Exam 2 and 3 - CEL, Comms, LEAPS Flashcards
How do you incorporate spiritual history taking?
FICA
F - Faith or Belief
I - Importance/Influence
C - Community
A - Address/Action
What are the pros/cons of a professional interpreter vs informal?
a) Professional Interpreter: PROS: - speed - accuracy - doctor confidence in communication - better informed consent process CONS: - time - cost - practically - not always trained in medical terminology
b) Informal interpreter: PROS: - convenience - availability - no cost - help with gaining patient trust CONS: - accuracy - understanding of medical terminology - increased appointment time - privacy may be compromised – patient might not disclose as much - difficult if they are a child
What 5 locations should you take a pule from?
- Atrial
- Radial
- Brachial
- Femoral
- Carotid
Where do you take an atrial pulse from?
Adult - 5th intercostal space, 8-10cm left of midline.
Child - 4th.3-5cm from midline
What is the first pulse you check?
Radial
How to you take a pulse?
Palpate a superficial artery and count number of beats felt.
Where do you take the femoral pulse?
Mid inguinal crease between anterior supernal iliac crest and pubic bone.
Femoral artery
Can laterally rotate leg to get better angle.
How do you describe heart rhythm?
i) regular regular – sinus rhythm = normal cardiac rhythm. (electrical impulse is the same as the normal rhythm)
ii) regular irregular – sinus arrhythmia (normal when HR is quicker during inspiration)
iii) irregular irregular – i.e. atrial fibrillation. Irregular intervals of sinus and contraction rhythms.
How do you define heart rate?
i) bradychardia - 100
What are the normal pulses, Systolic Bps and RRs of children?
a) 12 years
- Pulse: 60-120
- SBP: 90-150
- RR: 15-25
Where COULD you take a temp from? What temperatures are normal?
Where SHOULD you take a temp from?
a) Oral
i) Mean – 36.8 +- 0.4
ii) upper limit of normal: 37.2 at 6am and 37.7 at 4pm.
b) Rectal
- up to 0.5 higher than oral
c) Axilla (armpit) – less accurate
- up to 0.5 lower than oral
d) Tympanic (ear)
Prefered sites:
a) Up to 2 yrs – digital axilla
b) child – digital tympanic
c) adult – digital tympanic
When are the highest and lowest body temps during the day?
Highest – 4-6pm
Lowest – 6am
How do you take BP?
Auscultatory method.
a) positioning: patient should be seated/lying comfortably. Cuff should be approximately at heart level.
b) cuff application – 2cm above cubital fossa crease and artery line marking should be inline with brachial artery.
c) While palpitating pule, pump cuff to estimate systolic reading (when pulse disappears)
d) note value and deflate completely
e) Diaphram of steth goes over brachial artery
f) inflate 20-30mmHg above previous estimate of SBP.
g) Deflate at rate of 2-3mmHg per second and listen for Korotcoff sounds.
i) KI – SBP = first sound heart
ii) KII – sound increases in intensity
iii) KIII – sound decreases
iv) KIV – sound becomes muffled
v) KV – DBP – sound ceases
What are the parts of a stethoscope?
Two ear pieces, tubing and chest piece.
Chest piece has a diaphragm (amplifies high pitches) and bell (low pitches)
How do you describe BP?
a) Normal140/90
i) mild: SBP 140-159 and DBP 90-99
ii) moderate: SBP 160-179 and DBP 100-109
iii) severe: SBP>180 and DBO>110
What are some of the factors that can impact on blood pressure reading?
a) Patient activity:
i) Exercise/stress – increase
ii) Caffeine/Smoking – increase
b) cuff size:
Small will overestimate and low will under.
c) position of arm:
i) unsupported – increase
ii) If cuff to high – decrease. If too low – increase
iii) Tight clothing – underestimate
d) During the recording:
i) patient talking – increase
ii) moving – increase or decreasing depending on hight levels (see cii)
e) Errors in technique:
i) if correctly estimate SBP at first, might miss systolic reading. Auscultatory gap (10-20mmHg) can cause sound to disappear at rate lower than SBP and then reappear again.
ii) Quick deflation – decrease
ii) rounding off
iv) Repeat after a few minutes and check both arms. Normal for 5-10mmHg variation.
What should the cuff size for children be for BP reading?
