronic pancreatitis etc) 5) Tests § Use appropriate tests to rule out differentials (CBC, U&E, LFT, Coagulation screen, TFT) Describe the range and complexity of the 1) Biomedical model – Focus on illness rather than health (biological factors explaining Taught Psychology, Social science responses within a family to health and illness) illness 2) Biophysical model – Focus of health and illness (illness affected by bio, pscyho and social factors) 3) Health psychology – Focus on psychological factors contributing to health, illness and recovery 4) Can have mental responses, emotional responses, physical responses and behavioural responses. 5) Coping (next learning outcome) Describe ways in which individuals and Coping Process Taught Psychology, Social science their families/carers appraise and cope - Cognitive appraisal (Significance of the illness) with health and illness - Adaptive tasks (Formulation of tasks) - Coping skills (Denial, information seeking, goal setting) Coping Strategies a. Self education (Taking charge of situation) b. Symptom management c. Effective communication skills d. Access resources – Financial, insurance etc e. Set realistic goals f. Identify stressors and focus on relaxing g. Learning to handle emotions and letting go Describe how families can protect and - keeping things as normal as possible Taught Public health, Social science promote health and wellbeing and how - taking time with yourself they can influence and manage illness 1) Emotional stress of conflict within family members can cause physiological responses (potential to worsen chronic diseases) 2) Families protect and promote health by a. Good marital relationships/communications b. Clear rules, expectations and routines c. Proper organisation and generational boundaries 3) Chronic illness can be managed with better outcomes by a. Having good communication b. Balancing the needs of both the patient and the rest of the family c. Routines with flexibility Describe psychological and social Drivers of adolescent psychosocial development Self Study Social science development in adolescence Psychological - self-esteem, emotion, reward dependence, academic ability Social - housing, finances, culture, nutrition, social support, socialisation, healthcare Challenges of adolescence/Factors contributing to stress Psychological - Adjustment to new physical self - Growing verbal abilities - Development of personal and sexual identity - Development of personal value system - Development of abstract tinking skills Social - Development of stable/productive peer relationships - Renegotiation of relationship with parents - Increased health risk (smoking, alcohol) - Increasingly demanding roles and responsibilities - Development of social autonomy Social media - body image distortion - anorexia nervosa Learning Outcome Notes Delivery Discipline(s) Describe the normal Gross Motor Taught Communication, Public health developmental milestones of a - loss of reflexes (by 6 months) child from birth to 5 years old 1. head control 3 months - can lift head & shoulders when on tummy - no head lag 6 months - holds head when sitting 2. rolling & sitting (6 months) 3. pulls up to stand (9 months) 4. cruising & walking (12 months) 5. walking & crawls up stairs (18 months) 6. walks up stairs, kicking, walking backwards (2 years) 7. walks up stairs, alternating feet, jumps (3 years) 8. stands on one foot for more than 3 seconds, Walks down stairs, fluid & purposeful movements (4 years) Fine Motor & Vision 1. Fixing & Following (6 weeks) 2. Hold a rattle and shake it - palmar grasp (3 months) 3. Reaches for toys, transfers between hands, opens mouth for spoon (6 months - start weaning) 4. Pincer grip, holds cup with 2 hands, eats finger food (12 months) 5. Scribbles, helps with dressing, stacks blocks (18 months) 6. Takes off shoes, eats with a spoon, draws lines (2 years) 7. Dresses/undresses with help, draws circles (3 years) 8. Holds crayons, dresses self, can uses scissors (4 years) 9. Draws simple shapes and stick people, uses a knife & fork (4 years) Speech, language & hearing 1. cooing (oohhh), social smiling, startles to loud noise (6 weeks) 2. babbling (bababawaaba) - 6 months 3. single words & pointing - 12 months 4. joins 2 words - 18 months 5. 3-4 word sentences - 3 years 6. Tells past tense stories, counts 1-20 - 4 years 7. Knows colours, their age and their address, understood by strangers - 5 years Social & emotional 1. 12 months = stranger anxiety 2. 18 months = symbolic play (replicate world around you) 3. 