Final revision Flashcards
Reasons for non Adherence
1) Language barrier
2) Low education level
3) Poor doctor-patient relationship
4) System related obstacles
Clinical approach steps
1) History
2) Examination
3) Investigation
4) diagnosis
5) Treatment/follow up
Tertiary care
- specialized consultative health care
- referral from a primary or secondary health professional
- has facilities for advanced medical investigation and treatment, such as a tertiary referral hospital.
Secondary care is
Medical care that is provided by specialist
-upon referral by a primary care physician
-that requires more specialized knowledge,
skill than the primary care physician
Primary care is
-care provided by physicians trained for and
skilled in comprehensive first contact
-continuing care for persons with any health
concern
good physician treats the disease, but great physician treats…..
the patient who has the disease
Referral means
Referral does not mean transferring responsibility But it’s sharing responsibility in patient care.
How to write a referral letter?
1) Patient details
2) Name of physician
3) Reason for referral
4) Degree of urgency
5) Clinical points
6) Previous injury
7) Findings on physical exam/ investigations
8) Medication and drug sensitivity
9) Expected outcome and desirable follow up
4 levels of Referrals are
1st • From family physician primary health care to hospital specialist.
2nd • From specialist to another specialist.
3rd • From junior specialist to senior specialist.
4th • from general hospital to specialized hospital
disadvantages of teleconsultation
- No non-verbal cues, hidden agendas or fears
- No examination findings, No opportunity for near patient testing e.g. pregnancy test
- Deafness, language can be a big barrier to communication
- Reduced opportunity for health promotion
- Issues of confidentiality, who are you talking to and who may overhear?
Disadvantages of self medication
- Adverse Drug Reactions.
- Chances of using wrong medication.
- Drug & food interactions.
- Lack of knowledge about dose.
- Risk of disease aggravation.
History taking steps
1) Personal history: Full name, age, sex, marital status, occupation
2) Chief complaints: The main reason of visit. recorded in patients own words.
3) Present history: Elaborate on chief complaint in detail, describe each symptom in chronological order.
4) Past history: ask if they have any medical problems like past surgery/operation, history of trauma/accidents and drug history.
5) Family history: hereditary diseases
6) Social history: Smoking, drinking, occupation/education.
Other relevant history: Gynae history for female, immunization if small child and sexual/travel history if STI or infectious disease.
Top 5 reasons for consulting a doctor
- Reaching anxiety threshold
- Reaching symptom threshold
- For follow up
- For prevention “vaccine”
- For administrative reasons
Case 1: young healthy man has a low-grade fever. He may react to it by:
a) Neglect b)Taking time off work c) Self-medication d) Visiting his physician
Neglect
—-% of patients neglect their illness
20%
Case 2: A young healthy lady has a high fever. She may react to it by:
Self-medication
__% of the patients may try to help themselves by rest and self medication
75
Patient Agenda: model 6-Helman folk model 1981 suggest that patient comes to doctor to answer 6 questions:
1) What has happened 2) Why it has happened 3) Why now 4) Why me 5) What would happen if nothing done towards it 6) what should be done/who I should consult
Model-McWhinneys Disease-Illness model 1986 suggests
that the doctor weaves between his agenda and that of the patient’s in a formulated management plan that satisfies the patients expectations.
Good comunication skills consist of
- Greeting the patient
- Open ended questions, active listening
- Facilitating verbal and nonverbal cues
- Clarification of the problem: History of current problem
- Analysis of the problem
- Explore patient ideas
- effect of the problem on family
Patient centered case
1) Shared consultation and management with patient
2) Focus on the patient as a whole not the disease
Provides partnership with patient
Patients become active and consider medical decisions makers
enhance patient physician relationship
Understanding the whole process
Patient centered method
1) Explore both diseases and patients
2) Understanding the whole person
3) Finding common ground
4) Disease prevention and health promotion
- Health enhancement: detect areas in patients life that need improvement
- Risk reduction and early detection
- Complication reduction
5) Patient-Doctor relationship
- Caring and healing
- Trust and respect
- Different patient needs different approaches
6) Be realistic
- Time
- Resources
- Emotional and physical needs of doctor
Myths around patient centered care (PCC)
1) its the ‘softer medicine”
2) disables the doctor
3) Only applicable in certain types of visits
4) Only applicable in family medicine
5) time consuming
Benefits of patient centered care (PCC)
1) Greater level of patient satisfaction
2) Greater level of doctor satisfaction
3) Better patient adherence
4) Improves patient outcomes
5) positive impact on utilization costs
6) Fewer malpractice claims
7) Higher quality of self reporting
Complaince
The extent to which the person’s behavior coincides with medical advise. Important in chronic diseases.
