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Flashcards in EXAMPLE CASE STUDY Deck (20):
1

You are a partner in a large GP practice located in the centre of one of the more deprived housing estates in Aberdeen. You are about to start morning surgery.
Your first patient is 18 year old Hannah Myles. She left school last year, but is now working part-time in a supermarket and attending college two days per week, studying for Highers. She has a regular boyfriend, Stuart, whom she has been seeing for the last six months. She is much more settled at her work and college than she had been at school, but does enjoy attending parties and often drinks more alcohol than recommended by recognised guidelines. She uses the oral contraceptive pill and has booked an appointment today for a routine health check prior to her repeat prescription.
Hannah's pill check is satisfactory and you use the remainder of the consultation to discuss a healthy lifestyle.

1) List four aspects of lifestyle you MAY cover in a consultation with ANY patient when giving advice to promote a healthier lifestyle.
(4 marks)

 Diet
 Exercise
 Alcohol
 Smoking
 Illicit drug use
 Sexual health


2

You are a partner in a large GP practice located in the centre of one of the more deprived housing estates in Aberdeen. You are about to start morning surgery.
Your first patient is 18 year old Hannah Myles. She left school last year, but is now working part-time in a supermarket and attending college two days per week, studying for Highers. She has a regular boyfriend, Stuart, whom she has been seeing for the last six months. She is much more settled at her work and college than she had been at school, but does enjoy attending parties and often drinks more alcohol than recommended by recognised guidelines. She uses the oral contraceptive pill and has booked an appointment today for a routine health check prior to her repeat prescription.
Hannah's pill check is satisfactory and you use the remainder of the consultation to discuss a healthy lifestyle.

Eight weeks later, Hannah books another appointment. She had missed some of her pills during a weekend of partying and has now missed a period. She has already attended a local walk-in health clinic and has a positive pregnancy test. Hannah tells you that she has some worries about the pregnancy and the future challenges of being a young mother.


2) Which factors enable you, as her GP, to be the most appropriate professional to guide her about her current worries.
(4 marks)

 Aware of Hannah's current and past medical history
 Aware of Hannah's social circumstances e.g. family support
 GP has knowledge of a broad range of illnesses and health conditions
 Trusted health professional who is likely to have been known by the patient/family for some time, perhaps lifelong
 GP has role in prevention as well as diagnosing/treating illness/disease i.e. GP is responsible for holistic patient care
 GP likely to be local to Hannah's home and therefore accessible

3

When discussing Hannah's concerns you use open-ended questions. This type of question is not seeking any particular answer, but simply signals to the patient to tell their story or voice their concerns. This is just one of the types of question which can be used in the consultation.

3) List four other types of question which may be used in a consultation and give a brief explanation of each.
(8 marks)

 Direct question-asks about a specific item
 Closed question-can only be answered by "yes" or "no"
 Leading question-presumes the answer (and is best avoided)
 Reflected question-the doctor does not answer the question but asks the patient to think about the answer themselves

4

One of the topics you discuss with Hannah is that her current alcohol intake may be harmful to the baby. If Hannah is to stop drinking alcohol whilst pregnant, she must be motivated to change. Knowledge from psychology has identified several factors which are related to an individual's motivation to change.

4) List four factors which would make Hannah more likely to be motivated to change her behaviour and stop drinking. For each factor, give an example relating to Hannah.
(8 marks)

o The advantages of not drinking (e.g. healthy baby) outweigh the disadvantages
o Hannah anticipates a positive response from others to her behaviour change e.g. Hannah's boyfriend/family also want the unborn child to be healthy.
o There is social pressure to change e.g. very socially unacceptable to drink when obviously pregnant
o Hannah perceives the new behaviour to be consistent with her self-image e.g. perceives herself as an "earth mother"
o Hannah believes she is able to carry out the behaviour in a range of circumstances e.g. at home, at parties

5

5a) What is the World Health Organisation (WHO) definition of health? (4 marks)

Health is a state of complete physical (1 mark), mental (1 mark) and social (1 mark) well-being and not merely the absence of disease or infirmity (1 mark)

6

Blaxter (1995) found that lay beliefs about health included absence of disease, physical fitness and functional ability. Lay beliefs about health are influenced by a number of factors.


