Case Study/Formative

Question 1

What broad types of skills might the GP use during a consultation?

Answer 1

Content skills
Perceptual skills
Process skills

Question 2

One factor affecting a consolation may be personal factors, give another factor and four examples of it

Answer 2

Physical factors;
site and environment 
adequacy of medical records 
time constraints 
patient status

Question 3

Kinds of questions that can be used to elicit more information

Answer 3

Open-ended 
Direct 
Closed 
Leading 
Reflected

Question 4

What is the word used when body language and verbal language match?

Answer 4

Congruence

Question 5

Can you disclose information about one patient to another? What oath guides you about this?

Answer 5

No - patient confidentiality

The Hippocratic oath

Question 6

What percentage of the population are attending the GP for care at any point in time?

Answer 6

19%

Question 7

What are the possible issues in having done the majority of undergraduate training in hospital specialties when considering, for example, a child presenting with abdominal pain?

Answer 7

Hospital is the tip of the iceberg of care

You will see a narrow spectrum of presentations in hospital and may gain a distorted view of the presentation of illness

Question 8

What form of problem solving does a GP use to rapidly narrow down the list of likely diagnoses?

Answer 8

Hypothetico-deductive reasoning

Question 9

What is the WHO definition of health?

Answer 9

Health is a state of complete physical, mental and social wellbeing and note merely the absence of disease or infirmity

Question 10

Jim is out walking when he becomes clammy, out of breath and nauseated. He starts to sweat and has a heavy feeling on his chest. He becomes faint, collapses and an ambulance is called. What is the most likely diagnosis?

Answer 10

Myocardial infarction

Question 11

What groups of medication might Jim be on when he is discharged?

Answer 11

Anti-platelets
Anti-anginals
Anti-hypertensives
Statins

Question 12

Jim has decided not to start the medication he was prescribed, you endeavour to persuade him to start. What consultation model would be the preferred option when discussing Jim’s new treatment with him?

Answer 12

Mutual participation - he is an intelligent person who would likely respond to information about the risks and benefits of the proposed treatments. It would be important to allow him to ask questions and understand his treatment. This would likely result in improved concordance.

Question 13

What factors might put someone at risk of developing a long-term condition?

Answer 13

Genetic factors

Environmental factors

Question 14

Allison is a middle-aged woman. She noticed pins and needles over her trunk. A few months later she noticed that she was unable to open bottle tops and was asking her husband to help. At work she has found herself dropping papers, and friends have noticed her stumble on the stairs on a number of occasions. What is the likely diagnosis?

Answer 14

Multiple sclerosis

Question 15

Give examples of the potential impacts of long-term conditions

Answer 15

On the individual - can be negative or positive, includes denial, self-pity and apathy
On family - financial, emotional, health of other family members may be affected
Community/society - isolation of an individual may result, physical adaptions and changes in attitude may be required

Question 16

WHO attempts to classify disability, including that resulting from long-term conditions, into 3 categories, what are these?

Answer 16

Body and structure impairment
Activity limitation
Participation restrictions

Question 17

Allison is diagnosed with MS and her condition deteriorates rapidly. She needs increasing levels of support at home. What members of the primary care team may become involved in her care and what might their roles be?

Answer 17

GP - co-ordinating care and reviewing treatment and medication
District nurse - co-ordinating care at home, wound care, dressings, bloods, catheter care
Occupational therapist - assessing environment around the patient at home and work and providing aids to promote independence
Physiotherapist - looks to maximise patient’s physical function
Care manager - co-ordinating social care package

Question 18

What approaches are used to help patients overcome their limitations? Define them.

Answer 18

Therapeutic - change the nature of the disability e.g. treating osteoarthritis with anti-inflammatories
Prosthetic - change the environment e.g. taxi card, occupational therapy, rails at home

Question 19

What factors may influence the way someone reacts to their disability?

Answer 19

The nature of the disability
The information base of the individual i.e. education, intelligence and access to information
Personality of the individual
Coping strategies of the individual
Role of the individual – loss of role, change of role
The mood and emotional reaction of the individual
The reaction of others around them
The support network of the individual

Question 20

If a person diagnosed with a long-term condition is the main income earner of their family, give 3 areas of their life that might be affected by their diagnosis.