2 years = tantrums 4. 3 years = toilet trained, sharing 5. 4 years = playing alongside other children (parallel play) 6. 5 years = takes turns, plays games with rules, imaginative games Describe how to effectively Shared decision making Taught Clinical Skills, Communication communicate information about - Choice talk: what is important to patient? what choices are available? risk - Options talk: benefits & risk of each option, checking understanding - Preference talk: summarise & next steps, make a decision Patients are more engaged are more likely to: - be more knowledgable - adhere to treatment - have better outcomes Describe the challenges of, and Challenges Taught Embryology & development approaches to, communicating Data about risk and benefits to - appropriate amount patients and the public - reliable resources - easy presentation Perception of risk - based on culture/upbringing - different understanding of numeric risk Cognitive bias - anchoring effect - availability bias - optimisim bias Approaches - Using more frequencies than numerical data - Check your framing (positive for intervention, negative for screening) - Using decision aids - Q-risk tools Describe the clinical features - Loss of skill at any age Taught Embryology & development that are suggestive of - Failure to meet developmental milestones developmental delay in children - Hearing loss at any age - Squinting - Extreme changes in head circumference - Parental concern Describe the principles and - not just to prevent child from being harmed physically Taught Embryology & development, Social science importance of safeguarding - protect them children - provide opportunities to be the best versions of themselves What is the toxic triad? Types: emotional/physical/neglect/sexual/bullying/internet abuse/radicalisation/FGM/domestic abuse/human trafficking/forced Red flags when it come to marriage/honour based killings/modern slavery consulting with children 1. Presentation/Examination (RED FLAGS) - inconsistent history - late presentation - injuries at unusual sites - behavioural changes - sexualised behaviour 2. Family/Environment - who lives at home, deprivation & access to resources, stressors - parenting styles, domestic abuse, vulnerable carers 3. Child - Toxic triad > domestic abuse > mental ill-health > substance misuse Describe the pathogenesis, Pathogenesis Taught Infectious disease epidemiology, clinical - Replication in epithelial cell characteristics, diagnosis and - Lytic replication > vesicular rash management of Herpes - Affects sensory nerions Simplex Virus infections - Latent stage @ spinal ganglion (trigeminal ganglion) - Reactivate due to stress/immunosupression - Shed in oral/vagina secretions Epidemiology - occur by ageof 5 - trans by formites, close contact Clinical features Primary oral herpes (HSV 1/2) - Children (HSV1): gingivostomatitis, pharyngitis - Adults: herpes labialis, cold sores Genital herpes (HSV 2) - dysuria, vaginal discharge Herpetic whitlow (HSV 2 reactivation) - infection around the nail Complications - Occular HSV (HSV1): pain, blur vision - Encephalitis (HSV1) - Secondary bacterial infections - Meningitis Congenital infection: transmit at birth > skin/eye/mouth/CNS disease Describe the viral causes of [Viral Meningitis]- Taught Infectious disease, Pharmacology central nervous system (CNS) Causes: Coxsachie/Echovirus groups (non polio enteroviruses) , HSV1/2, VZV, infections together with their HIV, EBV clinical features Clinical Features: mild / self-limiting; flu-like; rarely with a rash; mostly undiagnosed; - resolves within 10 days usually; give aciclovir if herpes virus; treat as suspected bacterial meningitis until you know its viral [Viral Encephalitis] - Causes: HSV1 (2 in neonates), VZV, Enteroviruses, Morbilli Virus (measles), Paramyxovirus (mumps), EBV/CMV (in immunocompromised patients) - Clinical Features: more common/severe in very young/old patients; altered consciousness, seizures, raised ICP, papilledema, weakness/paralysis (focal neurology), altered personality; progressive - becomes fatal within 7-14 days; treated mortality = 19% (vs. 70%); needs to be treated with IV aciclovir for 10-21 days [Rabies] - Causes: rabies virus (ssRNA), lyssavirus - Clinical Features: zoonotic disease (dog bites - saliva); common in Asia and Africa; 40% of cases happen to under 15s; incubation period = 1-4 months - no symptoms, virus migrates to CNS; prodrome = 2-10 days - virus enters CNS - fever/malaise/fatigue/aches /pains; -then takes 1 of 2 paths 1. furious rabies = (80%) agitated, spasms; 