Concise Flashcards Sem 2B

Question 1

Give the names and functions of the fat-soluble vitamins.

Answer 1

Fat-soluble Vitamins = ADEK

Question 2

Explain the results of deficiency of each of the vitamins.

Answer 2

Vitamin Deficiencies

Question 3

Describe the pathogenesis of Wernicke-Korsakoff syndrome.

Answer 3

Question 4

Describe some features of Wernicke-Korsakoff syndrome.

Answer 4

Wernicke’s Encephalopathy

1. Occulomotor abnormalities – nystagmus, opthalmoplegia
2. Ataxia of gait (cerebellum) – wide-based stance and slow-uncertian, short-stepped gait
3. Derangement of mental function – confusion, apathy, disorientation

Korsakoff’s Psychosis

1. Retrograde amnesia – inability to recall events that occurred before the onset of amnesia
2. Anterograde amnesia – inability to acquire new information or make new memories
3. Confabulation – unconscious creation of facts and experiences to fill gaps in memory
4. Peripheral neuropathy, postural hypotension, tachycardia

Question 5

Briefly list the types of long-term memory.

Answer 5

Types of Long Term Memory

Explicit (Declarative) Memory

1. Facts (semantic)
2. Events (episodic)

Implicit (Non-Declarative) Memory

1. Priming - recognition or recall of words, objects or sounds improved by prior exposure to these stimuli
2. Procedural – skills and habits
3. Associative learning – classical and operant conditioning
4. Non-associative learning – habituation and sensitisation

Question 6

List the four main metabolic effects of alcohol.

Answer 6

Question 7

List the 4 major causes of death due to alcohol.

Answer 7

Major causes of death due to alcohol

1. Alcoholic liver disease
2. Motor vehicle crash injury
3. Cancer
4. Suicide

Question 8

List 4 criteria for which one or more needs to be met in a 12- month period to constitute alcoholism.

Answer 8

Alcoholism

1. Recurrent substance use resulting in failure to fulfil major role obligations at work, school or home
2. Recurrent substance use in situations in which it is physically hazardous (eg driving, using machinery)
3. Recurrent substance-related legal problems
4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

Question 9

Describe two medications that can be given to treat alcoholism.

Answer 9

Alcoholism - Pharmacological Treatment

Disulfiram: alcohol dehydrogenase inhibitor

• Requires a motivated patient and a dose supervision carer – begin >48 hours after last drink
• Remains inert unless ethanol is taken
• Within minutes of ethanol intake, the patient experiences headaches, dyspnoea, nausea, blurred vision, vomiting, sweating, weakness
• Reaction is short-lived but can be severe/life threatening

Naltextrone: opiod antagonist

• Blocks alcohol ‘high’ by blocking opoid receptors and → ↑ cravings
• Decreases rate of relapse

Question 10

List some of the features of simple withdrawal, withdrawal complicated by fits and delirium tremens.

Answer 10

Simple Withdrawal

1. Tremor
2. Sweating
3. Nausea
4. Vomiting
5. Malaise
6. Anxiety
7. Agitation
8. Depressed mood
9. Tachycardia
10. ↑ Blood pressure

Withdrawal Complicated by Fits → Grand mal tonic – clonal fits (usually only 1 fit during withdrawal)

Delerium Tremens

1. Occurs 24h-7d after cessation
2. Tremor & agitation
3. Clouding of consciousness
4. Disorientation
5. Hallucinations
6. Paranoid delusions

Question 11

Give some advantages and disadvantages of MRI and CT.

Answer 11

Question 12

List some contraindications to MRI.

Answer 12

Contraindications to MRI

1. Aneurysm clips placed in the last 6 months
2. Surgical clips placed in the last 6 weeks
3. Neurostimulator devices
4. Pacemaker or implantable defibrillator
5. Cochlear implant
6. Critical illness
7. Claustrophobia
8. Metallic ocular foreign body (welding history), metallic shrapnel
9. Other metallic implanted devices such as insulin pumps
10. Obesity (maximum table allowance is ~160kg)
11. Pregnancy

Question 13

List some general causes of anaemia.

