Exam 1 and 2 - CEL, Comms and LEAPS

Question 1

What are the advantages/disadvantages of different question styles?

Answer 1

Open:
Advantages:
-	Gain patient’s perspective
-	Give’s patient a chance to describe problem
Disadvantages:
-	may take longer/harder to control
-	may not be relevant info
-	may make note taking harder

Closed:
Advantages:
- specific info
- can fill in gaps/gain more precise info
- useful in emergency
Disadvantages:
- feels like interrogation
- patient limited in how they can respond
- cultural background may effect how patients respond to open/closed questions

Probing:
Advantages:
-	Patient can expand/give more details
-	Allows doctor to see form patient’s perspective
Disadvantages:
-	interview may be overly long
-	patient may go off track

Question 2

What are the 5 key elements of active listening?

Answer 2

• 1. Pay attention (eye contact, don’t look at watch, don’t mentally prepare rebuttal)
• 2. Show that you’re listening (own body language, facial expressions, posture, small verbal encouragers)
• 3. Provide Feedback (reflect, ask questions, ‘What I’m hearing is…’, clarify, summarize)
• 4. Defer judgment (allow speaker to finish, don’t interrupt)
• 5. Respond Appropriately (respectful, candid, open and honest)

Question 3

What are the benefits of silence and reflection?

Answer 3

• gives and yourself patient time to reflect
• opportunity to observe patient
• opportunity to plan next stage of interview

Question 4

What are the benefits of summarising?

Answer 4

Benefits to doctor:
- opportunity to pause
- chance to put thought in order, hypothesize
- chance to communicate back your understanding
- chance to clarify, check accuracy, move on
Benefits to patient:
- gives them space to think
- shows them doctor has heard their message
- gives them a chance to correct or add in, raise other concerns
- promotes trust and collaboration

Question 5

What are the steps in preparing for an interview?

Answer 5

1. Attend to self comfort (bathroom break, eating etc)
2. Finish previous patient notes
3. Read/Review relevant info, i.e. patient notes, test results, referral info etc before hand.

Question 6

What is patient-centred care?

Answer 6

Definition: Care that is respectful of, and responsive to individual patient preferences, needs and values. Patient centred care ensures that patient values guide all clinical decisions.

Question 7

1. Describe the steps in the medical interview using the Calgary Cambridge Framework.

Answer 7

1) Initiating the interview (pre-preparation, introduction, patient consent, ask open question etc)
2) Gathering info
3) Physical exam
4) Explaining and planning
5) Close the session (determine next steps, safety nets, prescription, referral, summary, what do do if things go wrong, check patient agrees and is comfortable, ask for correction or any other questions).

Question 8

History of presenting illness

Answer 8

• opening questions – what, when why when who etc
• S – Site (Where? Show me)
• O – Onset (when? Suddenly/gradually?)
• C – Character/Description (throbbing, sharp, stabbing?)
• R – Radiation (does it radiate/spread/travel and where?)
• A – Associated Symptoms – (nausea, headache ect?)
• T – Timing (When? Specific time of day, constant?)
• E - Exacerbating Factors – anything make it better? Pain meds?
• S – Severity – (pain scale, at rest, moving, upstairs etc)
• I – Impact (ability to work, sleep, relationships, mood etc)
• A – ‘Anything else?’
• Red flags?

Question 9

Comprehensive patient history

Answer 9

a) Current General Health
- Current problems
- medication use if relevant
- probe for age specific issues, such as oral contraceptive pill
- Specifically ask about common conditions such as hypertension in some patients.

b) Past Medical History
- Previous general health
- previous illnesses
- previous admissions to hospital
- any surgical procedures
- Accident and injuries

c) Medication
Why? – might be the cause of an issue (i.e. side effect),
- might preclude use of other medications
- if someone is admitted to hospital they might need to continue current medication
- it’s an opportunity to review need for taking, dosage and frequency
- opportunity to see if they are taking them as prescribed

Ask about:

• regular prescriptions
• over the counter
• natural therapies
• dietary supplements
• Complementary and integrated treatments (i.e. chiro, acupuncture).

