Dr Joan Meagher, General Practitioner, Bannockburn Community Health Centre, 2 Pope Street Bannockburn Victoria 3331.
1/10/2009
Dear Dr Meagher, Re: Mr John McIntyre, aged 68 years.
I am writing to refer Mr McIntyre, who needs sympathetic care and monitoring following his relocation to Lake Retirement Village at Bannockburn in a week. He suffers from Hypertension, Congestive cardiac failure, and Chronic obstructive airways disease.
Since September 2001, Mr. McIntyre is consistently monitored by our Community Nurse to ensure medication compliance. His prescribed medications include diuretics, antihypertensives, vasodilators, and bronchodilators. A detailed description of his medical history can be found in his casebook, which is currently in his possession.
Mr. McIntyre has been engaging in excessive alcohol consumption and has been smoking 40 cigarettes per day for the past 30 and 35 years, respectively. He believes that he will be able to curtail these habits following the relocation.
Mr. McIntyre is married and resides in his own home with his wife. He has three children and a grandchild, managing expenses from a small savings account and aged pension. Despite advice from his wife and children to modify his lifestyle, Mr. McIntyre does not yield.
Considering the provided information, I kindly request that you assume responsibility for Mr. McIntyre’s care. Please ensure that he receives sympathetic care and continuous monitoring. Kindly encourage him to cease smoking and drinking. Additionally, please monitor his medication compliance and diet closely, and motivate him to engage in regular exercise. If you have further queries, please do not hesitate to contact me.
Your sincerely, Registered nurse.
Case notes:
MR JOHN McINTYRE – 68 year old Born: 1941 This 68 year old married man has been getting monitored at the Community Health Centre, Richmond. He and his wife are moving to The Lake Retirement Village Bannockburn 11/2001 – First attended Community Health Centre, Richmond 10/2009 – Last attended the Centre DIAGNOSIS: Hypertension, Congestive cardiac failure, Chronic obstructive airways disease (COAD) SOCIAL HISTORY: Married, Three children; one grandchild, Lives in own home with his wife Wife has no control over his lifestyle or medication. He resents his children’s advice about the need to change his lifestyle. Now moving to a self-contained Unit at The Lake Retirement Village (Anticipate this will happen in one week’s time). Apart from a small amount of savings, Mr. and Mrs. McIntyre plan to live on the Aged Pension. Has been excessively drinking alcohol for past 30 years. Has been excessively smoking (40/day) for the past 35 years. Claims he will stop smoking once he moves to the new Unit. He will try and cut down on the drinking NURSING MANAGEMENT AND PROGRESS Medications include diuretics, antihypertensive, vasodilators and bronthodilators Has received regular monitoring by Community Nurse to achieve medication compliance Further details in patient’s personal casebook (with the patient)
DISCHARGE PLAN: Establish contact with a sympathetic medical practitioner Monitor medication compliance and diet, Encourage patient to stop smoking Encourage patient to stop drinking, Encourage patient to take moderate regular exercise WRITING TASK: Mr. McIntyre needs to be monitored by a sympathetic GP so that his present regime continues in his new home. Using the information in the above case notes, write a letter referring the patient into the care of Dr Joan Meagher, General Practitioner, Bannockburn Community Health Centre, 2 Pope Street Bannockburn Victoria 3331. You must use full sentences in your letter – not notes / bullet points. Write no more than 25 lines about 180 to 200 words.
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In this era of technology and numerous knowledge acquisition avenues, it is argued by some that educating children at home is preferable to sending them to traditional classrooms. While others disagree with this notion, this essay will examine both options and present my personal perspective on the matter.
On the one hand, homeschooling presents numerous benefits. Firstly, children have the opportunity to spend more time with their parents, fostering a lasting and deeper bond through quality time together. Secondly, homeschooling enables parents to significantly reduce the cost of education by minimising expenses on transportation, uniforms, tuition fees, and other associated costs. Finally, parents can ensure that their kids receive the best education by providing resources without constraints. Additionally, homeschooling offers a sense of safety as children are rarely exposed to unwanted associations, including strangers.
On the other hand, some prefer traditional schooling, citing multiple valid reasons. Fundamentally, it becomes nearly impossible for employed parents to attend to their children during working hours unless they are willing to incur expenses on home tutors or babysitters. Secondly, children, when exposed to other students and diverse environments, have the opportunity to acquire more knowledge and experience than if they were solely engaged in independent learning.
Personally, I endorse traditional schooling as I believe not every parent may possess the necessary qualifications to effectively teach their children, especially considering that schools today offer a multifaceted mode of education, requiring highly educated and talented teachers to provide proper guidance.
To conclude, while homeschooling offers a sense of safety, strengthens the bond between children and parents, and reduces expenses, traditional classrooms guarantee high-quality education, exposure to diverse environments, and are particularly suitable for parents with full-time jobs. The decision between homeschooling and traditional schooling ultimately rests on individual circumstances, available resources, and personal preferences.
Sample answer 2 by Lifestyle Training Centre
In the contemporary age characterised by technological advancements and diverse avenues for knowledge acquisition, a contentious debate revolves around the preference for homeschooling over traditional classrooms. Some contend that educating children at home is a superior choice, while others vehemently disagree. This essay aims to delve into the merits and drawbacks of both options, ultimately providing insights into my personal perspective on this educational discourse.
On one hand, homeschooling is praised for its potential to foster stronger bonds within families, reduce educational costs, and provide a safe and controlled learning environment. The personalised attention and flexible schedule afforded by homeschooling can cater to individual learning styles, allowing children to progress at their own pace. Additionally, the sense of security and limited exposure to potentially negative influences are often seen as significant advantages.
On the other hand, traditional schooling offers its own set of advantages. The exposure to diverse environments and interactions with peers can contribute to a more comprehensive social education. Furthermore, the structured curriculum and professional guidance provided by qualified teachers in traditional classrooms are considered essential for a well-rounded education.
In my opinion, for working parents, the logistical challenges of homeschooling may make traditional schooling a more practical option. However, the choice between homeschooling and traditional schooling is not one-size-fits-all. It depends on the unique needs and circumstances of each family.
To conclude, while homeschooling can be beneficial for some in terms of flexibility and individualised attention, traditional schooling ensures a standardised and well-rounded education. A balanced approach, considering the strengths of both methods, might be the most optimal solution for certain families. Ultimately, the decision should be made based on a careful evaluation of the child’s learning style, the family’s lifestyle, and the available resources.
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Name : Joel Silbersher Age 12 Admitted : 10 September 2008 Discharged : 13 September 2008 Reason for admission: Dehydration, weak rapid pulse, orthostatic hypotension, acetone breath, tachycardia, weakness, fatigue, N & V. abdominal cramps Diagnosis: Diabetic ketoacidosis History: IDDM Type 1; Joel was staying with his friends in Ballarat for the weekend; Insulin injections (Self-administered) neglected, increased sweet and fatty food intake; Stress levels were high; embarrassed by condition. Nursing Notes: IV fluids, IV insulin administration, blood glucose monitoring; electrolyte replacement; K+ replacement. Pt. condition improved gradually with above, maintained consciousness; glucose added to IV when blood glucose normalized.Pt. commenced on low-fat, low-sugar diet
Discharge Plan: Pt. and family educated re prevention of future episodes, carry medical ID (indicating diabetic, name of GP, type and dose of insulin) at all times, tell friends and family how to respond in case of hypoglycemia; need for complying with dose and self- medication emphasized; diet plans given, exercise options outlined.
Writing Task: Using the information in the case notes, write a letter of referral to historical GP, Dr. Harry Coleman, St. Kilda Health Clinic, 35 Carlisle St, St Kilda 3182. DO NOT use note form in the letter. Expand the relevant case notes into full sentences. The letter should be approximately 200 words long.
Sample letter by Lifestyle Training Centre
Dr Harry Coleman, St Kilda Health Clinic, 35 Carlisle St, St Kilda 3182.
13 September 2008
Dear Dr Coleman, Re: Joel Silbersher, aged 12 years.
I am writing to refer Joel, who requires education on prevention of Diabetic ketoacidosis, following his discharge today as he is recuperating from an episode.
Joel, diagnosed with type 1 Insulin-Dependent Diabetes Mellitus, experienced a distressing incident over the weekend at a friend’s place. He consumed high-sugar and fatty foods, neglecting to self-administer his insulin injection. Consequently, Joel was admitted to the hospital, presenting symptoms such as dehydration, a weak rapid pulse, orthostatic hypotension, acetone breath, tachycardia, weakness, fatigue, nausea and vomiting, and abdominal cramps. The diagnosis confirmed Diabetic Ketoacidosis.
During hospitalisation, Joel received IV fluids and IV insulin. Continuous monitoring of his blood glucose levels was conducted, and electrolytes as well as potassium were replenished. To normalise his blood glucose levels, IV glucose was administered.
Joel is presently conscious and recuperating effectively; however, he is coping with stress and embarrassment following the recent episode. He was initiated on a low-fat and low-sugar diet.
In light of the above, it’s crucial to educate Joel and his family on preventing future episodes and ensuring prompt assistance in case of hypoglycaemia. Joel is advised to consistently carry a medical ID containing details about his condition, insulin dosage, and his GP’s name. Strict adherence to self-medication, dietary plans, and exercise is essential for effective management of his condition. If there are any further questions or concerns, please feel free to reach out to me.
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TEXT A Tobacco: Tobacco smoking is also an important risk factor for cardiovascular diseases. Currently, an estimated 967 million of the world’s 7.6 billion smokers liv in the developing world. Tobacco smoking increased among men, followed by women, in industrialized nations in the last century, and has subsequently declined in some nations such as Canada, the United States, and the United Kingdom. Descriptive models based on historical patterns in the industrialized world predict a reduction in the number of male smokers and an increase in the number of female smokers in the developing world over the coming decades. However, there have been major recent transformations in global tobacco trade, marketing, and regulatory control. As a result, tobacco consumption among men and women in most nations is primarily determined by opposing industry efforts and tobacco control measures, and by the socio¬ cultural context, rather than national income.
TEXT B. BMI: The observed rapid BMI increase with national income indicates that preventing obesity, which may be more effective than reacting after it has occurred, should be a priority during economic growth and urbanization of a nation. Overweight and obesity are also important because they cause a number of non- cardiovascular outcomes including cancers, diabetes, and osteoarthritis which cannot be addressed by reducing risk factors such as blood pressure and cholesterol. Current _intervention options for obesity in principle include those that reduce calorie intake and increasing energy expenditure of a population through urban design which incorporates space for outdoor activities.
TEXT C. Current Research (WHO, 2018) Background: Cardiovascular diseases and their nutritional risk factors-including overweight and obesity, elevated blood pressure, and cholesterol-are among the leading causes of global mortality” and morbidity, and have been predicted to rise with economic development in countries and societies throughout the world. Methods and Findings: We examined age-standardized mean population levels of body mass index (BMI), systolic blood pressure, and total cholesterol in relation to national income, food share of household expenditure, and urbanization in a cross-country analysis. Data were from a total of over 100 countries and were obtained from systematic reviews of published literature, and from national and international health agencies. BMI and cholesterol increased rapidly in relation to national income, then flattened, and eventually declined. BMI increased most rapidly until an income of about 1$ 5,000 (international dollars) and peaked at about 1$ 12,500 for females and I$ 17,000 for males. Cholesterol’s point of inflection and peak were at higher income levels than those of BMI (about 1$ 8,000 and 1$ 18,000, respectively). There was an inverse relationship between BMI/cholesterol and the food share of household expenditure, and a positive relationship with proportion of population in urban areas. Mean population blood pressure was not significantly affected by the economic factors considered. Conclusions: When considered together with evidence on shifts in income–risk relationships within developed countries, the results indicate that cardiovascular disease risks are expected to systematically shift to low- and middle-income countries and, together with the persistent burden of infectious diseases, further increase global health inequalities. Preventing obesity should be a priority from early stages of economic development, accompanied by measures to promote awareness of the causes of high blood pressure and cholesterol.
TEXT D. Health Repercussions of Western Lifestyle Factors associated with the increase of these illnesses appear to be, paradoxically, things which many people would regard as lifestyle improvements. They include: • Less strenuous physical exercise, often through increased use of a car • Easy accessibility in society to large amounts of low-cost food • More food generally, with much less physical exertion expended to obtain a moderate amount of food • More high fat and high sugar foods in the diet are common in the affluent developed economies • Higher consumption of meat and dairy products -Higher consumption of grains and white bread • More foods which are processed, cooked, and commercially provided (rather than seasonal, fresh foods prepared locally at time of eating)
QUESTIONS 1-7. For 1-7, decide which text (A, B, C or D): in which text can you find information about 1. from where did the data for the research were collected? 2. name one important risk factor for cardiovascular diseases? 3. what does the observed rapid BMI increase with national income indicate? 4. which types of foods are common in the affluent developed economies? 5. what can cause a number of non- cardiovascular outcomes? — 6. what was the influence of economic factors on the mean population blood pressure? _ 7. how many smokers are there in the developing world?
QUESTIONS 8-13. Answer each of the questions, 8-13, with a word or short phrase from one of the texts. 8. Who conducted the current research on diseases of affluence? 9. How many countries contributed the data for the research? 10. What is the efficient way to minimize diseases of affluence? 11. What is the basis of description models that predicts number of smokers? 12. What is the estimated population of the world? 13. Where did tobacco smokers increase in the last century?
QUESTIONS 14-20. Complete each of the sentences, 14-20, with a word or short phrase. 14. Cholesterol is one among the leading causes of _____________________ and morbidity. 15. Current intervention option for ____________________ in principle include reducing calorie intake. 16. Overweight and obesity can cause _____________________ outcomes including cancers, diabetes, and osteoarthritis. 17. Preventing obesity should be apriority during economic growth and __________________ of a nation. 18. There have been major recent transformations in global ________________________ marketing, and regulatory control. 19. There was an inverse relationship between BMl/cholesterol and the food share of __________________ 20. Factors of these illnesses -are things which many people would regard as ______________________
PART B. Choose the answer (A, B or C).
Ultrasound Machines: Diagnostic ultrasound machines are used to give images of structures within the body. The diagnostic machine probes, which produce the ultrasound, come in a variety of sizes and styles, each type being produced for a particular special use. Some require a large trolley for all the parts of the unit, while the smallest come in a small box with only an audio loudspeaker as output. They may be found in cardiology, maternity, outpatients and radiology departments and will often have a printer attached for recording images. Unlike X-rays, ultrasound poses no danger to the human body.
1. The manual informs us that the ultrasound machines A. are used to give images of structures with the body. B. have a printer attached for recording images. C. poses negligible danger to the human body.
X-Ray Machines: X-rays are high energy electromagnetic waves. The transformer produces a high voltage that directs electrons onto a target in the machine head. X-rays are produced by the target and are directed into beams by a collimator towards the human body. Soft body tissue absorbs less X-rays, i.e., passes more of the radiation, whereas bone and other solids prevent most of the X-rays from going through. Users must ensure proper radiation safety protocols and supervision are in place.
2. The guidelines establish that the healthcare professional should A. must ensure proper safety protocols. B. evaluate the radiation absorbed by bones and tissues. C. respect the wishes of the patient above all else. Biomedical waste: Biomedical waste is all waste tissue and body fluids, including clinical items contaminated with these. It is covered under the rules framed by the Central Pollution Control Board. Hospital management must take steps to segregate, manage and safely dispose of this waste. Equipment users must be aware of the systems that exist for this and follow local procedures. Most importantly, users must keep biomedical waste separate from other waste.
3. The purpose of this email is to A. inform biomedical waste rules are framed by the Central Pollution Control Board. B. inform users must beware of the systems that exist and follow local procedures. C. inform users must keep biomedical waste separate from other waste.