2. paralytic rabies = (20%) withdrawn and calm; -most people die - no treatment! -prevention = highly protective vaccine or post-exposure prophylaxis ASAP Describe the range of tests that Crude hearing Taught Diagnostics can be used in the screening - detecting from conversation and investigation of hearing loss Whispered voice test - arms lengths, rub one tragus, whisper numbers Rinner's test (-) BC > AC (conductive HL) (+) AC>BC Weber's test (normal) lateralise equally - conducting HL (lateralise to bad ear) - sensorineural HL (lateralise to good ear) Otoscopy - canal (wax, discharge, redness, foregin body) - typanic membrane (should be pearly grey & translucent) - cone of light: 5 right, 7 left Audiometry - GOLD standard - right = red = O - left = blue = X - conductive HL (>10db difference) - sensorineural HL (drops below 60db) Describe the pathogenesis, Pathogenesis Taught Diagnostics, Infectious disease epidemiology, clinical - Respiratory mucosa/conjunctiva transmission characteristics, diagnosis and - Aerosol/rash contact management and prevention of - Replicates in lymph nodes Varicella Zoster Virus infections > Primary viremia: replicate in liver & spleen > Secondary viremia: disseminate to skin, causing rash 1. Varicella zoster = chicken pox 2. Latent phase in dorsal root ganglion 3. Reactivation > herpes zoster Epidemiology - peak age 5 yo - infectious from rash to until fully cruster - ZOSTER only transmits through contact Clinical features Congenital varicella missing digits, scarring and hypoplasia of limbs Chicken pox - Prodromal: fever, malaise, headache, anorexia, nausea, myalgia - Rash: trunk/head/neck, itchy, vesicular rash - Severe in adults Complications - Secondary bacterial skin infections - Varicella pneumonitis/encephalitis - Cerebella ataxia (children) Shingles - Prodromal: tingling/burning pain on skin - Rash: vesciular, single dermatome, @ trunk Complications - neuralgia - herpes zoster opthamicus - secondary bacterial infections - meningitis/encephalitis Diagnosis: clinical, serology, PCR Management Chickenpox - Children: self-limiting, calamine lotion/antihistamine - Adults: aciclovir/valaciclovir Shingles - Aciclovir/valaciclovir - Amitriptyline/pregablin (pain relief) - Refer to opthalmologist if eye involved Prevention - Varicella vaccine *not part of immunisation schedule - Post exposure prophylaxis (IM inj of VZV antibodies) Describe the process for - Notify local Health Protection team Self Study Diagnostics, Infectious disease reporting notifiable infectious - Fill in notification form as soon as you suspect it diseases - Doesn't require lab confirmation - PHE notified within 3 days OR verbally within 24 hours Describe the classification of Primary: Taught Diagnostics, Microbiology headache > red flag causes: raised intracranial pressure, SAH Secondary: underlying condition Criteria for secondary headache (lifted off Dr Wendy's slides, but online has some variations) > When we find evidence of a condition known to cause a headache > The headaches correspond in timing with the condition we have found > The headaches resolve if we treat the underlying disorder Describe the communication Using micro skills Taught Diagnostics, Reasoning skills that facilitate shared - assess patient's starting point decision making during a - how much do they want to know consultation - sign posting - chunk & check - avoid jargon - using visual methods - checking understanding Taking into consideration - ICE - personal values - health literacy Provide patient with the information (risk & benefits) to make an informed decision Apply the principles of clinical Causes of hearing loss Taught Diagnostics, Reasoning reasoning in formulating a - Genetic or Acquired differential diagnosis between - Disease (measles, miningitis) the different presentations of - Presbycusis (age related hearing loss, tends to be SHL) hearing loss - Drug damage (ototoxicity) Tinnitus - ringing in the ears - usually has a huge impact on daily life Otitis media - Acute: red & bulging - w. Effusion: glue ear, no inflammation - Chronic/suppurative: perforation with fluid leaking out Describe the differential Rinner's test Taught Diagnostics, Reasoning diagnosis of conductive and (-) BC > AC (conductive HL) sensorineural hearing loss (+) AC>BC Weber's test (normal) lateralise equally - conducting HL (lateralise to bad ear) - sensorineural HL (lateralise to good ear) Audiometry - conductive deficity (AC and BC has >10db difference) - sensorineural deficit (dips below 60dB) Describe the ways