Answer 13

Causes of Anaemia

1. Blood loss - acute (trauma), chronic (GIT lesions, gynaecologic disturbances
2. Impaired RBC production
   
   • Defective Hb production - iron deficiency, chronic disease
   • Defective DNA synthesis – B12/folate deficiency
   • Stem cell failure – aplastic anaemia
   • Bone marrow replacement – e.g. infiltration by malignant disease
   • Inadequate erythropoietin stimulation – chronic renal failure
   • Other nutritional/toxic factors: scurvy, protein malnutrition, chronic liver disease, hypothyroidism
3. Increased haemolysis
   
   • Intrinsic RBC abnormalities – haemoglobinopathies (sickle cell/thalassaemia), membrane defects, enzyme deficiency (G-6-Pase), acquired defects
   • Extrinsic causes - autoimmune haemolytic anaemia, haemolytic disease of the newborn, blood transfusion reactions, drug-induced immune haemolytic anaemia, infections (malaria, mycoplasma), snake venom, lead poisoning, physical trauma, hypersplenism

Question 14

Outline the process of iron absorption.

Answer 14

Process of Iron Absorption

1. Cytochrome B on the brush border converts Fe3+ to Fe2+ (vitamin-C dependent)
2. Fe2+ is transferred over the brush border by DMT-1
3. Some Fe2+ is converted back to Fe3+ and stored as ferritin
4. The rest of the Fe2+ is transferred into the interstitium by ferroportin (FP)
5. Fe2+ is then converted to Fe3+ by hephaestin (HP) or ceruloplasmin (copper-dependant)

Question 15

List 7 functions of iron.

Answer 15

Functions of Iron

1. Oxygen transport (haemoglobin)
2. Cellular respiration (TCA cycle, electron transfer chain etc.)
3. DNA synthesis
4. Neurotransmitter synthesis
5. Hormone synthesis
6. Embryogenesis (myelin synthesis)
7. Host defence (neutrophil killing)

Question 16

Outline the regulation of iron metabolism.

Answer 16

Regulation of Iron Metabolism

1. Haemochromatosis Protein (HFE) - reduces cellular uptake of transferrin
   
   • Binds transferrin receptor (TfR) and halves its binding capacity for transferrin
   • Also regulates release of Hepcidin by the liver
2. Hepcidin - regulates iron absorption
   
   • Released by the liver in response to ↑transferrin:Fe complexes
   • Inhibits ferroportin on entrocytes → buildup of iron in enterocytes → ↓absorption
   • Also inhibits DMT-1 and Cytochrome B → ↓uptake of iron into enterocytes

Question 17

List five general causes of iron deficiency.

Answer 17

Causes of Iron Deficiency

1. Blood loss (occult GIT bleeding and menstruation)
2. Pregnancy (loss of iron to the foetus)
3. Rapid growth (especially 0-2 years)
4. Malabsorption
5. Dietary insufficiency

Question 18

List 8 symptoms of iron overload.

Answer 18

Iron Overload Symptoms

1. Weakness
2. Abdominal pain
3. Muscle aches
4. Finger joint pain
5. Dyspnoea on exertion
6. Bronze colour
7. Hepatomegaly; cirrhosis
8. Pancreatic fibrosis, diabetes mellitus

Question 19

Summarise α and β- Thalassaemia.

Answer 19

Question 20

Summarise the pathogenesis of β-Thalassaemia.

Answer 20

Question 21

Summarise the pathogenesis of sickle cell anaemia.

Answer 21

Question 22

List some clinical features of homozygotic sickle cell anaemia.

Answer 22

Homozygotic Sickle Cell Anaemia - Clinical Features

1. Severe haemolytic anaemia
2. Patients present between 6 months – 3 years
3. 90% survive to 20 years, 50% survive > 50 years
4. Splenomegaly
5. Continuous fibrosis → autosplenectomy by adulthood
6. Defects in complement pathway → septicaemia/meningitis
7. Pain crises – episodes of hypoxic injury and infarction
8. General hypoxia → impairment of growth & development

Question 23

List 8 possible causes of an increase in Prostate Specific Antigen (PSA).

