2016 Formative Flashcards
Lisa is 17 and lives with her single mother, Jill. She attended the local Secondary School and left after S5. She is currently looking for work. She attends aerobics twice a week with her friends. Lisa started smoking at age 14 and met her current boyfriend Martin in a local bar when she was 15. She recently called the local GP surgery to get an appointment about contraception, but the appointment was four weeks away and clashed with a meeting at the job centre, so she did not attend. Lisa has now missed a period and discovered she is pregnant after having a pregnancy test done at the local pharmacy. Martin is 22. He also smokes and works in the local car maintenance garage. He drinks more than recommended guidelines, mostly at weekends. He used to play a lot of football at school. He notices that as he runs up the stairs at work he has become more breathless over the last year or two. Jill (Lisa’s mother), age 44 was a school cleaner until last year, when her arthritis became severe enough that she had to stop work because of it. She does not have any school qualifications of note. She has looked for other work but has struggled to find anything suitable. Brenda – Jill’s friend at her former workplace, also a cleaner. Baby Kayleigh. Born at 35 weeks gestation at 2400 grams. Bottle fed.
1) Lisa comes to see you in the early stages of pregnancy. She wonders whether she should keep the baby or not. List two ETHICAL, two PSYCHOLOGICAL and two SOCIAL issues that Lisa may be considering?
Ethical
- Beliefs regarding termination
- Any religious beliefs
- Thoughts regarding brining a child into the world that you do not feel able to care fore
Psychological
- Anxiety about being a parent
- Anxiety about going though with termination
- Stress / anxiety about level of support she may have from family and friends
Social
- Support network - does Lisa feel her friends would be supportive
- Her social life will dramatically change after having a baby
- Ability to find job / work will be affected in the short of longer term
Following discussion with her GP and close family and friends, Lisa decides to keep the baby.
2) Lisa knows that she doesn’t have the healthiest lifestyle, and until now has not felt much need for change.
What factors might increase the chance of someone changing their behaviour?
(Give five factors)
- You think the advantages of change outweigh the disadvantages
- You anticipate a positive response from others to your behaviour change
- There is social pressure for you to change
- You perceive the new behaviour to be consistent with your self-image
- You believe you are able to carry out the new behaviour in a range of circumstances
3) Using Smoking or Alcohol as an example, how might these apply to Lisa’s current situation of wanting to change her behaviour ?
(Give five factors)
- The advantages of not drinking/smoking (healthy baby) outweigh the disadvantages
- You anticipate a positive response from others to your behaviour change (e.g. your partner also wants the unborn child to be healthy)
- There is social pressure for you to change (very socially unacceptable to drink/smoke when obviously pregnant!)
- You perceive the new behaviour to be consistent with your self-image (a good mother)
- You believe you are able to carry out the new behaviour in a range of circumstances (at home, celebrations, etc.)
4) There are many factors which can affect a pregnant mother and her unborn child, including maternal smoking and alcohol intake. When discussing actions Lisa may take to keep her unborn baby healthy, you adopt the mutual participation style of doctor/patient relationship (as described by Szasz and Hollender, 1956).
Suggest three possible benefits of adopting the mutual participation style of doctor/patient relationship.
- Greater participation by the patient means they have a feeling of relatively greater personal autonomy
- The patient adopts greater responsibility for their own health through sharing of information and decision making
- Patients are generally more satisfied with consultations where they have been fully informed and are therefore less likely to complain about their care
- May increase compliance with advice / concordance with treatment
5) Name two other styles of doctor/patient relationship (other than mutual participation style) described by Szasz and Hollender and give a brief description of each.
Authoritarian or paternalistic relationship - the physician uses all of the authority inherent in his / her status and the patient has no autonomy. The patient tries hard to please the doctor and does not actively participate in their own treatment
Guidance / Cooperation relationship - the physician still exercises much authority and the patient is obedient but has a greater feeling of autonomy and participates somewhat more actively in the relationship
6) Communication in a consultation can be a complex process. However, it is recognized that three broad types of skills are needed for successful medical interviewing i.e.
- content skills
- conceptual skills and
- process skills
Give a brief description of each.