in which Monitoring Self Study Communication, Public health illness caused by - local disease surveillance, alert systems, national action plans communicable diseases and - doctors/labs to have legal duty to report about notifiable diseases non-infectious environmental hazards can be monitored and Control controlled - contact tracing - isolation/quarantines - vaccination - pre/post-exposure prophylaxis - appropriate hygiene measures - vector control Describe the epidemiology and Measles Clinical features Taught Diagnostics, Infectious disease clinical features of infections - Prodromal: malaise, fever, conjunctivitis, Koplik spots, runny nose with measles, mumps and - Maculopapular rash (face>trunk>limbs) rubella viruses and how they Complications can be prevented - diarrhoea - dehydration - otitis media/bronchopneumonia Rubella/Germen measles Clinical features - Adults (mild): maculpapular rash + lymphadenopathy Complications - Congenital rubella syndrome > less than 12 weeks : severe malformation > 13-16 weeks : sensorineural hearing loss + cataracts ~ can offer abortion to pregnant mother for the first 12 weeks Mumps Clinical featues - fever + parotitis Incubation: 14-21 days Prodromal: fever, malaise Infectious: 6 days before and 4 days after symptoms Complications - swollen testicles - viral meningitis - encephalitis MMR vaccine - live attenuated Describe the role of the family Parental factors Taught Embryology & development in supporting a childs - parental education development - mental health - socioeconomic status - social support - heath behaviours - cultural beliefs Perinatal - mother's self care - domestic violence - early cognitive underdevelopment - low birthweight - young mothers Early years - breastfeed duration - mothers habits (smoke/alcohol) - immunisation - interaction with family (spoken to/play) - parent-child relationship Describe the factors that may Biological factors Taught Embryology & development, Social science influence child development, - Chromosomal abnormalities including biological and - Inherited diseases psychosocial factors Psychological - domestic violence - lack of parent skills Social - social isolation - low socioeconomic status - abuse/neglect - recial inequality - school performance - access to healthcare Describe the clinical signs and - Fever Taught Infectious disease symptoms of meningitis - Photophobia - Headache - Neck stiffness Signs (low sensitivity, high specificity) - Kernig's sign (neck) > passive stretch of inflamed lumbar meninges + meningeal root > protective spasm of hamstrings > radicular pain How to perform > knee in supine position > hip & knee flexed to right angle - Brudzhinki's sign (thigh) > Involunatry flexion of knees and hips when neck flexed passively Describe how communication 1. Face the person, but not too close Taught Anatomy & histology may be tailored to meet the 2. Look directly at the person, do not look away needs of a patient who has 3. Ensure that your mouth is clearly visible hearing impairment 4. Speak clearly, do not shout 5. Be in a well-lit room 6. Use available resources - Interpreters - Lip readers - Video-relay interpreters  Notes Delivery Discipline(s) Describe the clinical features of human Two types of HHV6 (A+B) Taught Diagnostics, Infectious disease herpes virus 6 and 7 infections -Infects mononuclear cells, salivary glands, CNS Transmission = direct contact with infectious secretions Symptoms = roseola infantum (rash appears as fever settles) - can be mild or asymptomatic Complications = febrile convulsions (primary infection), encephalitis (primary) At Risk Groups = immunocompromised patients (generalized infection or organ specific disease) Describe the epidemiology and disease [Epidemiology] Taught Diagnostics, Infectious disease associations of human herpes virus 8 - 30% will have had a HHV8 infection in their lifetime infection (kaposis sarcoma associated - Affects people from Mediterranean bowl or those of Ashkenazi Jewish heritage virus) [Disease Associations] - symptoms depends on host - no treatment - treat immunosuppression or complications - associated with late-stage HIV, primary effusion lymphoma (B cells, pleural/pericardial/peritoneal effusions), multicentric Castleman's disease (affects multiple lymph nodes in the body) - endemic in Africa (no HIV association) ** Flat purplish plaque that develops into nodules/tumours (affecting lots of different areas of the body) Kaposi’s sarcoma Primary effusion lymphoma HHV-associated multicentric Castleman’s disease KSHV inflammatory