ALWAYS ASK – NAME, DOSAGE, FREQUENCE, SIDE EFFECTS, RESON FOR USE.

d) Allergies
- prescribed meds, foods, pollens/airbornes, animals, anything else (i.e. bee sting)
- Ask SEVERITY and TYPE of reaction.
- Do they carry an epipen?

e) Family History:
- may be suffering from or have predisposition to genetically determined disease.
- another family member might have experience with is
- ask about illnesses of parents/siblings
- ask about age/cause of death of parents, siblings etc

f) Social History
- how do they spend an average day?
- relationships – social, martial status, children and any related problems

Social history could:

• contribute to aetiology of illness
• aggravate/limit severity
• interfere/help with getting well
• SUPPORT SYSTEMS?

g) Lifestyle – Use of elicit drugs
- Ask about current and past.
- If Y- what types?
- how much at one time? (quantity)
- how often? (frequency)
- how long? (duration)
- how old were you?
- do you think it causes any problems in your day to day life?

h) Lifestyle – Alcohol
- do you currently drink?
- how often? (frequency)
- What type?
- how much do you drink on once occasion?
- Binge? How often and how much?
IF N – has this always been the case and is there a particular reason for stopping?

i) Lifestyle – Smoking
- Ask about current and past.
- IF Y- how many a day? (quantity)
- What type? (filtered, rolled)
- how often? (frequency)
- how long? (duration)
- have you ever tried to quite? When, how long, nicotine replacement, quitline?
- do you think it causes any problems in your day to day life?

• IF N – but yes to past:
• how long ago did you quit?
• how long did you smoke for?

j) Lifestyle – Exercise/Physical Activity
- do any exercise?
- what?
- how often?
- intensity?

k) Lifestyle – Diet
- it could be a risk factor for a number of problems
- Don’t accept ‘good’ as answer or ‘what is your diet like’
- Ask if they have a specific diet, i.e. vegan, vego etc
- Food allergies?
- average day?
- can go through food groups
- consumption of take away foods?
- soft drunk/energy drinks?
- how much water?

l) Red Flags
m) Is there anything else?

Question 10

What is the aetiology of anxiety disorders?

Answer 10

Psychosocial:

- origins lie in childhood events, i.e. separation and loss
- maladaptive learning (i.e. OCD)
- prior exposure to extreme stressor

Biological Factors:
 	- genetics
 	- gender
 	- altered neurotransmitter activity, specifically decreased activity  
 	of serotonin and more. 
 	- medical conditions
 	- substance abuse

Question 11

What are the symptoms of anxiety?

Answer 11

Feelings of panic, fear, and uneasiness
Problems sleeping
Cold or sweaty hands or feet
Shortness of breath
Heart palpitations
Not being able to be still and calm
Dry mouth
Numbness or tingling in the hands or feet
Nausea
Muscle tension
Dizziness
Loss of Appetite
Loss of sex drive

Question 12

What is the difference between normal and abnormal anxiety?

Answer 12

At the low end of the intensity range, anxiety is normal and adaptive. At the high end of the intensity range, anxiety can become pathological and maladaptive. While everyone experiences anxiety, not everyone experiences the emotion of anxiety with the same intensity, frequency, or duration as someone who has an anxiety disorder.

Question 13

Discuss the physiological mechanisms and pathways involved in anxiety

Answer 13

• increased HR and CO
• constriction of arteriolar and venous smooth muscle
• respiratory airways open
• breakdown of glycogen and fat increases plasma glucose and FFA
• skeletal muscle bloos vessels dilate - increased muscle BF
• pupils dilate
• digestive and urinary activities are shit down

Question 14

What is the prevalence of anxiety disorders in Australia?

Answer 14

14.4%

Question 15

What is the mental health first aid action plan?

Answer 15

ALGEE

A - Approach, assess and assist
L - Listen non-judgmentally
G - Give support and information
E - Encourage the person to get appropriate professional help
E - Encourage other supports - i.e. self help, family and friends

Question 16

What is mindfulness and what are the key features?

Answer 16

Definition: A mental discipline aimed at training attention.
“Bringing our awareness deliberately to the present moment and accepting what we find, as opposed to judging it or wanting to change it”

Key features:

• Utilising your 5 senses to train your attention
• Engaging your mind in the present moment
• Fostering self-control through non-aiachment to transitory experiences
such as thoughts, feelings and sensations
• Encouraging an aatude of openness and acceptance, and being non-
judgmental.
• Mindfulness is not a distrac4on from our worries - rather our anxiety, nega4vity, anger and fear are distrac4ons from life.
• Mindfulness is about developing an awareness and acceptance of these nega4ve feelings, but learning to be non-reac8ve and non-judgemental about them.
• Worrying about things might masquerade as prepara4on e.g., we might think we’re preparing for an exam when actually we’re just worrying about how we will go.

Question 17

What is the DDx of anxiety?

