Step 1 - Behavioral Science 2

denniskwinn's version from 2015-04-25 15:54


Question Answer
Fee for servicepayment for each procedure
Capitation basis-Fixed payment for time period
-Regardless of number of procedures
Salary basedHospitals, HMOs, universities pay fixed salaries
MedicaidFederal and state assistance for very low income people
Medicare Part AHospitAL
Medicare Part BDoctor Bills
CHIP (Children’s Health Insurance Program)Matching state and federal government funding for child heath care coverage
Third party payersInsurance companies collect money from large population to pay all or a portion of the medical bills of current patients


Question Answer
AutonomyObligation to respect patients as individuals and to honor their preferences in medical care
Beneficience-Physicians have special ethical (fiduciary) duty to act in the patient’s best interest.

-May conflict with autonomy. If the patient can make an informed decision, ultimately the patient has the right to decide
Nonmaleficence “Do no harm” However if the benefits of an intervention outweigh the risks, a patient may make an informed decision to proceed (most surgeries fall into this category)
JusticeTo treat persons fairly


Question Answer
Informed consent(defin.)1. Discussion of pertinent information
2. Patient’s agreement to the plan of care
3. Freedom from coercion - Patients must understand the risks, benefits and alternatives, which include no intervention
Exceptions to informed consent(4)1. Patient lacks decision-making capacity or is legally Incompetent

2. Implied consent in an emergency: person's silence or inaction, or action (vs expressly granted)

3. Therapeutic privilege-withholding information when disclosure would severely harm the patient or undermine informed decision-making capacity (Psyche)

4. Waiver-patient waives the right of informed consent
Consent for minors(4)Parental consent must be obtained unless minor is emancipated (e.g. Is married, is self-supporting, has children, or is in military)
Criteria for decision making capacity(6)1. Patient makes and communicates a choice
2. Patient is informed
3. Decision remains stable over time
4. Decision is consistent with patient's values and goals
5. Decision is not a result of delusions or hallucinations
6. The patient’s family cannot require that a doctor withhold information from the patient
Oral advance directive-Incapacitated patient’s prior oral statements commonly used as guide.

-Problems arise from variance in interpretation.

-If patient was informed, directive is specific, patient made a choice and decision was repeated over time, the oral directive is more valid
Written advance directives(e.g)-Living wills
-Durable power of attorney (designated surrogate to make medical decisions)
Exceptions to confidentiality1. Potential harm to others is serious
2. Likelihood of harm to self is great
3. No alternative means exist to warn or to protect those at risk
4. Physicians can take steps to prevent harm
Examples to break confidentiality to prevent harm1. Infectious diseases

2. Tarasoff decision (requires physician to directly inform and protect potential victim for harm; may involve breach of confidentiality

3. Child and/or elder abuse

4. Impaired automobile drivers

5. Suicidal/homicidal patients - physicians may hold patient involuntary for a period of time
4 Ds of malpractice1. Physician had a duty to the patient (Duty)
2. Physician breached duty (Dere-liction)
3. Patient suffers harm (Damage)
4. The breach of the duty was what cause the harm (Direct) - most common factor leading to litigation is poor communication between physician and patient - unlike a criminal suit in which the burden of proof is beyond a reasonable doubt: the burden of proof in malpractice is more likely than not
Good samaritan lawRelieves health care workers, as well as laypersons in some instances, from liability in certain emergency situations with the objective of encouraging health care workers to offer assistance without expectation of compensation


Question Answer
Appropriate response to noncompliant patientWork to improve the physician-patient relationship
Appropriate response to patient with difficulty taking medications-Provide written instructions

-Attempt to simplify treatment regimens
Appropriate response to family members asking for information about patients prognosisAvoid discussing issues with relatives w/o the permission of the patient
Appropriate response to a 17 year old girl who is pregnant and requests an abortionMany states require parental notification or consent for minors for an abortion. Parental consent is not required for :

1.emergency situation
2.treatment of STDs
3.medical care during pregnancy of drug addiction
Appropriate response to a terminally ill patient requests physician assistance in ending his life-In the overwhelming majority of states, refuse involvement in any form of physician-assisted suicide.

-Physicians may, however,prescribe medically appropriate analgesics that coincidentally shorten the patient’s life
Appropriate response to patient that says they find you attractive-Ask direct, close-ended questions and use a chaperone if necessary.

-Romantic relationships with patients are never appropriate.

-Never say “ there can be no relationship while you are a patient” because it implies that a relationship may be possible if the individual is no longer a patient
Appropriate response to patient that refuses a necessary procedure or desires an unnecessary one-Attempt to understand why the patient wants/does not want the procedure.

-Address the underlying concerns.

-Avoid performing unnecessary ones
Appropriate response to patient that is angry about the amount of time he spent in the waiting room-Apologize to the patient for any inconvenience.

-Stay away from efforts to explain the delay
(NO excuses)
Appropriate response to patient upset with the way he was treated by another doctor-Suggest that the patient speak directly to that physician regarding his/her concerns.

-If the problem is with a member of the office staff, tell the patient you will speak to that individual
Appropriate response to a child who wished to know more about his illness-Ask what the parents have told the child about his illness.

-Parents of a child decide what information can be relayed about the illness.
Appropriate response to patient continues to smoke, believing that cigarettes are good for him-Ask about how the patient feels about his/her smoking.

-Offer advice on cessation if the patient seems willing to make an effort to quit
Appropriate response to a minor requesting condomsPhysicians CAN provide counsel and contraceptives to minors without a parent’s knowledge or consent
Appropriate response to a drug company offering a referral fee for every patient a physician enrolls in a study-Eligible patients who may benefit from the study may be enrolled.