Bladder length – cover 80-90% of the circumference of the arm
Bladder width – length ratio should be at least 1:2
What should the cuff size for children be for BP reading?
Bladder length – cover at least 80% of the circumference of the arm
Bladder width – cover at least 40% of the circumference of the mid upper arm.
What is a postural drop?
Compare BP meadured from supine (on back) position vs standing after 2 mins. If SBP>20mmHd or DBP>10mmHg lower after 3 mins then this is a significant postural drop.
How do you take peripheral perfusion?
pressing for 3-4 seconds on pulp of fingertip then remove to check capillary refill time (time taken for are to return to original pink colour).
Normal -
Why are the normal vital signs for children so variable and why can’t you rely on them?
a) immature systems – won’t always mount an immunological or hypothalamic response to infection, so might not have fever with infections.
b) Compensation – BP change is a late response and may be serious, i.e. septic shock. They just compensate by increasing cardiac output when they have low circulating volume and increasing capillary tension.
c) Respiratory system less able to respond affectively – small and underdeveloped. Not good indicator of unstable physiology.
How do you wash your hands with alcohol?
- Apply
- Rub palms
- Right palm over left dorsum with interlaced fingers and visa versa
- Palm to palm with fingers interlaces
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of thumbs
- Rotational rubbing of finger tups on palm
- Dry - safe
How do you wash your hands with soap and water?
- Wet hands
- Apply
- Rub palms
- Right palm over left dorsum with interlaced fingers and visa versa
- Palm to palm with fingers interlaces
- Back of fingers to opposing palms with fingers interlocked
- Rotational rubbing of thumbs
- Rotational rubbing of finger tups on palm
- Rinse hands with water
- dry hands thoroughly with single use towel
- use towel to turn off faucet
- safe
What are the 5 moments of hand washing?
- Before you touch a patient
- Before you perform a clean/aseptic procedure
- After touching a patient
- After touching a patient’s surroundings
- After body fluid exposure risk
How do you put on gloves?
- Take out of box
- only tough top edge of cuff
- put on one glove
- Take second out with bare hand, only touching edge of cuff.
- Avoid touching skin on forearm by folding fingers into external surface
- don’t touch anything
How do you remove gloves?
- pinch write and pee off, allowing it to turn inside out
- hold removed glove in gloved hand
- slide ungloved fingers under glove and remove by rolling down hand and fold into first glove
- Discard
- Hand hygeine
What are the ethical principles that can be applied to medical problems?
- Treating people equally - ignores all other relevant principles
a) lottery
b) first come first serve - Prioritarianism (favouring the worst off)
a) Sickness first
b) youngest first - Utilitarianism
a) number of lives saved
b) prognosis/life years saved - Social Usefulness
a) instrumental value - future
b) reciprocity - past looking
What are the factors that affect perception of risk?*
- Trust vs lack of trust
- Voluntary/controllable vs coerced/uncontrollable
- natural vs man made
- not dreaded vs dresses
- chronic or catastrophic
- Familiar/awareness vs unfamiliar
- affects adults vs affects children
What are the stages of change in motivational interviewing?*
a) Pre-contemplation – raise doubt
b) Contemplation – tip the balance - address ambivalent
c) Determination – help them determine the best course of action (or preparation/decision making)
d) Action – help them take steps toward plan – ‘Action Plan’
e) Maintenance – prevent relapse
f) Relapse – renew stage of change
What are the broad determinants of health?*
- individual and psychological make up (effects everything)
- Broad features of society (culture, cohesion, media, politics)
- Environmental Factors (remoteness, natural)
- Socioeconomic characteristics
- knowledge, attitudes and beliefs (health literacy)
- health behaviours (lifestyle)
- psychological factors (stress, trauma)
- safety factors (OH&S, risk factors)
- biomedical factors (birth weight, BP, weight)
= health and wellbeing overtime
What is the Health Belief Model?
Likelihood of an individual taking action related to a given health problem is based on the interaction between four different types of belief:
- Perceived susceptibility to a problem (perceived threat)
- Perceived seriousness of consequences (perceived threat)
- Perceived benefits (outcome expectations)
- Perceived barriers (outcome expectations)
What communication strategies are used in motivational interviewing?
OARS
O - ask open ended questions
A - provide affirmation
R - reflective listening
S - summarizing statement
What are some important factors in motivational interviewing?
