Formative

Question 1

1A. You are a newly qualified GP in an Aberdeen City practice. You are consulting in your normal afternoon surgery. One of your patients, John Young is brought in by his mother. He is seven years old and has cerebral palsy. He walks with a limp and has mild learning difficulties, although manages to attend mainstream school. John’s mother is concerned because he has had earache for two days.
1a - The World Health Organisation (WHO) defines three categories under which disability can be described. List these three categories and give a brief explanation of each. (6 marks)

Answer 1

• Body structure and function impairment - is defined as abnormalities of structure, organ or system function (organ level)
• Activity limitation - is defined as changed functional performance and activity by the individual (personal level)
• Participation restrictions - is defined as the disadvantage experienced by the individual as a result of the impairments and disabilities (interaction at social and environmental level)

Question 2

1. You are a newly qualified GP in an Aberdeen City practice. You are consulting in your normal afternoon surgery. One of your patients, John Young is brought in by his mother. He is seven years old and has cerebral palsy. He walks with a limp and has mild learning difficulties, although manages to attend mainstream school. John’s mother is concerned because he has had earache for two days.

1B. Give any four examples of how these definitions could apply to John. (4 marks)

Answer 2

• Damage to motor area of brain
• Damage to cognitive area of brain
• Limited mobility
• Learning difficulty
• Exclusion or difficulty participating in certain activities e.g. riding a bike, certain sports

Question 3

Disability has far reaching implications for patients, their families and others around them. In general, what might be the effect of a disabled child on their parents, siblings, peers and teachers?
Give two different examples under each heading.
Note: Remember to put different answers under each heading. (8 marks)

Answer 3

Parents
• Mother and/or father may not be able to combine work with the demands of caring for disabled child - financial implications for family
• Guilt at having passed on the causative gene if genetic disorder
• Psychological strain
• Caring for disabled child may be detrimental to parent’s physical health
• Some parents may have difficulty bonding with disabled child
• Some parents may form a particularly strong bond with disabled child
• Marital problems
• Increased risk of child abuse
• Over-protection of disabled child
• May become a strong advocate for their child

Siblings
• Resentment at time parents spend caring for disabled child
• Resentment at restrictions to normal family life
• May have to develop carer role
• Grow up with greater understanding of disability
Peers
• May “look out” for disabled child
• Friend may be stigmatised along with disabled child
• May grow up with greater understanding of disability
• May need to adapt activities to include disabled friend
• Teasing by other peers
Teachers
• May have lack of understanding of disability/lack of training
• May have tendency to over-protect disabled child
• May be lack of willingness to integrate in mainstream activities
• May be additional challenges in personalising education for disabled child
• Stress of managing both mainstream and additional support needs pupils in the same class

Question 4

3. As the parent of a child with a disability/long term condition, John’s mother could be classed as an expert patient.

List two different points to show your understanding of the term “expert patient”. (2 marks)

Answer 4

• Patient/carer has an in-depth knowledge of their condition (or in this case the condition of the person they care for), sometimes exceeding that of health professionals
• Utilising the knowledge of the patient/carer (mutual decision making about management of the condition) is likely to greatly benefit the patient’s care and quality of life
• Historically, the knowledge and experience held by the patient/carer has been an under-recognised resource

Question 5

4. On this occasion John’s presenting symptom is not serious and his mother is happy with the advice you give.
   Your next patient is 62 year old Marion Yule. She has developed symptoms of chest discomfort and breathlessness when walking uphill over the last four months and found some information which suggested attending her GP.
   A lay source of information is just one of a number of factors influencing the uptake of medical care. List five different sources of information used by the general public which may influence their uptake of medical care. (5 marks)

Answer 5

• Peers / family / friends
• Internet - general information e.g. google, social media
• TV
• Health pages of newspaper or women’s magazine
• “What should I do?” / “When should I worry?” booklet
• SHOW (Scotland’s health on the web) website, NHS inform website
• GP practice leaflet
• GP practice website
• Adverts in public places e.g. bus stops, railway stations
• Health awareness events e.g. health fairs
• Pharmacies e.g. posters, leaflets

Question 6

5. By sourcing information, Marion has shown a degree of health literacy. Health literacy is being increasingly recognised as a significant health concern around the world.
   Provide a brief description of health literacy. (2 marks)

Answer 6

Health literacy is about people having the knowledge, skills, understanding and confidence to use health information, to be active partners in their care, and to navigate health and social care systems.