Answer 23

Causes of Increased PSA

1. Benign prostatic hyperplasia (BPH)
2. Prostate cancer – lower % free PSA than BPH
3. Ejaculation – increases PSA for 6-48 hours
4. Urinary tract infection
5. Urinary retention
6. Prostatitis
7. Prostatic massage (e.g. DRE – take blood first)
8. Prostatic needle biopsy

Question 24

Comment on the accuracy/quality of PSA testing.

Answer 24

PSA Testing

• Low specificity (91%)– organ-specific, but not cancer-specific
  
  • Significant overlap with PBH and prostate cancer (but BPH is generally lower)
  • Many false positives leading to unnecessary prostatic biopsies
• Low sensitivity - not all men with prostate disease have elevated PSA
  
  • Many false negatives – many cases missed
  • For PSA >4.0 ng/mL, sensitivity is ~91%
  • For PSA <4.0 ng/mL, sensitivity is ~56%

Question 25

Summarise the actions of different tumour supressors.

Answer 25

**Tumour Suppressors** 1. p21 2. p16 3. p53 4. pRB 5. p14ARF

Question 26

For each cyclin, state which cyclin- dependent kinase they bind to and what their function in the cell cycle is.

Answer 26

**Cyclins DEAB** * Cyclin D → CDK4 or CDK6 * Cyclin E → CDK2 * Cyclin A → CDK2 * Cyclin B → CDK1

Question 27

List the 5 pathologic zones of the prostate and state where most hyperplasia and carcinoma occurs.

Answer 27

_Zones of the Prostate_ 1. **Peripheral zone (PZ)** * Most carcinomas originate here 2. **Central zone (CZ)** * Cancers here (2.5%) are more likely to invade seminal vesicles 3. **Transitional zone (TZ)** * Most hyperplasias originate here = BPH 4. **Periurethral zone** 5. **Fibromuscular** **stroma** (non-glandular)

Question 28

Outline the pathogenesis of BPH (4 steps).

Answer 28

**Pathogenesis of BPH** 1. Stromal cells produce 5α-reductase 2. 5α-reductase converts testosterone to dihydroxytestosterone (DHT) * DHT is ~10x as potent as testosterone 3. DHT stimulates transcription of growth factors by stromal cells (autocrine) and epithelial cells (paracrine) * Oestrogen also binds androgen receptors, enhancing the response 4. Hyperplastic stromal and epithelial tissues compress the prostatic urethra, leading to bladder outflow obstruction

Question 29

List some symptoms of BPH.

Answer 29

**Symptoms of BPH** 1. Urinary frequency, urgency, hesitancy 2. Weak flow of urine, small volume voided 3. Nocturia 4. Interrupted stream 5. Incomplete bladder emptying 6. Dribbling

Question 30

List some general carcinogenic agents.

Answer 30

_Carcinogenic Agents_ * **Chemicals** - vinyl chloride, tobacco smoke (polycyclicaromatic hydrocarbons) * **Viruses** – HPV, hepatitis B, Epstein-Barr, herpes simplex * **Ionizing** (UV, X-rays, gamma rays) and non-ionising (α/β particles, neutrons, protons) radiation * Immediate effects – death, bone marrow failure, GIT effects * Late effects – leukaemia, thyroid cancer, lung/breast etc. cancer * **Exogenous** **hormones** – e.g. oestrogens in plastics * **Bacteria, fungi, and parasites** e.g. H. pylori * **Miscellaneous** agents (asbestos, metals)

Question 31

Contrast benign and malignant neoplasms in terms of: * Cell size and shape * Anaplasia * Differentiation * Rate of Growth * Local invasion * Metastasis

Answer 31

Question 32

List 10 types of urinary casts and what their presence is suggestive of.

Answer 32

**Urinary Casts** 1. Hyaline casts 2. Granular casts 3. Waxy casts 4. Fatty casts 5. Pigment casts 6. Crystal casts 7. RBC casts 8. WBC casts 9. Bacterial casts 10. Epithelial casts

Question 33

List some possible causes of tubulointerstitial nephritis.