- collaboration
- evocation
- autonomy
- exploration
- non-judgmental
- express empathy
- develop discrepancy
- roll with resistance
- support self efficacy
How do you evoke change talk?
- Disadvantaged of the status quo
- advantages of change
- optimism for change
- intention to change
Evoking change talk about importance:
Scale 0-10
- tell me why you chose that number?
- what could happen that would increase it?
Evoking change talk about confidence:
Scale 0-10
- tell me why you chose that number?
- what could happen that would increase it?
What are the main points for a brief intervention?
5A’s
- Ask
- Assess
- Advise
- Assist
- Arrange - regular follow ups
What is the attack rate of a disease?
No. of people at risk who develop illness/total number of people at risk
Herd immunity?
A situation in which a sufficient proportion of a population is immune to an infectious disease (through vaccination and/or prior illness) to make its spread from person to person unlikely
What are the 4 major factors of CD’s?
- Characteristics of the Infectious Organism
- Characteristics of the Host (individual who is infected)
- Characteristics of Transmission
- Influence of the Environment
What are the types of transmission of CDs?
- Air-borne
- Water-borne
- Blood-borne
- Vertical (i.e. syphilis)
- Sexual
- Faecal-oral
- Vector Borne
What are the steps to investigate a CD?**
A. Obtain background info:
- Prepare for field work
- Establish the existence of an outbreak, consider severity, potential for spread, public concern and availability of resources
- Verify diagnosis
B. Define the problem
- Define and identify the cases - case definition and line listing
- Describe and orient the data in terms of time, place and person (descriptive epidemiology) - PLOT EPIDEMIC CURVE
C. Formulate a hypothesis
6. Develop hypothesis (agent, host, environment, trait) = chain of transmission
D. Develop a study to test hypothesis, collect data and observations, evaluate results.
7. Evaluate hypothesis (analytical studies must have control group)
E. Determine if H is true/modify (8), formulate conclusion (9) and report results (10).
- Refine hypothesis and carry out additional studies
- Implement control and prevention methods
- Communicate findings
What is a CD outbreak and what are the main questions to ask to establish if an outbreak exists?
• Cases of disease in excess of expected number for a given
time, place and/or group
• Smaller scale than an epidemic
- Main questions:
- What is the disease?
- What is the source?
- How is it being spread?
- How can the outbreak be stopped?
What is involved in verifying diagnosis (Q4) for CDs?
Confirm through:
a) clinical (probable)
b) lab (confirmed)
Establish definition - standard set of criteria
What is involved in ‘Define and identify the case’ for CDs?
• Identify cases & case-finding: Notifications, GPs, Labs, Schools etc
• Gather information -Demographics, clinical details, exposures (eg. Food history)
- Questionnaires (hypothesis generating interviews)
- Line listing- Person, place and time
- Plot an epidemic curve
What is involved in ‘Describe and orient the data in terms of time, place and person’ (5) for CDs?
Time - epidemic curve
- Point source (i.e. food poisoning from a
- Extended source - often food contamination
- propagative - i.e. virus
What factors are involved in the emergence and re-emergence of diseases?
- microbial adaption and change
- human susceptibility to infection
- climate and weather
- change in human demographics and behaviour
- eco development and land use
- breakdown of public health measures
- poverty and social inequality
- war and famine
- intent to harm
Types of emerging infections classification, what do they mean and what are some examples?**
- Newly emerging - not previously recognised in humans (SARS, H1N1, HIV, Ebola)
- Re-emerging and Resurging infections - existed in past but are now increasing in incidence of geographical/human host (MDR TB, cholera, malaria, Dengue)
- Deliberately emerging infections (anthrax)
What are neglected tropical diseases?
They are called neglected because they have been largely wiped out in the more developed parts of the world and persist only in the poorest, most marginalized communities and conflict areas.
- double burden of disease
- > 1 billion people have one or more NTD
Examples: leprosy, trachoma, dengue fever
What are some emerging, re-emerging and NTDs?