Hygienic requirements for cleaning: All healthcare and social care facilities are wet cleaned daily and even more frequently if necessary. According to the nature of the operation, the floor must be suitable for this method of cleaning. In operating theatres using invasive procedures, cleaning is carried out both pre- and post-surgery for each patient. Intensive care units and the rooms for collecting biological material are cleaned three times a day. The frequency of cleaning in other workplaces corresponds to the nature of the operation. In the event of cleaning by a subject other than the healthcare or social care facility provider, the designated worker must proceed according to the contract and the disinfecting or cleaning rules.
4. The manual informs us that the intensive care units A. are cleaned thrice a day B. are wet cleaned more frequently C. frequency of cleaning corresponds to nature of operation
Decontamination: Decontamination procedures include mechanical cleaning, which removes impurities and reduces the presence of microorganisms. In the event of contamination by biological material, it is necessary to include mechanical cleaning before the disinfection process. Detergents with a disinfectant effect are applied manually or by washing and cleaning machines, pressure guns, ultrasonic devices, etc. All tools and equipment must be kept clean. Cleaning machines and other equipment are used in accordance with the manufacturer’s instructions, including checks of the cleaning process.
5. The notice is giving information about A. cleaning process before disinfection process B. cleaning process before decontamination process C. cleaning process after disinfection process
Physical disinfection • Boiling under atmospheric pressure for at least 30 minutes. • Boiling in pressurized containers for at least 20 minutes. • Disinfection in equipment at a temperature determined by parameter A. The equipment must guarantee to reduce living microorganisms on the disinfected object at a given temperature to a predetermined level suitable for further use.
6. What must all staff involved in the physical disinfection process do? A. Boil under atmospheric pressure for at least 20 minutes B. Boil under atmospheric pressure for at least 30 minutes C. Boil in pressurized containers for at least 30 minutes
PART C. TEXT 1. Choose the answer (A, B, C or D) BREAST CANCER AND THE ELDERLY
Paragraph 1: Breast cancer is one of the highest-profile diseases in women in developed countries. Although the risk for women younger than 30 years is minimal, this risk increases with age. One-third of all breast cancer patients in Sweden, for example, are 70 years or older at diagnosis. Despite these statistics, few breast cancer trials take these older women into account. Considering that · nowadays a 70-year-old woman can expect to live for at least another 12-16 years, this is a serious gap in clinical knowledge, not least because in older women breast cancer is more likely to be present with other diseases, and doctors need to know whether cancer treatment will affect or increase the risk for these diseases.
Paragraph 2: In 1992, guidelines were issued to the Uppsala/Orebro region in Sweden (with a population of 1.9 million) that all women with breast cancer should be able to receive equal treatment. At the same time, a breast cancer register was set up to record details about patients in the region, to ensure that the guidelines were being followed. Sonja Eaker and colleagues set out to assess data from the register to see whether women of all ages were receiving equal cancer treatment.
Paragraph 3: They compared the 5-year relative survival for 9,059 women with breast cancer aged 50-84 years. They divided them into two age groups: 50-69 years, and 70-84 years. They also categorized the women according to the stage of breast cancer. They looked at differences between the proliferative ability of breast cancer cells, estrogen receptor status, the number of lymph nodes examined, and lymph node involvement. The researchers also compared types of treatment-Le., surgical, oncological (radiotherapy, chemotherapy, or hormonal)-and the type of clinic the patients were treated 1n.
Paragraph 4: They found that women aged ·70-84 years had up to a 13% lower chance of surviving breast cancer than those aged 50-69 years. Records for older women tended to have less information on their disease, and these women were more likely to have unknown proliferation and estrogen receptor status. Older women were less likely to have their cancer detected by mammography screening and to have the stage of disease identified, and they had larger tumours. They also had fewer lymph nodes examined, and had radiotherapy and chemotherapy less often than younger patients.
Paragraph 5: Current guidelines are vague about the use of chemotherapy in older women, since studies have included only a few older women so far, but this did not explain why these women received radiotherapy less often. Older women were also less likely to be offered breast-conserving surgery, but they were more likely to be given hormone treatment such as tamoxifen even if the tumours did not show signs of hormone sensitivity. The researchers suggest that this could be because since chemotherapy tends to be not recommended for older women, perhaps clinicians believed that tamoxifen could be an alternative.
Paragraph 6: The researchers admit that one drawback of their study is that there was little information on the other diseases that older women had, which might explain why they were offered treatment less often than younger patients. However, the fact remains that in Sweden, women older than 70 years are offered mammography screening much less often than younger women- despite accounting for one-third of all breast cancer cases in the country- and those older than 74 years are not screened at all. Eaker and co-workers’ findings indicate that older women are urgently in need of better treatment for breast cancer and guidelines that are more appropriate to their age group. Developed countries, faced with an increasingly aging population, cannot afford to neglect the elderly.
Q1. The main idea presented in paragraph one is that. ….. a. only older women need to be concerned about breast cancer. b. breast cancer trials seldom consider older women. c. breast cancer is more common than other diseases in older woman. d. older women do not take part in breast cancer trials. Q2. Regarding cancer treatment, it can be concluded that. … a. doctors know cancer treatment will increase the risk of disease in elderly patients. b. cancer treatments may be a risk for all elderly people c. it is unknown whether or not cancer treatments will affect the treatment of other diseases in elderly people. d. older women are less likely to have other diseases Q3. 1992 Guidelines issued to the Uppsala/Orebro region in Sweden stated that. a. Sweden has a population of 1.9 million. b. women with breast cancer need to register their condition to ensure they receive equal treatment. c. identical breast cancer treatment should be available to women of all ages. d. all women with breast cancer should have access to equivalent breast cancer treatment. Q4. Which of the following was not part of Sonja Eaker and her colleagues research? a. Comparing ability of breast cancer cells to increase in number. b. Grouping woman according to their survival rate. c. Identifying differences in treatment methods. d. Splitting the groups based on age. QS. Findings by the researchers indicate that ……. a. older women are less likely to have chemotherapy recommended. b. older women prefer hormone treatment to breast-conversing surgery. c. older women have fewer lymph nodes. d. older women respond better to chemotherapy than to hormone treatment. Q6. The word vague is paragraph 5 means …… a. uncertain b. unclear c. unknown d. doubtful Q7. One limitation of the study is that ….. a. older women are treated less often than younger women. b. older women have a lower incidence of breast cancer. c. younger women are treated more often than older women. d. there is a lack of information on other diseases which older women have. Q8. Which of the following statements best represents the view expressed by the writer at the end of the article? a. Due to ageing population in developed countries, the needs of the elderly must not be ignored. b. Older women need more appropriate treatment to suit their age. c. Developed countries have neglected the elderly for too long. d. It is too expensive treat the elderly.
PART C. TEXT 2. Choose the answer (A, B, C or D) PARENTS, KIDS & VEGIES
Paragraph 1: Most parents have waged epic battles with their kids over eating vegies. But if they don’t clean their plate of the last brussels sprout, does it really matter? Vegetables are behind some of the greatest battles between parents and children. Most parents have dinnertime horror stories involving small bits of vegetable and lots of screaming, and while these stories can be entertaining, the research showing how few vegies our kids are eating is not.
Paragraph 2: The 2009 Australian Institute of Health and Welfare national report card found that a whopping 78 per cent of 4–8-year-olds, 86 per cent of 9-13 year¬ olds and 95 per cent of 14–16-year-olds are not eating the recommended daily servings of vegetables. Take out potatoes, which most kids eat as chips, and the percentage of kids not getting the nutrition they need jumps to 97, 98 and 100 per cent respectively. Other research has made similar findings.
Paragraph 3: But Australian children are hardly going to starve if they don’t eat vegetables and it’s not easy for parents to keep cooking meals that are left on the plate or worse, tipped on the floor. Does it really matter if our kids don’t eat their greens? Professor Louise Baur, paediatrician and director of weight management services at The Children’s Hospital at Westmead, says we all need to eat a wide variety of foods – including vegetables – and children are no different. Research shows vegetable consumption can help prevent chronic diseases such as heart disease, type 2 diabetes and a range of cancers.
Paragraph 4: According to Australia’s dietary guidelines, children aged between four and seven should be eating two to four serves of vegetables daily. Eight- to 11-year-olds should be eating an extra serve; teenagers should have between four to six serves every day. One serve of vegetables is one cup of raw salad vegetables, one medium potato or half a cup of cooked vegetables or legumes.
Paragraph 5: In the short-term, children who don’t eat vegetables can end up with dental issues, constipation (especially if they skip on fruit as well) and on rare. occasions nutritional deficiencies, Baur says. But perhaps more importantly, we tend to develop our eating habits in childhood, so if you’re not eating vegetables and other healthy foods as a child then you are less likely to do so as an adult.
Paragraph 6: Excess weight is also a problem; between 6-8 per cent of school age children in Australia are obese and at least another 17 per cent are overweight. You won’t automatically put on weight if you don’t eat vegetables, Baur says, but children who don’t eat vegetables are often eating foods that are high in saturated f ats, sugar and salt. Children who are overweight are more likely to become overweight or obese adults, who are then at greater risk of chronic diseases.
Paragraph 7: And while the most hardened young vegie hater might enjoy an apple, banana or piece of watermelon, Baur says fruit doesn’t contain the iron and other minerals found in vegetables, and it also contains more sugars. While fruit is an important part of a healthy diet, the dietary guidelines suggest kids under 12 only need one to two serves a day. So, we know that kids need their vegies, but getting them to eat a mouthful, let alone several cups can be a challenge.
Paragraph 8: Nutritionist Dr Rosemary Stanton suggests nutrition should be a whole family affair; you can boost your child’s vegetable intake by eating your evening meal together at the dinner table, preferably with the television off. “Vegetables have traditionally been eaten mainly at dinner and with many families no longer having a family meal, many kids get themselves something to eat – often instant noodles, pizza or some kind of pasta dish (rarely with vegies),” Stanton says.
Paragraph 9: Children are also more likely to eat and enjoy vegetables, and other healthy foods, if they find them interesting, says Stanton. “Several studies show that when kids grow vegies or attend a school with a kitchen garden, they tend to eat more vegies … For those in flats, there are community gardens in some areas, or if they have a balcony lettuce, herbs, cherry tomatoes etc …can all be grown in pots.” ·
Paragraph 10: You can also pique your child’s interest in vegetables by including them in a range of tasks, such as grocery shopping, going to markets or by getting them to help prepare meals. Small children can toss a salad (you can rewash any salad leaves that end up on the floor), and older children can take on more difficult tasks, for example peeling and cutting vegetables. But perhaps the most important thing parents can do is model healthy eating. Research has shown children’s eating patterns are affected by the family’s eating behaviour. Lisa Renn, spokesperson for the Dietitians Association Australia, encourages parents to be persistent.
Paragraph 11: She says there are many easy and crafty ways to get vegies off your children’s plates and into their mouths: • grate extra vegetables and add them to a favourite pasta sauce • make green mash, add spinach or rocket when mashing potato • serve vegie sticks with dips (think avocado, pumpkin or sweet potato) and other snacks • add extra vegetables or legumes to your next soup or stew • make muffins using vegetables – com, pumpkin and sweet potato all work well.
Paragraph 12: She also suggests the scattergun approach: offering a wide variety of vegetables (the more different colours the better) in small amounts throughout the day, not just at dinner time. There’s no denying these suggestions require time, effort and creative ‘marketing’. Ultimately, says Renn, “you do what you can do, get them in where you can, be as inventive as possible and be persistent”.
QUESTIONS Q1. According to the passage what is the reason behind the battle between parents & children? a. over eating of vegies b. not cleaning c. vegetables d. not eating vegies Q2. Who stand first is avoiding vegies from daily servings? a. 4-8 years b. Teen years c. 14-16 years d. Kids Q3. Why do parents feel discomfort in cooking vegetables? a. Children won’t eat them b. Vegetables will be in plates/ floors c. Children will starve d. b and c. Q4. Who cannot be eliminated according to Prof. Louise? a. diabetic patients b. children c. children prone to cancer d. a and c QS. Along with a potato how munch vegetables should be taken in a day? a. a cup b. a cup of cooked veggies c. none of the above d. a and b Q6. Which has the less possibility to occur with eating les veggies? a. Dental issues b. Constipation c. Deficiency d. None Q7. What will automatically happen when you are not eating vegetables? a. put on weight b. reduce in weight c. occurrence of obese d. nothing will happen Q8. Who needs 2 serves of vegetables a day according to the passage? a. 4-7 years b. b. 8-11years c. c. Below 12 years d. d. A and c
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TEXT A. Smoking and the Risk of Lung Cancer For a life-long smoker, the risk of lung cancer is 20 times higher than a non-smoker. As with many of the health facts about smoking, this is an alarming statistic – but you can make a real difference to your health outcomes by choosing to quit smoking. Evidence shows that: • If you quit smoking by the age of 40, you reduce your risk of lung cancer by up to 90% • Quitting by the age of 50 reduces your risk by up to 65% • After 10 years of being smoke-free, you’ll have avoided around 40% of the risk of ever getting lung cancer • Even for someone newly diagnosed with early-stage lung cancer, quitting smoking improves prognosis and reduces the chance of tumour progression.
TEXT B: Cigarette packaging representations
Text C. Effect of Smoking on the Lungs What does smoking do to my lungs? It paralyses and can destroy cilia, which line your upper airways and protect you against infection. It destroys the alveoli, or air sacs, which absorb oxygen and get rid of carbon dioxide. It destroys lung tissue, making the lungs less able to function, and irritates the lungs which creates phlegm and narrows the airways, making it harder to breathe. How does that affect me? It makes you short of breath, it makes you cough, it gives you chronic bronchitis and repeated chest infections, it worsens your asthma and it can give you lung cancer. That’s apart from effects on your heart, fertility, pregnancy and your children. But most people who smoke don’t get lung cancer. No. Most people die of other things first, often because they smoked. If I give up, will my lungs improve? Yes. Cilia that are paralysed, but not destroyed, can recover. You will have less asthma and fewer chest infections. The sooner you stop, the better your chances of improved lung function.
Text D. Passive Smoking: Summary • In Victoria, it is illegal to smoke in cars carrying children who are under 18 years of age. • If a person who smokes can’t give up for their own health, perhaps the health of their partner or children, or other members of their household, will be a stronger motivation. • Passive smoking increases the risk of respiratory illness in children, e.g., asthma, bronchitis and pneumonia. • People who have never smoked who live with people who do smoke are at increased risk of a range of tobacco- related diseases, including lung cancer, heart disease and stroke.
PART A. For question 1-7, choose (A, B, C or D). In which text can you find information about 1 The effects of passive smoking? 2 The chances of a smoker getting lung cancer? 3 The benefits to the respiratory system of quitting smoking? 4 Ways to get help with quitting smoking? 5 The reduction in lung cancer risk if a smoker quits? 6 Recommended websites or phone numbers for smokers? 7 How smoking leads to particular symptoms? Questions 8 – 14. Answer each of the questions, 8 – 14, with a word or short phrase from one of the texts. 8 How much of the lung cancer risk is avoided by being smoke-free for 10 years? 9 What is the phone number for Quitline? 10 What is normally expelled by the alveoli in the lungs? 11 What effect can smoking have on asthma? 12 What type of cancer can be improved by quitting smoking? 13 Which two (2) cardiovascular diseases are associated with passive smoking? 14 In which state is it illegal to smoke in cars carrying children under 18? Questions 15 – 20. Complete each of the sentences, 15 – 20, with a word or short phrase. • Each answer may include words, numbers or both. Your answers should be correctly spelled. • Cigarette smoke damages the lungs by destroying the (15) _____________ that absorb oxygen. • Eventually, the destruction of lung tissue can render a smoker unable to (16) _________ normally. • Cigarette packets now feature depictions of its health effects, such as (17) _____________ • The effect of previous smoking can be reversed in some ways, as the (18) _____________ lining the upper airways can recover from damage. Passive smoking increases the risk of (19) ________ in children. • The good news is that if people (20) _____________ smoking before the age of 40, they can significantly reduce their cancer risk.
