CFM 1 FINAL EXAM October 7, 2013
1. A physician takes time to counsel and educate patients on lifestyle modification for identified risk factors like hypertension and diabetes. What characteristic of care is given by the physician?
A. Primary B. Continuing C. Comprehensive D. Preventive
CHARACTERISTICS OF CARE OF FAMILY MEDICINE:
Primary – first contact care (OPD), emergency and home setting; unique consultation process
Continuing – chronologically, geographically, interdisciplinary, and non-health agencies; longitudinal
continuity
Comprehensive – ecological factors (social, cultural, economic, educational); how a patient copes
with and understands illness
Preventive – all levels of prevention with emphasis on health education; promotes health and
well-being
Curative – relieve symptoms, early diagnosis and treatment Rehabilitate – assist patient to go back to society
2. Based on systems theory, which among the following defines a family? A. Strong affection
B. Biologically related C. Permanent membership D. Changes through time
Based on systems theory, a family is composed of all emotionally significant people bound together by enduring ties.
3. A child of a middle-class couple is suffering from bedwetting. The child studies in a private preparatory school and undergoes annual preventive health maintenance. Upon examination of family function, the couple admits that they spend very little time with their child. They spank him every time he’s being naughty. What area of family function is affected?
A. Biologic B. Educational C. Affection D. Socio-cultural
BASIC AREAS OF FAMILY FUNCTION:
Biologic – reproduction, child rearing/caring, nutrition, health maintenance, recreation
Economic – provision of adequate financial resources, resource allocation, ensure financial security
of members
Educational – teach skills, attitudes and skills relating to other function
Psychological/Affection – promote the natural development of personalities, offer optimum
psychological protection, promotes ability to form relationship with people in the family circle
Socio-cultural – socialization of children, promotion of status and legitimacy
Societal expectations – sense of responsibility toward members and others; basis of affection/care Built-in problems – generation gap; dependence on members; emotional attachment/involvement
4. Ana, a separated woman lives with her children in a house located in her husband’s family compound. Her in-laws take care of her children while she’s at work. They also help provide financial help that her husband fails to do often. What is the type of family structure?
A. Nuclear B. Extended C. Single parent D. Kin network
TYPES OF FAMILIES:
Nuclear family – parents + dependent children
Nuclear family dyad – childless husband and wife, “empty nesters” (children have grown and left
home)
Extended family – 3 generations or more living either unilaterally or bilaterally extended
Kin network family – living in close geographical proximity and operating within a reciprocal system
of exchange of goods and services
Single-parent famly – one parent + children (parent’s singlehood due to divorce, separation,
abandonment, death, adoption, never-married or OFW)
Blended family – remarried men and women, living in common household with children from previous
marriages
Communal/corporate family – formed for specific ideological societal purposes (e.g. Korean
moonies, Amish community); monogamous or group marriage
Institutional family – children in orphanages, residential schools or correctional institutions
QUESTIONS 5-6
5. Paul, 14-y/o, accompanied by his grandmother, sought consult for difficulty of breathing. Data on past medical and immunization history were incomplete. When asked for his parents, Paul said, “They are working abroad. My siblings and I live with my grandmother.” This situation is one disadvantage of what type of family?
A. Nuclear B. Blended C. Extended D. Single parent (please refer to #4)
6. Which particular function of the family does Paul’s parents would have difficulty with specifically shown in this particular case?
A. Socialization of children B. Character education C. Personality development D. Health promotion
(please refer to #3)
7. Qualities of a good family assessment tool: A. Easily available
B. Not time consuming
C. Provide composite financial capacity of the family D. Must be acceptable to patient
A family assessment tool must be easily utilized by the practitioner. Tools which take minimal amount
of time to complete and which provide a composite picture of family strength and needs are most
beneficial.
8. In using the APGAR, this refers to how time, space, money are shared and measures the member’s satisfaction with the commitment made by other members:
A. Adaptation B. Growth C. Resolve D. Partnership
APGAR STANDS FOR ACRONYMS OF:
Adaptation – capability of the family to utilize and share inherent resources, which are either
intra-familial or extra-intra-familial
Partnership – sharing of decision-making; measures the satisfaction attained in solving problems by
communicating
Growth – both physical and emotional growth; measures the satisfaction of the available freedom to
change
Affection – how emotions like love, anger, and hatred are shared; measures the member’s
satisfaction with the intimacy and emotional interaction that exist in the family
Resolve – how time, space, money are shared; measures the member’s satisfaction with the
commitment made by other members of the family
9. Which area of the SCREEM addresses the family’s inability to utilize health care resources? A. Social
B. Educational C. Medical D. Economic
SCREEM FACTORS AFFECTING HEALTH THAT CAN BE CONSIDERED AS PATHOLOGY: Social – isolated from extra-familial; problem of over-commitment
Cultural – ethnic/cultural inferiority Religious – rigid dogma/rituals
Economic – economic deficiency, inappropriate economic plan Educational – handicapped to comprehend
Medical – not utilizing health care facilities/resources
QUESTIONS 10-11
10. Mr. and Mrs. Roxas celebrated their golden wedding anniversary. Both are retired and living by themselves. They maintain a healthy relationship with their children. What can be the most pressing concern of the couple that you can anticipate considering their present status?