5b) List four factors which influence lay beliefs about health AND give an example of how each of these factors may influence lay beliefs about health. (8 marks)

o AGE: older people concentrate on functional ability, younger people tend to speak of health in terms of physical strength and fitness
o SOCIAL CLASS -people living in difficult economic and social circumstances regard health as functional (ability to be productive, take care of others), women of higher social class or educational qualifications have a more multidimensional view of health
o GENDER -men and women appear to think about health differently (women may find the concept of health more interesting, women include a social aspect to health)
o CULTURE -different perceptions of illness/disease, differences in concordance with treatment

7

Georgina's obesity may increase the symptoms associated with her angina and emphysema and is a risk factor for a number of diseases. Scottish government figures show that since 1995 there has been a significant increase in the proportion of adults aged 16-64 categorised as obese (from 17.2% in 1995 to 25.6% in 2013).

6) List six actions the government could take to stem the rise in obesity. (6 marks)

o Health education-diet and exercise
o Tax on unhealthy foods, "fat tax"
o Legislation-proper labelling, lists of ingredients/food content
o Enforcement of legislation
o Ban on advertising unhealthy food
o Improve exercise/sport facilities
o Subsidise healthy food
o Transport policy e.g. cycle lanes
o Funding of NHS treatment for obesity e.g. specialist clinics, bariatric surgery

8

Later that morning, you see 28 year old Jenni Chua. She initially moved to the UK from Malaysia to study for a post-graduate degree, but is now happily settled in this country, working as a chemist for one of the large oil companies. Jenni is just one of a large number of patients in your practice population who are from a different culture. This requires you and your colleagues to demonstrate cultural competence.

7a) What is meant by cultural competence? (2 marks)

Cultural competence is the ongoing capacity of: healthcare systems,
organizations
and professionals
to provide for diverse patient populations high quality care that is;
safe
patient- and family- centred
evidence-based, and equitable.

9

7b) List five potential difficulties which may arise when consulting with a patient from a different culture. (5 marks)

o Lack of knowledge about NHS/UK health care system
o Lack of knowledge about common health issues/different health beliefs
o Fear and distrust
o Racism
o Bias and ethnocentrism
o Stereotyping
o Language barriers
o Presence of a third party e.g. family member, translator in the room
o Differences in perceptions and expectations between patient and doctor
o Examination taboos
o Gender difference between doctor and patient
o Religious beliefs
o Difficulties using language line
o Patient may not be entitled to NHS care

10

Jenni has developed a painful, itchy rash on her hands, which she thinks has resulted from contact with chemicals in the lab.
8a) List three different routes via which someone may be exposed to a hazardous substance (other than via skin)
(3 marks)

o Blood
o Inhalation
o Ingestion
o Sexual contact

11


8b) List two categories of hazard (other than chemical) AND give an example of each in relation to Jenni's work in the chemistry lab. (4 marks)

o PHYSICAL- heat, noise, radiation from lab equipment
o MECHNICAL - trips and slips
o BIOLOGICAL - spread of infection amongst colleagues e.g. respiratory, GI
o PSYCHOLOGICAL/stress - anxiety re job security, relationships with colleagues, stressful when busy/deadlines to meet

12

You are then consulted by 31 year old James McKay, who has brought his two year old son Mark to see you. James and his wife have been concerned about Mark over the last 24 hours as he has been fevered (pyrexial).
After a careful history and examination you diagnose a viral illness. However, it is well recognized amongst health professionals that young children can rapidly become very unwell. Hence, when reassuring James that you think Mark has a viral infection and advising him on how to deal with it, you also "safety net". Safety netting is one way in which risk can be minimized in the consultation as described by Neighbour (The Inner Consultation, Roger Neighbour, 2nd edition, 2004).

