Family Medicine Final

Communication Skills (General & Special Populations)

• Core Principles:
  • Good communication can decrease litigation and may decrease the need for investigation.
  • It involves being highly skilled, ruling out serious diseases, and avoiding being judgmental.
  • Pacing (matching language, body language) is a way to establish rapport.
  • Watch patient gestures and be aware of your own reactions.

• Active Listening:
  • False: Negotiating priorities is not part of active listening.
  • True: Involves asking open questions, summarizing, asking for clarification appropriately, and attending to verbal and non-verbal cues.

• Consultation Tasks & Questioning:
  • Stott and Davis Tasks: Identify presenting problem, promote health, manage continuing problems, identify hidden agenda, modify help-seeking behavior. (Identifying hidden agenda is often tested as not always achieved).
  • Question Types: Use open-ended questions initially ("How can I help you?"). Funneling involves starting open and moving to closed questions. Avoid leading questions (e.g., "Do you complain of something besides your pain?").
  • Therapeutic procedures are essential in the interview.
  • Summarizing the patient's message in your own words is facilitation.
  • Silence can be used appropriately.

• Special Populations:
  • Adolescents:
    • Treat as responsible.
    • Confidentiality is a major issue but may need to be breached in specific situations (this wasn't explicitly tested as breachable here, but context implies importance).
    • Use metaphor/humor appropriately.
    • HEADSSS acronym is a guide for psychosocial assessment (Not for elderly).
    • Take a curious, non-intrusive stance.
  • Elderly:
    • Home visits can build good relationships.
    • Consider elder abuse.
    • Pain threshold may be higher.
    • Patients often have multiple issues with different priorities than the doctor.
    • Do not assume talking loudly/slowly is always needed unless presbycusis is confirmed.
  • Children:
    • Toys in the clinic: Can help, but cannot accurately diagnose autism. Need toys for various age ranges (e.g., above and below 3 years).
  • Chaperones:
    • Needed for potentially embarrassing exams, regardless of examiner/patient gender.
    • Role: Offer emotional support, protect dignity/confidentiality, reassure, facilitate communication (e.g., language barrier). Not just to record everything.

• Withholding Information:
  • If a patient asks not to tell family (e.g., cancer diagnosis), respect the patient's wish initially and try to convince them otherwise. Do not tell family against their will unless specific harm conditions are met (not detailed here).
  • If family asks not to tell the patient, management should be guided by the patient's knowledge and desire to know.

Breaking Bad News

• Protocols:
  • SPIKES and ABCDE are frameworks. (SPIKES often cited).
  • 95% of patients wish for a frank and precise diagnosis.

• Key Steps (incorporating SPIKES elements):
  • Preparation: Choose an appropriate time (not during busy hours). Ensure privacy.
  • Assess Patient Perception: Ask what the patient knows or suspects ("Ask what she knows and understands up to this point").
  • Invitation: Ask how much the patient wants to know.
  • Knowledge: Give information directly but sensitively. Be aware patient may not understand, use diagrams/repetition if needed.
  • Empathy:
    • Acknowledge emotions ("I understand how you feel like" - though potentially cliché, source implies understanding is key). Use silence. Acknowledge the difficulty ("It must be a horrible thing to go through").
    • AVOID: Saying "I know exactly how you feel" or false reassurances ("Sorry, this happens but doesn't mean it will happen again").
    • Validate feelings: Tell the patient they have the right to be sad about the event.
  • Strategy & Summary: Explain the next steps clearly. Arrange follow-up. Explain all details related to diagnosis before they leave.

• Managing Emotions:
  • Anger: Keep calm, do not treat anger with anger. Do not stop consultation immediately or call security unless safety is threatened.
  • Crying/Sadness: Use silence, empathetic statements. Ask how it affects them.

• Common Errors:
  • Telling patient to read about disease on the internet.
  • Choosing a busy time/place.
  • Giving false hope or minimizing the situation.
  • Disengagement is NOT a helpful coping mechanism.

Diagnostic Process & Patient-Centered Medicine (PCM)

• Patient-Centered Medicine:
  • Core: Includes patient's beliefs, ideas, concerns, and expectations (BICE). Accentuates doctor-patient relationship. Considers family life cycle.
  • Activates patient involvement and generally improves compliance.
  • Clinician Behaviors: Calm listening, leaning forward (implied, contrasting leaning back), appropriate eye contact. Avoid frequent interruptions (unless for clarification, but source implies smooth flow is better).
  • Not PCM: Focusing only on social, environment, or expectations separately; it's the integration.

