NOTA USAHA

NBHX4300 – COMPREHENSIVE EXAM

20 Oktober 2022 (Khamis)

MCQ – 8am – 9.30 am (4 soalan each subjects)
MEQ – 10am – 1pm (1 soalan each subjects)

MENTAL HEALTH

a. Stress

b. Anxiety

c. Schizophrenia

- Psychosis – distortion in a person’s perception of reality. The diagnosis of

schizophrenia is made exclusively based on observed behaviour.
- Characteristic: hallucination (audio, visual, tactile, olfactory, gustatory), illusion,
delusion (persecution, grandeur, the idea of reference, thought insertion, nihilistic
delusion).
- Types of schizophrenia – for at least 6 months and at least 2 of the following:
 Delusion
 Hallucination
 Disorganised speech
 Disturbed or catatonic behaviour
 Negative symptoms such as flat affect or severe lack of motivation,
 Symptoms must also disrupt the patient’s work, relationship or self-care.
- Types of schizophrenia –
- Disorganised type – speech
- Paranoid type – delusion, auditory hallucination
- Catatonic types – motor behaviour (Kayu)
- Undifferentiated type – the mixture
- Residual type – no active psychotic symptoms

d. Bipolar Disorder / Depression

Depression
Depression is the most common mental health problem presented by patients in
wards. There is a wide range of social problems presented by depressed people, and
the extent of your interaction with these individuals will be largely influenced by
the severity of their depression. The more severe the depression, the harder you
may work to engage the patient because he will withdraw and lack energy and
interest. The problem of depression is so common that it is sometimes referred to as
the ‘common cold of psychological disorders. ‘Mood disorders’, ‘affective disorders’
or ‘emotional disorders’ mean the same thing.

It is mainly to do with ‘feeling’ or ‘emotions’. All emotions have characteristic

cognitive and behavioural features. The thoughts and behaviours associated with
depression. The words ‘depressed’ or ‘depressing’ is sometimes used in everyday
conversation without implying a clinically significant condition. The word ‘sad’ or
 ‘sadness’ is preferable as a healthy negative emotion as opposed to depression or
feeling depressed. It is not normal or natural to experience ‘depression’ which is an
unhealthy negative emotion. For example, given a negative or adverse situation,
failing an exam or the death of a loved one, it is normal and healthy to experience a
healthy negative feeling, sadness or even profound sadness. However, it would be
unhealthy and abnormal if one were to feel depressed about the negative situation.
Simply put, it is okay to feel sad but not depressed.

- Major Depression Disorder – The person must have been depressed for at least 2
weeks. During this period, experienced a loss of pleasure in almost all activities
(anhedonia). Other additional symptoms must include at least four of the following:

 Changes in appetite or weight.

 Changes in sleep pattern
 Psychomotor activity
 Decreased energy
 Feeling of worthlessness or guilt
 Difficulty in thinking, concentrating or making decisions.
 Persistent suicidal thoughts, plan or attempts.

- For diagnostic purposes, it is expected that these symptoms will be present every
day for 2 weeks and cause the patient sufficient distress to affect his work, social
life and other important areas of functioning.
- It is important – people are unique and likely to present a wide range of symptoms.
Most likely complain about a limited range of symptoms but will be preoccupied with
their everyday social realities. The patient may develop: It is also worth noting that
when a patient is severely depressed, it is likely, though uncommon, for psychotic
symptoms such as delusions, hallucination, disorientation and derealisation to be
present.

- Psychosocial Assessment – Responds to the patient’s immediate concerns and

develops a working relationship with the patient. Assess history, general appearance
and motor, mood and affect, thought process and content, sensory and intellectual
process, judgement and insight, self-concept, roles and relationships, and physiologic
and self-care concerns.

- Assessment tools – Beck Depression Inventory and Zung Self-Rating Depression

Scale may be routinely used. Some areas of concern identified from the assessments
include the risk of suicide, self-neglect (hygiene, nutrition), hopelessness, negative
self-regard and low self-worth, fatigue, sleeping difficulty, agitation, financial and
relationship problems, guilt and anxiety.