cytokine syndrome Describe the pathogenesis, Life cycle of EBV Taught Diagnostics, Infectious disease epidemiology, clinical features and 1. Primary infection diagnosis of Epstein Barr virus infection, - Can replicate in a wide range of cell types (incl. B lymphocytes and epithelial including its association with human cells) cancer 2. Latency (lifelong) -Latency in B lymphocytes – proportion of infected cells are quiescent (sleeping state) 3. Reactivation Adolescence - "kissing disease" Clinical features of EBV > Usually asymptomatic > Sore throat Adolescence May be asymptomatic Infectious mononucleosis (Glandular fever) Triad of: -Low grade fever -Lymphadenopathy (B cell infection) -Sore throat (viral tropism for epithelial cells) Abnormal liver function (jaundice rare) Splenomegaly → Consequence for contact sports/injuries (Splenic rupture) Malaise, anorexia, tiredness Incubation period: 1-2 months Diagnosis of EBV Monospot test → Detects “heterophile” antibodies (antibodies poorly defined so can bind to many anitgens) EBV serology → IgM and IgG Atypical lymphocytes → histology/blood film Cancers associated with EBV Burkitt's lymphoma Nasopharyngeal carcinoma Post-transplant lymphoproliferative disorder (PTLD) Immunosuppresion in EBV causes oral hairy leukopklia Describe the pathogenesis, [Pathogenesis] Taught Diagnostics, Infectious disease epidemiology, clinical features, - primary infection = lytic replication in a wide variety of organs so effects seen diagnosis and management of all over the body cytomegalovirus infection - latent period = in CD34+ lymphocytes - reactivation is normally due to a loss of T cells [Epidemiology] - 40% of young adults have been infected, and this increases by 1% every year following [Clinical Features] - transmission = contact with infectious secretions (saliva, blood, sexual secretions); not infectious in latent period --> Immunocompetent Patients - primary infection = usually asymptomatic; swollen lymph nodes/hepatitis/malaise/headache - reactivates intermittently throughout life - asymptomatic; virus is excreted in urine and saliva and is easily passed on; chronic inflammation = atherosclerosis --> Congenital CMV - CMV crosses placenta; more likely in a primary infection vs. reactivation; 87% of babies are asymptomatic at birth, 15% of these will suffer from hearing loss/developmental delay; 13% will be symptomatic - usually picked up as IUGR, jaundice/hepatosplenomegaly/encephalitis, 20% mortality rate --> Immunocompromised Patients - Solid Organ Transplants = greatest risk of primary infection in donor +ve, recipient -ve - Stem Cell Transplants = greatest risk of primary infection in donor -ve, recipient +ve - Worried about GI tract and eyes of AIDs patients - CMV Syndrome = fever/neutropenia/malaise/ headaches - Organ Invasive Disease = pneumonitis/GI disease/retinitis/encephalitis/hepatitis/myocarditis [Diagnosis] - Serology = IgM/IgG antibodies - not very specific - Molecular = viral DNA by PCR - useful for immunocompromised patients - use blood/urine/amniotic fluid - Histology = looking for owl's eye inclusions [Management] - immunocompetent patients generally won't need treatment - Ganciclovir will be given to symptomatic babies to reduce hearing loss in later life - Ganciclovir = inhibits viral DNA polymerase, needs activation by viral enzymes, toxic SE: myelosuppression, nephrotoxic, teratogenic - Valganciclovir = ganciclovir prodrug (better bioavailability) Immunosuppressed Patients - reduce immunosuppression if you can - IV ganciclovir or oral valganciclovir [Prevention] (for immunosuppressed patients) - Prophylaxis (oral valganciclovir at lower dose) - Pre-emptive monitoring (lots of blood tests) - No vaccine - trials but difficult to develop Apply the principles of clinical reasoning If P. jirovecii is colonising - suggestive of an immunodeficiency Taught Diagnostics, Reasoning in formulating a differential diagnosis Thinking it's an acquired ID - presenting later in life between the different presentations of Thinking it's more likely to be an isolated T cell defect vs. HIV (due to low CD8 immunodeficiency disease as well!!) Any other infections? Were they systemic? What are the infecting bacteria? Family history of ID? Nutritional status? - If it's a rarer bacterium - then more likely to ID IRIS - Immune reconstitution inflammatory syndrome - when the immune system is very low, there is no response to pathogens - when you try to boost the immune system, the immune system becomes hyper-aggressive (usually 4-6 weeks after starting