A. Coping with physical and mental decline [NOTE: Nakuha ko po ang sagot na ito sa previous samplex na naaral ko noon. ]
B. Dealing with loss of spouse
C. Managing stress in dealing with children in-laws D. Maintaining couple functioning
FAMILY IN LATER LIFE (FAMILIES OF MIDDLE YEARS & FAMILIES IN RETIREMENT AND OLD AGE):
The stage-related family tasks are 1) maintaining own or couple functioning and interest in face of physiologic decline, exploration of new famillial and social role options, 2) support for a more central
role for the adult children, 3) making room in the system for the wisdom and experienced of the elderly, supporting the older generation without over functioning for them, 4) dealing with loss of spouse, siblings and other peers, and preparation for own death, and 5) life review and integration. The stage-related health concerns are 1) promotion and maintenance of health, 2) deterioration of physical or mental health or both, coping with loss of function, provision of assistance and care, and 3) management of stress generated by changing role relationships within marital dyad and among parents and children.
11. The couple thought of visiting their attending physician. What are the activities that can be done during the visit?
A. Ask how they are preparing for future deaths B. Perform periodic health examination
C. Counsel them on how to improve their relationship D. Explore possibility of family meeting
(please refer to #10)
12. Whenever there’s an issue in the family, two groups usually emerge with conflicting opinions and interests. This family organization reflects ____________.
A. Alliance B. Coalition C. Hierarchy D. Subsystem
STRUCTURAL PARAMETERS OF A FAMILY:
Hierarchy – how power or authority is distributed within the famliy; power is institutionalized through
respect, fear, esteem or position
Subsystem – ways in which a family differentiates and carries out its function (eg. nurturance and
socialization of children are functions of the parental subsystem)
Boundaries – defined limits of a family and its members; rules defining who participates in the
subsystem and how they participate
Roles – position in a faily within a series of reciprocal expections
Scapegoat or noble symptom bearer – family’s source of problems, accepts the family’s
blame, and through his symptom reflects the dysfunction of the family as a whole
Parentified child – child in the family, often the oldest, who performs the parental functions
when one or both have abdicated the rold
Values – mental and emotional sets which aid persons in judging the relative worth or importance of
things, ideas or events; creates a problem for family members only when diverge or are in conflict
Alliance – positive relationship between any two members of a system
Coalition – relationship between two persons in which two collide against a third
13. The social service of a hospital was asked to get in touch with the family of Lolo Jose who has not visited him since he was confined. Relationship in Lolo Jose’s family may be described as ____________.
A. Enmeshed B. Disengaged C. Functional D. Dysfunctional
PROCESS PARAMETERS OF A FAMILY:
Enmeshment – members have few interpersonal boundaries, limited individual autonomy, and a high
degree of emotional reactivity; diffused boundaries
Disengagement – members are emotionally distant and unresponsive to each other; too rigid
boundaries
Triangulation – third person is drawin into a two-person system in order to diffuse anxiety over issues of
intimacy in the two-person system
Transactional patterns – chief assessment tool in family dynamic; reflects the repeating sequence of
family interactions; may be viewed as rituals
14. APGAR was administered to a couple which revealed a score of 4. Which of the following figures represents their family map?
A. Husband - - - wife B. Husband ______ / ______ wife C. Husband . . . wife D. Husband ____________ wife APGAR SCORING 8–10 – highly functional 4–7 – moderately functional 0–3 – severely dysfunctional
15. The following are healthy family characteristic EXCEPT:
A. After typhoon “Ondoy,” a family busied themselves in joining clean-up activities in their community
B. Members of a family in the evacuation center was heard blaming each other for their losses [NOTE: Nakuha ko po ang sagot na ito sa previous samplex na naaral ko noon. ] C. At the height of the typhoon, a family was able to survive because they took time to talk
and plan their strategy D. None of the above
16. An adolescent was warned by his friends to be careful with his adventures like drugs, drag racing, etc. He said not to worry because his parents have connections that will help him avoid arrest or getting into jail. The behaviour of the parents reflects ____________.
