Sexual History Taking, Eating Disorders, Pain Management

Question 1

List the 8 steps involved in taking a comprehensive sexual history

Answer 1

1. Ask- Most people will not be comfortable to bring up sexual matters, however if a provider asks, they will gladly provide that information
2. Use Patient Centered Language
3. Normalize
4. Ask Permission
5. Assure Confidentiality
6. Non-judgemental attitude
7. Share limited information
8. Focus hx and counseling on HIV/STI reduction

Question 2

key info to ask about when taking a sexual hx

Answer 2

1. assess number of partners in last 6 months, abstinence, or monogomy
2. sexual orientation and behavior
3. type of barrier/contraception
4. avoiding sex w/ excessive substance use
5. recommend truvada?
6. harm reductions

Question 3

when is recommending Truvada appropriate

Answer 3

1. Sero-disconcordant couples
2. MSM with STI in past 6 months
3. Any high risk behaviors above
4. IV drug use

Question 4

what are some harm reduction approaches for sexual practices

Answer 4

1. Monogamy with an uninfected partner
2. Reduction in the number of sexual partners
3. Engaging in lower-risk sexual practices
4. Consistent and correct use of barrier methods
5. Avoiding excessive substance use
6. Referrals to community programs

Question 5

ABC-T of reducing sexual risk

Answer 5

1. abstinence
2. be monogamous
3. condoms
4. truvada

Question 6

how can you use patient centered language when taking sexual history

Answer 6

1. Use language appropriately to what a patient uses to describe themselves and their family
2. A patient has the right to define themselves as they wish
3. Use gender-neutral pronouns
4. For relationship status and sexual health discussions, use the term “partner” rather than boyfriend, girlfriend, husband or wife

Question 7

Develop a standard phrase to use in normalizing sexual history taking

Answer 7

Discussing sexual concerns with a stranger is not typical for your patients, so try to normalize by saying something like

“Sexual health is important to overall health; therefore, I always ask patients about it.”

Question 8

Develop a standard phrase to use in obtaining permission to ask sexual history questions

Answer 8

• Always ask permission when discussing “sensitive” matters

Ex: “If it’s okay with you, I’ll ask you a few question about sexual matters now.”

Question 9

Explain to a patient the significance of confidentiality as it pertains to sexual information

Answer 9

-Assure to the patient that everything they say will be kept confidential, even within your practice

Ex: “Everything we discuss is private protected information between you and me as your provider” 

-Only reason confidentiality wouldn’t be kept is if laws around breaking confidentiality (ex. Certain STDs need to be reported to the state, if the patient is a harm to themselves or others, etc.)

Question 10

Identify risk factors associated with the development of an eating disorder

Answer 10

1. Perfectionist personality: harm avoidant: do not take risks
2. Genetic factors: dopamine and chromosome-related factors
3. Social family stress
4. Cultural pressure / body dissatisfaction
5. Competitive sports
6. Puberty: teenage girls most common (middle of bell curve)

Question 11

Recognize the typical pattern and warning signs associated with the development of an eating disorder

Answer 11

1. Temperament traits: perfectionism, harm avoidance, intolerance of uncertainty
2. Body dissatisfaction
3. Stressors related to transition to a different school, peer group changes, athletic competition, family changes
4. Decision to change body shape / weight
5. Cutting down in food eaten, usually starts with eliminating desserts / fats, then carbs, and portion sizes
6. Efforts to increase exercise
7. Skipping meals, purging, laxative abuse
8. Increasing levels of preoccupation and intensity of behaviors

Question 12

Behavioral warning signs for eating disorder

Answer 12

1. Change in eating patterns
   - Smaller portions
   - Avoiding desserts
   - Preference for non-fat or vegetarian foods
   - Binge eating / food missing
2. Avoiding eating with others
3. Frequent comments about body dissatisfaction
4. Increasing amounts of exercise (can appear driven)
5. Weight loss or weight fluctuations

Question 13

List the key symptoms/DSM 5 criteria for diagnosing anorexia

Answer 13

Requires presence of all 3 of the following:

1. Energy restriction leading to significantly low body weight (adjusted for age, sex, etc.)
2. Intense fear of gaining weight or behavior interfering with weight gain
3. Disturbance of self-perceived weight or shape
   - Distorted body image

Subtypes:

• Restricting type: no recurrent episodes of binging of purging in last 3 months
• Binge-eating/purging type: recurrent episodes of binging of purging in last 3 months

Question 14

sub types of anorexia

Answer 14

• Restricting type: no recurrent episodes of binging of purging in last 3 months
• Binge-eating/purging type: recurrent episodes of binging of purging in last 3 months