Bipolar Disorder:
- Individuals who become depressed will also experience emotions at the other end of
the spectrum where they will be high or manic (2 poles – bipolar)
- Old diagnostic system – manic-depressive disorder or commonly called manic
depression.
- Today – mood swings diagnosed as bipolar disorder – one does not have to
experience a depressive episode to be diagnosed with bipolar disorder. During the
manic phase, the patient will likely be elated, outgoing, energetic, sleepless and
 grandiose.
- Because of the high energy level – the patient’s thoughts and speech will be rapid,
jumping (flight of ideas) or from activity to activity, very distractible and usually
display poor judgment.
- During the depression phase – same as MDD. Symptoms can appear in a few weeks
to a few months.
- Manic episode – must experience a period of abnormally and persistently elevated or
irritable mood lasting at least one week.
- During this period, 3 of the following features must be present, four if the mood is
only irritable:

 Inflated self-esteem/grandiosity
 Decreased need for sleep
 Increase talkativeness
 Flight of ideas/racing thought
 Distractibility
 Increase in goal-directed activity / psychomotor agitation
 Excessive involvement in pleasurable activities with potentially painful consequences

- Treatment – lithium carbonate (mood stabiliser) – prevent highs and lows;

anticonvulsant drugs may use for patients who can’t relate to lithium – carbamazepine
(Tegretol), valproic acid (Depakote). Antidepressant use during a depressive phase.
Antipsychotics are used to treat psychotic symptoms.
- Healthcare intervention – psychotherapy, assessment (risk of violence, nutritional
status)
-
-
MEDICAL BIOCHEMISTRY

a. Acid / Base (interpret ABG) – how to differentiate Acids and Bases. pH  Homeostasis.

- Higher H+ ions – Acidic. E.g. HCl

- Bases can accept protons H+ ions. E.g. NaOH.
- pH normal = acidic 7.35 – alkaline 7.45
- what disturbs the body’s pH? –
 CO2 production (respiration) – produced when glucose is metabolised via
glycolysis (in the liver).
 Metabolic acid – lactic acid production under strenuous exercise, anaerobic
metabolism occurs.

- Buffers – allow acid to be ‘stored’ temporarily. Bicarbonate / CO2 is the most

important. H+ + HCO3  CO2 + H2O.
- Excess acid (H+) drives the reaction to the right. CO2 produced can be excreted by
the lungs (may cause the patient to become tachypneic). Metabolic acids are excreted
by the kidney.
- Therefore, excess acid produces acidosis, and an excess base produces alkalosis.
Acidosis and alkalosis can be produced from either respiratory or metabolic sources.
- CO2 high = respiratory acidosis, CO2 low = respiratory alkalosis, metabolic acids too
high = metabolic acidosis, metabolic acids too low = metabolic acidosis.
- Blood gases – normal values
  pH – 7.35-7.45
 paO2 – 10-13 KPa
 paCO2 – 4-4.5 KPa
 BE - -2 - +2 mmol/l (-ve = acidosis, +ve = alkalosis)
 HCO3 – 35-45
- 1 – look at pH – tells the overall problem
- 2 – look at the PaCO2 – respiratory works
- 3 – BE – metabolic component
- 4 – compensated or not – needs HCO3 – pH normal, then HCO3 react to CO2.

b. Feedback mechanism (negative feedback) – the process in which part of the system’s
output is returned to its input to regulate its further output.

- Positive feedback mechanism = output of the system acts to enhance the changes to
the input of the system. In most cases, once the purpose of the feedback loop is
completed, counter-signals are released that suppress or break the loop.

E.g. –
Oxytocin is released into the body, which stimulates more contraction.

Blood clotting – activate platelets releases chemicals to activate more platelets

causing a rapid cascade and the formation of the blood clot.

Lactation – the more the baby suckles, the more milk produces.

- Negative feedback mechanism = output of a system acts to oppose changes to the

input of the system.

- Example – endocrine system.