Answer 20

Personal
Economic
Social

Question 21

What are the differences between the way that Jim and Allison presented with their illnesses. What are the important pre-morbid factors. How might this affect their psychological adaptation to their illnesses?

Answer 21

Both consider themselves healthy and did not expect to become unwell. Jim is a little older so might have a different attitude to illness. His illness is relatively common and he might have friends with IHD and therefore some knowledge. However, his illness presented very suddenly, and he has had little time to adjust psychologically before becoming a patient on a significant number of medications.

Allison is very young to develop life-changing illness. She will have little experience of her condition (unless family or a friend have MS) and would not expect to have become unwell. However, her symptoms have developed gradually, so she may have had somewhat more time than Jim to adjust to her condition.

Question 22

Brenda attends the GP noticing that she has been coughing much more than usual and is noticeably more short of breath than a year ago. She has no chest pain but can’t manage a brisk walk. She is a smoker. What is the most likely diagnosis?

Answer 22

COPD secondary to smoking

Question 23

What would be the most important bit of advice or treatment option for Brenda?

Answer 23

To stop or reduce smoking

Question 24

What barriers might stop Brenda from smoking?

Answer 24

Most likely used as a coping strategy to manage other life stresses
Likely that she will return to smoking until she finds other ways of coping
May be peer pressure from other friends/relatives who smoke

Question 25

The WHO defines three categories under which disability can be described. List these three categories and give a brief explanation of each

Answer 25

Body structure and function impairment – defined as abnormalities of structure, organ or system function (organ level) Activity limitation – defined as changed functional performance and activity by the individual (personal level) Participation restrictions – defined as the disadvantage experience by the individual as a result of the impairments and disabilities (interaction and social and environmental level)

Question 26

Give any four examples of how the WHO definitions of disability could apply to John, a 7-year-old patient with cerebral palsy.

Answer 26

``` Damage to motor area of brain Damage to cognitive area of brain Limited mobility Learning difficulty Exclusion or difficult participating in certain activities e.g. riding a bike, certain sports ```

Question 27

Disability has far-reaching implications for patients, their families and others around them. In general what might the effect of a disabled child be on their parents?

Answer 27

Mother/father may not be able to combine work with the demands of caring for a disabled child – financial implications for the family Guilt at having passed on causative gene if a genetic disorder Psychological strain Caring for a disabled child may be detrimental to parent’s physical health Some parents may have difficulty bonding with a disabled child Marital problems Increased risk of child abuse Over-protection of disabled child

Question 28

Disability has far-reaching implications for patients, their families and others around them. In general what might the effect of a disabled child be on their siblings?

Answer 28

Resentment at time parents spend caring for the disabled child Resentment at restrictions to normal family life May have to develop a carer role Grow up with a greater understanding of disability

Question 29

Disability has far-reaching implications for patients, their families and others around them. In general what might the effect of a disabled child be on their peers?

Answer 29

May “look out” for the disabled child Friend may be stigmatized along with the disabled child May grow up with greater understanding of disability May need to adapt activities to include the disabled friend Teasing by other peers

Question 30

Disability has far-reaching implications for patients, their families and others around them. In general what might the effect of a disabled child be on their teachers?

Answer 30

May have lack of understanding of disability/lack of training May have a tendency to over-protect the disabled child May be lack of willingness to integrate into mainstream activities May be additional challenges in personalising education for the disabled child Stress of managing both mainstream and additional support needs pupils in the same class

Question 31

John's disability is congenital. This is recognised as one of several causes of disability worldwide. List six other causes of disability worldwide.

Answer 31

``` Congenital Communicable disease Non-communicable disease Alcohol Drugs – iatrogenic Drugs – illicit use Tobacco use Mental illness Malnutrition Injury Obesity ```

Question 32

List medical factors which may influence the uptake of care

Answer 32

``` New symptoms Visible symptoms Increasing severity of symptoms Duration of symptoms Psychological impact of symptoms e.g. stress, anxiety ```

Question 33

List non-medical factors which may influence the uptake of care

Answer 33

``` Personal/family crisis e.g. relationship difficulty, loss of job Peer pressure e.g. wife/friend sent me Patient beliefs about illness Patient expectations Social class Economic implications e.g. not paid if off work Culture Ethnicity Age Gender Media information Interference with social activities Access ```

Question 34

Describe the inductive reasoning model and its benefits

Answer 34

Can be used for patients with vague/unexplained symptoms Can be used by inexperienced doctors Involves systemic and comprehensive examination and history Often involves investigations e.g. blood tests, scans Evidence is then assessed to find an explanation for the symptoms

Question 35

Give a brief description of how hypothetico-deductive reasoning might be used in a patient presenting with chest pain.