-But it is never acceptable for a physician to receive compensation from a drug company


Question Answer
Apgar scoreAppearance, Pulse, Grimace(reflex), Activity, Respiration
-0 points for blue, none, none, Limp, none
-1 point (pink trunk, HR<100, Grimace, some activity, Irregular respiration),
-2 points (all pink, HR>100, Grimace+cough, activity, regular respiration)
Low birth weight-<2.5kg
- A/w greater incidence of physical and emotional problems
- Caused by prematurity or intrauterine growth retardation - Complications include:
- Infections
- Necrotizing enterocolitis
- Intraventricular hemorrhage
-Persistent fetal circulation


Question Answer
Milestones 0-3morooting reflex and orienting to voice
Milestones 3 moHolding head up, Moro reflex(spread/unspread arms) disappears, social smile
Milestones 7-9moSits alone, crawls, stranger anxiety
Milestones 15 monthsWalks, Babinski disappears, Few words, separation anxiety
Milestones 12-24 months-Climb stairs
-3 blocks at 1 year
-6 blocks at 2 years
-object permanence(ball behind back..still exist)
- 200 words and 2 word sentences at age 2
Milestones 24-36 moCore gender identity, parallel play: side by side but basically on their own
Milestones 30-36 moStacks 9 blocks, Toilet training,
Milestones 3 yRides tricycle, copies line or circle, 900 words and complete sentences
Milestones 4 yearssimple drawings (stick figure)
-hops on1 foot
-cooperative play, -imaginary friends
- grooms self, brushes teeth, buttons and zips


Question Answer
Piagets Sensorimotor stage(birth to age 2) egoeentrie exploration of the world with the 5 senses. Novel use of objects to obtain a goal (e.g .• use of stick to reach something). - Understanding of object permanence is achieved.
Piagets Preoperational stage(ages 2-7)-acquisition of motor skills. magical thinking predominates. with no “logical" thinking.
Piagets Concrete operational stage(ages 7-12)
-start of logical thinking. but confined to concrete concepts.
- No longer egocentric.
Piagets Formal operational stage(age 12+ )-devclopment of abstract reasoning.


Question Answer
Tanner stage 1Childhood
Tanner stage 2Pubic hair appears (adrenarche); breasts enlarge
Tanner stage 3Pubic hair darkens and becomes curly ; penis size/length ↑
Tanner stage 4Penis width ↑ darker scrotal skin. development of glans. raised areolae
Tanner stage 5Adult; areolae are no longer raised


Question Answer
Changes in elderly1. Sexual (men slower erection/ejaculation, longer refractory period, women vaginal shortening, thinning and dryness)
2. Sleep patterns (↓ REM, slow-wave sleep, ↑ latency and awakenings)
3. Common medical conditions - arthritis, HTN, heart disease, osteoperosis
4. ↓ incidence of psychiatric disorders
5. ↑ suicide rate (males 65-74 years of age have the highest suicide rate in the US)
6. ↓ vision, hearing, immune response, bladder control
7. ↓ renal, pulmonary, GI function
8. ↓ muscle mass, ↑fat
Grief-Normal bereavement characterized by shock, denial, guilt and somatic symptoms - typically lasts up to 2 months. May experience illusions. -Pathologic grief includes excessively intense or prolonged grief or grief that is delayed, inhibited or denied. May experience depressive symptoms, delusions and hallucinations
Kubler-Ross grief stages-DABGA
-Denial, Anger, Bargaining, Grieving, Acceptance
- not necesssarily in this order, more than one stage can be present at once
- Death Arrives Bringing Grave Adjustments
Stress effectsStress induces production of free fatty aCIds, 17-OH corticosteroids (immunosuppression), lipids, cholesterol, catecholamines; affects water absorption, muscular tonicity, gastrocolic reflex, and mucosal circulation.
Sexual dysfunction ddxincludes:
1. Drugs (antihypertensives, neuroleptics, SSRIs, ethanol)
2. Diseases (depression, diabetes)
3. Psychological (performance anxiety)
BMImeasure of weight adjusted for height
- <18.5 underweight
- 18.5-24.9 normal
-25.0-29.9 overweight
- >30.0 obese
- >40 morbidly obese


Question Answer
Sleep stage 1Light sleep - 5%
Sleep stage 2Deeper sleep - bruxism - 45%
Sleep stage 3-4Deepest non-REM - sleepwalkings; night terrors; bedwetting (slow-wave sleep)
REM sleep25% - Dreaming, loss of motor tone, possibly a memory processing function, erections, ↑ brain O2 use
Key to initiating sleepserotonergic predominance of raphe nucleus
NE and REM sleep reduces REM sleep
Extraocular movements during REM are due toActivity of PPRF (paramedian pontine reticular formation/conjugate gaze center)
Paradoxical sleep (desynchronized sleep)REM sleep having same EEG pattern as while awake and alert
Benzodiazepines and sleepshorten stage 4 sleep = useful for night terrors and sleepwalking
Imipramine and sleeptreats enuresis because it ↓ stage 4 sleep
REM sleep characteristics (1. ↑ and variable pulse 2. REM 3. ↑ and variable BP, 4. Occurs every 90 minutes. 5. Ach principal neurotransmitter involved 6. ↓ with age.
Narcolepsy (6)1. Disordered regulation of sleep-wake cycles. 2. May include hypnagogic or hypnopompic hallucinations 3. Sleep episodes start with REM sleep 4. Cataplexy (loss of all muscle tone) in some patients 5. Strong genetic component 6. Treat with stimulants
Circadian rhythm (3)1. Driven by suprachiasmatic nucleus (SCN) of hypothalamus which is regulated by light 2. Controls ACTH, prolactin, melatonin, nocturnal NE release. 3. SCN→Ne release→pineal gland→melatonin

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