- Insulin and glucose
- Water regulation

- Temperature regulation of the body

c. Amino acids, peptides and proteins

- Amino acid sequences

- Protein function – catalysis, transport (e.g. oxygen transport), information transfer
(e.g. hormones).
 - Understand the terms of amino acid function and how amino acids determine the
different functions of systems and organs – it depends on the types of polypeptides
and amino sequences.

d. DNA mutation and repairs

- Substitution, deletion, or insertion of a base pair. Chromosomal deletion, insertion, or
rearrangement.

- Types of mutation:
 Somatic mutations – occur in somatic cells and only affect the individual in
which the mutation arises.
 Germ-line mutations – alter gametes and pass to the next generation

- Types of point mutation

 Base pair substitution

Transition
Convert a purine-pyrimidine to other purine-pyrimidine. There are 4 types of
transition A <> G and T <> C. most transition results in synonymous
substitution because of the degeneracy of the genetic code.
 Transversion
Convert a purine-pyrimidine to pyrimidine-purine. 8 types of conversion: A<>
T, G <> C, A <> C and G <>T. transversion is more likely to result in
nonsynonymous substitution.

 Base pair deletions and insertions

Missense mutation
Base pair substitution results in the substitution of different amino acids.

Nonsense Mutation
Base pair substitution results in a stop codon (shorter polypeptides).

Neutral Mutation
Base pair substitution results in substituting amino acids with similar chemical
properties (protein function is not altered).

Silent Mutation
Base pair substitution results in the same amino acids.

Frameshift mutation
Deletions or insertions (not divisible by 3) result in the translation of incorrect
amino acids, stop codons (shorter polypeptides), or read-through of stop
codons (longer polypeptides).

MEDICAL MICROBIOLOGY AND IMMUNOLOGY

a. Bacterial structure (Virulence factors)

- Virulence factors – factors that aid or enhance the microbes’ ability to invade and
spread within the host.
- Adherence – for microbes to cause disease, they must first adhere to a host surface.
Some microbes produce materials or structures to allow them to stick to membranes
or surfaces and thus escape defences.

Pili (fimbriae) – N. gonorrhoea – if a stain has no pili, it is not pathogenic the

chemicals that allow such attachment are called ‘adhesins’ – often glycoproteins or
proteins that bind to receptors on host cell surfaces.

Glycocalyx – capsule is a tightly bound polysaccharide material outside certain

bacterial cells (part of a bacterial envelope). Streptococcus pneumonia.

Spikes – the viral envelope of some viruses, influenza A

Enzymes –
 collagenase (breaks down collagen, the protein holding cell together, thus
spreading. E.g. Clostridia that invade tissue can produce these proteases to
digest connective tissue elements (C. perfringens).
 Hyaluronidase – breaks down hyaluronic acid, the polysaccharide that may
hold some cells together (S. pyogenes – causes necrosis and blackening of
 tissues).
 Coagulase – affects the fibrin in the blood, causing it to clot. S. aureus
produces one and prevents phagocytosis.
 Haemolysin – exotoxin and lyse RBC. E.g. S. pyogenes.

Evading defences – once tissue, some organisms can ‘evade; the natural defence of a
host.

 Capsule – phagocytes can’t engulf the pathogen – S. pneumoniae

 Surface proteins – protein prevent phagocytosis – leukostatin, leukocydins of
Staph and Strep
 Survive inside phagocyte – get a free ride and spread (T. bacillus, L. bacillus
and others)
 Evade immune response – genetic variability occurs, and the result is that
antibodies lose effectiveness quickly – genetic shift/drift of the antigenic
nature of the influenza A virus.

b. Immunoglobulin (active immunity vs passive immunity)

- Bagaimana system immunity Badan berfungsi – interact with bacterial, how

phagocytosis occurs, passive immunity, B cell, T cell

c. Immunity System

- Active – make your own antibody.

 Natural – a chance encounter with Ag, pregnancy
 Artificial – vaccination, introduce Ag.

- Passive–transfer preformed antibody

 Natural – mother to foetus.
 Artificial – immune therapy

- Innate immune response –we are born with phagocytic cells, complement proteins,
anatomical and physiological - first line defence.

- Adaptive immune response – the defence that develops with exposure/time e.g. serum
antibodies, T-cells.

