2024b

Case 1. 40 minutes.

Belle Ringer, a 25-year-old Pākehā female, has a 4 year history of recurrent episodes of crampy abdominal pain, fever, diarrhoea and weight loss. She has been diagnosed with inflammatory bowel disease (IBD). Medication has helped but she is especially troubled by bouts of severe diarrhoea lasting for several days.

Part A. 10 minutes.

Belle’s diarrhoea can cause electrolyte and acid-base abnormalities as well as volume depletion.

Question 1: Describe and explain the changes you would expect to see in the following plasma electrolyte measurements with severe diarrhoea: 

• Plasma sodium concentration
• Plasma chloride concentration
• Plasma potassium concentration

Question 2: Belle has an arterial blood gas taken. Selected results are shown.

Parameter	Value	Reference range
pH	7.33	7.35 - 7.45
HCO3	17 mmol/L	24 - 30 mmol
PaCO2	33 mmHg	37 - 43 mmHg
Interpret the arterial blood gas (ABG) results AND explain how they could have come about in severe diarrhoea.

Part B. 10 minutes.

Belle develops a bowel obstruction and is admitted to the surgical ward. On the ward round the consultant quizzes their team on the difference between Crohn’s Disease and Ulcerative Colitis.

Question 3: BRIEFLY state how each of the following features presents in Crohn’s Disease and in Ulcerative Colitis.

• Bowel segment involved 
• Pattern of involvement  
• Presence of granulomas  
• Ulcer morphology

Question 4: One of the images below represents a biopsy of a section of Belles’s gastrointestinal tract. The other image shows a different type of IBD.

Image A	Image B
For EACH image identify the type of IBD, AND BRIEFLY provide your rationale for your identification.

Part C. 10 minutes.

Question 5: Describe the anatomical features that distinguish the small intestine from the large intestine AND Where relevant, how these would help identify whether the obstruction was a small or large bowel obstruction on an x-ray radiograph.

Part D. 10 minutes.

Question 6: Describe the mechanism of action of TWO (2) drug classes commonly used to treat IBD.

Case 2. 30 minutes.

Mere (she/her) is a 55 year-old Māori retired engineer. She visits her general practitioner (GP).

Today, Mere will see the practice locum doctor, who is meeting Mere for the first time. Reviewing Mere’s notes before seeing her, the doctor learns that Mere was diagnosed with hypertension about six months ago, at which time the GP prescribed a once daily antihypertensive medicine. It is also noted that Mere’s GP explained how high blood pressure can lead to serious health complications, including heart disease, stroke, and kidney damage. Mere’s questions about the role of medication in lowering blood pressure and preventing these complications were answered.

Mere’s blood pressure was taken by the practice nurse before the doctor spoke to Mere, and it was found to be 160/95 mmHg.

The locum doctor decides to use the Hui Process to guide their consultation.

Part A. 10 minutes.

Question 8: Name AND describe the four stages in the Hui Process.

Question 9: Discuss why the Hui Process is a useful framework for interactions with Māori patients.

Part B. 12 minutes.

Question 10: List THREE (3) lifestyle factors that could be potentially contributing to poor control of Mere’s hypertension?

Question 11: Mere would like to engage in more frequent exercising, however this has been difficult for her. What might be a barrier for her? (List THREE (3) potential barriers.)

Question 12: To get an idea of Mere’s motivation for changing her lifestyle, the Stages of Change model could be used.

Describe what Mere’s behaviour may look like if she is currently in the preparation stage of this model

Quesiton 13: Mere was motivated to change her lifestyle.

She began to exercise vigorously and injured her right leg, which developed into persistent (chronic) pain.

What is persistent (chronic) pain? (MCQ)

• Pain that lasts for less than a day
• Pain that only occurs after an injury
• Pain that lasts beyond the natural healing time
• Pain that disappears once the tissue damage is treated
• Pain that is a false pain alarm

Question 14: Which of the following best describes factors that could influence the pain experience? (MCQ)

• Beliefs/concerns (e.g., no pain no gain)
• Cultural issues (e.g., expectations)
• Existing medical conditions
• Psychological factors (e.g., anxiety, anger)
• All of the above

Part C. 8 minutes.

During the consultation, Mere also revealed that her mother had experienced psychotic symptoms for approximately 2 months following the death of her sister.

Question 15: Complete the sentences below about the diagnostic criteria for psychotic spectrum disorder.

• Brief Psychotic Disorder 
• Delusional Disorder 
• Schizophreniform Disorder 
• Substance Induced Psychotic Disorder 
• Schizotypal Personality Disorder 
• Catatonia 
• Schizoaffective Disorder 
• Schizophrenia 
• Schizophrenia (I assume there is the option to use this twice)

In the case of (____), the DSM 5-TR stipulates that psychotic symptoms needs to have been present for a period of 6 months and include at least one month of active symptoms. Whereas in the case of (____) symptoms need to be present for more than 1 month but less than 6 months. 