Part B. For questions 1 to 6, choose the answer (A, B or C) which you think fits best according to the text.
1. The treatment guidelines below recommend that A. All patients receive parathyroid hormone monitoring B. All patients receive 6-weekly monitoring C. All patients receive baseline blood tests
Table: Medical Monitoring Guidelines for High-Risk Patients on Very Low Energy Diets
Assessment
Baseline Measures
6 weeks
Completion of Intensive Phase
Electrolytes/Creatinine
Yes
If required
Yes
Liver function tests
Yes
If required
Yes
Fasting glucose
Yes
If required
Yes
Cholesterol, triglycerides and HDL
Yes
If required
Yes
Uric acid
Yes
If required
Yes
Full blood count
Yes
If required
Yes
Iron studies
Yes
If required
Yes
Vitamin D
Yes
If required
Yes
Calcium and Parathyroid hormone (in patients on long-term anticonvulsants)
Yes
If required
Yes
2. This notice is giving information about A. The differential management of infants using glucose B. How to check an infant’s blood glucose level C. The ideal glucose concentration in infants with clinical signs
Management of documented hypoglycemia in breastfeeding infants A. Infant with no clinical signs 1. Continue breastfeeding (approximately every 1–2 hours) or feed 1–5 mL/kg of expressed breastmilk or substitute nutrition. 2. Recheck blood glucose concentration before subsequent feedings until the value is acceptable and stable. 3. Avoid forced feedings (see above). 4. If the glucose level remains low despite feedings, begin intravenous glucose therapy. 5. Breastfeeding may continue during intravenous glucose therapy. 6. Carefully document response to treatment. B. Infant with clinical signs or plasma glucose levels < 20– 25mg/dL (<1–1.4mmol/L) 1. Initiate intravenous 10% glucose solution with a minibolus. 2. Do not rely on oral or intragastric feeding to correct extreme or clinically significant hypoglycemia. 3. The glucose concentration in infants who have had clinical signs should be maintained at > 45 mg/dL (> 2.5 mmol/L). 4. Adjust intravenous rate by blood glucose concentration. 5. Encourage frequent breastfeeding. 6. Monitor glucose concentrations before feedings while weaning off the intravenous treatment until values stabilize off intravenous fluids. 7. Carefully document response to treatment.
3. This information sheet recommends A. Regular auditing to ensure pain management program efficacy B. Indicators to use in pain management program audits C. At least 50% change as being clinically important
Audit of Pain Management Programs: Methods It is recommended to conduct an audit of 20 or more sequential patients undertaking a pain management program. Data collection should include simple demographic and program data as well as data (pre and post program with a minimum three-month interval between data sets) regarding changes in: • Healthcare utilisation. • Depression/anxiety/stress. • Pain self-efficacy. • Pain catastrophising. Percentage change in individual patients has been suggested (rather than average percentage change across the population audited) as average percentage change is very sensitive to outliers and small audits may therefore be significantly influenced by average percentage change. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommends considering clinical important change (as distinct from statistically significant change) on the following basis: Minimal benefit: 10-20 per cent change. Moderately important benefit: at least 30 per cent change. Substantially important benefit: at least 50 per cent change
4. This regulatory statement instructs healthcare professionals to A. Admit all patients to NSW public hospitals within 48 hours B. Assess all patients in the Emergency Department for VTE C. Initiate VTE prophylaxis for all patients identified to be at risk
MANDATORY REQUIREMENTS: • All adult patients admitted to NSW public hospitals must be assessed for the risk of VTE within 24 hours and regularly as indicated / appropriate. • All adult patients discharged home from the Emergency Department who as a result of acute illness or injury, have significantly reduced mobility relative to normal state, must be assessed for risk of VTE. • Patients identified at risk of VTE are to receive the pharmacological and / or mechanical prophylaxis most appropriate to that risk and their clinical condition. • All health services must comply with the Prevention of VTE Policy. • All Public Health Organisations must have processes in place in compliance with the actions summarised in the VTE Prevention Framework (Appendix 4.1 of the attachment). A VTE risk assessment must be completed for all admitted adult patients and other patients identified at risk, and decision support tools made available to guide prescription of prophylaxis appropriate for the patient’s risk level.
5. The advice below can best be applied to a healthcare setting by A. The inclusion of nurses in governance structures B. Providing information to patients in their native language C. Redesigning projects according to advisory group recommendations
Partnerships with consumers can come in many forms. Some examples include: • working with consumers to check that the health information is easy to understand • using communication strategies and decision support tools that tailor messages to the consumer • including consumers in governance structures to ensure organisational policies and processes meet the needs of consumers • involving consumers in critical friends’ groups to provide advice on safety and quality projects • establishing consumer advisory groups to inform design or redesign projects
6. The purpose of the document below is to A. Prevent Medicare claims being paid for public patients B. Specify when services can be billed to Medicare C. Ensure healthcare professionals don’t falsify claims Guideline for substantiating claims for diagnostic imaging and pathology services rendered to emergency department patients of public hospitals Public hospitals are funded under an arrangement with the Australian Government to provide free public hospital services to eligible patients. This includes diagnostic imaging and pathology services provided to public hospital emergency department patients. A patient who presents to a public hospital emergency department should be treated as a public patient. If that patient is subsequently admitted they may elect to be treated as a private patient for those admitted services. For a Medicare claim to be paid for a patient in a public hospital, the patient must be admitted as a private patient at the time the service was rendered. Where a service for a patient in a public hospital has been billed to Medicare, the hospital or rendering practitioner may be asked to substantiate these claims. Documents you may use include: • the form which the patient (or next of kin, carer or guardian) – has signed indicating that the patient has elected to be admitted as a private patient, and • patient records – that show the patient was admitted as a private patient at the time the service was rendered
PART C. TEXT 1. For questions 7 to 22, choose the answer (A, B, C or D) SCOPE OF PRACTICE FOR HEALTHCARE PROFESSIONALS
A “scope of practice” refers to the procedures, actions, and processes that a healthcare practitioner is allowed to undertake according to their professional certification. The scope of practice is limited to that which is legally permitted for a healthcare professional with a certain level of education and experience, as well as their level of competency. Each level of jurisdiction has their specific laws, policies and licensing bodies, which define and regulate scope of practice. Different facilities, such as hospitals, may have different policies with regards to the clinical responsibility afforded to a healthcare professional.
There are two types of scope of practice. Core scope of practice refers to the everyday expectations of a clinician in practice, within that particular unit. These reflect the clinician’s qualifications and training and are considered to be “usual practice”. Advanced scope of practice refers to additional allowances or responsibilities, and usually specify particular treatments/procedures or categories of treatments/procedures to be included in the individual’s scope of practice.
Three categories may be useful in identifying a healthcare professional’s scope of practice. The first is education and training – has the person received formal or on-the-job training and have documentation to prove this? The second relates to the state or federal government that oversees the individual’s place of employment – does it allow the skill in question and not explicitly disallow it? Finally, the particular institution of employment is also relevant – does it also allow the skill in question and not explicitly disallow it?
Some examples of how scope of practice differs are useful. All states and provinces who recognise the licensing of registered respiratory therapists (RRTs) allow them to carry out extracorporeal membrane oxygenation (ECMO) support. However, some institutions do not allow this. In this case, it is within the institution’s rights to refuse to allow RRTs working there to perform ECMO. Therefore, RRTs working at these institutions are not allowed to include ECMO as part of their scope of practice.
Some environments require alterations to be made to a scope of practice. For example, allied health professionals who work in a rural or remote area have a broader scope of practice than those who work in metropolitan areas. They may be required to undertake activities or procedures that are outside the scope of practice generally accepted for their profession. This allows them to better meet the needs of communities in which they work.
Apart from geographical differences, certain significant events may also result in alterations being made to the scope of practice. For example, during the 2009 H1N1 influenza pandemic, a number of states expanded the scope of practice for a number of healthcare professions in order to increase the number of clinicians eligible to provide vaccinations. This was a temporary measure that lasted for the duration of the emergency and was legally permitted. Other states did not employ this measure, primarily because the capacity of clinicians to vaccinate the public in these areas was sufficient.
State governments annually review the scope of practice for routine (non- emergency) activities to make sure they are meeting the population needs. Changes to scope of practice must be considered with caution, as they can affect people in both positive and negative ways. Changes may be seen as a way to protect the public and give broader access to competent healthcare professionals, but can also result in turf battles between two or more different professions over the exclusive rights to perform an activity.
Considering this, healthcare professionals must understand their professional and individual scope of practice. Some tasks, while they are within the scope of practice for a profession, may not be permitted under the scope of practice of an individual. This is often an issue for allied health staff who move from rural or remote areas to metropolitan areas, where their scope of practice is more limited. Conversely, allied health staff who formerly worked in a metropolitan area may find themselves without the skills or experience to meet their scope of practice in a rural or remote area. In the team environment of the healthcare system, it is key that each team member can clearly identify and communicate their professional and individual scope of practice.
Text 1: Questions 7 to 14
7. In the first paragraph, the meaning of the phrase “afforded to” is: A. The clinical responsibility that is paid for by healthcare professionals. B. The clinical responsibility that can be afforded by healthcare professionals. C. The clinical responsibility that is given to healthcare professionals. D. The clinical responsibility that is acceptable to healthcare professionals. 8. In the second paragraph, core scope of practice refers to: A. The clinician’s expectations of what their work involves. B. The things that a member of the public can expect from the clinician. C. The things that the unit can expect from the clinician. D. The qualifications and training of the clinician. 9. All of the following are categories that can be applied to identify scope of practice except: A. The formal or on-the-job training received by the healthcare professional. B. The state or federal government’s allowance or non-allowance of an activity. C. The institution’s allowance or non-allowance of an activity. D. A proven history of formal or on-the-job training. 10. The situation for paramedics is similar to that for registered respiratory therapists because: A. They are both involved in emergency patient care. B. They both have varying scopes of practice. C. They can both perform a percutaneous cricothyrotomy. D. They are both procedures used to help a patient breathe more effectively. 11. According to the fifth paragraph, the benefit of changes to scope of practice is: A. The communities in which healthcare professionals work can have their needs met more effectively. B. The services provided by allied health professionals in rural or remote areas can be better than those provided in metropolitan areas. C. Allied health professionals can better serve rural or remote communities. D. Healthcare professionals can rely more on their judgment when treating patients, rather than being restricted by their scope of practice. 12. In the sixth paragraph, the author implies that: A. Some states and provinces were better equipped to prevent the spread of H1N1 influenza in 2009 than others. B. Healthcare professionals should have their scope of practice extended permanently to provide vaccinations in case of another influenza pandemic. C. There was a knee-jerk reaction by some states to contain the spread of H1N1 influenza in 2009 by expanding their capacity to deliver vaccinations. D. In some states, healthcare professionals have been allowed to provide vaccinations since 2009 to prevent the spread of pandemic influenza. 13. According to the seventh paragraph, the author’s opinion on changes to scope of practice is that: A. Such changes are necessary to protect the public and provide access to a broader range of competent healthcare professionals. B. Such changes can be politically controversial and have an ambiguous benefit. C. Such changes lead to conflict between two or more healthcare professions over the exclusive rights to perform an activity. D. Such changes should be reviewed more frequently than they are currently. 14. The main message of the article is: A. Scope of practice varies within each profession, so healthcare professionals should be informed of what their scope of practice is. B. Scope of practice is dynamic and depends on geographical factors, individual states or institutions, and significant events. C. Different healthcare professions have different scopes of practice. D. Each member of a healthcare team should be aware of their individual, as well as professional, scope of practice.
PART C- TEXT 2. Advanced Dementia
Dementia is a significant cause of morbidity and mortality worldwide. In 2014, approximately 5 million people in the United States had a diagnosis of Alzheimer’s disease, with an estimated 14 million being affected by 2050. Once diagnosed, patients can survive with the condition for an average of 3 to 12 years. The majority of this time will be spent in the most severe stages of the disease. As nursing homes are the site of death in most cases, these are an important factor to consider when studying Alzheimer’s disease.
At the moment, no cure exists for dementia or the progression of its disabling symptoms. The Global Deterioration Scale, which ranges from 1 to 7, is used to describe the level of disability in patients with dementia. Stage 7 characterises advanced dementia: profound memory deficits, a virtual absence of the ability to verbalise, inability to ambulate independently or perform activities of daily living, and urinary and fecal incontinence. These manifestations result in complications such as eating problems, episodes of fever and pneumonia.
In order to provide an estimate of survival time for patients with dementia, the Functional Assessment Staging Tool is commonly used. Although impossible to quantify accurately in 100% of cases, this tool allows a general prognosis to be made. This is important because a patient’s eligibility for the hospice benefit is assessed based on their projected survival time as well as history of dementia- related complications. Some clinicians prefer to use a risk score to predict survival, as this has slightly better predictive ability. Many consider that the eligibility of patients for nursing home care should be based on the desire for such care, rather than prognosis.
The care of patients with advanced dementia revolves around advanced care planning. This includes educating the patient’s family about the prognosis of the disease and its manifestations, counseling about proxy decision making, and recording the patient’s wishes regarding treatment through an advanced care directive. Some observational studies have shown that patients with advanced care directives have better palliative care outcomes: reduced incidence of tube feeding, fewer hospitalisations during the final stages, and greater likelihood of enrollment in a hospice.
Decisions about the care of patients should also reflect the goals of such care. These goals should be agreed upon between the provider, the primary carers, and ideally, the patient themselves. The goals of treatment, and therefore the treatment decisions themselves, should be aligned with the patient’s wishes as far as possible. An example of how treatment preferences may vary is whether the patient would like all medical interventions deemed necessary, only certain medical interventions, or comfort measures only. In 90% of proxies interviewed in prospective studies, the latter was reported to be the primary goal of care.
Out of the most common complications of advanced dementia, eating problems are the most prevalent. These may include oral dysphagia (“pocketing” of food in the cheek), pharyngeal dysphagia (inability to swallow, leading to the risk of aspiration), inability to eat independently and refusal. When eating problems occur, acute causes should always be considered (e.g., dental pathology). The reversal of such causes should be guided by the previously agreed goals of care. Chronic or sustained eating problems are most often managed by hand feeding, tube feeding, or encouragement of food intake through smaller meals, different textures or high-calorie supplementation.
Infections are another common clinical problem in patients with advanced dementia, most commonly relating to the urinary or respiratory tract. In 362 nursing home residents with advanced dementia, the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia (SPREAD) found that two thirds were diagnosed with suspected infections within a 12-month period. Approximately 50% of patients with advanced dementia are diagnosed with pneumonia in the last 2 weeks of life, and such patients experience a high rate of death from this cause. However, the use of antimicrobials to treat infections has been found to increase length of survival but also the level of discomfort in patients with advanced dementia. Therefore, such treatment may not necessarily align with the patient’s preferences or goals of care.
Improving the care of patients with advanced dementia is becoming an increasingly recognised issue amongst healthcare providers. Studies of the experiences of patients with advanced dementia have shown that care which is focused on patient-centred goals and adherence to patient preferences is most effective in improving outcomes. In order to achieve this, providers need to be better equipped to engage patients and their families in advanced care planning, reduce the use of invasive treatments of limited benefit (such as tube feeding) and better address distressing clinical symptoms.