- Mechanism of immunity
Cellular – cells responsible for protection (lymphocytes/phagocytes)
Humoral – antibodies (in serum) are responsible for protection.
 Cell-mediated response –

T-cells can only recognise and respond to processed fragments of protein. T cells are
suited for cell-to-cell interaction and target body cells infected by viruses, bacteria
and abnormal or cancerous body cells or transplanted cells.

Activation of T-cells – receptors bind to antigens presented by the antigen-MHC

complex. CD4 and CD8 proteins interact with an antigen and help maintain MHC-
antigen coupling. Types of T-cells: helper T cells (CD4), cytotoxic T cells (CD8) and
Memory T-cells.

d. Culture and sensitivity – TB

- How to ambil sampel dan interpret sampel result – penyakit Tb, pneumonia, URTI,
influenza. Guna teknik apa,
MEDICAL INSTRUMENTATION

a. Radiation therapy – bagaimana radioterapi dijalankan, types

- Radiation therapy is – a type of cancer treatment that uses beams of intense energy to
kill cancer cells.

- Damages cells by destroying the genetic material that controls how cells grow and
divide – both healthy and cancerous cells are damaged by radiation therapy, the goal
of radiation therapy is to destroy as few normal, healthy cells as possible. The normal
cell can often repair much of the damage caused by radiation.

- At high doses – radiation can kill cancer cells or slows their growth by damaging
their DNA (DNA damaged = stop dividing / die). It takes days or weeks of treatment
before DNA is damaged enough for cancer cells to die, and then cancer cells keep
dying for weeks or months after radiation therapy ends.
 - Types of radiotherapy:
a. External Beam Radiation Therapy – comes from a machine called a linear
accelerator (LINAC). It moves around the patient, sending radiation to a part of the
body from many directions. External beam radiation therapy is a local treatment (that
treats a specific part of the body). E.g. cancer is in the lung, and the radiation will
irradiate the chest, not the whole body.

b. Internal radiation therapy – the source of radiation put inside the body. A source
can be solid or liquid.

Internal radiation therapy with a solid source is called brachytherapy – seeds, ribbons
or capsules that contain a radiation source are placed in the body, in or near the
tumours. It is a local treatment, and treating only a specific body part will give off
radiation for a calculated time.

Internal radiation therapy with a liquid source is called systemic therapy – a

radioactive source travels in the blood to tissues throughout the body, seeking out and
killing cancer cells. Patients receive systematic radiation therapy by swallowing
through a vein via an IV line or injection. Body fluids such as urine, sweat and saliva
will give off radiation for a certain time period.

c. Therapeutic Radionuclides – beta minus emitters are ideal for therapy applications
because the beta particle energy is primarily deposited in the organ that takes up the
radionuclide.

Sodium I-131 – commonly used for hyperthyroidism and thyroid cancer – high
thyroid doses.

Y-90 labelled microspheres can be lodged in the small blood vessels of liver
neoplasms to deliver therapeutic doses.

Sr-89 – administered intravenously to treat painful osseous metastases from prostate

and breast cancer.

Sr-89r – pure beta emitter poses no hazard to medical staff or patient families except
for urinary excretions for a few days.

When the patient is kept in the hospital following radionuclide therapy, the people at
risk of exposure include the hospital staff, whose duties may or may not be directly
involved in the use of radiation. Protective clothing should be used in radionuclide
therapy areas where there is a likelihood of contamination. The clothing serves both
to protect the body of the wearer and to help to prevent the transfer of contamination
to other areas. Protective clothing should be removed before going to other areas. The
protective clothing may include laboratory gowns, waterproof gloves, and overshoes.
When handling beta-emitters, the gloves should be thick enough to protect against
external beta radiation.

b. MRI – Safety issues

- Static Magnetic Field – potential hazard around magnetic fields is the missile effect
for ferromagnetic objects (scissors, screwdrivers) may be pulled into the magnet.
 Ferromagnetic devices implanted in their bodies, e.g. stainless steel aneurysm clips.
The pacemaker may be deactivated by fields above 0.5mT.