Answer 33

_Causes of Tubulointerstitial Nephritis_ 1. **Infections** – pyelonephritis 2. **Toxins** – drugs, analgesics, heavy metals 3. **Metabolic** **diseases** – urate nephropathy, hypokalemic nephropathy 4. **Obstruction** – of urinary tract 5. **Neoplasms** – multiple myeloma 6. **Immune** **reactions**

Question 34

Outline some major types of glomerulonephritis and whether they present with non-specific symptoms, nephritic syndrome or nephrotic syndrome.

Answer 34

Question 35

Outline some of the different ways patients with glomerular conditions will present.

Answer 35

_Glomerular Conditions - Clinical Presentation_ 1. **Nonspecific** → haematuria or polyuria 2. **Nephrotic** **syndrome**→ proteinuria, hypoalbuminaemia, hyperlipidaemia, lipiduria * Leakage of large amounts of protein due to increased glomerular permeability 3. **Nephritic** **syndrome** → proteinuria, haematuria, azotaemia, oliguria, hypertension, oedema * Leakage of protein and red blood cells due to renal inflammation 4. **Acute** **renal** **failure** - acute nephritis, proteinuria 5. **Chronic** **renal** **failure** - azotaemia → uraemia progressing for months to years

Question 36

List the 7 changes essential for malignant growth to occur, and give some examples of mutations.

Answer 36

_Changes Essential for Malignant Growth_ 1. **Self**-**sufficiency** of growth signals (↑oncogenes) – mutations in growth factors, GF receptors, RAS, MYC, cyclins, CDKs 2. **Insensitivity** to growth-inhibitory signals (↓tumour suppressor genes) * BRCA1, BRCA2 (breast cancer) * APC (colorectal cancer) * p53 (many tumours) * Rb (retinoblastoma) * NF1 (neuofibromatosis) 3. **Evasion** **of** **apoptosis** – mutations in Bax, Bcl, caspases 4. Defects in **DNA repair** 5. Potential for **limitless** **replication** - e.g. maintenance of telomere length 6. **Angiogenesis** 7. **Invasion and metastasis**

Question 37

Summarise the 4 steps in the process of haemostasis.

Answer 37

_Haemostasis_ 1. **Vasoconstriction/Spasm** * Direct trauma (local myogenic spasm), chemical signals from damaged cells (e.g. TXA2 from platelets), nervous reflexes (from pain impulses and sensory inputs) 2. **Platelet Plug Formation** 1. Adhesion: platelets bind to exposed collagen – aided by vWF (platelets) 2. Activation: by exposed collagen - activated platelets secrete ADP and TXA2 3. Aggregation onto the growing platelet plug 3. **Blood Coagulation – The Clotting Cascade** * Prothr. activator catalyses prothrombin → thrombin - catalyses fibrinogen → fibrin 4. **Restoration of Normal Bloodflow** * Clot lysed by Fibrinolysis - Plasminogen → plasmin → catalyses breakdown of fibrin

Question 38

List 3 endogenous substances that limit coagulation and describe their mechanism.

Answer 38

_Endogenous Substances that Limit Coagulation_ 1. **Antithrombin III** (ATIII) – binds to activated clotting factors (IIa, IXa, XIa, XIIa) and inactivates them – heparin increases ATIII activity 2. **Activated Protein C** (APC) – activated by thrombin - inactivates factors V and VIII 3. **Protein S** – cofactor for protein C on platelet surface

Question 39

Summarise the four major causes of disorders of haemostasis.

Answer 39

**Disorders of Haemostasis** 1. Vessel Wall Abnormalities 2. Platelet Deficiency (thrombocytopenia) 3. Defective Platelet Function 4. Abnormalities in Clotting Factors

Question 40

Summarise disseminated intravascular coagulation (DIC) and its pathogenesis.