Emerging:
- Aids
- Legionnaires
- Hendra virus
- SARS
- MRSA infection
- pandemic influenza
- Clostridium difficile
- H1N1 (swine)
Re-Emerging:
- Malaria
- Pertussis
- Cholera
NTDs:
- leprosy
- trachoma
- dengue fever
What is involved in ‘Implement control and prevention methods’ (9) for CDs?
a) Source
- treat cases
- isolate cases
- food recall
b) Transmission
- environment measures
- hand washing
- hygiene
c) Host
- immunisation
What is involved in CD surveillance? (‘secondary prevention’)
Ongoing systematic data collection
• Determine background level of the disease
• Examine trends over time
• Examine difference between locations & populations (so determine risk factors)
• Identify outbreaks and epidemics
• Monitor effects of interventions (eg. Immunisation)
What are the surveillance types?
a) Passive
• Notifiablediseases
• Notificationrequiredbylaw
• Need to be monitored for public health purposes (immunisation, contact tracing, investigation of outbreaks)
• Completeness depends on disease (severity, rarity, accurate diagnosis)
b) Active
• Finding cases in potential epidemic situations
c) Sentinel
• Cost effective
• A sample of places or people -GPs/Specific hospitals
• Early warning; less serious diseases
d) Enhanced
Gathering more detailed information from cases (from the notification system)
What are the facts about H5N1?
- Avian Flu
- affects poultry flocks in an increasing number of countries
- Aggressive infection - quickly kills whole flocks
- Can infect humans - mainly only people living/working with poultry
Over 200 people infected - more than half have died (mortality rate >60%)
- Cannot yet easily spread from person to person
- affected China, Vietnam, Indonesia etc
What are the 3 attributes that a flu virus needs to become a pandemic? (i.e. Avian flu)
- novel
- causes significant illness/death
- spreads easily
1) A novel (new) virus which humans have no immunity
2) The virus causes significant human illness and death
3) The virus can spread easily from person to person (Avian flu does not have this)
Why are flu pandemics recurring events?
- virus continues to mutate
What is the global burden of CDs?
- About 15 million (26%) of 57 million annual deaths
- Burden most heavy on developing countries – infants and children
- Developed countries – Indigenous and disadvantaged people
- 2nd leading cause of death world wide
- More than half the world’s population is at risk of these diseases
CASE: Measles in Australia and globally
- elimination of endemic measles due to good uptake of MMR in 1999
- Average = 100 per year due to imported cases
- two doses of MMR to Aus children at 12 and 18 months
- contagious - 1 person = 12-18
- Aus - campaigns to prevent measles being brought in to the country by unvaccinated travellers
- AMA guidance is that vaccination rates below 93% are unsafe
- Rachel and Lola - deaf
- NOTIFIABLE DISEASE
GLOBAL:
Disney land - 95 infected
Worldwide many countries got >1000 cases per 5 month period from 2013
- one of the leading causes of vaccine-preventable death in children world wide
What do you do with notifiable diseases?
You contact the local Public Health Unit to inform them you have seen a likely case of measles.
The Public Health Unit staff’s role now is to work with both you and the patient to:
• find out how the infection occurred
• identify other people at risk of
infection
• implement control measures (such as immunisation and restrictions on attending school or work)
• provide any other advice as needed
CASE: Pertussis in Australia
- early 2015, baby Riley died of whooping cough in Perth
CASE: TB in Australia
- Tuberculosis (TB) is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent
- huge in south africa
- Stop TB partnership
In Aus, • The Western Australian Department of Health is notified and the Western Australian Tuberculosis Control Program take over the management of the outbreak. The Department of health staff begin tracing and screening close contacts – this includes immediate household members, extended family and friends and workplace contacts (staff and patients)
CASE: Chlamydia in Australia
Australian re-emerging infection
83,000 cases diagnosed in 2012
What are some of the homeostatic results of intense exercise?
- Breathing rate increases (Respiratory rate, increase tidal volume, minute volume ventilation)
- Heat and sweat
- Heart - cardiac output, heart rate, stroke volume
- get flushed - blood flow increases to the skin
- feel hot (cognitive sensation of heat)
- dehydration, body mechanisms come into play to try and conserve water. ADH - antidiuretic hormone
Describe at least one example of a neural control system and one example of a hormonal control system
Neural – hypothalamus and temperature
ADH = anti-diuretic hormone. Increased levels of ADH result in greater reabsorption and decreased water excretion.
What are the three muscle metabolic systems in exercise?