A. Enmeshment B. Disengagement C. Enabling
D. Conflict avoidance
FOUR CORE CHARACTERISTICS OF PSYCHOSOMATIC FAMILIES:
Enmeshment – members are overly reactive to stress on one member and demostrate a lack of
individual autonomy
Overprotectiveness – members are not permitted to handle their own problems
Conflict avoidance – open airing of disagreement is not permitted, although covert conflict is
rampant
Rigidity – transactional patterns are repeated, inflexibility, and change is resisted FAMILY’S REPEATING INTERACTIONAL PATTERNS RELATED TO THE PROBLEM:
Enabling – any conscious or unconscious behavior that encourages an individual to continue acting
in a specific manner primarily by shielding the person from the consequence of the behavior
17. It is the body’s instinct to protect itself from emotional or physical pressure, or in extreme situations, from danger.
A. Pressure B. Catastrophe C. Stress
D. Life events
Stress – the nonspecific response of the body to any demand; body’s instinct to protect itself from
emotional or physical pressure or, in extreme situations, from danger; normal reaction; how the body prepares for change
18. The stress of exhilarating, creative successful work is beneficial. A. Eustress
B. Distress
C. Situational stress D. Maturational stress
TYPES OF STRESS:
Distress – unpleasant or disease-producing stress (Selye); “bad stress”; person feels threatened and
not in control of the situation; “abnormal stress”
Eustress – seen as good, pleasant, or curative stress; “good stress”; person feels stimulated and able
to manage the situation; “normal stress
TYPES OF CRISIS:
Situational – non-normative (eg. divorce, illness, relocational, failing an exam, marriage of a second
year college student)
Maturational – normative; occurs across the life spectrum (eg. graduation, marriage, circumcision,
death)
19. A mother whose daughter has cerebral palsy deals with parents whose children calls her child abnormal. This is an example of ____________ stressor.
A. Intrafamilial B. Interfamilial C. Extrafamilial D. External
STRESSORS:
Internal stressors – intrafamily; within the unit itself; include allocation of roles and conflict among
family members
External stressors
Interfamily – develop as the famly interacts with other systems in the environment that directly
influence the family such as schools, health care agencies, physicial initiating a relationship with a family, or the work place
Extrafamily – occur as the famliy is influenced directly by political, social and cultural issues
20. A graduating medical student with asthma had exacerbation during the final exam week. He crammed for the make-up exams and for the submission of requirements for graduation. What type of crisis did he experience?
A. Maturational B. Situational C. Both D. None (please refer to #18)
21. A patient feels mixed emotions after a tragedy that struck her family. Which one of the following is correct in helping the patient initially?
A. A concerned woman telling the patient to stop crying and that everything would be all right with God’s help.
B. A doctor teaching the patient what to do so she can deal with the situation.
C. A friend who patiently listened while patient was crying, talking and at times shouting. [NOTE: Nakuha ko po ang sagot na ito sa previous samplex na naaral ko noon. ]
D. A health volunteer who allowed the patient to be alone.
22. Time phase of illness where the family proceed with a life of normalcy despite the presence of a chronically ill family member.
A. Crisis B. Chronic C. Terminal
D. All of the above
PHASES OF ILLNESS:
Crisis – symptomatic period; before diagnosis and intial period of adjustment
Chronic – gradual in onset placing the family in a prolonged state of uncertainty; between diagnosis
and readjustment period
Terminal – includes preterminal stage where the inevitability of death becomes apparent or
dominant in life
23. Maria, 30 y/o, single, suffers from abnormal bleeding due to myoma. Hysterectomy was recommended. Implication was discussed by the attending physician. She sought second and third opinion regarding treatment. She cannot decide on what to do. In what stage in the illness trajectory did Maria got stuck?
A. Stage 2 – reaction to diagnosis B. Stage 3 – major therapeutic efforts C. Stage 4 – early adjustment to outcome D. Stage 5 – permanency of outcome
STAGES IN FAMILY ILLNESS TRAJECTORY:
STAGE 1: Onset of illness – onset of symptoms; prior to contact with medical care providers; acute
illness (rapid, clear onset) provide little time for physical and psychological adjustments predisposing the family to crisis; chronic illness (gradual in onset) family in a prolonged state of uncertainty
STAGE 2: Reaction to diagnosis/impact phase – signs and symptoms progression patient becomes
STAGE 3: Major therapeutic efforts – factors doctor should consider during treatment; includes
alternative choices
STAGE 4: Early adjustment to outcome/recovery – outcome of treatment; patient returns from the
hospital; recovery/adaptation (of the family) at home with patient; can also be permanent disability (if illness cannot be treated anymore)