Answer 40

**_Disseminated Intravascular Coagulation (DIC)_** **Summary** * Excessive activation of coagulation, leading to formation of thrombi in the microvasculature * Occurs as a secondary complication of many different disorders * Presents with signs and symptoms related to tissue hypoxia/infarction or haemorrhage **Pathogenesis** 1. Release of tissue factor or thromboplastic substances into the circulation, or 2. Widespread injury to endothelial cells

Question 41

Compare acute lymphoblastic and chronic lymphocytic leukaemia in terms of: * Cells composed of * Presentation * Clinical Features

Answer 41

Question 42

Summarise the types of lymphoid neoplasms their cells of origin.

Answer 42

_Types of Lymphoid Neoplasms_ 1. **Lymphoid** **Neoplasms** – the phenotype of the neoplastic cell resembles a stage of lymphocyte differentiation * **Acute** **lymphoblastic** **leukaemia** (ALL): proliferation of pre-B/T cells * **Chronic** **lymphocytic** **leukaemia** (CLL): proliferation of B cells * **Lymphoma**: proliferation of B/T/NK cells in tissues 2. **Myeloid** **Neoplasms** – arise from haematopoietic stem cells that differentiate into myeloid lineages * **Acute myeloid leukaemia** (AML): accumulation of immature progenitor cells in bone marrow * **Myelodysplastic syndromes** : due to ineffective haematopoiesis * **Chronic myeloid leukaemia** (CML): accumulation of terminally differentiated myeloid cells 3. **Histiocytoses** – proliferative lesions of macrophages and dendritic cells

Question 43

Compare Acute and Chronic Myelogenous Leukaemia in terms of: * Cells composed of * Presentation * Clinical Features

Answer 43

Question 44

Summarise the prognosis of the 4 major types of leukaemia.

Answer 44

_Major Types of Leukemia - Prognosis_ 1. **Acute Lymphoblastic** - ~95% of children will achieve full remission with aggressive chemotherapy, and ~80% are cured 2. **Chronic** **Lymphoblastic** - extremely variable, median survival is 4-6 years 3. **Acute** **Myelogenous** - difficult to treat, 60% of patients achieve full remission using chemotherapy, but only ~20% remain disease-free for 5 years 4. **Chronic** **Myelogenous** - insidious onset and slow-progressing disease, without treatment, the median survival is 3 years * Allogenic bone marrow transplantation in young patients is curative in 75% of cases

Question 45

Summarise purine metabolism.

Answer 45

**Purine Metabolism**

Question 46

Summarise pyramidine metabolism.

Answer 46

**Pyramidine Metabolism**

Question 47

List some common side effects of chemotherapy.

Answer 47

_Chemotherapy - Side effects_ * **Bone** **Marrow**: myelosuppression * Leukopenia, lymphocytopenia, thrombocytopenia, anaemia * Increased risk of infection * Impaired wound healing, haemorrhage * **GIT**: oral/intestinal ulceration → nausea, vomiting, diarrhoea * **Hair** **roots**: alopecia * **Gonads**: menstrual irregularities, amenorrhoea, infertility * **Any** **tissue**: predisposition to future cancer (disruption of DNA) * **Foetus**: teratogenesis

Question 48

Explain two limitations of chemotherapy, that are overcome by combination therapy.

Answer 48

_Overcoming Limitations of Chemotherapy_ 1. **Toxicity** * Most drugs are cytotoxic – kill normal cells as well as cancer cells 2. **Resistance** * Inability of tumour cells to undergo apoptosis in response to drug-mediated DNA damage * Alteration of the drug target, ↑expression of the drug target, ↑rate of repair following damage * ↓ drug uptake, ↑ drug efflux/clearance, ↓ activation of prodrug

Question 49

Explain some of the difficulties a rural doctor might face.

Answer 49

**Difficulties faced by a rural doctor** * Being the ‘outsider’ when entering into the community – local rules * Isolation * Difficult for spouse & children – lack of family support, difficulty in making friends * Often a low standard of working environment * Extended on-call period * Boundaries between personal and professional relationships may become blurred

Question 50

Describe 7 rural barriers to healthcare.