Answer 17

1. Organic causes
2. Other mental illnesses - schizo and hyperchondria
3. GAD
4. Panic Disorders
5. Phobias
6. OCD

First we need to rule out ‘organic causes’ of the symptoms of anxiety:
- excessive caffeine intake
- substance abuse and withdrawal
- hyperthyroidism, B12, anemia, hypo/hyperglycemia, tumor etc
- cardiovascular or pulmonary disorder
- depression
Then also need to distinguish from other mental illnesses, specifically schizophrenia and hypochondriases.

• GAD would be free floating anxiety
• Panic Disorder is characterized by panic attacks, during which patient has striking cardiac and respiratory symptoms that lead them to believe they are about to die. Can be accompanied with agoraphobia. Also chronic, and has an increased risk of depression.
• Phobias – unfounded, irrational fears of certain things or situations. Can be specific, or social phobia, or agoraphobia. But have to distinguish from normal shyness or other mental illnesses.
• OCD – recurrent, unwanted, intrusive, negative feelings, thoughts and images (obsessions) and anxiety + compulsions and sometimes obsessive thinking. Don’t confuse with Tourette’s or temporal lobe epilepsy.
• Depression

Question 18

List the diagnostic criteria for general anxiety disorder (GAD). DCM-5

Answer 18

• persistent symptoms of anxiety, including hyperarousal and excessive worrying
• over at least 6 month period
• their symptoms cause them significant distress
• but are FREE FLOATING (not specific person or situation)

Treatment often needed indefinitely as symptoms are chronic.

Question 19

Outline appropriate non-pharmaceutical treatments for anxiety disorders

Answer 19

• CBT
• systematic desensitization
• Flooding and implosion
• group therapy

Question 20

Discuss the role of cognitive behavioural therapy (CBT) in treating anxiety disorders

Answer 20

• Structured form of talking therapy with specific time limits, structured activities and homework tasks.
• It involves working with patients to challenge and change unhelpful ways of thinking to helpful ways
• simplest form – exercise prescription teaching relaxation techniques, assistance with sleep hygiene, scheduling pleasurable activities and guiding patient through thought identification and challenge.

Three types of factors influencing success of CBT:
- Patient factors (i.e. can they recognize and talk about thoughts,
awareness, accept personal responsibility, develop trust, capacity
to remain focused etc)
- Therapist factors (active listening, equal collaboration, non
judmental, expecting optimism, formulation of plan etc. )
- External Factors i.e. affordability, support from family/friends

Question 21

Which psychiatric disorder is GAD often comorbid with?

Answer 21

Major Depressive Disorder

Question 22

Identify non-pharmacological treatments for GAD/anxiety disorders

Answer 22

CBT
Systemic desensitisation are the most effective for phobias
Group/leaderless therapy is good for PTSD

Question 23

What is the prevalence of GAD in Australia?

Answer 23

Between 3-5%

Question 24

Define a mental illness

Answer 24

A condition that is characterised by a disturbance of thought, mood, volition, perception, orientation or memory, which significantly impairs the person’s judgement or behaviour

Question 25

Give five specific symptoms of depression that are included in DMS-5

Answer 25

``` Depressed mood/irritable most of the day Anhedonia Weight changes Sleep changes Change in activity Fatigue Inability to concentrate Guilt/worthlessness Suicidaility ```

Question 26

What is the proportion of Australians who have a mental/behavioural condition?

Answer 26

17.5%

Question 27

Do males or females report feelings of depression more often?

Answer 27

Females - 10.4% vs 7.4% in males

Question 28

1 in X Australians report having depression/feelings of depression. What is X?

Answer 28

11

Question 29

What are three things that can reduce Stigma?

Answer 29

Protest, education and contact

Question 30

What is the DSM-5 criteria for Major Depressive Episode?

Answer 30

Five (or more) symptoms that have been present during the same 2 week period and represent a change from previous functioning; at least one of the symptoms is either symptom (1) or (2). 1. Depressed mood most of the day, nearly every day 2. Markedly diminished interest or pleasure in all, or almost all 3. Significant weight loss when not dieting or weight gain 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness 9. Recurrent thoughts of death

Question 31

What is the hierarchy of ICD-10 diagnostics?

Answer 31

* Level I: Organic brain disorders (e.g. dementia, delirium) * Level II: Psychotic disorders (e.g., schizophrenia, mania) * Level III: Non-psychotic disorders (e.g., anxiety, OCD) * Level IV: Personality disorders (e.g borderline, antisocial)