Content - what doctors communicate, the substance of their questions and responses, the information they gather and give, the treatments
Perceptual - what they are thinking and feeling, their internal decision making, clinical reasoning, their awareness of their own biases, attitudes and distractions
Process - how they do it, the way doctors communicate with patients, how they go about discovering the history or providing information, the verbal and non-verbal skills they use, the way they structure and organise communication
7) The health of pregnant women is just one aspect of population health. What kinds of actions might a government take to promote health in the population as a whole?
(List five actions)
- Legislation / policies on smoking / alcohol i.e. minimum age to buy products, licensing laws, taxation
- Improvements in housing
- Provision of health education
- Health and safety laws
- Traffic / transport legislation / policies
8) Despite the issues of Lisa’s smoking and alcohol intake raised above, she considers herself to be quite healthy and normal.
What is the World Health Organisation (WHO) definition of Health?
Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity
9) Using this definition (WHO health), suggest reasons why might Lisa feel she is healthy?
(Suggest five reasons)
- She has no illness / long term condition (chronic disease)
- She exercises regularly
- She is on no regular medication
- She manages to work, socialise
- Healthy diet
- She managed to become pregnant
10) Lay beliefs about health can differ from views of health held by medical professionals. Blaxter (1995) identified a number of factors which influence lay beliefs about health. List four such factors.
Age
Social class
Gender
Culture
11) Lisa thinks that smoking is “normal” behaviour. Why might she feel that smoking is normal behaviour?
(Give two reasons)
Might be normal for her peer or social group, but would be abnormal perhaps for the wider population and / or a different population group
Might watch TV programmes where smoking is normal behaviour
13) After a relatively uneventful pregnancy, Baby Kayleigh is born at term (on time).
A number of different health professionals may be involved in helping to keep Lisa and Kayleigh healthy and normal. Suggest three different health professionals and describe their role in the health care of Lisa and Kayleigh.
GP - postnatal examination of Lisa, 8 week baby check, advice on immunisations, care of any medical problems
Midwife - follow-up of Lisa and Kayleigh for first 10 days after birth, advice on feeding
Health Visitor - advice on early child care from 10 days to school age, immunisations
Pharmacist - advice on and supply of over the counter medication, minor illness advice, smoking cessation advice
14) When Kayleigh is 3 months old, Lisa brings her to the surgery with a 3 day history of diarrhoea and fever. You use hypothetico-deductive reasoning and diagnose viral gastro-enteritis (a simple “tummy bug”/infective diarrhoea). Describe how you might use the hypothetico-deductive reasoning process to make this diagnosis.
- The patient history leads to making several diagnostic hypotheses, based on your past experiences i.e. simple infective diarrhoea, infection elsewhere such as respiratory infection, malabsorption syndrome or acute appendicitis
- Rare, but not immediately concerning diagnoses can be excluded at this stage i.e. malabsorption syndrome, as although important, it is not immediately life threatening
- Acute appendicitis is also rare, but is life threatening, so needs to be actively excluded
- Strengthen the case for diagnosis through a more detailed history and examination and possible some initial investigations. this may help provide evidence for your initial hypotheses, but if not
- Extend the search if no diagnosis identified
- Hypothetic-deductive reasoning is not necessarily about common diagnoses but about likely diagnoses
- If the patient does not follow the expected pattern of illness / recovery from the postulated diagnosis, revision of the diagnosis is required i.e. persistent diarrhoea may then make a diagnosis of malabsorption more likely and this will need to be investigated
15) It is well recognized amongst health professionals that babies and children can rapidly become very unwell. Hence, when reassuring Lisa that you think Kayleigh has simple viral gastroenteritis and advising her 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).
What might safety netting advice include?
Advise the patient of the expected course of the illness / recovery
Advise of symptoms indicating deterioration
Advise who to contact if patient deteriorates
16) List three other ways in which Neighbour suggests risk can be minimized. (other than safety netting)
Summarise and verbally check that reasons for attendance are clear
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
Deal with the housekeeping of recovery and reflection i.e. record keeping, referral if necessary, pausing to reflect before next patient