- Phosphocreatine-Creatine system - very high E and very quick - 8-10 seconds. moles of ATP/min = 4
- Glygocen-Lactic Acid System (anaerobic) - alot faster than aerobic. 1.3-1.6 mins. ATP/min = 2.5
- Aerobic system - mitochondria - glucose, fatty acids, amino acids. Unlimited time as long as nutrients last (so high carb diet is better). ATP/min = 1
What are the steps in the catabolism of carbs?
xxx
What are the steps in the catabolism of proteins?
xxx
What are the steps in the catabolism of fats?
xxx
What are the physiological changes in the respiratory system during exercise?
High respiratory and heart rate. Oxygen debt, also RR is high because heart rate is still very high and they are linked.
Training doesn’t have that big of an effect on the oxygen-diffusion capacity of our lungs. This is because its not really the limiting factor in delivery of oxygen - the heart is.
What are the physiological changes in the cardiovascular system during exercise?
Vasodilation to get more blood to muscle and heat out of skin, AND more blood to muscles. Increased HR, increased Stroke Volume, Increased BP.
EFFECTS OF TRAINING - HEART CHAMBERS ENLARGE AND MUSCLE
HYPERTROPHIES, so heart pumping effectiveness increases due to greater stroke volume, so heart rate can decrease.
What is Exertional hyponatremia?
Exertional hyponatremia – low sodium concentration in blood which typically results from an athletes ingestion of more water or low solute drinks and not replacing sodium lost through sweating.
What happens if your body temp boas above 40?
> 40, temp becomes destructive to tissue cells, especially brain cells.
What is the normal temp range during exercise?
37-40
What is the difference between heat stroke and heat exhaustion?
Heat stroke - >40 degrees
What do you do when someone has heat stroke?
- call for an ambulance
- resuscitate following the Basic Life Support Flow Chart (ANZCOR Guideline 8)
- place the victim in a cool environment
- moisten the skin with a moist cloth or atomizer spray and fan repeatedly
- apply wrapped ice packs to neck, groin and armpits.
ANZCOR suggest a 3-8% carbohydrate electrolyte fluid [any commercially available “sports drink”] for the treatment of exertion related dehydration (CoSTR 2015, weak recommendation, very low quality evidence)8. If carbohydrate electrolyte fluid is unavailable, water is an acceptable alternative.
What do you do when someone has heat exhaustion?
- lie the victim down in a cool environment or in the shade
- loosen and remove excessive clothing
- moisten the skin with a moist cloth or atomizer spray
- cool by fanning
- give water to drink if fully conscious
- call for an ambulance if not quickly improving.
What is anaphylaxis?
An acute allergic reaction to an antigen (e.g. a bee sting) to which the body has become hypersensitive. Multisystem involvement. Extreme end of the allergy spectrum.
What are potentially life threatening symptoms of anaphylaxis?
- Difficult/noisy breathing
- Swelling of tongue
- Swelling/tightness in throat
- Difficulty talking and/or hoarse voice
- Wheeze or persistent cough
- Persistent dizziness and/or collapse
- Pale and floppy (in young children)
What are less severe symptoms of allergic reactions that can precede anaphylaxis?
- Swelling of face, lips and/or eyes
- Hives or welts
- Abdominal pain, vomiting (these are signs of anaphylaxis for insect allergy)
- Several factors can influence the severity of an allergic reaction. These include exercise, heat, alcohol, and in food allergic people, the amount eaten and how it is prepared.
In what way in anaphylaxis a mixed shock?
low blood volume and pressure
What are immunological and non-immunological triggers for anaphylaxis?
- Immunological - a) IgE - food, bites, stings and sometimes drugs
b) non IgE = complement, immune complexes, autoimmune, coag activation - viruses - Non-immunological - mast cell degranulation, cold air/water, exercise, some drugs
Food = eggs, cows milk, peanuts, tree nuts, wheat, fish, shellfish, soy, sesame. Bugs = bee stings,
wasps, ants etc.Drugs: penicillin, anaesthetic etc. Other: latex,
How should you monitor a child with anaphylaxis?
Pulse rate, BP, pulse oximitary, ECG, respiratory rate. Remember in children, BP can be fairly constant, but one of the early signs is the RR going up and anxiety.
What is the mechanism of action of adrenaline? Where does it act according to your concept map?
Vasoconstriction. Part of our sympathetic nervous system – neurotransmitter is noradrenaline. Bronchodilator which helps for breathing. Increase heart rate,
Explain the adverse effects and precautions for adrenaline, based on what you know about autonomic effects of the sympathetic nervous system for each organ system.