Question 15

describe the BMI classifications for mild, moderate, severe, extreme

Answer 15

• Mild: BMI > 17 kg/m2
• Moderate: BMI 16-16.9 kg/m2
• Severe: BMI 15-15.9 kg/m2
• Extreme: BMI < 15 kg/m2

Question 16

List the key symptoms/DSM 5 criteria for diagnosing bulimia

Answer 16

1. Recurrent episodes of binge eating
2. Recurrent inappropriate compensatory behavior (must have a purging behavior - or Dx would be BED)
3. Binge eating and compensatory behaviors both occur at least once a week for 3 months

Note: dx cannot be made if binge and compensating behaviors occur only during episodes of anorexia nervosa

Question 17

what is the best tx for bulimia

Answer 17

CBT

Question 18

List the key symptoms/DSM 5 criteria for diagnosing binge eating disorder (BED)

Answer 18

1. Binge Eating Disorder (BED) – above without criterion B (no purging)
2. Binge eating episodes are associated with at least 3 of the following:
   - Eating more rapidly than normal
   - Eating until feeling uncomfortably full
   - Eating large amount of food when not feeling physically hungry
   - Eating alone because embarrassed by how much one is eating
   - Feeling disgusted with oneself, depressed, or guilty after over eating

Note: dx cannot be made if binge behavior occurs only during episodes of anorexia nervosa or bulimia nervosa

Question 19

Ask pertinent history questions to assess a patient for a potential eating disorder

Answer 19

1. In the context of concern about weight loss or weight fluctuations related to an eating disorder
2. personal “story” of disordere eating
3. max and minimum weights (large flutcuations is a BIG flag)
4. goal weight, size, appearnace
5. dietary practices

Question 20

Explain the most important components of the physical exam related to eating disorders

Answer 20

• the growth chart, the gowned weight and the urine specific gravity)
  1. REVIEW GROWTH CHART
  2. Gown weight after voiding (to get rid of water, removal of heavy clothes)
  3. Urine specific gravity (if water loading is suspected)
  4. Orthostatic vital signs (lying down – standing up)
  5. History of weight patterns (highest, lowest)
  6. History of eating patterns (changes, vegetarian, narrowing of variety?)
  7. Menstrual history (for females)
  8. Exercise history (increase in activity?)
  9. Drive for thinness, fear of fat?
  10. Changes in mood: withdrawal from friends and family, depression, suicidal ideation?
• Self Injurious behavior
  11. Purging, laxative use, diet pills

Question 21

Decide when a patient needs increased care and/or hospitalization for anorexia

Answer 21

1. Biggest: bradycardia (resting pulse less than 45) – lying down
2. Most common factor precipitating medical admission is a dramatic increase in activity level leading to bradycardia and more rapid weight loss
3. Weight less than 75% of Ideal Body weight
4. Resting Pulse less than45
5. Potassium (K+) <3.0 – from purging (electrolyte imbalance)
6. Intake less than 750 calories / day

Question 22

runner vs anorexic

Answer 22

• runner will have bradycardia all of the time

- Hint to anorexia nervosa is when this changes from resting, morning, during day

Question 23

Explain some of the most common medical complications of anorexia

Answer 23

1. sucide is leadin gcuase of death in eating disorders
2. cardiac events are second
3. Osteopenia and osteoporosis (weak bones)
4. Bone marrow suppression: anemia/increased risk of infection
5. Seizures: possible effect of fluid loading to hide weight loss at medical visits
6. Amenorrhea, fertility issues, growth retardation, dentil erosion, anemia, constipation, poor sleep, impaired immunity, pancreatitis edema, etc.

Question 24

Explain the cause and risks associated with Refeeding Syndrome

Answer 24

• Complex condition that occurs as a result of severe electrolyte and fluid shifts in response to refeeding if calories are increased too quickly (NG feeding)
• Too much for body to handle
  1. Hypophosphatemia is the hallmark
  2. Hypokalemia and hypomagnesia may occur

Complications:

3. hypotension,
4. arrhythmia,
5. cardiac or
6. respiratory failure,
7. rhabdomyolysis,
8. CNS: delerium, seizure, coma
9. Liver edema, hepatitis

Question 25

what is a safe increase of calories for refeeding

Answer 25

Safe: inc. 250 calories a day

Question 26

Be able to effectively follow an anorexic patient post-hospitalization

Answer 26

1. multidisciplinary team (include the family) 2. freuquency of visits detemined by pt and family needs 3. readjust IBW every 2-3 months 4. post-goin weight, resting HR, orthostatic HR 5. labs: electrolytes if vomiting, urine specific grav. if water loading