treatment) HIV is a big possibility in adult onset immune defects Never fully discount HIV in children - may have missed vertical transmission Ethical Taught Ethics People with infectious diseases are vulnerable They may feel guilty People can exploit their vulnerability Disclosing to patients who have had close contact with the patient who has the communicable disease Disclosing information to those providing direct care Legal A patient can be subject to medical examination, removed from the hospital, detained in hospital or kept in quarantine if they are contaminated and be at risk of serious harm to human health - Public health act 1984 If a patient objects to disclosure of personal information that you are convinced is essential to provide them with safe care, you should follow the Confidentiality guidance, paragraphs 30 & 31. o If a patient objects to particular personal information being shared for their own care, you should not disclose the information unless it would be justified in the public interest, or is of overall benefit to a patient who lacks the capacity to make the decision. o You sho=uuld explain to the patient the potential consequences of a decision not to allow personal information to be shared with others who are providing their care... If, after discussion, a patient who has capacity to make the decision still objects to the disclosure of personal information that...is essential to provide safe care, you should explain that you cannot refer them or otherwise arrange for their treatment without also disclosing that information. Critically evaluate the ethical and legal When ordered to do so by court or judge Taught Ethics issues relating to patients with a serious communicable disease Notification of notifiable diseases Contact tracing If public interest outweighs confidentiality - protection from crime or disease Human Rights Act 1998 UK on patient’s privacy to be respected is not absolute. It may be interfered where the law permits in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others. Common law - disclosure of confidential information if patient consents, it is required by law or in repose to court order, justified in public interest Human rights act 1998 UK - persons right to privacy is respected but not absolute. May be interfered with where law permits and necessary in a democratic society. NHS act 2006, defined medical purposes when disclosing without consent Discuss and critique the concept of a justifiable claim (legal/moral) to have something - encoded in laws/constitutions Taught Ethics, Public health right to health Universal Declaration of Human Rights: right to an adequate standard of living for health & well-being (food/clothing/housing), right to security in circumstances beyond control (sickness, disability etc.) Right to health is part of a country's constitution - have to regularly report back to UN - means NGOs and Action groups can use the right to health to win access to drugs etc. (cheaply and for all) - attainable but aspirational commitment - applies to everyone (safe drinking water etc. AND access to medical services) Closely related to, and dependent upon, numerous other human rights, such as the rights to life, education, and access to information. It includes freedoms (e.g. right to be free from discrimination and involuntary medical treatment), and entitlements (e.g. right to essential primary health care.) Requires an effective, responsive, integrated health system of good quality that is accessible to all. Describe the epidemiology, clinical [Epidemiology] Self Study Infectious disease features, treatment and prevention of - 10th most common cause of death worldwide (1.7 million deaths in 2017, 0.3 pulmonary tuberculosis million had HIV) - Worldwide incidence is decreasing 2% each year and deaths are also decreasing - Disproportionately affects lower income countries (Sub-Saharan Africa and South East Asia) - Rates in the UK have been decreasing in recent years - classified as a low- incidence country - notifications in UK linked to people born outside the UK in areas of deprivation - deaths have been very low since antibiotics - MDR-TB = major public health crisis - Leading cause of death among people with HIV (1 in 3 AIDs-related deaths) but overall decrease in HIV +ve cases/deaths [Clinical Features] - transmission = respiratory route; difficult to treat as the mycobacterium tuberculosis is slow-growing - Disease Patterns: exposure to TB case --> 70% = no infection, 30% will be infected; of that 30% --> 90% will ha