For (____) to be diagnosed, there needs to have been a sudden onset of psychotic symptoms that lasts for less than 1 month. 

(____) is characterised by distorted thinking and/or eccentric behaviour and there are two types of (____), namely bipolar and depressive types.

Question 16: Looking further through her file, the locum doctor notices that Mere has presented frequently to the emergency department (ED) and emergency psychiatric services (EPS) in the last five years for a range of unrelated complaints. It was noted that Mere had a tendency to present as angry, demanding, and easily distressed.

According to the biopsychosocial model of personality, what are the two factors that interact to determine personality traits?

Case 3. 40 minutes.

Holly Graham is a 9 year-old female taken to the GP by her mother, who noticed that Holly gets ‘wheezy’ when running around with her friends. Holly has also been coughing during the night recently and sleeping poorly. Her mother explains that this has happened before but that Holly’s breathlessness had got more pronounced when Holly ‘came home with a cold’ (upper respiratory tract infection). The GP examined Holly’s respiratory system and noted she was short of breath. The GP heard high pitched wheezes on auscultation.

Part A. 10 minutes.

Question 17: Briefly describe the nerve supply of the lung.

Question 18: State two differences between bronchi and bronchioles.

Question 19: List the layers that make up the respiratory membrane.

Question 20: Name the labelled structures in the chest x-ray radiograph below.

Part B. 10 minutes

Holly’s shortness of breath suggests her work of breathing (WOB) may be increased.

Question 21: What are the determinants of WOB? How are they most likely to have changed in Holly’s case?

Question 22: Holly’s lung function tests, performed when she was short of breath, are shown below.

|FEV1
litres|VC
litres|FVC
litres|RV
litres| |---|---|---|---|---| |Predicted|2.6|3.1|3.1|1.9| |Actual|1.6|2.5|2.4|2.2| |Bronchodilated|2.2||2.9||

Indicate, with reasons, what type of lung dysfunction Holly has, AND whether it is likely to respond to a bronchodilator.

Question 23: Discuss the role of peak expiratory flow rate (PEFR) measurements in the investigation and management of Holly’s problem.

Part C. 10 minutes.

After reviewing Holly’s notes, the GP decides to commence Holly on a single combination pressurised metered dose inhaler (m.d.i.) containing salmeterol and fluticasone.

Question 24: Describe the mechanism AND site of action of salmeterol, and fluticasone.

Question 25: What are the possible oral adverse effects of fluticasone when using an m.d.i. AND how would you mitigate them?

Question 26: Would either of these drugs act as rescue inhalers? 
If not, how would you adjust the prescription to provide immediate relief in the event of an acute respiratory exacerbation?

Part D. 10 minutes.

Holly was diagnosed with asthma. One month later Holly and her mum return to the GP for follow-up regarding her asthma control. The practice nurse gives Holly and her mother an Asthma Control Test to complete. This reveals that Holly’s asthma is still problematic and the GP wants to know why.

Question 27: The GP asks questions related to Holly’s compliance with inhaler therapy and to assess whether Holly and her mother are aware of asthma triggers. Name ONE (1) factor aligned to how a medication is administrated that could impact compliance with inhaler therapy in a child, AND explain why it could.

Question 28: Holly’s known triggers appear to be exercise and respiratory tract infections, but there could be more that the doctor has not yet learned about. List THREE (3) other asthma triggers that a child could be exposed to in their day-today activities.

Question 29: Holly’s mother explains that she had a family friend some years ago who had died from her asthma. Select the changes that occur to arterial blood gases and the pH when a patient with a severe asthma attack becomes exhausted and develops type 2 respiratory failure.

For each of these	Choose high low or no change or each
PaO2	high no change low
PaCO2	high no change low
pH	high no change low

Case 4. 25 minutes.

The Das family, including Mum (Ayesha), Dad (Ishmael), Grandma (Bibi), and three children, recently arrived in Aotearoa New Zealand from Bangladesh. Ishmael is a Civil Engineer, and Ayesha is a nurse. Because both parents are working, Grandma Bibi looks after the children, who are aged 5, 6, and 8. Ishmael, Ayesha, and the children speak English. However, Grandma Bibi does not speak any English at all. Bibi came with her family to the Emergency Department because she had acute abdominal pain, nausea and vomiting.  She was admitted to an inpatient ward.

Part A. 10 minutes.

Question 30: Identify TWO (2) important elements to an effective doctor-patient relationship. Discuss why EACH of these are important.

Part B. 5 minutes.

Question 30: According to Hofstede’s cultural dimensions, Bangladesh is a collectivist culture with a high-power distance. Identify AND briefly describe TWO (2) issues a doctor would need to consider when applying these cultural dimensions to their interactions with the Das family.

Part C. 5 minutes.

Question 31: The test results show that Bibi has a large bowel tumour, which has caused an obstruction. As Bibi does not speak English, how should the clinical team communicate this information to her and her family AND who should they speak to?

Part D. 5 minutes.

Question 32: Explain why the family might withhold information from Bibi?