Answer 50

_Rural Barriers to Healthcare_ 1. **Decreased** **access** to healthcare * Geographical remoteness * Limited resources (e.g. imaging/pathology) * Lower proportion of people with private healthcare * Difficulty attracting local specialists * Shortage of nursing homes 2. **Lower socioeconomic status** 3. **Harsher environments** 4. **Sparse** **infrastructure** 5. **Poor** **uptake** of health promotion messages 6. Increased **occupational hazards** 7. Attitudes towards safety and more frequent indulgences in **risky behaviour**

Question 51

State the path of milk in the mammary glands, from the alveoli to the nipple.

Answer 51

**Path of Milk** 1. Alveoli 2. Intralobular ducts 3. Terminal interlobular ducts 4. Lactiferous ducts 5. Lactiferous sinuses

Question 52

What 4 muscles are deep to the breast?

Answer 52

1. Pectoralis major 2. Pectoralis minor 3. Parts of serratus anterior 4. External oblique

Question 53

Briefly explain the lymphatic drainage of the breast.

Answer 53

**Lymphatic Drainage of the Breast.** * Lateral: anterior axillary nodes (75%) * Medial: parasternal nodes

Question 54

For each of the structures of the glandular and ductal systems of the mammary gland, state the type of epithelium involved and the function of the structure.

Answer 54

**Mammary Gland**

Question 55

Describe the hormonal control of mammogenesis.

Answer 55

_Hormonal Control of Mammogenesis_ 1. **Growth and branching of the ductal system and stroma is stimulated by:** * Oestrogen * Growth hormone * Prolactin * Insulin * hCG * Placental lactogens (hCS) 2. **Development of alveolar tissue is stimulated by progesterone** * Synergised by oestrogen and other hormones 3. **Prolactin levels are increased** * Prolactin stimulates milk production * This is inhibited by oestrogen and progesterone until after parturition

Question 56

List some of the physiological effects of menopause.

Answer 56

**Menopause** 1. Reduction in size of breasts and uterus 2. Mood changes, anxiety, depression 3. Hot flashes – intense heat, sweating, tachycardia 4. ↑risk of cardiovascular disease 5. Memory loss – anecdotal but no studies 6. Vaginal dryness 7. Dry skin 8. Insomnia 9. Fatigue 10. ↑ risk of osteoporosis

Question 57

Explain the triple assessment for diagnosis of breast cancer, and state its sensitivity and specificity.

Answer 57

_Triple Assessment of Breast Cancer Diagnosis_ 1. **Clinical** – inspection and palpation 2. **Radiological** – mammography, ultrasound, CT 3. **Pathological** – fine needle aspiration, histological assessment Sensitivity: 99.6% Specificity: 62%

Question 58

List 14 risk factors for breast cancer.

Answer 58

_Breast Cancer - Risk Factors_ 1. **Gender** – 99% of cases occur in women (1% in men) 2. **Age** – peaking at 75-80 years 3. **Age** **at** **menarche** – menarche at 11 years old → 20% increased risk 4. **Age** **at** **1st** **live** **birth** - giving birth \<20 years → 1/2 risk vs. nulliparous 5. **First-degree relatives with breast cancer** 6. **History of atypical hyperplasia** 7. **Race** – risk of developing invasive carcinoma in the next 20 years: * Non-hispanic white women 1 in 15, African Americans: 1 in 20, Asian/Pacific islanders: 1 in 26, Hispanics: 1 in 27 8. **Estrogen** **exposure** – postmenopausal hormone therapy (↑risk by ~1.5) 9. **Breast** **density** – high breast radiodensity 10. **Radiation** **exposure** – cancer therapy, atomic bomb, nuclear accidents 11. Carcinoma of contralateral breast or endometrium 12. **Geographic** – rates in the USA and Europe 4-7x higher than other areas 13. **Obesity** – ↓ risk in obesity; ↑ risk with postmenopausal obesity 14. **Not** **breastfeeding** – the longer a woman breastfeeds the lower the risk

Question 59

For each major histological subtype of breast cancer, state how often each occurs and explain their histological appearance and how they present clinically.

