Exam 1 - Sensitive Topics

Question 1

What are the main sensitive topics for patients to discuss?

Answer 1

Societal taboos
Sexual practices
Death and dying
Financial concerns
Racial and ethnic bias
Family interactions
Mental illness
Drug use in pregnancy
Same-sex practices

Question 2

Guidelines for discussing sensitive topics

Answer 2

Do not judge the patient.
>Your goal is to learn about the patient and help that patient achieve better health.

Explain why you need to know certain information.

Find opening questions for sensitive topics and learn specific kinds of information needed for your assessments.

Consciously acknowledge any discomfort you feel.
>Denial may lead you to avoid the topic.

Question 3

How can you make sensitive topics more comfortable?

Answer 3

Read medical and lay literature about the topic.

Talk to selected colleagues and faculty about your concerns.

Take special courses to help you explore your own feelings.

Keep an open mind.

Reflect on your own life experiences.

DO NOT share them with your patients.
Listen to experienced clinicians.

Question 4

Important topics of sexual history

Answer 4

Pregnancy
STDs/STIs, including HIV and AIDS
Sexual dysfunction due to certain medications or medical conditions

Question 5

When do you ask a sexual history?

Answer 5

GU symptoms, OB/GYN symptoms, and if a comprehensive history is needed.

Question 6

Important to ask all populations, regardless if they are:

Answer 6

Elderly
Disabled
Chronic illness

Question 7

What are some ways you can ask about sexual history?

Answer 7

“I need to ask you some questions about your sexual health and practices.”

“I routinely ask all patients about their sexual function.”

“To figure out why you have this discharge and what we should do about it, I need to ask some questions about your sexual activity.”

Question 8

Helpful hints with sexual conversation

Answer 8

Have a “matter of fact” style.

Use specific language.

The term “sexually active” is too ambiguous.
Refer to genitalia with explicit words such as penis and vagina, avoid saying “private parts.”

Choose words that the patient understands or explain exactly what you mean

Question 9

You NEVER make assumptions.

Answer 9

Marital Status

Domestic partnership does not always imply same-sex couple.

Sexual Preference

Sexual Behaviors

Attitudes toward pregnancy and contraception.

Question 10

Alcohol usage opening questions:

Answer 10

“Tell me about your use of alcohol.”

“What do you like to drink?”

Assess what your patient considers alcohol to be.

Ask quantity consumed at any one given time.

“How much wine do you drink at one sitting?

To detect problem drinking, ask:
“Have you ever had a drinking problem?”

“When was your last drink?”

If within last 24 hours-suspect problem drinking.

Question 11

CAGE Questions?

Answer 11

Cut down
“Ever felt you needed to cut down your use of ______?
Annoyed with others’ comments about your drinking?
Guilty
about your use of _______?
Eye opener
Need to use in AM to function?

TWO or more positive answers are strongly associated with addiction.

Question 12

When you suspect ETOH abuse, ask about history of any of the following:

Answer 12

Seizures
Accidents/injuries while drinking
Blackouts (loss of memory during drinking)
Job problems
Conflicts in relationships
Legal problems
Ask specifically about driving or operating heavy machinery

Question 13

Illicit drug use opening questions

Answer 13

“Have you ever used any drugs other than those prescribed for medical reasons?”

“Have you ever used drugs not prescribed to you?”

Ask about pattern of use.

Last use, how often, substances used, amount?

Ask about modes of consumption.
Injected, smoked, snorted, inhaled?

**Adopt the CAGE questions.

Question 14

Follow up questions when suspecting drug addiction:

Answer 14

Consider asking
“Are you always able to control your use of drugs?”
“Have you had any bad reactions?”
“What happened?”
“Any drug related accidents, injuries, or arrests?”
“Job or family problems?”
“Have you ever tried to quit?”
“Tell me about it.”

Question 15

Family Violence

Answer 15

High prevalence of physical, sexual, and emotional abuse.

Many authorities recommend routine screening of female patients for domestic violence.

Question 16

Approach questions to family violence:

Answer 16

Start the interview with general questions.
“Since abuse is common in many people’s lives, I’ve begun to ask about it routinely.”
“Are there times in your relationship that you feel unsafe or afraid?”
“ Many women tell me that someone at home is hurting them in some way, is this true for you?”
“During the last year, have you been hit, kicked, punched, or otherwise hurt by someone you know, if so, by whom?”

**Go from GENERAL to SPECIFIC.

Question 17

Clues to physical abuse

Answer 17

Unexplained injuries.
Injuries in multiple stages of healing.
Injuries inconsistent with the patient’s story.
Delay of patient seeking treatment for trauma
If patient’s partner/family has a history of alcohol or drug abuse.
If the partner dominates the interview, will not leave the room, or seems unusually anxious or solicitous.

Question 18

What to do when you suspect abuse?

Answer 18

Spend time alone with the patient for further questioning.
Be aware of diagnoses that have a high association with abuse.
>Pregnancy
>Somatization disorder

Question 19

What do you ask when you suspect child abuse?

Answer 19

Ask parents
“What is your approach about discipline?”
“How do you cope with a baby who won’t stop crying?”
“Do you have any fears that you may hurt your child?”

Find out about how caregivers or companions handle these situations as well.

All abuse is reported to the appropriate county agency!!!!!

Question 20

5 Stages of Grief

Answer 20

Denial and Isolation
Anger
Bargaining
Depression or Sadness
Acceptance

Learn to be sensitive to the patient’s feelings at any stage of the process.
The stages may occur sequentially or overlap.

Question 21

Death and dying patient

Answer 21

Get to know the WHOLE patient.
>The patient’s illness is only part of the patient.
GIVE the patient opportunities to talk.
>You need to listen and not be rushed.
Understand the patient’s wishes about treatment and end of life decisions.
»This is not the time to assert your own belief system.

Question 22

What two things do you need to do when you find out that your patient is dying?

Answer 22

1. Asking about Do Not Resuscitate (DNR) status is difficult if you have not established a good rapport with the patient.
2. Important to establish a health proxy who can act as the patient’s health decision maker.
   >“Who” is allowable by law varies state to state in the US.
   >There still exists inequity in same-sex marriages such that a partner may not be allowed by law to carry out the patient’s last wishes.