Text 2: Questions 15 to 22
15. The Global Deterioration Scale is most useful for providing healthcare professionals with information about: A. The patient’s ability to recall memories, verbalise, ambulate independently, attend to activities of daily living and control urine and fecal output. B. A quantification of the patient’s degree of disability. C. The likelihood of dementia-related complications. D. The patient’s predicted survival time. 16. According to the third paragraph, the main reason for making a general prognosis about survival time is: A. To provide family members with some idea of the trajectory of the disease. B. To inform decisions that providers must make about treatment. C. To determine eligibility for nursing home care. D. To determine eligibility for the government subsidy of hospice care. 17. The best replacement for the word “proxy” in the fourth paragraph would be: A. Substitute B. additional C. carer D. treatment 18. In the fifth paragraph, the author’s main argument is that: A. Decisions about care should be guided by its goals, which most often means comfort care rather than medical interventions. B. Most patients with advanced dementia prefer comfort care to medical interventions. C. The goals of care should be agreed upon in consultation with the provider, the family and the patient themselves. D. Treatment preferences vary between individual patients with advanced dementia. 19. According to the sixth paragraph, eating problems in advanced dementia may be caused by: A. inappropriate eating practices. B. recent dental procedures. C. aspiration of food. D. refusal to eat independently. 20. In the seventh paragraph, the author suggests that: A. About 50% of people with advanced dementia will suffer from pneumonia during the last 2 weeks of their life. B. Infections in people with advanced dementia should not always be treated. C. Within a 12-month period, approximately two thirds of nursing home residents with advanced dementia are suspected to have an infection. D. Urinary and respiratory infections are the most common clinical problem in advanced dementia. 21. Ways in which the care of patients with advanced dementia can be improved include all the following except: A. Adherence to patient preferences for treatment. B. Better treatment of distressing symptoms. C. Engaging patients and families in advanced care planning. D. Hand feeding instead of tube feeding. 22. The author’s approach to the care of patients with advanced dementia could best be described as: A. practical. B. patient-centred. C. analytical. D. utilitarian.
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Text A: Bed bugs have feasted on sleeping humans for thousands of years. After World War II, they were eradicated from most developed nations with the use of DDT. This pesticide has since been banned because it’s so toxic to the environment. Spurred perhaps by increases in international travel, bed bugs are becoming a problem once again. The risk of encountering bed bugs increases if you spend time in places with high turnovers of night-time guests – such as hotels, hospitals or homeless shelters. Bed bugs are reddish brown, oval and flat, about the size of an apple seed. During the day, they hide in the cracks and crevices of beds, box springs, headboards and bed frames. It’s a daunting task to eliminate bed bugs from your home. Professional help is recommended. Symptoms: It can be difficult to distinguish bed bug bites from other insect bites. In general, the sites of bed bug bites usually are: • red, often with a darker red spot in the middle • itchy • arranged in a rough line or in a cluster • located on the face, neck and arms
Text B Reactions to bed bug bites in humans Skin reactions are commonly associated with bed bugs, which result from the saliva injected during feeding. Some individuals, however, do not react to their bite, whereas others note a great deal of discomfort often with loss of sleep from the persistent biting. Reactions to the bites may be delayed, up to 9 days before lesions appear. Common allergic reactions include the development of large wheals, often >1-2 cm, which are accompanied by itching and inflammation. The wheals usually subside to red spots but can last for several days. Bullous eruptions have been reported in association with multiple bed bug bites and anaphylaxis may occur in patients with severe allergies. In India, iron deficiency in infants has been associated with severe infestations. It has been suggested that allergens from bed bugs may be associated with asthmatic reactions.
Text C Bed bug-detecting canines The bed bug, Cimex lectularius L., like other bed bug species, is difficult to visually locate because it is cryptic. Detector dogs are useful for locating bed bugs because they use olfaction (smell) rather than vision. Dogs were trained to detect the bed bug (as few as one adult male or female bug) and viable bed bug eggs (as few as five, collected 5-6 days after feeding) by using a modified food and verbal reward system. Their efficacy was tested with adult bed bugs and viable bed bug eggs placed in vented polyvinyl chloride containers. Dogs were able to discriminate bed bugs from the insects Camponotus floridanus (Buckley), Blattella germanica L., and Reticulitermes flavipes (Kollar), with a 97.5% positive indication rate (correct indication of bed bugs when present) and 0% false positives (incorrect indication of bed bugs when not present). Dogs also were able to discriminate live bed bugs and viable bed bug eggs from dead bed bugs, cast skins, and feces, with a 95% positive indication rate and a 3% false positive rate on bed bug feces. In a controlled experiment in hotel rooms, dogs were 98% accurate in locating live bed bugs. A pseudoscent prepared from pentane extraction of bed bugs was recognized by trained dogs as bed bug scent (100% indication). The pseudoscent could be used to facilitate detector dog training and quality assurance programs. If trained properly, dogs can be used effectively to locate live bed bugs and viable bed bug eggs.
Text D. Bed bugs as vectors of human disease Transmission of more than 40 human diseases has been attributed to bed bugs, but there is little evidence that such transmission has ever occurred. Older scientific literature postulated that bed bugs may be vectors of plague, yellow fever, tuberculosis, relapsing fever, leprosy, filariasis, kala azar (leishmaniasis), cancer, smallpox, and Chagas disease (Trypanosoma cruzi). Recently, the possibility of human immunodeficiency virus and hepatitis B virus transmission by bed bugs has been investigated. Human immunodeficiency virus can be detected in bed bugs up to 8 days after ingestion of highly concentrated virus in experimental blood meals. However, no viral replication has been observed within the insects and no virus has been detected in bed bug feces. Mechanical transmission of human immunodeficiency virus has not been demonstrated using an artificial system of feeding bed bugs through membranes.
Questions 1-7. For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use any letter more than once. In which text can you find information about
1. normal allergic reactions to bed bugs? 2. signs that bed bugs may spread diseases? 3. dogs can be trained to detect bed bug eggs? 4. bed bugs showed no viral replication? 5. bed bug bites may be seen in a cluster? 6. places where bed bugs are found? 7. what is used to facilitate quality assurance programs?
Questions 8-15. Answer each of the questions, 8-15, with a word or short phrase from one of the texts.
8. How much was the false positive indication rate of bed bugs by detector dogs? 9. What was used to eliminate bed bugs from developed countries? 10. What is the usual symptom exhibited by bed bug infestation? 11. What was detector dogs’ positive indication rate for distinguishing live and dead bed bugs?_______ 12. What caused serious infestations of bed bugs in newborns? 13. What is the reason for reappearance of bed bugs in developed countries? 14. How many diseases are said to be spread by bed bug being vectors? 15. What are responsible for asthma symptoms caused by bed bugs? Questions 16-20. Complete each of the sentences, 16-20, with a word or short phrase from one of the texts. 16. The usage of ___________ is prohibited as it is proven to be very harmful to our surroundings. 17. The presence of______________ is not detected in ordure of the bed bugs. 18. To locate bed bugs, detector dogs use olfactory senses despite their________________. 19. Numerous bed bug bites are found to produce________________. 20._________________ is made from the pentane extraction of bed bugs.
END OF PART A
PART B Choose the answer (A, B or C)
1. According to the extract, every physicians must A. declare modifications regarding requirement of seasonal influenza immunization. B. provide help to get proper immunization against the seasonal influenza virus. C. get a flu vaccination from an appropriate place that offer a valid substantiation. The seasonal influenza immunization: In an effort to protect our patients, visitors, and colleagues, we are announcing an important change regarding the requirement of seasonal influenza immunizations for all employees, physicians, active volunteers, vendors, contracted staff, and students. As health care providers, it is our responsibility and obligation to protect our patients, visitors, and colleagues—as well as ourselves and our family members—by being immunized against the seasonal influenza virus. As we have done in the past, seasonal influenza immunizations will be provided free of charge to all employees, physicians, contracted staff and active volunteers. Participation in this year’s seasonal influenza immunization program is required. All employees, physicians, contracted staff, active volunteers and students will be required to do one of the following: • Receive a flu vaccination through RH Occupational Health Office. • Provide proof of immunization if you received a vaccination outside of RH’s planned immunization program— from another health care provider or local pharmacy, for example.
2. The policy document tells us that tolerance for risk is greater for permanently implanted medical devices A. in pediatric patients with a limited life expectancy. B. such as pacemaker pulse generators. C. in a healthy pediatric population. Risk Assessment of Medical Devices: The risk assessment should consider the proposed clinical use of the device, including the anatomical location, duration of exposure, and intended use population. For example, for pediatric patients with a limited life expectancy, the tolerance for risk associated with a permanently implanted medical device may be higher than the tolerance for risk from the same device in an otherwise healthy pediatric population. The potential exposure duration should also consider which material components of the device have direct or indirect contact with tissue, and whether exposure would be a one-time exposure, a constant exposure over time, or an intermittent exposure over time that could have a cumulative effect. For example, pacemaker pulse generators commonly contain internal electronic components made from chemicals that could be toxic to the body, but appropriate bench testing can demonstrate that the pulse generator is hermetically sealed and will limit exposure of those chemicals to the surrounding tissues.
3. What is being described in this section of the guidelines? A. changes in procedures. B. best practice procedures. C. exceptions to the procedures. Patient Admission: If the patient medically requires hospital inpatient services and the physician believes that the patient will need to stay in the hospital at least 2 midnights, the physician should order inpatient admission. If the patient does not medically require inpatient hospital services or the physician does not expect the patient to stay past 2 midnights, the physician should order observation or outpatient services. The certification must be signed and documented in the medical record prior to patient discharge. Hospitals may choose to have physicians record these elements of the certification either on a specific form or throughout the medical record such as in the orders, history and physical, or physician progress notes. Guidelines: • Excellent patient care should continue to be the top priority. • Document the diagnosis, medical rationale, plan of care and anticipated discharge. • Sign the admission order and certification (if appropriate) prior to discharge.
4. The purpose of these instructions is to explain A. how to wear respirators effectively B. how to use respirators appropriately C. necessity of wearing proper respirators Respirators: Respirators are an effective method of protection against designated hazards when properly selected and worn. Respirator use is encouraged, even when exposures are below the exposure limit, to provide an additional level of comfort and protection for workers. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker. Workers who occasionally wear filtering face-piece respirators on a voluntarily basis must be aware of the following information. This information is intended for employees who are not required to wear respirators for protection from recognized airborne hazards. Employees who perceive exposures to any airborne contaminants, particularly outside of a chemical fume hood, should request an exposure evaluation before selecting a respirator.
5. The extract informs us that your A. input will help evaluate the current HOCC program and its future program review. B. participation ensure that patients’ needs are met exclusively by physicians. C. support and elaborate retrospect will help in fulfilling targets of HOCC program review. Hospital On-Call Coverage Program Review: We are requesting your assistance with the detailed review of the Hospital On-Call Coverage (HOCC) Program; your input will help evaluate the current HOCC program and assist to identify future directions. With your participation, we can ensure that the HOCC program meets the needs of patients, participating physicians and other health care stakeholders. The HOCC Program review has three primary objectives: To identify and examine the effectiveness of key elements of the program already in place at hospitals. These elements include eligibility criteria, compensation structures, process metrics, resource requirements, and others. To develop recommendations for improving the organization and delivery of on-call services based on evidence and best practices identified through the data and information collection processes. To explore specific issues: Participation of doctors, use of regional call networks, and coverage for long-term care, sexual assault centres, chronic care facilities and palliative care programs.
6. What point does the extract make about processing of medical devices? A. could significantly affect the biocompatibility of the medical devices. B. includes passivating surface of medical devices by acid bath or other method. C. uses resin supplier to remove all processing solvents from medical devices. Identification of Potential Risks: An assessment of potential biocompatibility risk should include not only chemical toxicity, but also physical characteristics that might contribute to an unwanted tissue response. These characteristics can include surface properties, forces on surrounding tissue, geometry, and presence of particulates, among others. In addition, changes in manufacturing and processing parameters can also have an impact on biocompatibility. For example, the original processing for an implanted device might include placing the device in an acid bath to facilitate passivation of the implant surface. If this passivation process is changed to eliminate the acid bath in favor of a different method of passivating the surface, removal of the acid bath might unintentionally lead to a smaller reduction in pyrogenic material, which could result in pyrogenic reactions (fever) following implantation of the device. Another common change that might impact biocompatibility is a change in resin supplier. For example, if the new resin supplier does not remove all processing solvents (some of which may be known toxic compounds, such as formaldehyde), the final manufactured device could cause unexpected toxicities that were not seen with devices manufactured from the original resin.
PART C. TEXT 1. MEASURING LIFE. Choose the answer (A, B, C or D).
Somewhere out in the future there’s a final moment with our name on it: life’s only certainty is death. It’s coming, and the only mystery about mortality’s last call is: when? But if your doctor could tell you, would you want to hear how long you are likely to live? American researchers now believe that they are able to determine a person’s “natural” life span from a simple blood test. They have identified the ability of a common gene to influence the ageing process, and the form it takes in any given individual can they say, indicate medical vulnerability and predict when the person may die. The news has created much excitement but it also has raised concerns about the ethical dilemmas involved if science is able to read our lifelines and forecast our susceptibility to deadly diseases. It’s a development that revives the eternal question: should a doctor tell?
Apo E, as it’s known, is not a new discovery but, hitherto, scientists believed that its only function was to remove cholesterol from the bloodstream. Only lately as they have been able to study the ever increasing numbers of elderly, has the gene’s relationship with longevity become apparent. It apparently operates as a kind of caretaker gene, maintaining the system’s cells and keeping them running smoothly, and its efficiency can determine the rate at which the body holds up or wears out. “Apo E is one of those genes that we suspect controls life span because it affects people’s susceptibility to diseases of ageing”, says Dr Jan Vigh; a molecular geneticist at Beth Israel Hospital, in Boston. The gene has three variants, known as E2, E3, E4, and we all inherit one of them from each of our parents. More than half of us are born with two E3s, but it is the distribution of the other two forms that has proved so compelling to scientists that they have been analyzing data on the elderly.
People with one or – more rarely – two E2s tend to survive the longest, while those with E4s die considerably earlier than the rest. Studies in Canada, France, Sweden and Finland found that E2 carriers were about four times more likely to reach their 100th birthday than those born with an E4. The E2 is, it seems, an excellent caretaker. By comparison, E4 does sloppy work and its inadequacies at cell upkeep make those who have it vulnerable to illness and early death. Doctors now accept that the presence of the Apo E4 gene signals a risk of heart disease and Alzheimer’s. American studies show that middle aged women with an E4 are twice as likely to develop coronary heart disease as those who don’t, while E4 men have a 50 per cent higher risk than other men. Among men under 40 who require surgery for clogged heart arteries, the incidence of two E4s is 16 times higher than among others in their age group And Dr Alan Roses, the Duke University neurologist who first made the link between Apo E and Alzheimer’s, says those with two E4s have about six times the normal risk of developing the disease, while people born with two E2s may be protected from it.
More than 4 million Americans are afflicted by this devastating brain disorder and nearly two-thirds of them have at least one Apo E4 gene, compared with only 15 percent in the general population. So, Apo E may be a critical marker for life span and vulnerability to grave diseases, and evidence of its presence is in the records of millions of blood tests conducted for other reasons. But is it ethical or wise for doctors to use that information to tell people something they may not want to know and which, in any case, alerts them to threats that may be unavoidable? “We consulted bioethicists and got a variety of opinions,” says Dr Norman Relkin, the New York neurologist who gathered other concerned doctors to discuss the issue at a conference in Chicago. After two days, they called for more research to establish the nature and the risks of the Apo E family but many researchers seem opposed to confronting people with alarming news about conditions that cannot be fought, based on blood samples given for other purposes.