9a) List three aspects of advice you may give to the patient/their carer when safety netting.
(3 marks)

o Advise the patient of the expected course of the illness/recovery
o Advise of symptoms indicating deterioration
o Advise who to contact if patient deteriorates

13


9b) List three other ways in which Neighbour suggests risk can be minimized.
(3 marks)

o Summarise and verbally check that reasons for attendance are clear
o Hand over and bring the consultation to a close i.e. hand over to the patient at the end to ensure all issues have been covered
o Deal with the housekeeping of recovery and reflection e.g. record keeping, referral if necessary, pausing to reflect before next patient

14

Following this, you see Michelle White, a 55 year old office worker with Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis. She had been stable for a number of years and was discharged from the chest clinic some time ago. Over the last three months, she has been unwell with recurrent chest infections and several different antibiotics have failed to help, despite sputum culture and appropriate antibiotic sensitivities being noted and discussions with the microbiology lab having occurred. She has a poor appetite, has lost weight and her mood is low. She also feels her inhalers are not so effective as they used to be and her concordance with treatment is erratic. Fortunately, she has an understanding employer and sick leave has not been a problem. Following discussion with Michelle, you decide to refer her back to the chest clinic, employing your role as a "gatekeeper". The GP is often described as the "gatekeeper" of the NHS.

10a) What is meant by the term "gatekeeper" in this context? (1 mark)

o a person who controls patients' access (via referral) to specialist / secondary care

15

10b) List four advantages of GPs as gatekeepers.
(4 marks)

o Identify those patients who are in need of 2° care assessment
o Personal advocacy
o Patient does not necessarily know which specialty to go to
o Increases likelihood of referral to appropriate department
o Increases likelihood of appropriate referral/use of resources
o Limits exposure to certain investigations e.g. MRI scan, X-rays
o GP acts as co-ordinator of care
o Puts GP in position to provide patient education

16

Whilst Michelle is awaiting assessment at the chest clinic, you decide to contact other members of the health and social care team who work in the community to assist with her care.

11) List three health and social care team members who work within the community whom you may decide to contact to assist with Michelle's care AND give an example of their role.
(6 marks)

o Physiotherapist e.g. help to clear chest secretions
o Pharmacist e.g. advice on medication/interactions/timing of antibiotic medication/encouragement re concordance
o Dietician - assessment of nutrition and advice on improving appetite/weight gain
o Counsellor - assessment and management of low mood
o Practice nurse - assessment and advice re inhaler use/chronic disease (long term condition) monitoring clinics/flu and pneumococcal immunisation
o Occupational therapist - assess for aids to assist daily living e.g. stair lift, shower rail

17

You decide that Michelle's recent care has been sufficiently complex and challenging to warrant writing up a Significant Event Analysis (a form of audit of patient care). As you do this, you reflect on the four ethical principles that underpin medical practice and how these apply to the scenario about Michelle.
One of these ethical principles is Justice.

12a) List the three other ethical principles. (3 marks)

o Autonomy
o Beneficence (do good)
o Non-maleficence (do no harm)

18

12b) Explain how each of the three principles you have listed in 12a) may apply to the scenario about Michelle.
(3 marks)

o Autonomy -patients right not to take advised treatment (inhalers) even if fully informed of benefits
o Beneficence -her care has been maximised i.e. treatment of infection, discussion with colleagues in microbiology, involvement of practice team, referral for specialist opinion
o (1 mark)
o Non-maleficence -culture of sputum and discussion with microbiology to minimise risk antibiotic resistance (1 mark)

19

Discuss the five core concepts of social cognitive theroy

Observational learning/modelling (people learn by observing others – learned behaviours)
Outcome expectations
Self-efficacy
Goal setting
Self-regulation

20

According to Social Cognitive Theory, an individual’s behaviour is influenced by personal, behavioural and environmental factors.
4b) Give three examples of environmental factors which may influence an individual’s behaviour.

Culture
Social support
Location
Income
Time
(CLITS)