Question 7

6. Following investigation, Marion is diagnosed with angina and she commences treatment.
   In managing Marion’s angina, you refer to SIGN (Scottish Intercollegiate Guidance Network) Guidelines. The guidelines are based on a systematic review of the scientific literature and are aimed at aiding the translation of new knowledge into action, and are intended to achieve three main aims.
   List the three intended aims of SIGN Guidelines. (3 marks)

Answer 7

• Help health and social care professionals and patients understand medical evidence and use it to make decisions about healthcare
• Reduce unwarranted variations in practice and make sure patients get the best care available, no matter where they live
• Improve healthcare across Scotland by focusing on patient-important outcomes

Question 8

7. Scotland has a high prevalence of the risk factors associated with heart disease, such as smoking, poor diet and physical inactivity. Overall, it is estimated that around 7.5% of men and 4.6% of women are living with Coronary Heart Disease/CHD (2015 data). Ascertaining prevalence of diseases within a population is important for health service planning and funding. Doctors working in population health use a variety of sources and types of epidemiological data to ascertain prevalence of a large number of diseases found within the population.
   Give six examples of sources/types of epidemiological data. (6 marks)

Answer 8

• Mortality data
• Hospital activity statistics
• Reproductive health statistics
• Cancer statistics
• Accident statistics
• General practice morbidity
• Health and household surveys
• Social security statistics
• Drug misuse databases
• Expenditure data from NHS
• ISD Scotland statistics

Question 9

8. The results of studies looking at risk factors for diseases can be made harder to interpret by the presence of confounding factors.
   Give a brief explanation of what is meant by a confounding factor AND give two examples of common confounding factors. (4 marks)
   A confounding factor is one which is associated independently with both the disease and with the exposure under investigation and so distorts the relationship between the exposure and disease.
   Common confounding factors

Answer 9

• Age
• Sex
• Social class

Question 10

9. You are then consulted by 84 year old Sadie Grant. She is accompanied by her daughter, who helps to care for her. Sadie has smoked for most of her life and has osteoarthritis, hypertension and Chronic Obstructive Pulmonary Disease (COPD). She consults you because the over-the-counter ibuprofen (non-steroidal anti-inflammatory drug/NSAID) she has been using for her joint pain is not providing adequate pain relief. Sadie is just one member of an increasingly elderly population. Population pyramids for all countries show general trends of increasing numbers of older people and fewer younger people. Some reasons for these trends relate directly to improvements in health care provision e.g. better treatment and prevention of diseases. However, there are a number of reasons for these trends in population demographics which are not directly related to health care provision.
   List six reasons for these trends which are not directly related to health care provision. (6 marks)

Answer 10

• Decrease in birth/fertility rates
• Improvements in housing
• Improvements in water supplies
• Improvements in sanitation/sewerage systems
• Improvements in nutrition
• Improved safety and reduction of injury
• Migration (some areas only)
• War/genocide (some areas only)

Question 11

10. Ageing populations have a variety of implications and consequences in different countries.
    List five different social implications associated with Scotland’s increasing elderly population. (5 marks)

Answer 11

• Increasing dependence on families and/or carers who are also ageing and perhaps still working themselves
• Demand for home carers likely to increase
• Demand for Care home/nursing home places likely to increase
• Increasing emphasis on social activities for the elderly within communities
• Role of elderly as grandparents and carers of grandchildren likely to change e.g. may have fewer/no grandchildren, may still be in employment themselves
• Housing demands are likely to change as more elderly people live alone e.g. increased demand for one-bedroom flats, sheltered housing
• Elderly people remaining in employment for longer may lead to an increase in unemployment rates in the young (this point could equally well be made as an economic implication)