Increase heart rate, vasoconstriction, high BP, feeling anxious, headaches and burred vision, tachycardia, chest pain, shortness of breath, sweating, nausea and vomiting. Inhibits mast cells.
What are the pharmacological agents used in anaphylaxis?
Frontline therapy = adrenaline (if they don’t respond to first shot, give a second one within 5 mins) Also Oxygen, saline.
Other = adrenaline infusion in ED, glucagon, vasopresin (vasoconstrictor), metarinol, salbutamol (if they are wheezing)
What do you need to do for a rural transfer?
People, equipment you have available and transfer – timing and safety.
TRANSPORT/PEOPLE: Need 2 personnel to go with ambulance to another setting. Some rural ambos are volunteers and are not trained enough. Also important they have medical staff left at the first medical place.
EQUIPMENT: oxygen, drugs, speak to specialist colleagues (can do this on phone)
- transfer with oxygen (have already given adrenaline and have inserted IV line in case of emergency.
- communication is important, i.e. with parents/guardians, and with transport people and people at place you a re transferring them to.
- many places have transfer protocols
- you are dealing with an anxious child, so you need to tell parent to be calm so the child can be more relaxed. Parent accompanies child in the ambulance to help.
Why do children have a higher pulse?
Cardiac output = HR x Stroke Volume.
Stroke volume is markedly reduced in kids, so to maintain cardiac output they have a high HR.
Why do children have a higher RR?
Tidal volume is significantly less, therefore need to take more breath for sufficient gas exchange.
As vital signs can’t always be relied on for children, what else can you look for as a warning sign?
behavioral changes such as anxiety, restlessness, lethargy
How do you communicate with children
- it’s going to dependent the age of the child. Babies are totally reliant on the parent so you rely on the parent to give a history and to consent an examination. Around 12 month mark they become a bit more mobile, but they still have their parental figures for comfort and security.
- Approach them in a friendly way.
- Kids love toys.
- Eye level.
- But sometimes they are so distressed, so may need parents help – i.e. to hold the child still or to let the child sit on their lap while you examine them.
What is an action plan for a mild allergic reaction?
- For insect allergy, flick out sting if visible. Do not remove ticks.
- Stay with person and call for help.
- Locate EpiPen® or EpiPen® Jr adrenaline autoinjector.
- Give other medications (if prescribed)………………………………………………. • Phone family/emergency contact.
What is an action plan for anaphylaxis?**
1 Lay person flat. Do not allow them to stand or walk. If breathing is difficult allow them to sit.
2 Give EpiPen® or EpiPen® Jr adrenaline autoinjector.
3 Phone ambulance*: 000 (AU) or 111 (NZ).
4 Phone family/emergency contact.
5 Further adrenaline doses may be given if no response after
5 minutes, if another adrenaline autoinjector is available.
In what ways are epidemics such as Ebola and Zika driven by pathologies of society?
- the way populations move and migrate. Migrant populations don’t have great access to health care
- hybrid viruses that appear in food processing factories and increase the chances of human-animal interactions
- increased interactions between humans and forest animals - indigent populations are forced deeper into forested areas to look for food.
- economic exploitation - results in under resourced and weak health systems
What are some of the political challenges faced by refugees in the process?
- process can be long – 10 months on average
- in Thailand, they are not issued with a passport but with a travel document. The only way they can return is with a passport from their host country.
- only small amounts of cultural orientation – 3-5 days
- no medicare, PBS etc
What are some of the common diseases/conditions that refugees might have?
- Food insecurity and nutritional deficiencies - especially vitamin D and iron
- Infectious - TB, malaria (1/3 refugee children have had malaria before arriving in Aus), HIV, H.pylori, tinea; parasites including schistosomiasis, strongyloides, giardia; immunisation status
- Haematological- anaemia assoc. with chronic infection, iron deficiency, haemoglobinopathies (thalassemia, sickle cell disease)
- Dental - varies (but only 1/3 report toothache despite being severe)
- Failure to thrive - multifactorial; psychological factors can have significant impact; nutritional compromise prior to arrival
- physical problems associated with journey itself
- physical problems due to torture/abuse/violence
FAMILY HISTORY MIGHT NOT BE KNOWN