• Diagnostic Principles:
  • Diagnosis is a state of probability, not certainty.
  • Consider: Most Probable, Most Serious, Most Treatable, Rarity.
  • Hypothetico-deductive Method: Involves generating and testing hypotheses. Does not require comprehensive history/systemic inquiry for every patient. Errors often stem from the diagnostic process, not just lack of knowledge.
  • Time can be a diagnostic tool, but doesn't always avoid investigations.

• Differential Diagnosis (DDx) Approach:
  • Use a structured approach (e.g., 3-phase diagnosis).
  • Rank probabilities based on history and context (e.g., age, risk factors).
  • Red Flags: Be aware of warning signs (e.g., headache onset > 45, immunocompromised, neck pain, worst ever).

• Common Scenarios from Source:
  • Chest Pain: DDx: MI, Anxiety, Musculoskeletal (prioritize based on risk factors/presentation).
  • Neck Pain: DDx: Mechanical, Disc, OA, Tension headache, Metastasis (consider context).
  • Fatigue: DDx: Exhaustion, Anemia, Lifestyle, Hyperthyroid, Depression/Anxiety, Malignancy, TB (especially with weight loss).
  • Headache: DDx: Tension, Migraine, Spondylosis, Tumor (rare but serious). Consider psychogenic factors (e.g., recent stressor like father's death).
  • Back Pain: Benign features are common. Malignancy/serious causes less likely in younger patients without red flags vs. older patients or those with surgical history.
  • Knee Pain: DDx: Osteoarthritis, Patellofemoral syndrome common with activity-related pain.
  • Diarrhea (Chronic): Consider malignancy in older patients.

Anticipatory Care, Preventive Medicine & Health Promotion

• Levels of Prevention:
  • Primary: Prevents disease occurrence (e.g., vaccination - Pneumococcal, smoking cessation advice). Aims to decrease incidence.
  • Secondary: Early detection and treatment (e.g., Screening tests - Pap smear, mammography, BP check).
  • Tertiary: Reduces complications of established disease (e.g., Rehab after stroke).

• Screening Principles:
  • Screening tools require high sensitivity.
  • Consider life expectancy (e.g., colonoscopy may not be suitable if < 5 years).
  • Consider cognitive status/fitness for procedures.

• Specific Screening Guidelines (from source - may differ from current guidelines):
  • Hypertension (HTN): Screen annually for age ≥ 40. (Intervals vary based on initial BP and age).
  • Breast Cancer: Mammography every 1-2 years after age 40. (Not indicated for 75 y/o in one question).
  • Cervical Cancer: Pap smear (e.g., every 3 years if normal; Co-testing with HPV every 5 years mentioned for age >30 or specific scenario).
  • Diabetes: Screen obese age 30-70. Screen for GDM after 28 weeks gestation.
  • Colon Cancer: Colonoscopy (interval depends on findings/risk; e.g., 10 years if normal, sooner if high risk/polyps). Stool occult blood also mentioned. Yearly low dose CT mentioned for high-risk smoker (lung ca screen, not colon).
  • AAA (Abdominal Aortic Aneurysm): Screen indicated in specific populations (e.g., 67-year-old smoker hypertensive male).
  • Aspirin Prophylaxis: Consider for primary prevention in specific age groups (e.g., Men 45-79, Women 55-79) to prevent MI/stroke based on risk.
  • Depression (PHQ-9): Assesses symptoms over past 2 weeks. Screening tool, score >20 suggests severe depression, max score 27. Ask about appetite changes/duration (2 weeks) or feeling down/duration (1 month) or anhedonia. Suicidal ideation is a key question.

• USPSTF Recommendations:
  • Grade A/B: Recommend service, high/moderate certainty of net benefit.
  • Grade C: Selectively offer based on individual judgment/preference, small net benefit.
  • Grade D: Recommend against, no net benefit or harms outweigh benefits.
  • Grade I: Insufficient evidence.

• Anticipatory Care Example: For a 45-year-old smoker: Discuss smoking cessation, measure BP, offer relevant screening (Pap, Mammo). Routine yearly CXR for lung cancer screening is NOT indicated.

Evidence-Based Medicine (EBM)

• Five Steps:
  1. Convert info needs into answerable questions.
  2. Track down best evidence.
  3. Critically appraise evidence for validity, impact, applicability. (Accountability is not the term used for appraisal itself).
  4. Integrate evidence with clinical expertise and patient values.
  5. Evaluate performance.

• Study Types:
  • Case-Control: Retrospective, compares exposure in cases vs. controls. Good for rare diseases.
  • Cohort: Prospective or retrospective, follows groups with/without exposure over time to see outcome incidence.
  • Randomized Controlled Trial (RCT): Experimental, random assignment to intervention vs. control. Gold standard for therapy effectiveness.
  • Meta-Analysis: Statistical pooling of results from multiple similar studies.
  • Systematic Review: Comprehensive review of literature on a specific question using systematic methods. Not an observational study.

