D. Prueba de impulsos
5.1.2.15.2. Para los engranajes
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● Advising a newly diagnosed epileptic to stop driving
Communi C ation skills and ethi C s
tips
It is important to familiarize yourself with the DVLA guidelines for the common medical conditions e.g. epilepsy, diabetes, heart disease and dementia.
Case 7
Information for the candidate
You are the medical doctor. You are called by the ward nurse to speak to Miss Jones. She was admitted 48 hours ago with pyelonephritis and has improved with IV antibiotics. She is due for discharge on oral ciprofloxacin 500 mg b.d. However, during her admission, she was prescribed temazepam 10 mg o.n. by the on-call team since she complained she could not sleep. This was not included in her discharge medications. However, the ward nurse explains that Miss Jones is demanding to be discharged with a month’s supply of temazepam 10 mg o.n. On review of the notes, Miss Jones is 39 years old, with no relevant past medical history. She is not on any regular medication.
Please speak to Miss Jones about prescribing her 1 month’s supply of temazepam.
Brief for the actor
You are Daisy Jones, a 39-year-old lady who owns a café. For the past 8 weeks you have had trouble sleeping. This is becoming progressively worse and over the last 4 weeks you hardly slept, sleeping a maximum of 2–3 hours per night. When admitted to hospital recently for a kidney infection, the medical on-call prescribed you some sleeping tablets. You slept better. You have not used sleeping tablets in the past.
You own a café, and have been consumed by worry about the business. You have fallen into a lot of debt and worry the business could fold anytime soon. You are generally becoming more irritable. You live with your boyfriend. You lack interests. You are do not smoke or use recreational drugs. You drink 2–3 units of alcohol on special occasions. You may answer ‘no’ to any other questions posed about your psychological or physical wellbeing.
You have tried various simple measures to improve sleep such as leaving the room and reading. These have made little difference. The sleeping tablets in hospital were so useful that you want a supply for 1 month. You will become irritated with the doctor if asked other questions about work and personal circumstances.
If the doctor is sensitive and interested in your circumstances, you begin to open up and speak more freely about the situation. You will then recognize and accept that these factors are contributing to your sleep problems. However, you still want some sleeping tablets. If the doctor addresses your concerns about not sleeping and explains why he/she can only prescribe a short course of sleeping tablets, you find this acceptable. If the doctor does not address these issues, then you maintain your request for several weeks’ supply.
Preparation
Make sure you appreciate the main points in the history:
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● Establish the reason for requesting sleeping tablets
Station 4 Communi C ation skills and ethi C s ●
● Explore any measures she has taken to help her sleep ●
● Screen for anxiety and depression
ethical and communication issues:
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● Respect the patient’s request even if you do not necessarily agree with it ●
● Be prepared to listen to the patient’s reasons for requesting a month’s supply of
medication
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● Ensure the patient is fully informed of the risks of taking long term courses of
sleeping tablets
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● Emphasize alternative courses of action in managing the sleep problem ●
● Be prepared to negotiate with the patient
Discussion with the patient
Introduction●
● Introduce yourself ●
● Explain you were asked to speak to her by the ward nurse ●
● Clarify why Miss Jones wants sleeping tablets ●
● Exclude depression and suicidal risk
Provide an explanation
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● Explain that you think the main factors affecting her sleep are related to the
stressful situation surrounding her financial circumstances. Discuss conservative measures
Sleep hygiene
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● Go to bed and get up from bed at the same time each day ●
● Exercise regularly each day. Evidence suggests regular exercise improves restful
sleep
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● Get regular exposure to outdoor or bright lights, especially in the late afternoon ●
● The temperature in your bedroom should be comfortable ●
● Your bedroom should be dark enough to facilitate sleep ●
● Keep the bedroom as quiet as possible ●
● Use your bed only for sleep and sex ●
● Use relaxation exercises and breathing techniques prior to going to sleep ●
● Have a warm bath, massage or use balms to relax the muscles
Stress management ● ● Yoga ● ● Meditation ● ● Aromatherapy ●
● Exercise and hobbies
offer support services
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● Offer counselling CBT
Communi C ation skills and ethi C s ●
● Suggest she seek help with her debts and finances, e.g. by speaking to her bank
manager
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● Inform her of support groups such as the Sleep Council and British Sleep Society
Consider medical treatments
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● Explain that sleeping tablets are a short-term solution and do not address the
root of the problem
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● Highlight that if used long term could lead to dependence ●
● Discuss the side effects of sleeping tablets e.g. tiredness in the daytime and
developing tolerance, Decline to offer a prescription or offer a short course for 3 days with follow up with her GP
offer follow up
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● Suggest she sees her GP to discuss her sleeping problems, further management
and possible sick leave
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● Provide her with information leaflets about insomnia
Discussion with the examiner
Potential areas of discussion include: What do you know about insomnia?●
● 1 in 5 people have some form of sleep disturbance. ●
● Females are affected > males and it is more common with age. ●
● Insomnia can be classified as primary or secondary.
Can you explain primary and secondary insomnia?