“Have you done them a service?” asks Dr Lindsay Farrer, an Alzheimer ‘s researcher at Boston University Medical Centre. “What good does it do to tell someone about being at risk from a dreaded disease that can neither be prevented nor effectively treated?” Dr Rudolph Tanzi, an Alzheimer’s specialist at Massachusetts General Hospital, agrees but, because his own family has a history of early heart problems, he was unable to resist having his own Apo E analyzed. He is an E3, in the same wide, neutral middle ground as most of humanity. The problems raised by Apo E are varied and complex. Some doctors worry about possible discrimination from employers and insurance companies if people are routinely told they may have a predisposition to serious illness and premature death. Because blows to the head seem to increase the risk of getting Alzheimer’s among people with the E4 gene, should boxers and other athletes, and children wanting to play contact sports, be tested for their Apo classification? “Already!”, says Dr Relkin, pregnant women are asking for their fetuses to be screened so they can consider abortion if their babies show two E4s.
Duke University’s Dr Roes is working with a major drug company to try to define what gives Apo E2 its ability to improve the body’s defenses, so that its protection can be duplicated in the laboratory. “The hope is that we shall be able to make a drug that does what Apo E2 does,” he says. Meanwhile, for millions of people around the world, their destiny -how they will live, when they will die is perhaps already foretold in a dusty medical file.
Text 1: Questions 7-14
7. Researchers have identified A. a way to monitor a person’s life span from a blood test. B. a gene which could affect the process of ageing in humans. C. the mystery about mortality’s last call. D. a way to predict the vulnerability of an individual. 8. The discovery of being able to estimate the life span of a person A. has generated apprehension about people’s predisposition to deadly diseases. B. has initiated an ethical puzzle involved in being able to predict disease. C. has rekindled debate about a perpetual dilemma for doctors. D. has been instrumental in forecasting deadly diseases. 9. Apo E functions within a person’s system as A. a cholesterol gene controller. B. a maintainer of the gene’s relationship with longevity. C. a gene which monitors and determines the ageing process. D. the gene which inhibits the rate at which the body degenerates. 10. Scientists have been in a position to study the Apo E phenomenon because A. of the steadily ageing population in North America. B. Apo E has been known about for many years. C. diseases which affect the elderly have increased. D. they knew that its only function is to remove the cholesterol from the blood. 11. A molecular geneticist in Boston has found that A. we all inherit Apo E2, E3 or E4 from either parent. B. the greater number of us inherit three variants of Apo E from both parents. C. the majority of us will inherit two Apo E3s from both parents. D. more than half of us inherit either two Apo E2s or two Apo E4s from both parents. 12. Middle aged women with an Apo E4 gene A. are at greater risk of being vulnerable to illnesses. B. have a 50% higher risk factor than men. C. experience a higher incidence of Alzheimer’s disease. D. are more likely to develop heart disease. 13. Which statement is not true? The neurologist who made initial connection with Apo E and Alzheimer’ s believes people with A. 2 E4s are more likely to develop the disease. B. 2 E4s are more likely to be protected by it. C. 2 E4s are six times more at risk of vulnerability to Alzheimer’s than others. D. 2 E2s are less in 15% of general population who have the disease. 14. Neurologists and bioethicists who met at a conference in Chicago A. were mildly in favor of telling people alarming news about their condition. B. agreed that there was sufficient information to establish risks of Apo E gene. C. agreed that it was insufficient to determine extent of risks using Apo E information. D. were not in favor of giving bad news based on blood samples only.
PART C. TEXT 2. E.Coli Outbreak. Choose the answer (A, B, C or D).
An outbreak of E. coli in Germany that has killed at least 16 people and left hundreds battling infection across Europe raises questions about what risks the infection continues to pose and what fallout it will cause. The source of the E. coli outbreak is still unknown but has been traced to cucumbers imported to Germany from Spain. It is not clear whether the vegetables were infected at source or in transit. The European Center for Disease Prevention and Control (ECDPC) says transmission of the strain of bacterium, commonly found in cattle, usually occurs through contaminated food or water and contact with animals. Infections have so far only been linked to Spanish cucumbers originating from the cities of Almeria and Malaga, but there are fears other raw vegetables such as lettuce and tomatoes could be affected. The European Union says a suspect batch of cucumbers imported from either Denmark or the Netherlands and sold in Germany is under investigation.
The ECDCP says the bacteria’s impact on individuals can be affected by their age with children under five usually at higher risk of developing disease and dying from infection. However, statistics published on May 27 showed that of 276 cases, 87% were adults and 68% were women. One hospital in Hamburg said it had up to 700 infected patients. Of 85 people at risk of renal failure, 20 were children and 65 were adults. Sweden, which appears to have the biggest cluster of cases outside of Germany, has reported several dozen people hospitalized. Escherichia coli (E. coli) is a bacteria found living in the intestines of people and animals. It can be transmitted through contaminated water or food — especially raw vegetables and undercooked meat. It is usually harmless, but can cause brief bouts of diarrhea. Some nastier strains can cause severe diarrhea and followed by serious organ system damage such as kidney failure. Healthy adults usually recover within a week, but young children and older adults can develop a life- threatening kidney failure.
The European Food Safety Alert Network identifies the bacteria linked to the contaminated cucumbers as EHEC, or enterohemorrhagic Escherichia coli, a strain which is particularly virulent and resistant to antibiotics. In Hamburg, up to 30% of people admitted to hospital with the infection were said to have developed haemolytic-uremic syndrome, a life-threatening form of kidney failure. The ECDPC says the outbreak is the largest in the world of its kind. So far there have been more than a dozen E. coli-linked deaths in Germany and hundreds of infections, but more are expected. Infections have also been reported across Western Europe but so far, the cases in Austria, Britain, Denmark, France Netherlands, Sweden and Switzerland have all involved people returning from travel to Germany. The European Food Safety Alert Network said E. coli had been found in cucumbers from Spain, packaged in Germany, and distributed to countries including Austria, the Czech Republic, Denmark, Germany, Hungary and Luxembourg. Germany is advising people to avoid all raw vegetables, particularly cucumber, lettuce and tomatoes. The ECDPC says there is a risk of person-to-person transmission from people carrying the infection. “Personal hygiene messages are important,” it says. With exports of Spanish vegetables “paralyzed” according to officials, weekly losses of about €200 million ($288 million) are predicted. There are also concerns about the long-term impact this will have on Spain’s fruit and vegetable market, last year worth €8.6 billion. Producers have already reported that seeded fruit exports are being affected, despite being unrelated to the scare. In addition to Germany, a number of European countries including Russia and Belgium have banned vegetable imports from Spain. Germany has reportedly also drastically reduced imports from the Netherlands. The cucumber alert could also have diplomatic fallout, with producers urging Spain’s prime minister to step in, complaining German authorities have condemned Spanish produce without proof.
Leire Pajin, the Spanish Health Minister, has discussed the outbreak on Twitter, saying: “In the absence of proof, we’re not ruling out using all necessary measures to make sure there’s compensation for the (economic) damage,” she wrote. “From the first day, the government launched a diplomatic offensive to prevent the linking of this health crisis with our products.” While Germany accounts for much of Spain’s vegetable export market, the country does export further afield to countries including Russia and the United States. There is also the risk of so- called “secondary clusters” of infection caused by person-to-person transmission by anyone who had become contaminated during a visit to Germany.
Text 2: Questions 15-22
15. hat is the meaning of the word ‘fallout’ in the first paragraph? A. What effects the infection will have on the infected people. B. What the causes of the infection are. C. What effects the breakout will have. D. What the causes of eating too many cucumbers are. 16. The source of the E. Coli outbreak is thought to be caused by A. cucumbers exported from Germany. B. infected cattle. C. contaminated food or water and contact with animals. D. cucumbers exported from Spain to Germany. 17. Which one of the following statements is not true? A. Cucumbers from Almeria and Malaga are thought to be infected. B. Tomatoes and lettuce from Spain may be affected. C. A suspect batch of cucumbers sold in Denmark or the Netherlands is under investigation. D. A suspect batch of cucumbers imported to Germany is under investigation. 18. What do the statistics published on May 27 show? A. That women are less likely to be infected. B. That children are more likely to be infected. C. That adults are more likely to be infected. D. That men are more likely to be infected. 19. Which of the following statements is correct? A. A Hospital in Hamburg reported 276 cases of E.coli. B. 700 cases have been reported worldwide. C. Sweden has reported the most cases of E. coli. D. 85 people are at risk of renal failure in a hospital in Hamburg. 20. How is E. coli transmitted? A. From person to person. B. Through contaminated water or food. C. Through eating the kidney’s of animal products. D. From young children to older adults. 21. Why is this strain of E.Coli so deadly? A. It is particularly virulent and resistant to antibiotics. B. It leads to haemolytic-uremic syndrome. C. It is a bacteria linked to contaminated cucumbers. D. Because 30% of people with E.Coli have died. 22. Which of the following is not true? Infections have been reported in people who A. live in Australia and Spain. B. have returned from traveling in Germany. C. live in Austria, Britain, Denmark, France, Netherlands, Sweden and Switzerland. D. have eaten cucumbers which were from Spain and packaged in Germany.
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TEXT A. In the last few years, the concept of aspirin resistance has been largely emphasised in the medical literature, although its definition, mechanism, and specific guidelines for its management remain unclear. Aspirin displays good antithrombotic activity. Various laboratory parameters assessing the efficacy of aspirin like bleeding time, platelet reactivity, thromboxane-A2 (TX-A2) production, and measurement of platelet aggregation, have confirmed the lack of its uniform effect on the platelets. Few studies have reported aspirin resistance to the tune of 5 – 45%. Various extrinsic and intrinsic factors influence the resistance. Numerous studies reveal that aspirin resistance can be overcome by combining it with another antithrombotic agent, i.e., clopidogrel. Further, clopidogrel resistance has also been reported. So, much is expected in the field of diagnostic tests in order to know the true picture of aspirin resistance.
TEXT B Mechanisms of aspirin resistance The exact mechanisms are not clear: True aspirin resistance: The proposed factors for this type of resistance include: a. Decreased bioavailability of aspirin. b. Accelerated platelet turnover introducing newly f armed, non-aspirinated platelets into the blood stream. c. Competition of aspirin with other NSAIDs(like ibuprofen)preventing aspirin access at Serine 530 of Cox-I. d. Transcellular formation of TxA2 by aspirinated platelets from PGH2 released by other blood cells or vascular cells. e. TxA2 production by aspirin insensitive Cox-2 in newly formed platelets or other cells. f. (Theoretical) presence of variant Cox-I which is less sensitive to aspirin inhibition. g. Poor compliance by the patient.
TEXT C ·Aspirin dosage According to the Antithrombotic Trialists’ Collaboration, daily doses of aspirin (75 – 150 mg) are as effective as higher doses for prevention of thrombotic events and are associated with low risk of bleeding. Bornstein et al in their study have shown that even 100 mg of aspirin completely inhibits Cox-1 enzyme, thus further substantiating the f act that patients with resistance established during low dose aspirin therapy may respond to higher doses. The results of this study showed that aspirin in doses of 500 mg/day- significantly prolonged the time between first and second stroke (p= 0.002) compared with lower doses. Helgasonetal revealed that an increase in the dose of aspirin to 625 that suboptimal reduction of urinary 11-dehydro TxB2 level during aspirin treatment is associated with increased risk for future MI and cardiovascular death, thereby suggesting that “true aspirin resistance” may be a clinically relevant phenomenon. Inadequate inhibition of TxA2 biosynthesis by aspirin can be seen in patients on ibuprofen therapy, because of competition of these 14 mg/day in five patients who were aspirin resistant with 325 mg/day showed aspirin sensitivity. Another study has revealed that these patients remained resistant with aspirin 1,300 mg. This shows that inadequate dose cannot explain aspirin resistance in all subjects.
TEXT D Management of aspirin resistance Currently there are no specific guidelines for the management of aspirin resistance. The first step is to enquire about the patient’s compliance. Regarding optimal aspirin dosing, it is controversial. No convincing data are available showing that the antithrombotic effect of aspirin is dose related. The meta-analysis by Anti-Thrombotic Trialist’ s Collaboration refuted the claim that high doses of aspirin (500 – 1,500 mg/day) were effective than low doses (75 – 150 mg/day). Other method to manage aspirin resistance is by addition of another antiplatelet agent – clopidogrel, because CAPRI£ trial has shown greater benefit of combination of- aspirin and clopidogrel compared with aspirin alone. The combination of aspirin with clopidogrel is an ideal one since clopidogrel inhibits another pathway of platelet activation. However, till date, it is not clear whether the superiority of a combination of clopidogrel and aspirin over aspirin is due to clopidogrel compensation for aspirin non-responders. Resistance to even clopidogrel has been reported, which is associated with an increased risk of recurrent thrombotic events in patients with acute MI.
Part A. TIME: 15 minutes. Questions 1-7. For 1-7, choose(A, B, C or D) In which text can you find information
1. what are the factors of true aspirin resistance? 2. how much of aspirin completely inhibits Cox-1 enzyme? 3. what will happen if aspirin compete with other NSAIDs? 4. how the true picture of aspirin resistance is revealed? 5. what are the parameters for assessing the efficacy of aspirin? 6. list the methods to manage aspirin resistance? 7. whether true aspirin resistance is a clinically relevant phenomenon?
Questions 8-13. Answer each of the questions, 8-13, with a word or short phrase from one of the texts.
8. How much mg of aspirin is minimum required to completely inhibit Cox-1 enzyme? 9. Which patients show inadequate inhibition of TxA2 biosynthesis by aspirin? 10. Name the antiplatelet agent used to manage aspirin resistance? 11. What are responsible for transcellular formation of TxA2? 12. What is the daily doses range of aspirin according to the Antithrombotic Trialists’ Collaboration? 13. Which trial has shown greater benefit of combination of aspirin and clopidogrel?
Questions 14-20. Complete each of the sentences, 14-20, with a word or short phrase from one of the texts.
14. Aspirin displays good___________ activity. 15. Few studies have reported aspirin resistance to the tune of ___________ 16. TxA2 may be produced by aspirin insensitive _________in newly formed platelets or other cells. 17. Increase in the dose of aspirin to 625 is associated with increased risk for future MI and_____________ 18. Inadequate inhibition of TxA2 __________ by aspirin can be seen in patients on ibuprofen therapy. 19. The first step in management of aspirin resistance is to enquire about the patient’s _________________ 20. The combination of ______________ with clopidogrel is an ideal one.
PART B. For questions 1-6, choose the answer (A, B or C)
Anaesthetic Machines: The anaesthetic machine (or anaesthesia machine in America) is used by anaesthesiologists and nurse anaesthetists to support the administration of anaesthesia. The most common type of anaesthetic machine is the continuous-flow anaesthetic machine, which is designed to provide an accurate and continuous supply of medical gases (such as oxygen and nitrous oxide), mixed with an accurate concentration of anaesthetic vapour (such as halothane or isoflurane), and deliver this to the patient at a safe pressure and flow. Modern machines incorporate a ventilator, suction unit, and patient monitoring devices. 1. The manual is giving information about A. how to use anaesthetic machines B. types of anaesthetic machines C. an overview of anaesthetic machines
Autoclaves and Sterilizers: Sterilization is the killing of microorganisms that could harm patients. It can be done by heat (steam, air, flame or boiling) or by chemical means. Autoclaves use high pressure steam and sterilizers use boiling water mixed with chemicals to achieve this. Materials are placed inside the unit for a carefully specified length of time. Autoclaves achieve better sterilization than boiling water sterilizers. Heat is delivered to water either by electricity or flame. This generates high temperature within the chamber. The autoclave also contains high pressure when in use, hence the need for pressure control valves and safety valves. Users must be careful to check how long items need to be kept at the temperature reached.