Question 12

11. You ask Sadie to stop the ibuprofen because you are concerned about potential side-effects.
    Suggest three possible side-effects of Sadie’s use of ibuprofen which may concern you. (3 marks)

Answer 12

• Worsening of hypertension/interaction with anti-hypertensive medication
• Cardiotoxicity
• Nephrotoxicity
• Exacerbation COPD
• GI upset

Question 13

12. Statistics show that 40% of carers care for their parents or parents-in-law. Being a carer may carry a significant financial impact, as well as other social, physical and mental implications.
    List four possible financial implications of being a carer. (4 marks)

Answer 13

• Almost 1 in 3 (30%) carers had seen a drop of £20,000 or more a year in their household income as a result of caring/significant loss of income due to caring role - e.g. working less hours in order to fulfil carer role
• A third of carers had cut back on essentials like food and heating (32%)/cutting back on household basics
• 45% (large numbers) of carers said their financial circumstances were affecting their health
• 42% (large numbers) of carers have missed out on financial support, e.g. missing out on benefits, as a result of not getting the right information and advice

Question 14

13. It is increasingly common for elderly patients with multimorbidity such as Sadie, to have Anticipatory Care Plans (ACPs). ACPs usually include legal, personal and medical issues.
    List two examples of legal issues which may be included in an Anticipatory Care Plan for ANY patient. (2 marks)

Answer 14

• Welfare power of attorney
• Financial power of attorney
• Guardianship

Question 15

14. Just as you finish surgery, you are asked to attend an urgent house call to 87 year old Sandra Fraser. She is widowed and lives alone in a three-bedroom council house. She has Parkinson’s disease and in the last six months has become increasingly frail and has had several falls. You have spent some time with Sandra and her family trying to adjust her medication, but improving the situation has been challenging and Sandra has recently developed a low mood and poor appetite. She has had another fall this afternoon and “feels very shaken” as a result. Sandra’s son is with her and is concerned about his mother’s condition.
    After assessing Sandra and excluding fractures, you admit her to the Department of Medicine for the Elderly for further assessment. Following assessment, she is moved to a rehabilitation ward and is discharged to a “very sheltered housing” complex several weeks later. She has developed a pressure sore on her right hip, but the rehabilitation she has commenced in hospital, along with further changes to her medication, has reduced her likelihood of falls. In order for Sandra to continue her rehabilitation in this setting following her fall, several members of the health and social care team are likely to be involved with her care.
    List ten members of the community health and social care team who may be involved with Sandra’s care in her home AND give a short description of each of their roles in Sandra’s care. (20 marks)

Answer 15

• GP - day to day medical support, monitoring of Parkinson’s disease and other conditions, co-ordination of care
• District nurse - dressings and management of pressure sore
• Nurse practitioner or paramedic practitioner or physician’s associate -acute home visits with GP phone, support or follow up visit
• Home carer - practical tasks e.g. bathing, dressing
• Pharmacist - advice on medication, dosette box
• Social worker/care manager - advice on benefits e.g. attendance allowance, contact with agencies
• Occupational therapist - adaptation of living environment to maximise independence
• CPN - assessment and management of low mood
• Physiotherapist - continue to improve mobility and stability
• Dietician - advice on improving appetite, assessment nutrition
• Receptionist - first point of contact for any issues/concerns/house calls
• GMED/NHS 24 - out-of-hours care for unexpected deterioration/new condition
• Parkinson’s Nurse specialist - specialist advice to Sandra and her family relating to Parkinson’s disease, assist contact with local Parkinson’s support group
• Community geriatric nurses - discharge assessment, support with development of a care plan
• Community geriatrician - specialist overview of care/advice on care