Answer 35

Doctor’s experience generates a differential diagnosis from presenting symptoms Specific questions are used to establish a diagnosis, giving consideration to conditions requiring urgent attention e.g. MI Examination and investigation are used as appropriate to help establish a diagnosis

Question 36

Give a brief description of how pattern recognition may be used in a patient presenting with chickenpox.

Answer 36

Doctors experience will allow them to recognise the natural history of disease and pattern/type of spots This allows the doctor to draw a conclusion from the pattern and reach a certain or near certain diagnosis

Question 37

Using the WHO definition of health, give an example of the possible physical effects of cardiac failure on health.

Answer 37

Reduced mobility due to breathlessness/chest pain Difficulty with stairs Requirement for medication Difficulty with lifting/using tools at work

Question 38

Using the WHO definition of health, give an example of the possible psychological effects of cardiac failure on health.

Answer 38

Anxiety that illness may become worse Depression secondary to long-term condition Stress related to any time off work/no longer being able to do job to the best of his ability

Question 39

Using the WHO definition of health, give an example of the possible social effects of cardiac failure on health.

Answer 39

Reduction in working hours – less social contact Loss of earnings if time off work Illness limiting social activities/hobbies

Question 40

List 5 examples of differences in care provided by the GP and secondary care doctors of a patient with cardiac failure

Answer 40

GP likely to have been responsible for care for much longer (cradle to grave), secondary care only involved once cardiac symptoms developed GP responsible for all medical care, not just cardiac illness. Cardiac clinic only deals with his cardiac failure i.e. GP provides breadth of care compared with depth of care provided by secondary care consultant GP likely to look after other family members; unlikely that secondary care will be dealing with other family members Secondary care doctors have easier access to investigations than GP Risk and uncertainty relating to Andrew’s health more likely to be accepted by GP than secondary care doctors e.g. GP more likely to use time, try empirical treatment Quality of doctor/patient relationship likely to be improved by continuity of care in general practice, although patient with long-term condition such as Andrew is also likely to have good quality relationship with secondary care Opportunistic health care and health promotion more likely to occur in general practice setting Multiple short appointments in GP versus longer, less frequent appointments in secondary care GP looks after Andrew even when his condition is stable. Likely to be discharged from secondary care once condition is stable GP acts as a gatekeeper to secondary care. Secondary care doctors rarely employ a gatekeeper role

Question 41

List the advantages of house calls for the patient

Answer 41

Convenience e.g. no travelling May be essential – unfit to leave the house Social contact e.g. if patient lives alone/is isolated May be able to let GP see difficulties they have in their home environment

Question 42

List the disadvantages of house calls for the patient

Answer 42

Invasion of privacy Some will feel compelled to tidy, even if feeling very unwell Confidentiality issues e.g. a family member, carer, neighbour might be present Not every examination can be done at home so may be a delay in diagnosis Lack of ability to see their doctor of choice Lack of defined time for visit

Question 43

List 10 members of the health and social care team who may be involved in the care of an elderly patient with Parkinson's disease and give a brief description of their roles

Answer 43

GP – day-to-day medical support, monitoring of Parkinson’s disease and other conditions, coordination of care District nurse – dressings and management of pressure sore Home carer – practical tasks e.g. bathing and dressing Pharmacist – advice on medication, dosette box Social worker/care manager – advice on benefits e.g. attendance allowance, contact with agencies Occupational therapist – adaptation of living environment to maximise independence CPN – assessment and management of low mood Physiotherapist – continue to improve mobility and stability Dietician – advice on improving appetite, assessment of nutrition GMED/NHS 24 out-of-hours – care for unexpected deterioration/new condition Parkinson’s nurse specialist – specialist advice to patient and family relating to Parkinson’s disease, assist contact with local Parkison’s support group