• Key Concepts:
  • Selection Bias: Occurs when study participants are not representative of the population of interest, limiting generalizability. Can happen with very strict exclusion criteria.
  • P-value: Indicates probability results are due to chance. Lower p-value (e.g., <0.01) suggests lower probability of chance finding.

Doctor-Patient Relationship (DPR) & Difficult Patients

• Core Elements:
  • Human relationship, empathy, warm non-verbal communication.
  • Patient needs: Listening, competence, truth-telling.

• Relationship Dynamics:
  • Transference: Patient unconsciously redirects feelings from past relationships (e.g., father) onto the doctor.
  • Counter-transference: Doctor's unconscious emotional reaction to the patient.
  • Dependence: Can be a consequence of long-term relationship.

• Managing Difficult Patients (e.g., multiple complaints, hypochondriasis):
  • Do: Structure visits (e.g., regular short visits), show genuine interest in their life (not just complaints), accept symptoms as expressions of neurosis/distress.
  • Do NOT: Stop seeing them abruptly, give up trying to cure (focus shifts to coping/management), become annoyed or dismissive. They are often depressed and may need more attention initially, not less.
  • Somatizing Patients: Present with multiple, vague, unrelated symptoms. Distinct from psychosis (hallucinations/delusions). May involve drug-seeking, but not always the primary driver.

• Addressing Patient Concerns:
  • If patient is angry about a colleague, ask about what's causing their concern.
  • When patient refuses treatment, explore their worries, feelings, ideas, concerns (BICE), share options, but respect their right to refuse.

Geriatric Care Principles

• Aging Theories: Dysfunction of the immune system IS related to life expectancy (contrary statement was marked wrong).

• Common Issues:
  • Polypharmacy: Defined as ≥ 5 drugs. Multimorbidity increases risk.
  • Functional Assessment: Use tools to assess Activities of Daily Living (ADLs). Executive function and judgment are needed to perform ADLs.
  • Geriatric Syndromes: Common ones include dementia (impaired memory), severe heart failure, stroke, falls, incontinence, frailty. Insomnia is common but may not be a core "syndrome" in the same vein.
  • Screening: Use Geriatric Depression Scale (GDS) or PHQ-9 for depression.
  • Physical Findings: S3 heart sound needs further investigation.

• Physiological Changes:
  • Homeostenosis: Narrowing range of physiological reserve, reduced ability to adapt to stress. NOT equivalent to homeostasis.

Management Planning

• Principles:
  • Doctor must fully understand the patient and impact of the problem.
  • Reach a shared understanding of the problem.
  • Negotiate the management plan.
  • Give the patient responsibility for the problem/management.
  • Investigation should monitor progress, but not only for monitoring.

• Influencing Factors:
  • Patient's understanding of the illness is crucial for adherence/taking drugs correctly.
  • Patient's attitude towards the doctor.
  • NOT solely made by doctor because they know more. Shared decision making is key.

• Adherence:
  • Address patient's ideas, concerns, and expectations (ICE) about treatment (e.g., patient stopping statin due to weight gain despite medication).
  • For non-adherent patients (e.g., Type 1 DM kid), need to discuss the illness and its implications.

• Referral:
  • Indicated when problem exceeds GP's expertise or resources.
  • Can be to colleagues, senior doctors, specialists.
  • Should include referral to appropriate resources (books/info were debated in source, but generally providing patient info is good). Doctors involved must be proficient.

Introduction to Family Medicine

• Characteristics: More personal, comprehensive, requires wide knowledge. Deals with uncertainty and problem-solving in limited time frames. Uses tools, but not defined by sophistication. Consultation time may vary.

• Scope: Includes acute major cases (~15%), life-threatening emergencies (MI, aneurysm), minor self-limiting issues (~40% - source answer C implies this number might be wrong, maybe 50%?), chronic problems (~25%).

• Aim: Community-based care (NOT turning it into hospital-based). Function includes coordination, continuity, comprehensive care (direct-to-point care is not the definition).

• Help-Seeking Behavior:
  • Patients may delay seeking help due to being busy, financial reasons, distance, rude staff, fear, etc. Getting only reassurance/advice without meds is NOT typically a reason to refuse care if appropriate.
  • Factors increasing seeking help: Symptoms interfering with life (e.g., sore throat interfering with social life), visible signs, anxiety. Child with chronic cough annoying classroom may prompt visit.

Counselling Principles

• Definition: Primarily helping the patient explore their own situation. Not primarily giving advice or directions.

• Aims: Includes asking open-ended questions. Does NOT include negotiation to change patient values.

• Benefit of GP: GPs are generally good at counselling integrated into care, but maybe not "excellent at working alone" without network/support.