The different dimensions of adherence are
1) Socio-economic
2) Health care system
3) Condition-related
4) Therapy related
5) Patient related
______ is the biggest and the most common threat to medical practices.
Non-adherence
Non adherence maybe:
1) Intentional= active patient decision
2) unintentional= passive: carless or forgetful
Reasons for not taking medication
1) Forgetful
2) Symptoms disappear
3) Save money
4) Considered drug ineffective
5) Don’t need
6) side effects
7) Prevent other activities
8) No Rx reminder
Average information retention of patient:
1) 80% forgotten immediately
2) 20% of this 20% half misunderstood (10% overall) and half remember accurately (10% overall)
Effects of Non adherence
1) increase hospital readmission
2) Increase complications
3) Increase cost
4) decrease quality of life
5) patient death worst case scenario
Methods to detect non adherence
1) Direct objective: Measure drug level in blood
2) Indirect objective: pill count, prescription refilling
3) Health outcome measures: BP control/ asthma severity
4) Utilization of health core services: clinical attendance/appointment
5) Indirect subjective: patient interview
External Factors affecting compliance
1) health care provider
2) pharmacist
3) product/packaging
4) News/media
5) Government/payers
Patient experience affecting compliance
1) Side effects
2) Phycological issues
3) cost/insurance
4) awareness
5) co-morbidities
6) Rx benefits not noticeable because of delayed onset.
To simplify therapeutic regimen you could
Minimize the complexity of the doses
When educating the patient about medication you must explain
Name of med Action Route of Administration Common side-effects Self monitoring Storage Drug interactions Action if does is missed Selection of Over the counter drugs
What are the vital signs
Reflect body physiological and homeostatic state which include Temperature Heart rate/pulse Respiratory rate Blood pressure
Purpose of the vital signs checking
Base line data bout condition
Diagnostic purpose
Therapeutic purpose
When should you check vitals
On admission
Change in health status=symptoms or signs
Nursing or medical order
Before and after medications that may affect CVS and respiratory system
Before and after surgeries or invasive procedures
Before and after nursing procedures
Hospital policy
Conditions of the room for vitals taking?
Must be quite and warm
Before taking vitals you should……
Observe patient for a minute
Normal temperature via oral route is ……..
37 C
Core temp is often measured because it is ……..
Constant for most of the time and tells you about the state of internal organs
Surface temperature ranges from …….to…… degrees C. It _____indicate internal state
20-40, doesn’t
Pyrexia is
A fever ranging from 38-41 C
Hyperpyrexia is
Very high fever, greater than 41 C and it may be fatal.
Hypothermia is
Drop in body temperature. Usually between 34-35 C; if it drops below 34, its likely fatal.
Factors affecting body temperature
Age Sex Circadian rhythm Hormones Stress Environment
What controls body temperature
Thermo-regulator center, preoptic in hypothalmus
Body physiological reactions to heat loss is….
Vasoconstriction
Shivering
Increase thyroid H
Increase sympathetic
How the body reacts to heat gain
Vasodilation
Sweating
Indications for measuring temperature
- Obtain baseline temp. to compare with future
- Close observation raise/fall of temp.
- Observe patients with infections
- Monitor anti-microbials
- Monitor reaction for blood transfusion
Methods of measuring temperature are
Oral
Axillary
Rectal
Tympanic
Describe Oral site for temp measuring
Sublingual. The most common site. 0.65 less than rectal and 0.65 more than axillary. Leave for (3-5min)
How is the oral temp method inconvenient
unconscious
Infants
Oral ulcers
Persistent cough
Advantages of Oral temperature measuring
Easy and comfortable
Disadvantages of oral temp measuring
False readings from hot drinks or smoking (wait 10-15 minutes for mouth to cool down)
What are the contraindications of the oral route of measuring temp.