Answer 59

**Histological Subtype of Breast Cancer** 1. In situ ductal carcinoma (DCIS) 2. In situ lobular carcinoma (LCIS) 3. Invasive ductal cancer 4. Invasive lobular cancer 5. Other invasive cancer

Question 60

Describe 3 options of hormonal therapy for ER+ breast cancers.

Answer 60

_Treatments for ER+ (oestrogen receptor positive) cancers_ 1. **Selective Oestrogen Receptor Modulators** (SERMS) * Tamoxifen * Raloxifene * Selectively antagonise/agonise E receptors → ↓ growt 2. **LHRH agonists (GNRH agonists)** * ↓ LH and FSH → ↓oestrogen * Effective in premenopausal women 3. **Selective aromatase inhibitors (steroidal/non-steroidal)**

Question 61

List some major prognostic indicators for breast cancer.

Answer 61

_Prognostic Indicators for Breast Cancer_ 1. **Invasive vs. In situ** * The majority of women with DCIS are cured 2. **Distant** **metastasis** – cure is unlikely, but long-term remissions are possible 3. **Lymph** **node** **metastasis** – the most important diagnostic factor * No nodal involvement – 10-year survival rate is 70%-80% * 1-3 nodes involved – 35-40% * \>10 nodes involved – 10-15% 4. **Tumour size** 5. **Locally** **advanced** **disease** – into skin or skeletal muscle 6. **Inflammatory carcinoma** – breast swelling and skin thickening * 3-year survival rate is only ~3-10%

Question 62

Describe a commonly used strategy for breaking bad news.

Answer 62

_Strategy for Breaking Bad News = SPIKES_ * **S – Setting** → Basic communication and facilitation skills, be available, ensure privacy, involve significant others – e.g. family, close friends * **P – Perception** → Ask the patient what they already know or suspect, determine the patient’s perception of the seriousness of the situation as well as their comprehension * **I – Invitation** → Obtain a clear invitation to share information; determine the level of detail the patient wants, leave option to request information open * **K – Knowledge** → Warn that bad news is coming, start at the same level of the patient’s comprehension, give information in small chunks, check that content is understood * **E – Empathy** → Identify emotion/cause of emotion, respond to show a connection has been made * **S – Strategy and Summary** → Summarise major points, ensure that patient understands Strategise – make a clear contract for the next meeting

Question 63

Explain the concept of classical conditioning.

Answer 63

**Classical Conditioning** * A neutral conditioned stimulus is repeatedly paired with an unconditioned stimulus which invokes a conditioned response * Over repeated trials the neutral stimulus eventually evokes a similar response * E.g. Pavlov’s dog – the sound of footsteps (CS) began to evoke salivation (CR) in dogs anticipating food (UCS)

Question 64

Explain the concept of operant conditioning.

Answer 64

_Operant Conditioning_ * Actions which result in reinforcement are strengthened and more likely to occur * **Positive** **reinforcement** – e.g. more parental attention with symptoms of anxiety * **Negative** **reinforcement** – removal of a negative stimulus e.g. avoiding school to avoid bullying * Actions which result in punishment are weakened and less likely to occur * **Punishment** – presentation of a negative stimulus * **Negative** **punishment** – removal of a reinforcer e.g. removing pocket money

Question 65

What specifically are the main causes of morbidity and death in young people?

Answer 65

**Morbidity & Mortality - Young People** * Mental health problems are the major burden of disease (50%) in young people * Primarily anxiety disorders * Affective disorders * Substance abuse disorders * Injury is the leading cause of death (2/3) * Suicide (27%) * Transport accidents (45%)

Question 66

List some of the changes that occur during adolescence.

Answer 66

Changes that occur during adolescence: * Peers and Parents * Autonomy * Education & Vocation * Sexuality * Body image & identity

Question 67

What are three main features of anxiety in general?

Answer 67

**Anxiety - Clinical Features** 1. Cognitive experience of dread 2. Associated physiological changes 3. Behavioural attempts to escape or avoid

Question 68

Identify some cognitive and behavioural manifestations of anxiety.