- Varying Magnetic Field (Gradient Fields) – time varying magnetic field from 20G
to 30G and frequency range from 1 to 100Hz created by the gradient coils may induce
weak electrical current in the human body. These can result in mild skin sensation,
involuntary muscle contraction and irregular heart rhythm etc. it is no harmful effects
to the CNS. Rapid changes of current inside the coils also created vibrations resulting
banging sound inside the machine. This creates noise level ranges from 65-120dB,
earplug or headphones can be used as hearing protection during MRI procedures.

- RF Fields – waves less than 100MHz. the possibility of slight degree of heating from
absorption of RF power will increase tissue temperature. However, this absorbed
energy is well below the values where potentially harmful effects are expected
(mechanical injury, suffocation, etc).

c. Pathophysiology of heart block, abnormalities in PQRST wave, segment (interpret ECG)

- ECG – recording of the sum of all the action potentials produced by the pacemaker
and myocytes cells of the heart.

P wave – represented by electrical impulses that spread throughout the atria when the
SA node activates and cause them to depolarize. The atrial contraction (systole) starts
roughly 100ms after the P wave begins.

PQ Segment – denotes the time the impulses travel from the SA node to the AV node.

QRS Complex – triggering of the AV node and characterizes ventricular

depolarization.

Q wave – to the depolarization of the interventricular septum.

S wave – denotes the last phase of ventricular depolarization at the base of the heart.
The atrial repolarization also happens during this time but the impulse is
overshadowed by the large QRS complex.

ST segment – signifies the plateau in the myocardial action potential. This occurs
when the ventricles contract and pump blood.

T wave – ventricular repolarization immediately before ventricular relaxation

diastole.
REHABILITATION, GERIATRIC AND PALLIATIVE CARE

a. Polisi penjagaan geriatric / palliative – bagaimana nak libatkan community dalam care.

- Principles of palliative and geriatric care management

 Scope of care – patients of all ages suffering from a life-threatening disease,
disability or accident who need symptom relief for physical, psychosocial or
spiritual pain.
 Timing of care – begin as soon as possible
 Patient and family-centred care
 Holistic care
 Multidisciplinary care
 Effective communications
 Knowledge and skills
 Seamless care

b. Penyakit – Alzheimer

- Def – deterioration of intellectual capabilities, memory, judgement and personality to

the extent that daily functioning and quality of the seriously impaired. Generally, it
occurs in the elderly impairing brain function, which can lead to dementia
- Clinical features – loss of short-term memory and ability to create memories,
concentration on the past, loss of time, communication diminishes, personality
changes, delusions, immobilised and comprehending, death due to resp. failure.
- Diagnosis – only definitive way to use CT brain to see plaques in tangles in brain
tissue.
-
c. Penjagaan warga emas di pusat jagaan.

- Bagaimana utk memberi penjagaan yang terbaik kepada warga emas di pusat jagaan –
DM HPT, luka yang lambat sembuh – what issues u need to address and intervention.

d. Penyakit – COPD

- Def – common, preventable and treatable dz that is characterised by persistent

respiratory symptoms and airflow limitation that is due to airway and/or alveolar
abnormalities usually caused by significant exposure to noxious particles or gases.
-
PAIN MANAGEMENT

a. Assessment in pain management (pain scale)

- Pain def – unpleasant sensory and emotional experience associated with actual or
potential tissue damage. Disease  invasive devices  immobility  routine care.
- Pain score tools – wong-barkers pain score, Behavioural Pain Scale (BPS), Critical
Care Pain Observation Tool (CPOT) – utk pesakit xsedarkan diri

b. Opioid-induced constipation

- 3 different opioid receptors mediate the GI effects of opioid medication: m,d and k.
m-receptors – located in the small GI and proximal colon. And k-receptors in the
stomach and small GI.
- Adverse effects of opioids – constipation 9common), GERD, nausea vomiting,
bloating and abdominal pain.
- Activation of enteric m-receptors – increased tonic non-propulsive contractions in the
small and large intestine, increased colonic fluid absorption and stool desiccation,
increase anal sphincter tone.

c. Pain treatment planning (decrease pain and improve function)

d. Rawatan – neuropathic pain.