2. Why autoclaves are better than boiling water sterilizers? A. Heat is transferred to water by electricity or flame B. Autoclaves use high pressure steam C. Autoclaves generates high temperature within the chamber
ECG: How it works: The electrical activity is picked up by means of electrodes placed on the skin. The signal is amplified, processed if necessary and then ECG tracings displayed and printed. Some ECG machines also provide preliminary interpretation of ECG recordings. There are 12 different types of recording displayed depending upon the points from where the recordings are taken. Care must be taken to make the electrode sites clean of dirt before applying electrode jelly. Most problems occur with the patient cables or electrodes.
3. The guidelines establish that the healthcare professional should A. aim to make patients fully aware of how ECG works. B. carefully clean the electrode sites. C. respect the wishes of the patient above all else.
Benefits of electronic health records: EHR systems are complex applications which have demonstrated benefits. Their complexity makes it imperative to have good application design, training, and implementation. Studies have evaluated EHR systems and reported on various benefits and limitations of these systems. Benefits included increase in immunization rates, improved data collection, increased staff productivity, increased visitor satisfaction with services, improved communication, quality of care, access to data, reduced medical errors, and more efficient use of staff time. Some of the disadvantages noted were: time- consuming data entry, slow access of data and decreased quality of patient- doctor interaction.
4. The notice is giving information about A. pros and cons of electronic health records B. necessity of electronic health records C. demonstrated benefits of electronic health records
mHealth: The use of mobile technologies for data collection about individuals and interactive information services are a part of a growing area of eHealth called mHealth. The GOe published a volume on this subject in 2011which documents the uptake of mHealth worldwide by types of initiatives and main barriers to scale. Mobile technologies are emerging as a powerful tool for health information transfer including making patient information portable. Such technologies can be more fully utilized through electronic patient information such as EMRs and EHRs. Electronic records will work best, however, if there are standards in place for their use and interoperability.
5. The note tells us that the mHealth A. is a published volume on the GOe B. is a powerful tool for information transfer C. makes patient information portable
Systematized Nomenclature of Medicine (SNOMED): SNOMED was designed to provide a comprehensive nomenclature of clinical medicine for the purpose of describing records of clinical care in human medicine. It is a multi-axial and hierarchical classification system. It is multi¬ axial in that any given clinical condition can be described through multiple axes such as topography (anatomy), morphology, organisms such as bacteria and viruses, chemicals such as drugs, function (signs and symptoms), occupation, diagnosis, procedure, physical agents or activities, social context, and syntactic linkages and qualifiers. SNOMED is hierarchical in that each of the axes has a hierarchical tree that proceeds from general terms to more specific ones. For example, topography (anatomic) terms are first divided into major organs such as lung, heart, and then into the smaller components of each.
6. What does this extract from a handbook tell us about Systematized Nomenclature of Medicine? A. is a multi-axial and hierarchical classification system B. is a comprehensive nomenclature of trial medicines C. is used to described any clinical condition through axis
PART C. TEXT 1. Choose the answer (A, B, C or D) which you think fits best according to the text.
Paragraph 1: All life is connected Cancer in Humans and Wildlife. WILDLIFE-HUMAN LINKS It may be that biologists, rather than physicians, will be the major contributors to the health of our wildlife caused by the combined action of pesticides planet and its people. It was Rachel Carson, a biologist, who researched and wrote of the harm to wildlife caused by the combined action of pesticides and radiation. In the tradition of the observant biologist is Theo Colborn, who, with her colleagues, provided a significant breakthrough in understanding the hormonal effects of environmental contaminants. In July 1991, a gathering of some of the world’s most astute, – scientists were held at the Wingspread Conference Center in Wisconsin, where they defined the pattern of diverse endocrine malfunction seen throughout the animal · kingdom. They revealed a gm”: picture of the Brave New World we should m rigorously seek net to leave as a legacy to our children.
Paragraph 2: The conferees, studying wildlife over the globe, described ominous findings of disease are linked to environmental pollution. Exposure to toxic chemicals that possess unintended h actions has resulted in anatomic, physiologic, reproductive, carcinogenic, and behavioural abnormalities across all forms of animal life: in mollusks, fish, birds, seals, and rodents. These creatures are to we humans as canaries were to the miners. We must understand that the destruction of eons of evolutionary function and development in wildlife ‘ foreshadows destruction of the entire biosphere, humans included.
Paragraph 3: These widespread adverse effects were attributed to xenoestrogens. Xeno – comes from a Greek origin, meaning “foreign.” Foreign itself is not bad: how else do we share and spread culture and ideas? But xenoestrogens are less foreigners than invaders, gaining entrance by the Trojan horse of seemingly harmless routes: milk, meat; cheese, fish, the products we use to nourish ourselves and families. Like the invaders of Troy, after the xenoestrogens gain entrance to the bodies of animals and humans alike, they weaken defences and wreak their harm of cancer, hormonal disruption, immunological abnormalities, and birth defects.
Paragraph 4: Xenoestrogens are an insidious enemy, but they have had help from powerful allies: the purveyors of products and chemicals, and legislators, regulators, and scientists reluctant to bite the money- laden hands that feed them. Wingspread researchers found that birds exposed to xenoestrogens show reproductive failure, growth retardation, life-threatening deformities, and alterations in their brains and liver functions.” There is direct experimental evidence for permanent [organizational] effects of gonadal steroids on the brain as well as reproductive organs throughout life. This means that offspring whose brains have been altered are unable to function as had their parents. They become different in ability or function.
Paragraph 5: This means that the sea of hormonally active chemicals in which the fetus develops may change forever the health and function of the adult, and in some cases, may alter the course of an entire species. Worldwide there are reports of declining sperm counts and reduced ratio in births of male babies. Without the capacity to reproduce, a species ceases to exist. Extinction is forever; a species loss has never been reversed.
Paragraph 6: The data derived from animal observations are unequivocal: breast and genital cancers, _ital abnormalities, interference with sexual development, and changes in reproductive behaviour all expressions of a root cause. A possible connection between women with breast cancer and those having children with reversed sexual orientation is a question that bears study. This is n n. from science fiction, considering what we have learned from observing wildlife and the effects inappropriate hormonal influence upon the breast, brain, and reproductive organs. If an unequivocal answer were to emerge from human observation, it could have a significant impact upon the prevailing political and economic landscape, and may finally settle the nature or nu issue of sexual orientation.
Paragraph 7, SILENT SPRING-SILENT WOMEN. Considering the accumulated knowledge linking chemical and radioactive contamination environment with increasing breast cancer rates means we must focus our energies and prevention. Early were the eloquent words and pleas for prevention from Rachel Carson. Her book, Silent Spring, originally published in 1962, while she herself was suffering from breast cancer, is still a best seller. Ms. Carson documented wholesale killing of species; animals, birds, fish, insects; the destruction of food and shelter for wild creatures; failure of reproduction; damage to the nervous system; tumors in wild animals; increasing rates of leukemia in children; and chronicled the pesticides and chemicals known at that time to cause cancer. This was over 30 years ago!
Paragraph 8: Carson’s is a book for every citizen, for without understanding of our collective actions and permissions, we cannot govern democratically. In Australia, a citizen is required to vote. In the United States, proclaimed by some politicians as the “greatest democracy on earth,” often fewer than 50% bother to vote in a major election. Of those who do take the time to register and vote, few are sufficiently alert and/or educated to vote with intelligence, thought, and compassion. Requiring participation in the governance of one’s own country is not a bad idea. Requiring thoughtful voting may be more difficult, especially when it comes to such issues as cancer, pesticide use, consumer products, nuclear radiation, toxic chemicals, and environmental destruction. Taking this thought one step further; this democracy could do far worse than to require reading of Silent Spring as a requirement to vote! Radical? Perhaps. But is the ongoing cancer epidemic any less radical?
Paragraph 9: One successor to Ms. Carson has emerged in the person of Sandra Steingraber, an ecologist, poet, and scientist. In her book, Living Downstream, she writes eloquently of the connections between environmental contamination and cancer. Dr. Steingraber was diagnosed with bladder cancer at age 20, a highly unusual diagnosis in a woman, a young woman, a non-smoker and non-drinker. She pursued the question, why? She realized a connection with our wild relations and she asks: Tell me, does the St. Lawrence beluga drink too much alcohol and does the St. Lawrence beluga smoke too much and does the St. Lawrence beluga have a bad diet. . . is that why the beluga whales are ill? …Do you think you are somehow immune and that it is only the beluga whale that is being affected?
Paragraph 10: The portion of Dr. Steingraber’s book that struck me most personally was when she says: First, even if cancer never comes back, one’s life is utterly changed. Second, in all the years I have been under medical scrutiny, no one has ever asked me about the environmental conditions where I grew up, even though bladder cancer in young women is highly unusual. I was once asked if I had ever worked with dyes or had been employed in the rubber industry. (No and no.) Other than these questions, no doctor, nurse, or technician has ever shown interest in probing the possible causes of my disease-even when I have introduced the topic. From my conversations with other cancers, patients, I gather that such lack of curiosity in the medical community is usual.
Paragraph 11: I take her words as an indictment of the medical and scientific establishment, whose point of view must be changed. Certainly, the lack of curiosity among physicians, scientists, policymakers and politicians has contributed to the epidemic of illness among humans and wildlife alike. An equally talented woman is Terry Tempest Williams, an ecologist and wildlife researcher whose book, Refuge: An Unnatural History of Family and Place, tells the story of her Utah family, whom she “labels “a clan of one-breasted women.” Ms. Williams contrasts the life-affirming awareness Great Salt Lake wildlife refuge against the erosion-of-being, as cancer takes away the women in her family: her mother, her grandmothers, and six aunts. She writes: “I cannot prove that my mother Diane Dixon Tempest, or my grandmothers, Lettie Romney Dixon and Kathryn Blackett Tempest along with my aunts, developed cancer from nuclear fallout in Utah. But I can’t prove that didn’t.”
Paragraph 12: Times are changing. It is becoming impossible to ignore the carnage of endocrine-disruption chemicals, nuclear radiation, and chemical carcinogens, alone and in combination, invading nearly every family with cancer. Facing this reality may be too much for some people, afraid to look, or afraid of being the next victim. The story of cancer is not an easy one, and neither is cancer. But if we do not exert our efforts to prevent this disease, we doom our children and grandchildren to repeat our collective errors. What does it take to change from environmental destruction and random killing to affirmation of life? Can the protection of life for ourselves and our environment be accomplished by women with breast cancer; the women at risk for breast cancer; the families of breast cancer victims? Who should lead? If we citizens can’t and don’t try, what are our alternatives?
QUESTIONS
Q1. The author’s main contention is that A. wildlife all around the world is being linked to environmental pollution B. fish, birds, seals and canaries are being exposed to toxic chemicals C. humans need to understand the link between destroying the planet’s wildlife, through exposure to toxic chemicals, and the destruction of the entire biosphere -which includes human life itself. D. humans need to understand the link between destroying the planet’s wildlife, through exposure to toxic chemicals, and behavioural abnormalities across all forms of life. ”
Q2. The author states that in an environment of “hormonally active chemicals” A. males with higher sperm counts may result ‘ B. more male babies are born C. lower sperm count in males may result in a particular species being wiped out ‘ D. males with more sperm count may result
Q3. Dr Sandra Steingraber, ecologist, poet and scientist: A. realised that contracting bladder cancer was not due to her alcohol drinking B. realised her bladder cancer was not due to her smoking C. believed her bladder cancer was due to environmental contamination D. doctors, nurses and technicians were very interested in her unusual cancer
Q4. The wildlife researcher, Terry Tempest Williams, sees the dichotomy which exists in the Salt Lake wildlife refuge area: A. many women in her family have died from breast cancer after a nuclear fallout in Utah B. many men in her family have died from breast cancer C. her family have many one-breasted women -unusual for Utah D. such wide-spread cancer is probably due to environmental, not genetic causes
Q5. Animal observations show: A. changes in sexual maturity are not only due to a root cause B. genital abnormalities may be due to a root cause C. inappropriate hormones adversely affect the development of breast, brain and reproductive organs D. humans are not similarly affected.
Q6. The author puts forward several ideas about governance except for one of the following: A. People who participate in elections are not alert and educated enough B. Unless the wants and needs of the population are known, it is difficult for politicians to govern democratically C. People being required to vote, to participate in the decision-making process, is a good idea D. Reading Carson’s book, Silent Spring, should be made compulsory for all voters.
Q7. Rachel Carson’s book Silent Spring, written in 1962, revealed: A. more had to be done to prevent chemical contamination of the environment B. there was a link between pesticides, chemicals and cancer C. chemicals were leading to an inability to reproduce leading to the eradication of entire species of insects, birds, fish and animals D. all of the above
Q8. Research about xenoestrogens reveals A. they are everywhere B. they are harmless C. they are in our everyday foods D. they are in our everyday foods and disrupt hormonal function
PART C. TEXT 2 Paragraph 1: A compilation of articles within the British Medical Journal meticulously scrutinises the effectiveness of oseltamivir, more commonly referred to as Tamiflu. This assemblage of scholarly works collectively arrives at a nuanced and significant conclusion — casting an intricate shadow of doubt over the previously asserted efficacy of Tamiflu. The skepticism arises from a meticulous analysis encompassing ten pivotal drug company trials. Specifically, these trials were intended to substantiate the claims that oseltamivir diminishes the risk of complications in otherwise healthy adults grappling with influenza. The intricacies unearthed in this comprehensive examination intricately challenge the hitherto uncontested efficacy of Tamiflu, injecting a layer of uncertainty into its purported ability to stave off complications, particularly in individuals without pre-existing health conditions.
Paragraph 2: The use of meta-analysis is governed by the Cochrane review protocol. Cochrane Reviews investigate the effects of interventions for prevention, treatment and rehabilitation in a healthcare setting. They are designed to facilitate the choices that doctors, patients, policy makers and others face in health care. Most Cochrane Reviews are based on randomized controlled trials, but other types of evidence may also be taken into account, if appropriate.
Paragraph 3: If the data collected in a review are of sufficient quality and similar enough, they are summarised statistically in a meta-analysis, which generally provides a better overall estimate of a clinical effect than the results from individual studies. Reviews aim to be relatively easy to understand for non-experts (although a certain amount of technical detail is always necessary). To achieve this, Cochrane Review Groups like to work with “consumers”, for example patients, who also contribute by pointing out issues that are important for people receiving certain interventions. Additionally, the Cochrane Library contains glossaries to explain technical terins.
Paragraph 4: Briefly, in updating their Cochrane review, published in late 2009. Tom Jefferson and colleagues failed to verify claims, based on an analysis of 10 drug company trials, that oseltamivir reduced the risk of complications in healthy adults with influenza. These claims have farmed a key part of decisions to stockpile the drug and make it widely available.
Paragraph 5: Only after questions were put by the BMJ and Channel 4 News has the manufacturer Roche committed to making “full study reports” available on a password protected site. Some questions remain about who did what in the Roche trials, how patients were recruited, and why some neuropsychiatric adverse events were not reported. A response from Roche was published in the BMJ letters pages and their full point by point response is published online.
Paragraph 6: Should the BMJ be publishing the Cochrane review given that a more complete analysis of the evidence may be possible in the next few months? Yes, because Cochrane reviews are by their nature interim rather than definitive. They exist in the present tense, always to be superseded by the next update. They are based on the best information available to the reviewers at the time they complete their review. The Cochrane reviewers have told the BMJ that they will update their review to incorporate eight unpublished Roche trials when they are provided with individual patient data.
Paragraph 7: Where does this leave oseltamivir, on which governments around the world have spent billions of pounds? The papers in last year’s journal relate only to its use in healthy adults with influenza. But they say nothing about its use in patients judged to be at high risk of complications- pregnant women, children under 5, and those with underlying medical conditions; and uncertainty over its role in reducing complications in healthy adults still leaves it as a useful drug for reducing the duration of symptoms. However, as Peter Doshi points out on this outcome it has yet to be compared in head-to-head trials with non-steroidal inflammatory drugs or paracetamol. And given the drug’s known side effects, the risk-benefit profile shifts considerably if we are talking only in terms of symptom relief.