Question 27

what is a reasonable wt gain for someone who was anorex

Answer 27

1/2-1lb per week

Question 28

Describe problems associated with opioid overuse/misuse in individual patients and to society as a whole

Answer 28

1. high abuse potential for opioids | 2. prescription drug OD: resp. depression and sedation

Question 29

Harms Associated with high dose Opioids

Answer 29

1. Constipation, nausea, sedation, respiratory depression and others 2. Hyperalgesia: paradoxical increased sensitivity to pain (can occur w/ high doses – increased pain) 3. Hypogonadism/lowered testosterone levels, falls/fracture risk

Question 30

Explain how increased opioid prescribing is related to the increase in heroin use (and overdoses)

Answer 30

- Opioids for chronic pain often prescribed with no ceiling dose (bad medicine!) - Risk of overdose begins to increase at over50 mg morphine mg equivalents (MME)/day, and continues to rise in dose-dependent fashion - Very limited data on effectiveness of opioids at higher doses - Increased opioid prescribing can increase dependence on higher doses of opioids - Patients develop tolerance to opioid and turn to heroine

Question 31

risk of OD begins to increase age ___ morphine mg equilavents (MME/day) and continues to rise in a dose dependent fashion

Answer 31

over 50mg morphine equivalent

Question 32

Opioids do not address __ contributors to pain

Answer 32

psychosocial

Question 33

chronic pain is a ___ condition

Answer 33

complex BioPsychoSocial

Question 34

additonal componetns of pain management

Answer 34

1. Psycho-social contributors to stress and pain 2. Encourages physical activity and movement 3. Sets goals for functioning and resuming activities of daily living (ADLs) 4. Utilizes other non-opioid treatments: exercise, chiropractic care counseling, meditation, psychiatric meds, improved sleep, etc.

Question 35

the goal should be to get pain a __/10

Answer 35

3-5 out of 10

Question 36

- If I prescribe you more, your pain will get worse | - This is the max I prescribe – we need to figure out other ways to cope

Answer 36

60mg morphine equivalents/day --> 90mg ME absolute MAX

Question 37

Develop an initial pain management plan for a patient, including pharmacologic and non-pharmacologic recommendations

Answer 37

First line: acetaminophen and NSAIDS 2nd: muscle relaxants, antidepressants (SSRIs) 3rd line: opiods- Reserve opioids for patients who don’t respond to initial therapies, are in high pain, too limited in activities, or selected cases with very severe symptoms

Question 38

Opioids are generally accepted as effective for various types of acute pain when used for how long?

Answer 38

20-30% pain relief for short term (less than 12 weeks)

Question 39

when changing opioids, first ___ and then __

Answer 39

convert to morphine equivalents first and then reduce dose by 30-50% for initial dose

Question 40

Non-pharmacologic recommendations for pain

Answer 40

2. Psycho-social contributors to stress and pain 3. Encourages physical activity (exercise) and movement 4. Sets goals for functioning and resuming activities of daily living (ADLs) 5. Others: chiropractic care, acupuncture, counseling, meditation, improved sleep, etc.

Question 41

Develop a treatment/tapering plan for a patient whose daily dose of opioids is excessive, including pharmacologic and non-pharmacologic recommendations

Answer 41

Pharmacologic recommendation: -10% per week reduction Non-pharmacologic recommendation: -Interventions to address psychological symptoms / maladaptive coping: counseling, exercise

Question 42

Explain how Suboxone (buprenorphine/naloxone) works in treating opioid addiction

Answer 42

1. Sublingual drug w/ large binding capacity 2. Totally fills receptors, removes craving, and makes it so narcotics result in no effect 3. Prescribers can call in refills – no need for written script 4. MDs have to go through training to Rx; bill in progress for PAs to prescribe 5. Helps with pain and takes away craving 6. Heroine addicts: on for a couple years

Question 43

outpatient tx for opioid addicted patients (heroine addicts)

Answer 43

suboxone

Question 44

suboxone benefits compared to methadon

Answer 44

methadone: older med - Would have to go to methodone clinic to get medication (Suboxone is outpatient) - Methodone is cheaper than Suboxone

Question 45

Provide anticipatory guidance to patients around potential withdrawal symptoms from opioids

Answer 45

Early sxs: agitation, anxiety, muscle aches, inc. tearing, insomnia, runny nose, sweating, yawning Late sxs: abdominal cramping, diarrhea, dilated pupils, goose bumps, nausea, vomiting

Question 46

when do opioid withdrawal sx typically start

Answer 46

begin w/in 12 hrs of last heroine dose and 30 hrs of last methadone dose)