-
-
-
-
-
EPIDEMIOLOGY

a. Association to causation

- Analyse how to eradicate disease.

- Sequence of studies
 Clinical observation
 Available data – bandingkan data
 Case-control studies – 1 merokok / 1 x
 Cohort studies – berapa banyak perokok dapat barah dalam satu2 batch.
 Randomised trials –
- Types of association: real/spurious
- 12 criteria for causation:
 Cause distributed at the same level
 Incidence much higher in the exposed population
 Exposure more frequent
 Disease should follow exposure
 Dose dependent
 Expected response
 Association should be the same
 Other cause-effect ruled out
 Control results in decreased disease
 Modification of the host results in a decrease
 Human volume always increases
 Findings should make sense
- Factors in the causation of diseases: predisposing (memang ada kes)
/enabling/precipitating (habit yang mengancam) / reinforcing
- Guidelines for judging whether an association is causal
  Temporal relationship
 Strength of the association
 Dose-response relationship
 Replication of the findings
 Biologic plausibility
 Consideration of alternate explanations
 Specificity of the association
 Consistency with other knowledge

b. STD and HIV (Syphilis)

- Siflis –
 Primary – chancre – papule erodes into a painless ulcer with a hard edge and
clean base. Usually in the genital area. Appears 9-90 days after exposure. It
can be solitary or multiple. Heals with scaring 3-6 weeks.
 Secondary – 6 weeks to 6 months after chancre – lasts for several weeks – a/w
fever, malaise, generalised lymphadenopathy and patchy alopecia. The
maculopapular rash is usually on palms and soles, and condyloma lata on
perianal or vulva areas. Possible mild hepatosplenomegaly.
 Latent phase – positive serology – rapid plasma regains (RPR), venereal
disease research lab (VDRL).
 Tertiary stage – CVS – aortic valve, aneurysm. CNS – meningitis,
encephalitis. Gumma formation – deep cutaneous granulomatous pockets.
Ortho – Charcot joints, osteomyelitis.

c. Nipah Virus

- Agent – genus Henipavirus – severe, rapidly progressive encephalitis among humans.

- Reservoir – flying foxes (fruit bats) – carry the virus. Virus found in urine.
- Transmission – direct contact with body fluids. Aerosolisation of respiratory or
urinary secretion. Bat-to-person, person-to-person.
- Epid – Malaysia, 265 hospitalised, 105 deaths.

PROFESSIONALISM AND ISSUES IN HEALTHCARE

Lembaga / autonomy / expanded and extended roles

a. Topik 3- Autonomy in the AMO Profession

b. Topik 5- Association and Professionalism

c. Topik 7- Expanded and extended roles of AMOs

RESEARCH METHODOLOGY AND SCIENTIFIC COMMUNICATION

a. Understanding research process – focused on steps in the research process (1st step – find
the problem)
- Phase 1 – Preparation:
  Select a problem for research
 Review the literature
 Formulate a research question
 Select research approach and design
 Select the data collection method
 Specify a population

- Phase II – Implementation
 Collect data
 Analyse data

- Phase III – Outcome

 Interpret research findings
 Report the study

b. Research methodology – interview – types of interviews

- Interviews can be unstructured or structured. Unstructured interview uses open-ended
question, while structured interviews use close-ended questions. Semi-structured
questions containing both open-ended and close-ended questions are also used in
interviews.

c. 1 Way ANOVA vs Paired T – Test.

- ANOVA (Analysis of Variance) – test null hypothesis that all of the treatment means
are equal against a null hypothesis that there is at least one mean not equal to others.
 - T-test – comparison 2 means when the data is collected from 2 independent groups.

- 1 way ANOVA, paired T test – criteria guna ANOVA and paired T Test.
SYSTEMIC PATHOLOGY

a. thrombolytic drugs – STEMI, ACS – efficacy of thrombolytic treatment.

-
b. DM – focused on complication - macrovascular and microvascular – focused on
neuropathy extremities

c. GIT – gastric cancer – risk factors – H.pilori

d. acute glomerulonephritis – how to diagnosis – UFEME – urea presence in urine.