• Liability: Apologizing for diagnostic difficulty is NOT evidence of liability.

Medical Records

• Types:
  • POMR (Problem Oriented Medical Record): Requires constant updating of the problem list.
  • SOMR (Source Oriented Medical Record).

• EMR (Electronic Medical Record): Requires encryption for security.

• Record Retention: Medical records are kept for many years (e.g., patient returning after 16 years). Disposal policies vary.

• Audit: Self-auditing can use audio or video. Source suggests video is more comprehensive than audio alone (audio tape is not equal to video tape).

Smoking Cessation

• Nicotine Replacement Therapy (NRT): Requires extra caution in cardiovascular disease.

• Most Effective Pharmacotherapy (according to source): Varenicline (Chantix).

Miscellaneous Key Clinical Points

• Low Back Pain (LBP):
  • Acute LBP is < 6 weeks.
  • Red flag: Cauda equina symptoms (needs urgent referral). Bilateral symptoms may indicate need for imaging.
  • Management: Resume exercise/activity as tolerated for acute LBP. Acetaminophen up to recommended doses (source mentions 2g limit instead of NSAIDs, possibly context-specific or error, standard max is higher but caution needed). Short-term opioids are third-line.

• Vertigo:
  • BPPV: Lasts seconds to minutes, triggered by head movement.
  • Labyrinthitis/Neuritis: Lasts hours to days, often constant.
  • Meniere's Disease: Episodic vertigo (minutes to hours) with hearing loss/tinnitus. Family history may be relevant. Nystagmus suggests peripheral (labyrinthine) cause.
  • Most common cause overall is BPPV, not Meniere's. Transit ischemia less likely common cause than peripheral ones.

• Other:
  • Pap Smear: Tell patient she can ask you to stop if painful.
  • Osteoporosis Association: Associated with Hypogonadism. (Not Prolactinoma or Prostate Ca directly).
  • Psych Issues: Child with decreased appetite after father's death needs psychological support (Psychologist).
  • IBS-like Symptoms: Crampy abdominal pain, increased with stress, relieved by defecation suggests IBS; requires good therapeutic doctor-patient relationship.
  • Post-Carpal Tunnel Surgery: Manage pain (e.g., NSAIDs if appropriate).
  • Herpes Zoster Vaccine: Indicated for immunocompetent adults (age varies), including those who had VZV (chickenpox) as child or shingles previously (if >60). Contraindicated in severe immunocompromise (e.g. active HIV debated, but source implies caution).
  • Pneumococcal Vaccines: PCV13 (stronger antibody reaction) and PPSV23 (covers more pathogens). Indications/timing depend on age/risk factors (e.g., healthy 50yo non-smoker - source answer E implies 'to immunocompromised' but standard guidelines differ).
  • Acute Bronchiolitis: Mostly viral, diagnosis usually clinical (CXR not routine unless atypical), clears in 2-3 weeks.
  • Microcytic Anemia: In older adult (54yo), needs investigation for blood loss -> Upper and lower endoscopy.
  • CPPD (Pseudogout): Affects knee most commonly. Deposition of calcium pyrophosphate crystals. Does not classically affect 4th/5th MCPs (that's hemochromatosis).
  • Hemoccult Testing: Positive stool warrants further investigation (e.g., colonoscopy), even with history of hemorrhoids. Negative repeat doesn't rule out pathology if initial was positive.
  • Metabolic Syndrome: Criteria include abdominal obesity (Waist >88cm women, >102cm men - source has >88 for men as wrong), high TG, low HDL, high BP (source has >139/89 as wrong, likely threshold is 130/85), high glucose (>100 or 110 depending on criteria, source >125 implies diabetes threshold).
  • Hypothyroidism: Symptoms include brittle hair, bradycardia, goiter. Pretibial myxedema is characteristic of Graves' hyperthyroidism, not hypo.
  • HTN Treatment Choice: ACEI often first-line, especially with comorbidities like DM (source answer B implies ACEI preferred over B-blocker/thiazide/CCB in a general scenario).
  • Idiosyncrasy: Unpredictable adverse drug reaction, not dose-dependent, may have genetic basis. (Source answer C+D suggests genetic AND dose-independent).
  • Hepatitis B Serology: HBsAg (-), HBsAb (+) = Immune (due to vaccination or past infection).
  • Pneumonia Admission: Criteria often include CURB-65 score elements (Confusion, Urea >7, RR >30, BP <90/60, Age >65). Source mentions WBC > 7000 (low threshold), Urea=18 (high), Diabetic BS >80 (very low threshold), good family support (social factor). Context suggests severity markers needed.
  • Drug causing least bleeding: OCPs (compared to NSAIDs, Warfarin, ASA).