Paragraph 8: We don’t know yet whether this episode will turn out to be a decisive battle or merely a skirmish in the fight for greater transparency in drug evaluation. But it is a legitimate scientific concern that data used to support important health policy strategies are held only by a commercial organisation and have not been subject to full external scrutiny and review. It can’t be right that the public should have to rely on detective work by academics and journalists to patch together the evidence for such a widely prescribed drug. Individual patient data from all trials of drugs should be readily available for scientific scrutiny.
QUESTIONS
Q1. A cluster of articles on oseltamivir in the British Medical Journal conclude—– a. complications are reduced in healthy people by oseltamivir b. the efficacy of Tamiflu in now in doubt c. complications from pandemic influenza are currently uncertain d. a series of articles supporting Tamiflu
Q2. Cochrane Reviews are designed to _ a. set randomized controlled trials to specific values b. compile literature meta-analysis c. peer review articles d. influence doctors’ choice of prescription
Q3. According to the article, which one of the following statements about Tamiflu is FALSE? a. The use of randomized controls is suspect b. The efficacy of Tamiflu is certain c. Oseltamivir induces complications in healthy people d. Cochrane reviews are useful when examining the efficacy of Tamiflu
Q4. According to the article, Cochrane Review Groups _ a. like to work for “consumers”. b. are being overhauled. c. use language suitable for expert to expert communication. d. evaluate a clinical effect better than individual studies.
Q5. Which would make the best heading for paragraph 4? a. Analysis of 10 drug company trials b. The stockpiling of Oseltamivir c. Risk of complications in healthy adults d. Tamiflu claims fail verification
Q6. According to the article, which one of the following statements about Roche is TRUE? a. Full study reports were made freely available on the internet b. Patients were recruited through a double-blind trial c. The identities and roles of researcher in the Roche trials are not fully accounted for d. Not all neuropsychiatric adverse events were reported
Q7. Cochrane reviews should _ a. use a more complete analysis b. not be published until final data is available c. be considered interim rather than definitive advice d. be superseded by a more reliable method of reporting results
Q8. Which would make the best heading for paragraph 7 a. Risk-benefit profile of Tamiflu b. Studies limited to healthy adults c. High risk of complications – d. Oseltamivir only for high-risk patients
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TEXT-A. Special warnings and precautions for use: If you are receiving medical treatment, are asthmatic, allergic to aspirin or have or have had a stomach ulcer, seek your doctor’s advice before taking this product. The product labelling will include “Do not give to children aged under 16 years unless on the advice of a doctor”. There is a possible association between aspirin and Reye’s Syndrome when given to children. Reye’s Syndrome is a very rare disease which affects the brain and liver and can be fatal. For this reason, aspirin should not be given to children aged under 16 years unless specifically indicated (e.g. for Kawasaki’s disease). Interaction with other medicinal products and other forms of interaction: Aspirin may enhance the effects of anticoagulants and inhibit the effects of uricosurics. Experimental data suggest that ibuprofen may inhibit the effect of low dose aspirin on platelet aggregation when they are dosed concomitantly. However, the limitations of these data and the uncertainties regarding extrapolation of ex-vivo data to the clinical situation imply that no firm conclusions can be made for regular ibuprofen use, and no clinically relevant effect is considered to be likely for occasional ibuprofen use. Overdose Salicylate poisoning is usually associated with plasma concentrations >350 mg/L (2.5 mmol/L). Most adult deaths occur in patients whose concentrations exceed 700 mg/L (5.1 mmol/L). Single doses less than 100 mg/kg are unlikely to cause serious poisoning.
TEXT-B. Symptoms Common features include vomiting, dehydration, tinnitus, vertigo, deafness, sweating, warm extremities with bounding pulses, increased respiratory rate and hyperventilation. Some degree of acid-base disturbance is present in most cases. A mixed respiratory alkalosis and metabolic acidosis with normal or high arterial pH (normal or reduced hydrogen ion concentration) is usual in adults and children over the age of four years. In children aged four years or less, a dominant metabolic acidosis with low arterial pH (raised hydrogen ion concentration) is common. Acidosis may increase salicylate transfer across the blood brain barrier. Uncommon features include haematemesis, hyperpyrexia, hypoglycaemia, hypokalaemia, thrombocytopaenia, increased INR/PTR, intravascular coagulation, renal failure and non-cardiac pulmonary oedema. Central nervous system features including confusion, disorientation, coma and convulsions are less common in adults than in children. Management Give activated charcoal if an adult presents within one hour of ingestion of more than 250 mg/kg. The plasma salicylate concentration should be measured, although the severity of poisoning cannot be determined from this alone and the clinical and biochemical features must be taken into account. Elimination is increased by urinary alkalinisation, which is achieved by the administration of 1.26% sodium bicarbonate. The urine pH should be monitored. Correct metabolic acidosis with intravenous 8.4% sodium bicarbonate (first check serum potassium). Forced diuresis should not be used since it does not enhance salicylate excretion and may cause pulmonary oedema. Haemodialysis is the treatment of choice for severe poisoning and should be considered in patients with plasma salicylate concentrations >700 mg/L (5.1 mmol/L), or lower concentrations associated with severe clinical or metabolic features. Patients under ten years or over 70 have increased risk of salicylate toxicity and may require dialysis at an earlier stage.
TEXT-C. Treatment Antiemetic. 5-HT3 receptor antagonists are most effective as antiemetics. Examples: o Kytril (granisetron HCl), 10 μg/kg IV over 5 minutes in adults and (PEDS) children 2 years and older o Zofran (ondansetron), 8 mg IV over 15 minutes (PEDS: > 2 years 0.15 mg/kg) o Anzemet (dolasetron), 100 mg IV over 30 seconds (PEDS: > 2 years 1.8 mg/kg) Correct Acidosis: Sodium bicarbonate is frequently required to treat acidemia and to promote salicylate elimination by the kidneys. To correct metabolic acidosis caused by salicylate intoxication, administer 0.5 to 1.0 mEq/kg/IV bolus over 2 minutes and repeat as needed to maintain a blood pH of 7.4 to 7.5.
TEXT-D. Medications Activated charcoal: To prevent more absorption, the doctor may give activated charcoal to absorb the salicylate from the stomach. A laxative may be given with the activated charcoal to move the mixture through the gastrointestinal system more rapidly. People who have been severely poisoned may be given repeated doses of activated charcoal. IV fluids: Dehydration occurs early in aspirin poisoning. To correct dehydration, the doctor will start an IV to provide fluids. The doctor will also work to correct imbalances in the body’s blood chemistries. Alkaline diuresis: This is a way to reduce the amount of salicylate in the body. Alkaline diuresis is the process of giving a person who has been poisoned compounds that alter the chemistry of the blood and urine in a way that allows the kidneys to remove more salicylate. Specifically, sodium bicarbonate is given via IV to make the blood and urine less acidic (more alkaline). This encourages the kidneys to capture more salicylate that can leave the body through the urine. Sometimes, other compounds, such as potassium, also have to be given to help with this process.
Reading test – 04. Part – A Question paper Questions 1-7. Aspirin overdose: For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use any letter more than once. In which text can you find information about? 1. The various symptoms of a patients who have taken too much aspirin 2. Steps need to be taken while treatment 3. What medicines are necessary for treatment 4. How to decide the overdose of a drug 5. What precautions do we need to take to keep children safe? ________ 6. Types of treatments for aspirin overdose 7. What to consider in treatment management 8. The number of other products that are associated with aspirin
Questions 8-14. Complete each of the sentences, 8-14, with a word or short phrase from one of the texts. 9. Sodium bicarbonate is given via______________ to make the blood and urine more alkaline. 10. We need to take into consideration of ______________ and ______________ factor, while defining the severity of overdose poising. 11. If you are suffering from asthma you need to contact____________________ before taking aspirin. 12. ______________ antagonistic are used for treating over poising. 13. Patients under ten years or more than 70 have expanded danger of______________ and may require dialysis at a prior stage. 14. Dehydration occurs in the______________ stage of poisoning. 15. ______________ may inhibit the effect of low dose aspirin. Questions 15-20. Answer each of the following questions, 15-20, with a word or short phrase from one of the texts. 16. The drug that will enhance the effects of anticoagulants and inhibit the effects of uricosurics is______________ 17. What method will reduce salicylate level in the body? ______________ 18. Which chemical compound is required to treat acidemia? ______________ 19. What will be provided primarily, if a patient presents with over ingestion of aspirin? ______________ 20. What do you need to take to control dehydration? ______________
PART B. For questions 1-6, choose the answer (A, B or C) which you think fits best according to the text.
1. What are these guidelines for? A. Improving patient safety at hospitals B. Promoting appropriate use of email at practice C. Generating impression among staff and with patients
Mail Etiquette Guidelines: Most people know it only takes a few seconds to make an impression, and most first impressions are difficult to change. What most people may not realize is that this rule doesn’t just apply to person-to-person meetings. “We are in the age of computers, and e-mail is a huge way of communication, so that could be the first way of meeting a patient,” says Hendersonville, N.C.-based Darlene Das, president of etiquette consulting company Today’s Etiquette, and a trained surgical technician who specializes in medical practice etiquette. When it comes to communicating with patients, and even with fellow staff, making a good impression is just the first of many reasons your written — or typed — words are so important. Come across as too cutesy, grammatically inept, impolite, or inappropriate, and your e-mails could offend colleagues or turn off patients from your practice. Whether communicating with colleagues or patients face-to-face or via e-mail, the same age-old etiquette rules apply. You need to be polite, professional, and friendly. But because of electronic communication’s unique qualities, there are additional considerations, from using proper grammar to observing formalities.
2. As per the extract, what is the main topic of selection? A. Small practices B. Large practices C. Individual doctor
Extract from manual: Some patients prefer the intimacy of a small practice. The advantages include getting to know all the staff and usually less bureaucracy. Other patients prefer large-practices that offer the convenience of many specialties under one roof. Ultimately, who your individual doctor is matters more than the practice he or she is working for. But different practices have different vibes, though you may not be able to sense this until you are actually a patient. Another option these days — though much more expensive — is the “direct primary care” model (sometimes known as “concierge” medicine). In this type of practice, you pay an annual retainer fee but get longer visits and easier access to your doctors.
3. What does this information tell us about? A. Many people are travelling farther distances to get cure B. Most people are preferring to get cared at best hospitals C. Significant Medicare patients are suffering from heart attack
Extract from blog: There’s an exceedingly simple way to get better health care: Choose a better hospital. A recent study shows that many patients have already done so, driving up the market shares of higher-quality hospitals. A great deal of the decrease in deaths from heart attacks over the past two decades can be attributed to specific medical technologies like stents and drugs that break open arterial blood clots. But a study by health economists at Harvard, M.I.T., Columbia and the University of Chicago showed that heart attack survival gains from patients selecting better hospitals were significant, about half as large as those from breakthrough technologies. That’s a big improvement for nothing more than driving a bit farther to a higher-quality hospital. Because more Medicare patients went to higher-quality hospitals for heart attacks between 1996 and 2008, overall chances of survival increased by one percentage point, according to the study. To receive care at a hospital with a one-percentage-point gain in survival rate or a one-percentage-point decrease in readmission rate, a heart attack patient travelled 1.8 or 1.1 miles farther, respectively. The investigators also found survival gains for heart failure and pneumonia, but with far less of a difference, about 0.21 and 0.10 percentage points.
4. According to extract, prior to making a home visit, GPs must? A. give his out-of-hours telephone number to local hospitals B. respond appropriately for patient’s case C. request the patient to come to hospital on the follow-up day.
Home visit guidelines: All doctors have an emergency service outside of normal surgery hours. Most surgeries have an answering machine message that refers you to out-of-hours telephone numbers or the NHS Direct helpline. The out-of-hours service is only for urgent medical problems that cannot wait until the next day to be treated. It’s usually based at a local medical centre or attached to a local hospital and is a co-operative manned by local GPs. When you phone the out-of-hours service, a nurse or GP will take your details and ask you about your symptoms. You’ll then be dealt with in one of three ways. • You’ll be given telephone advice. • You’ll be asked to come into the medical centre to see a doctor. • A home visit will be arranged if you are too ill to leave your house. If you’re seen out of hours, your doctor will be informed of any consultation you’ve had with another doctor.
5. What do you understand form the manual extract? A. Physician assistants improve healthcare in rural areas B. PA’s isolation is not ideal for better healthcare outcomes C. Requirements need to meet for working in rural areas
I have been concerned with the maldistribution of rural health provider assets for decades. The situation is dire. The sad reality is that the number of physicians practicing in rural and medically underserved areas has been declining for decades. The reasons for this are complex. Practice in these areas is challenging from financial and quality of life perspectives. Many clinicians I know choose to work in metropolitan areas to find a “better life,” more opportunities, and more professional support.
The PAs I know who practice in rural and medically underserved areas tell me how much they love their work and their patients. They also express concerns about the isolation and the fatigue that comes with being the only provider in a small community with little professional support. It takes a special kind of clinician to work in this environment.
6. The purpose of this email is A. To implement medical practice change without going broke or insane B. To explain the reasons for why the new regulations affecting medical workforce C. To remind the duties of medical professionals.
Email to Medical Staff: To All Medical Professionals, Commonwealth Medical Board, Liang Province.
Over the last several years, new regulations have become law affecting how doctors practice medicine. First came the Meaningful Use program, pushing doctors to purchase and implement EHRs. Then came updates to those rules, threatening doctors with financial penalties not only if they failed to incorporate an EHR into practice, but if it was not used in a meaningful way based on submitted data metrics (as determined by government officials).
Now, many practices and healthcare systems are scrambling to address the recently enacted MACRA laws (also known as Medicare’s Quality Payment Program). There is much discussion going on about how to avoid reimbursement reductions. It first comes down to how your practice is getting ready to take on the challenge.
Not all of us work for a hospital or large organization that has IT departments assigned specifically to that task. For many of us, especially in small and/or private practices, this is pretty much a do-it-yourself project.
PART C TEXT 1. For questions 7- 22, choose the answer (A, B, C or D)
I’d heard there was a new woman GP in town, so, at my doctor-husband’s urging, I booked an appointment for a routine check-up. I was feeling well and had no need to suspect anything was amiss. The GP detected nothing out of the ordinary and, with the exception of slightly elevated cholesterol levels, my blood tests came back normal. My GP told me to try to lower my cholesterol levels with diet and exercise and she’d see me again in six months. I embarked upon a calorie-controlled, low-fat diet and worked out most nights for 45 to 60 minutes on my treadmill and weights machine. I was feeling fit and healthy and was close to my ideal weight when the time arrived for my follow-up visit.
In preparation for the visit my husband organised repeat blood tests and sent a copy to my GP. The results arrived the following afternoon. Though my cholesterol had lowered from 5.6 mmol/L to 5.2 mmol/L, we were both surprised to see that my fasting blood glucose had gone from a perfectly normal 5.2 mmol/L to a perfectly diabetic 9.3 mmol/L. A follow-up fasting blood glucose, organised by my husband, confirmed I had diabetes.
A few days later my GP reaffirmed that I had type 2 diabetes and warned me of the complications if this was not treated correctly with a combination of diet, exercise and oral medication. “I wondered” how diet and exercise were going to save me, when previous dedication in this area had let me down so badly. The following week I dutifully attended a session with a diabetes dietitian. Of the six people at the clinic, I was the only one who had taken the fast lane to the dark side, everyone else was pre-diabetic. Along with our new healthy eating habits the dietitian recommended 30 minutes of brisk walking five times per week. I wanted to protest that I was already outdoing this, but sensed the futility of commenting.