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● Primary insomnia occurs when there are no associated underlying conditions. ●
● Secondary insomnia is associated with underlying conditions:
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●psychological illness e.g. bipolar disorder, depression and anxiety ●
●physical illness e.g. sleep apnoea, asthma, hyperthyroidism, heart failure ●
●drug use e.g. antidepressants, anti-epileptics, b-blockers, oral theophyllines and steroids
how do you manage patients with insomnia? Short-term (<4 weeks) insomnia management
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● Discuss sleep hygiene measures (also useful to discuss for long-term insomnia
management)
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● Consider a short course of sleeping tablets
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●advise the patient that sleeping tablets cannot be prescribed repeatedly ●
●start at a low dose and warn about side effects
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● If after 2 weeks the patient still has sleeping problems, consider cognitive–
behavioural therapy (CBT).
Station 4 Communi C ation skills and ethi C s
Long-term (<4 weeks) insomnia management
table 10 Management options in long-term insomnia Relaxation therapies Relaxation classes
Audio material Meditation Breathing techniques
CBT Re-train negative thoughts about falling asleep
Biofeedback Trains the patient to control certain physiological processes e.g. heart rate, breathing rate and BP
Sleep restriction therapies Patients are advised to restrict their sleeping hours so they eventually become tired again and establish new routines to fall asleep
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● Avoid use of hypnotics for long-term insomnia except for acute relapses ●
● There is not enough evidence to support the use of antidepressants,
antihistamines and barbiturates for insomnia. Antidepressants may be useful if there is underlying anxiety or depression.
When should a patient be referred to a sleep clinic?
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● Consider referral to a sleep clinic in patients for:
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●primary insomnia ●
●long-term insomnia not responding to treatment ●
●patients where there is diagnostic uncertainty
Case 8
Information for the candidate
You are a medical doctor with the Dermatology team. You are reviewing Salima Shah, a 24-year-old Pakistani lady, who was referred to you by her GP with moles on her left thigh and right shoulder. She saw her GP because she was worried these could be cancerous and would like them removed. She has no family history of skin cancer, is on no regular medication and has no relevant past medical history. She seems quiet and when you offer to examine her she initially declines. However, you explain the necessity for the examination and she reluctantly accepts. Examination reveals two benign moles. However, you notice she has several bruises on her limbs, back and abdomen. You are worried she may be experiencing domestic violence. Please discuss this with the patient.
Brief for the actor
You are Salima Shah, a 24-year-old Pakistani lady. You noticed two moles on your left thigh and right shoulder. You saw your GP because you were worried these may be cancerous and want the moles removed. He referred you to the dermatology team to have them reviewed. You have come to the OPD alone because your husband, Khalid, was at work. He does not know you have attended today.
Two days ago Khalid became angry because you were on the telephone to your mother in Pakistan. He abused you because he did not want you to contact your family and calling Pakistan was too expensive. You tried to explain you called your
Communi C ation skills and ethi C s
mother because she had recently had hip surgery following a fall. He punched you on the arms several times, pushed you and then kicked you on your back and legs. He told you he would kill you if you ‘misbehaved’ again. You are terrified and unsure of what to do next, or who to speak to.
You lived in Pakistan and moved to the UK 6 months ago after having an arranged marriage. Khalid drinks heavily and when drunk he has forced you to have sex. You do not have children. Khalid refused to let you work. You have no friends in the UK. You are scared of leaving Khalid – you cannot support yourself financially and are concerned how your community will react if you did. You believe you will not be allowed to stay in the UK if you leave him, and will cause shame to your family if you return to Pakistan.
The violence occurs every few days. It happens at home. You have not spoken to anyone because you feel you are to blame. You are not suicidal but feel confused and scared. Khalid has never hit you with an object, or tried to strangle you. You have never called the police and are unaware of any services available to help you.
During the consultation, you appear timid. If the doctor asks you how the injury occurred, you say that you ‘fell over’. If the doctor is caring and approaches the topic of domestic violence, you will open up slowly and explain how the injury really happened. You provide small amounts of information at first, but if the doctor shows empathy, you answer the questions with more detail. If the doctor communicates poorly, you stop talking or maintain the bruises occurred from falling over.
Preparation
Make sure you appreciate the main points
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● Reassure the patient that the moles are benign and do not need to be removed ●
● Conduct a domestic violence risk assessment
ethical and communication issues
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● Use open body language and approach the situation in a gentle and non-
threatening way
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● Allow for silence, giving her time to speak ●
● Explore her fears about her marital situation ●
● Explore her cultural and religious beliefs about marriage ●
● Encourage her that she has options available ●
● Respect her autonomy on future action, and do not pressurize her into following
a particular course of action
Discussion with the patient
Introduction●
● Introduce yourself and explain you work for the dermatology team ●
● Reassure Salima that both moles are non-cancerous ●
● Explain the sinister features of moles e.g. bleeding, itching, growing in size and
advise her to speak to her GP if these occur
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● Sensitively discuss your suspicions of domestic violence as a cause of the bruises