Answer 68

_Cognitive & Behavioural Manifestations of Anxiety_ * **Hypervigilance** – rapid and global scanning for threats * If a threat is detected, the anxious person’s attention focuses narrowly and intensely on it * **Selective** **attention** – narrowing of attention that occurs in response to a threat * External e.g. lightning – someone with a storm phobia will constantly watch the skies * Internal e.g. heart beat – someone with hypochondriasis will pay close attention for skipped beats * Excessive self-focus is the basis for abnormal behaviour and experience * Alcohol inhibits self-focussing – can reduce anxiety in social situations * **Avoidance Behaviour** * Initially, intense relief with avoidance of a feared situation - reinforcing * In the long term, avoidance strengthens the belief and maintains the anxiety

Question 69

List some physiological manifestations of anxiety.

Answer 69

**Physiological Manifestations of Anxiety** 1. Dizziness 2. Confusion – impairment of concentration, new learning, recall 3. Syncope 4. Hyperreflexia (twitching) 5. Tremors; restlessness 6. Diarrhoea, upset stomach 7. Pupillary mydriasis 8. Tachycardia; palpitations 9. Hyperhidrosis (excess sweating) 10. Hypertension 11. Urinary frequency, hesitancy, urgency

Question 70

State the 3 diagnostic criteria for Obsessive Compulsive Disorder (OCD).

Answer 70

**OCD - Diagnostic Criteria** 1. Presence of obsessions (pervasive and intrusive thoughts, impulses, images) and/or compulsions (repetitive behaviours or mental acts that must be applied rigidly) 2. The person must realise that the obsession and/or compulsions are excessive and unreasonable 3. The obsessions and/or compulsions cause marked distress, are time consuming (\>1hour/day), or significantly interfere with day‐to‐day functioning

Question 71

Identify 4 pharmacological treatment options for anxiety.

Answer 71

_Anxiety - Pharmacological Treatment Options_ 1. **Antidepressants** * Selective serotonin reuptake inhibitors (SSRIs) * Tricyclic antidepressants (TCA) 2. **Anxiolytic Drugs** * Benzodiazepines * Azapirone * Beta-blockers 3. **Anticonvulsant** **drugs** * Valproate * Gabapentin 4. **Atypical** **antipsychotic** **drugs** * Risperidone * Olanzapine

Question 72

Identify 6 non-pharmacological treatment options for anxiety.

Answer 72

_Anxiety - Non-pharmacological Treatments_ 1. **Relaxation, Breathing Training, Mindfulness** - deep breathing, progressive muscle relaxation, imagery, hyperventilation control, mindfulness 2. **Exposure** **Therapy** - gradually exposing patients to identical or similar stimuli to what he/she fears, to habituate the patient to the stimulus 3. **Systematic** **Desensitisation** - exposure therapy & relaxation training 4. **Cognitive‐Behavioural Therapy** - focuses on information processing, learning and problem solving by identifying automatic thoughts and core beliefs associated with anxiety, then challenging and restructuring unhelpful thoughts and beliefs * What’s the worst thing that could happen? How likely is it that it will happen? What’s an alternative explanation? 5. **Social** **interventions** - managing stress, friendships & supports, relaxing activities 6. **Diet** - avoid alcohol, caffeine, illicit substances, foods with preservatives, medications with pseudoephedrine (where practical)

Question 73

Explain Gillick’s ratio.

Answer 73

**Gillick's Ratio** A minor can consent to medical treatment once s/he has achieved a “sufficient understanding and intelligence to enable him or her to understand fully what is proposed”.

Question 74

Give 4 aspects making up the profile of a resilient child.

Answer 74

_Profile of a Resilient Child_ 1. **Social competence** * Responsiveness o Flexibility * Empathy * Caring * Communication skills * Sense of humour 2. **Problem solving skills** * Critical thinking * Generating alternatives * Planning * Producing change 3. **Autonomy** * Self-esteem * Self-efficacy * Independence * Adaptive/healthy distancing 4. **Sense of Purpose and Future** * Goal directedness * High motivation * Educational aspiration * Persistence * Hopefulness * Coherence