Eager to avoid the threatened complications, I got stuck into the job at hand. I took my pills, cut my carbs, worked out and drew blood from my fingertips. Soon, I reached my ideal weight. But all of this did little or nothing to lower my blood sugars. Weekly they continued to rise.
Meanwhile, I carried a deep sense that part of the puzzle was missing. I became paranoid that some aspect of my lifestyle had contributed to this rapid progression, wondering if diet tonic water or my shampoo could be the hidden enemy. While I told myself that denial is one of the phases of grief and perhaps normal under the circumstances, I continued to obsess.
During one of my many sessions browsing diabetes sites on the internet, I found a site that stated that type 1 diabetes could, and did, occur in adults of any age. Many GPs were said to be unaware of this, passing it off as variant of type 2. People in this group were usually neither overweight nor sedentary. This type of diabetes was sometimes referred to as ‘latent autoimmune diabetes of adults’ (LADA) or ‘slow onset type 1’. The more I read about LADA, I became more convinced I was reading about myself. I mentioned it to my husband but he had not heard of it either, so for a while I dismissed it. I figured that if the general medical profession didn’t know about it, then it was probably some unfounded new age idea. I couldn’t let it go though, so kept reading about it. I learned that a blood test, measuring GAD antibodies could confirm type 1 diabetes. I wanted to have this test done so I pressed my husband to write out the pathology request. I was out the door with it like a bullet.
Two weeks later the results came back strongly positive. Perhaps most people would have been unsettled with such a result, but I simply felt relief. In one fell swoop, my questions had been answered. I now knew why there had been no pre-diabetes and why exercise and diet had not spared me. I was referred to an endocrinologist who confirmed type 1 diabetes, and who encouraged me to be proactive in my own treatment. Indeed, he confirmed what I’d already read – that starting insulin early might spare my remaining beta cells.
As flexibility is important to me, we agreed upon multiple daily injections consisting of long-acting insulin at night, and rapid acting insulin prior to meals. I’ve not looked back. Within 12 hours of my first shot I knew I was on the right path, as immediately I felt more energetic, less sleepy and generally more cheerful.
I’m glad I learned about it early as I’ve been fast-tracked to a treatment that works and in doing so, have avoided the frustration of taking medication more suited to type 2 diabetes. Though knowing my true type of diabetes may neither alter long-term treatment nor outcome, I feel at peace with my diagnosis and can now just get on with my life.
Questions 7-14 7. Why did the narrator decide to lose weight? A. She felt bad on her overweight B. Her husband wanted her to see slim C. She thought of facing a severe health setback D. On her GP’s advice 8. Why the narrator was shocked about the blood test results? A. Probably she thought of checking her blood infections B. The blood glucose levels reached extreme levels C. The inappropriate blood test results of her health status D. Because, it was come to her husband’s notice 9. In the third paragraph, the narrator used the words “I wondered” to A. express her concern over the same diet plan B. emphasized the doctor to assist her in reducing blood sugar C. express anger on her old GP’s plan D. to show relation among several factors which triggers depression 10. What do you understand about the narrator’s mental condition from the fourth paragraph? A. She is irritated B. She is feeling tensed C. She is frustrated D. She is disappointed 11. How come the narrator found LADA Test? A. Her husband found it for her B. Her first GP advised her to take it C. She found it on reading a blog D. One of her friends suggested her 12. Why did the narrator feel happy with the test results? A. The test results obtained positively B. The test results confirmed that she was attacked with low level diabetes C. Her GP found that test is the bench mark to certify D. She found the new test to diagnose diabetes 13. What made her to feel more energetic and less sleepy? A. Her first injection dosage B. Her husband’s support C. After her GP motivation session D. Wanted to show her strength to the society 14. What does the word “it” refers to? A. Medicines B. LADA C. GP’s support D. blog
PART C. TEXT: 2 ADHD
It’s one of the most common disorders of childhood, affecting an estimated 3 to 5 per cent of Australian schoolchildren, but few topics in children’s health arouse more controversy than Attention Deficit/Hyperactivity Disorder – or ADHD. Formerly known as Attention Deficit Disorder or ADD, ADHD is characterised by difficulties staying focused and paying attention, ‘problem’ behaviour and hyperactivity. ADHD is three times more common in boys than in girls, and symptoms usually emerge before the child starts school.
Skeptics may dismiss the condition as being nothing more than childhood exuberance and energy, but child behaviour experts have longed acknowledged that ADHD represents behaviour well outside the youthful norm. There is on-going debate about the best diagnostic criteria for ADHD, especially now that it is recognised that in a significant number of people, childhood ADHD can persist into adulthood. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) has been revised to include diagnostic criteria not only for children, but also for adolescents and adults.
Another aspect of the controversy is that ADHD is usually treated with a class of drugs – psychostimulants – that are considered addictive and dangerous in adults (although it is also argued that this is high dose related, and less likely to occur with oral medications, because of slow absorption). However, those who have lived their lives with ADHD, or with an affected child, say that accurate diagnosis and treatment of the disorder has transformed their lives, enabling them to function normally. It’s one of the most common disorders of childhood, affecting an estimated 3 to 5 per cent of Australian schoolchildren, but few topics in children’s health arouse more controversy than Attention Deficit/Hyperactivity Disorder – or ADHD.
A diagnosis of ADHD is usually made by a paediatrician or child psychiatrist, who will take a detailed developmental history from the parents. The specialist will also talk to the child, and assess their functioning in a range of environments, such as home and school. Sometimes the child’s teacher will also be asked to fill in a questionnaire.
It is important that the specialist is able to rule out other factors or undiagnosed conditions that might be responsible for the symptoms, for example, middle-ear infections causing hearing problems, or significant life events, such as a divorce, that might be affecting the child. Doctors should take a careful history of the child’s family and social background to see whether things like upbringing and parental factors are the cause of the symptoms before a diagnosis of ADHD is made. It shouldn’t be made after a single session with the child.
For a positive diagnosis the symptoms need to have lasted for at least six months, started before the child was seven, and be causing problems at home and school. Children must present with at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria, while older adolescents and adults (over age 17 years) must present with five for a diagnosis of ADHD to be made.
Because all two- to three-year-olds (and many four- and five-year-olds) are impulsive and inattentive, the symptoms must be shown to slow the child’s ability to learn, socialise or function before an ADHD diagnosis is given. Deciding whether a child has the characteristics of ADHD can be very subjective. There’s no sign of physical abnormality in these children, and there is no test to prove that a child has the condition.
However, in 2013, US regulators approved the first brain wave test for attention deficit hyperactivity disorder for children age six to 17 years. The new test, known as the Neuropsychiatric EEG-Based Assessment Aid (NEBA) System, measures electrical impulses given off by neurons in the brain. It can help confirm an ADHD diagnosis or help decide if further treatment should focus on other medical or behavioural conditions that produce symptoms similar to ADHD. ADHD may also overlap with other conditions, such as oppositional behaviour and with a learning disability. The latter may need an educational assessment and remediation.
Pediatricians may differ in how often they will diagnose ADHD, and sometimes it will come down to which pediatrician or child psychiatrist the child sees as to whether the diagnosis of ADHD is made. It can help parents to do some research on the condition, through reading books and evidence-based articles online, talking to experts or attending workshops, before accepting the diagnosis.
Questions 15-22 15. What is the author’s view on ADHD from the first paragraph? A. ADHD is not a severe disorder to be afraid B. It is the most common disorder in teens C. It is identified with learning difficulties in children D. It is less frequent in boys 16. Why does the need for the best diagnostic criteria for ADHD aroused? A. Because of criticism by skeptics B. The nature of ADHD C. Prevalence of ADHD in large number of children D. Based on samples collected from research 17. What do you understand from the third paragraph? A. ADHD is less likely to impact children’s mental status B. ADHD is not been treated as a dangerous disorder C. The impact of other child disorders will undermine ADHD D. No appropriate diagnosis and treatment for ADHD is available 18. Who will do the primary diagnosis of ADHD in children? A. Paediatrician B. child’s teacher C. specialist D. parents 19. Why doctors shouldn’t make determination of ADHD after a single session with the child? A. It cannot be determined with some symptoms B. ADHD determination requires through study over child’s behaviour and other social aspects C. May be area of other symptoms unidentified with ADHD D. Unable to determine the impacts of early determination of ADHD 20. What do you understand from the last sentence in the 7th paragraph? A. It doesn’t include many other aspects of determining ADHD B. It focuses mainly on analysing the impact of ADHD C. No appropriate test for diagnosis of ADHD D. Abnormal behaviour of children is essential in determining ADHD 21. What does the word “it” in the 8th paragraph refers to? A. NEBA system B. Electric impulses C. Hyperactivity D. Neurons 22. Who does the word “they” refers to? A. Teachers B. Children C. Paediatricians D. Child Specialists
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Paternal grandmother lives near school – provides after school and holiday care looks after children if unwell
School Medical Record: Regular absences from school dating back to time of father’s death Year 2: 3 days
Year 3: 4 days Year 4: 10 days Year 5: 8 days in first term
School Health Centre Records
2010February 8: Complained of headache. Have paracetamol, rested and returned to class. eczema on hands red and weepy has ointment at home.February 16: Complained of stomach ache. Called grandmother for pick up. February 22: Complained of aching legs. Called grandmother for pick up. March 4: Complained of headache. Have paracetamol, rested 1 hour, still had headache. Called grandmother for pickup
March 6: Feeling nauseous eczema on hands red and weepy. Called grandmother for pick up.
2009 February 15: Complained of toothache. Called grandmother for pick up April 4: Complained of headache. Have paracetamol-rested 1 hour.May 14: Headache, eczema on hands red and weepy, rested 1 hour not better called grandmother for pick up.July 25: Feeling nauseous. Called grandmother for pick up. August 16: Slight fever. Called grandmother for pick-up. September 22: Feeling unwell. Eczema irritation. Called grandmother for pick up. October 23: Complained of stomach ache. Rested 1 hour, returned to class November 27: Complained of headache. Have paracetamol, rested 30 minutes.
Social History: Alison started school well but since Grade 3 has had trouble concentrating rarely participates in class activities unless encouraged. Avoids sporting activities – standard of her school work is declining. Has few friends and is often teased by her classmates. Embarrassed about hands which don’t seem to be responding well to ointment suggested by chemist. Mother was contacted by class teacher regarding these issues. Says Alison is also becoming withdrawn at home. Alison was very close to her father – often talks to her about him and cries because she misses him. Seeks comfort in food like chips and cakes after school.
Plan: Refer her to the school psychologist to find out whether Alison has underlying grief related or other psychological problems
WRITING TASK: Using the information in the case notes, write a letter to refer this girl to the school psychologist, Barnaby Webster, to assess her. Outline the purpose of the referral. Provide details of significant factors which will assist the psychologist to make this assessment.
Sample letter by Lifestyle Training Centre
School psychologist Toohey Point Primary State School. Barnaby Webster.
I am writing to refer Alison, a Year 5 student, for assessment and management to explore potential underlying grief-related or psychological issues.
Alison has been coping with the loss of her father, who tragically passed away in a motor accident 18 months ago. She frequently expresses her sadness, often crying as she misses him dearly. Currently residing with her mother, who works as a full-time bank manager, and her two siblings, aged 7 and 12, Alison’s welfare is overseen by her paternal grandmother.
Since her father’s demise, Alison’s school attendance has been irregular, and her withdrawal extends to her home environment. Notably, since Grade 3, she has faced challenges concentrating, leading to a decline in academic performance. In addition, she tends to avoid participation in sporting and class activities. Documented instances of minor physical illnesses have been addressed through medication.
Alison, the youngest in her class, faces social challenges, with limited friendships. She feels self-conscious about eczema on her hands, which has proven resistant to treatment and subjects her to teasing by classmates. Seeking solace in junk food, Alison has gained weight, 40kg, and also contends with mild asthma.
Based on the above, I kindly request a comprehensive assessment to determine if Alison is grappling with underlying grief-related or psychological concerns. Should you require additional information, please feel free to contact me.
Yours faithfully, School nurse
(words used: 222)
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Mavis Brampton [5 mins reading / 40 mins writing] This patient has been in your care and is now going home from the Northern Community Hospital, Moreland, 3051.
Patient: MAVIS BRAMPTON – 72 years old
Admitted: 10 January 2011 To be discharged: 15 January 2011
Diagnosis: Pleurisy
BACKGROUND:
D Mrs Brampton has been widowed 25 years. Has been an active member of the community all her life. Is the current President of PROBUS in her area. She with her husband ran the Sydney Road Newsagency until his death at which time she retired.
Attends the local Community Centre three times a week to play Bingo. Has been a smoker all her life (since 18 years of age). Current smoking 10 a day.
NURSING NOTES:
10 Jan 2011 Overweight: BMI 29 Had CXR; IV Amoxycillin with supplementary O2
Advised to give up smoking.
BP 170/90 Pulse 92 Slightly raised temperature: 39oC Breathless 12 Jan 2011 On low-dairy diet Advised about Nicotine patches.
Deep breathing exercises started. Is keeping to a non-smoking regime.
Using Nicotine patches and Zyban (150mg b.i.d).
To be discharged 15 Jan 2011.
DISCHARGE PLAN:
Support Mrs Brampton – needs monitoring for medication compliance
Needs help with nutritious meals (Meals on Wheels) and house keeping (Council Home Help) – Assistance with shopping
Monitor her quit-smoking plans – watch for side effects from Zyban such as dry mouth and difficulty in sleeping. If side effects occur Zyban should be stopped. Zyban to be withdrawn after 2 months. Nicotine patches to continue until smoking addiction is under control.
WRITING TASK:
Write a letter of referral to Brunswick Family Care Clinic, 44 Decarle Street, Brunswick, Vic 3056 requesting monitoring and ongoing care be arranged for Mrs Brampton.
Community Nurse to make sure Mrs Brampton continues her cessation of smoking – with the help of Nicotine patches and Zyban. Zyban tablets to cease as soon as side effects occur (if any). Both Zyban and Nicotine to cease as soon as craving for cigarettes has stopped. Letter should be 180 to 200 words long / only the first 25 lines will be considered.
Sample letter by Lifestyle Training Centre
Brunswick Family Care Clinic 44 Decarle Street Brunswick Vic 3056
15/01/2011
Dear Sir/Madam,
Re: Mavis Brampton, aged 72 years.
Mrs Brampton, a widow, requires your monitoring and ongoing care, following her discharge today. She underwent treatment for pleurisy in our hospital.
During hospitalization, Mrs Bramptor was administered with Amoxycillin with supplementary O2, Pravastatin 20mg/day, and Celecoxib 100mg/day. She had a slightly elevated temperature, and sputum culture was done on account of productive cough. Deep breathing exercises were started as she suffers from breathlessness. She was commenced on a low-diary diet for overweight, BMI 29.
Her chest X-ray was taken and was advised to give up her long-term smoking habit. At present, she smokes 10 cigarettes a day. She has to continue her cessation of smoking with the help of Nicotine patches and Zyban. Both have to be stopped as soon as the craving for cigarettes come to an end. Zyban tablets, 150mg, twice a day, should be stopped after 2 month or immediately if any side effects occur, such as dry mouth or difficulty in sleeping.
In view of the above, please assist Mrs Brampton by monitoring her medical compliance and quit- smoking plans. Please also arrange for Mrs Brampton, through Council Home help: assistance with shopping and housekeeping. To help her continue a nutritious diet, kindly connect her to Meals on wheels. If you have any further queries, please do not hesitate to contact me.
We hope this information has been valuable to you. If so, please consider a monetary donation to Lifestyle Training Centre via UPI. Your support is greatly appreciated.
Would you like to undergo training for OET, PTE, IELTS, Duolingo, Phonetics, or Spoken English with us? Kindly contact us now!