Patient can't follow instructions Child less than 7 years old Unconscious Epileptic or mentality ill Patient receiving O2 Persistent cough Oral ulcers or surgery Nasal obstructions or tube
In the rectal temp taking method you must hold thermometer for about ______ minutes
3-5 minutes
Advantages of rectal temp measuring
More accurate and reliable
Disadvantages of rectal temp reading
Injury to rectum
Needs privacy
Inappropriate to use with diarrhea and anal fissure
Contraindications of rectal temp measuring
Rectal or anal surgery
Fecal impaction
Recital impaction
Advantages of axillary temp measuring
safe and non invasive
Recommended for infants and children
Disadvantages of axillary temp measuring
Longer time (5-10 min)
Less accurate
Influenced by factors such as bathing
Advantages of Tympanic temp measuring
In outer ear canal, so its very fast (1-2 sec)
Suitable in pediatrics and unconscious
Disadvantage of tympanic temp measuring
Uncomfortable
Risk of injuring tympanic membrane
May be affected by wax
Right and left ear may have different measurements
The tympanic method uses a ________ to measure from the ________
Special tympanic thermometer that senses infrared rays, tympanic membrane
The pulse is
a wave of blood created by contractions of Left ventricle, it reflects the heart beat
The pulse is influenced by
Stroke volume and arterial compliance
Peripheral pulse is
pulse in the periphery of the body
The apical pulse is
the central Pulse at the apex of the heart
Pulse difference between apical and peripheral is usually
zero
Factors affecting pulse rate
1)Age: infant (100-160) Adult (60-100)
2)Sex: after puberty girls have higher pulse rate
Autonomic stimulation
Exercise
Fever increases PR due to lowered ABP and increased metabolic rate
Medications such as:
- Digoxin drops PR
- Beta blockers decrease PR
- Diuretics increase PR
Pulse sites
Carotid Temporal Apical (routine for children under 3) Brachial Radial (routinely used) Popliteal Femoral Post tibial Pedal
To asses pulse you must observe
Rate
Rhythm; if irregular dysthymia
Volume/force
Elasticity of arterial wall
If pulse is regular, count_____ if irregular count _______
30 sec, whole minute
Hyperventilation is
Deep and rapid
Hypoventilation is
Shallow resp
Adults use ______breathing
Costal
Children use _______breathing
Abdominal+ diaphragmatic
Factors affecting respiration
Age; Adults have lower rates
Medication; Narcotics decrease breathing rate
Stress and exercise increase breathing rate
High altitudes increase breathing rate
Gender: women have higher breathing rate than men
In normal adult RR is
15-20 per minute
If regular RR count ______if irregular count ______
30 sec, whole minute
Eupnea is
normal rate and depth in breathing
Apnea means
cessation
1/2 patients gasp during
Cardiac arrest
To measure BP you use a
Sphygmomanometer
Which arteries are most common used to measure BP
Brachial and popliteal
Factors affecting BP
Fever Stress Arteriosclerosis Cold Obesity Hemorrhage Low hematocrite (hemoglobin) External heat
Define hypertension
Persistent elevated ABP in 3 successive different occasions
In hypertension the primary is_____and secondary is____
Unknown causes, known causes
Stage 1 hypertension
130-139 systole and 80-89 diaystole
Stage 2 hypertension
greater than 140 and greater than 90
Hypertension urgency is
systole greater than 120, no end organ disfunction
Hypertension emergency
Systole greater than 120 accompanied by end organ disfunction
White coated hypertension is when
BP measured higher at clinic than at home
Isolated systolic hypertension grade 1 and 2
grade 1: systolic 150-159 diastolic less than 80
Grade 2: Systolic greater than 160 diastolic less than 80
Difference between sinusitis and rhinitis
Sinusitis has headache, cough and fever and pungent rhinorrhea
Rhinitis has runny nose, itch red eyes, and nasal crease with clear rhinorrhea
_______always precedes _______itits
Rhinitis, sinusitis
How to encounter patient with sinusitis or rhinitis
Reassure that antibiotics are not needed immediately
When to prescribe antibiotics
Patients systemically unwell
Having signs of serious illness
Patient having complications
Serious complication