STAGE 5: Adjustment to the permanency of outcome – acceptance and adjustment to
disability/death
24. How would you characterize the patient’s degenerative arthritis as to onset, course, incapacitation and outcome?
A. Acute, progressive, incapacitating, potentially fatal B. Acute, constant, not debilitating, nonfatal
C. Gradual, progressive, incapacitating, nonfatal D. Gradual, constant, not debilitating, nonfatal
Degenerative – (of a disease or symptom) characterized by progressive (happening or developing
gradually or in stages), often irreversible deterioration, and loss of function in the organs or tissues
Incapacitate – prevent from functioning in a normal way
25. A patient was discharged after removal of appendix. He was given one week of sick leave before he goes back to work. What would be the main task in this stage?
A. Continue to stay in bed to avoid abdominal pain B. Start to walk and move around gradually
C. Resume regular physical activity including exercise D. Get a caregiver to assist in activities of daily living 26. Questions that one may asked to assess family dysfunction:
A. What are the sources of stress on the family? B. How adaptable or rigid is the family?
C. How cohesive is the family? D. All of the above
ASSESSING FAMILY DYSFUNCTION:
What are the sources of stress on the family? How adaptable or how rigid is the family? How cohesive is the family?
o Enmeshment – too much cohesiveness; family members are protective and over reactive to one another’s pain; seen in the following behaviors: 1) members speaking for one another, 2) continual interruption while someone is speaking, 3) high levels of emotionality, and 4) either unwillingness to discuss conflict or reactive conflict where family members flare up angrily at slight provocation
o Disengaged – noncohesive families; boundaries are rigid and impermeable separating the members of the system; sense of abandonment
What are the family’s repeating interactional patterns related to the problem? 27. What are the signs of family dysfunction?
A. Family violence B. Substance abuse C. A and B
D. None
PHYSIOLOGICAL VARIABLES OF FAMILY DYSFUNCTION:
Alcoholism and substance abuse Family violence
28. Which of the following statement is TRUE?
A. Report to authorities suspected case of child abuse B. Filing of case in wife abuse needs consent of victim C. A & B
D. None
Currently physicians and other health care givers are mandated by law to report only incidence of
suspected child abuse. Situations that involve the abuse of adults such as spouse or elder abuse are
not covered under these laws. Wide variations exist concerning how the legal system addreses these episodes of adult violence.
29. An elderly patient was noted to have hematoma and bruises in the legs. Upon probing, patient claimed he fell from the bed. Caregiver was hesitant to bring him to the hospital for medical management. What is the most appropriate thing to do?
A. Report to police
B. Assess home environment C. Refer to social worker D. Assess family functioning
30. Given a competent patient who is a victim of wife abuse, the following may be done by the doctor EXCEPT
A. Report to police
B. Suggest safety measures
C. Refer to mental health professional
D. Refer to women’s desk for legal assistance if warranted (please refer to #28)
31. Why is there a need to study and understand the Filipino family?
A. The basic unit of the Philippine social organization is the bilateral extended family. B. The elementary family and sibling group form the primary bases of corporate action
C. The Filipino family is typically adult-centered with great affection towards elders and grandparents.
D. All are correct
32. Which of the following strongly demonstrates the influence of the Filipino family on each sector of society?
A. The large images carried in community processions during Holy Week are owned and kept by the wealthy families.
B. Among paid agricultural workers, two or more members of a family will commonly be found working together.
C. The so-called “corporations” found in urban areas are generally family holdings D. All of the above
33. The only condition/s where legal separation is permitted in the Philippines is/are: A. Mental incapacity of any spouse
B. Bigamy
C. Suicidal tendencies D. All of the above
34. As a rule, the residence of a family is with the paternal kin; in which case will there be an exception?
A. Boy is the youngest among several siblings B. Girl is the middle child
C. Boy is the only child
D. Girl is the only child with considerable land
As a rule the residence of a family is with the paternal kin that is near or in the barrio of the parents of
the husband. The actual residence of a married couple is determined, however, by a number of
variables: the location and relative amount of the land which the two bring to marriage; their
respective number of siblings; and the extent of intra-village marriage. If the girl is the only child and has land, while the boy has many brothers and sisters and very little land, residence may be near the parents of the girl.
35. In cases where a husband abuses his wife and the kinsmen intervene or when a husband seeks the advice of his father; these instances are examples of:
A. Family of procreation B. Family of protection C. Family of orientation D. Family of the spouse
Though marriage forms a new “family of procreation,” the husband and wife are still integral parts of
their respective “families of orientation.” Thus, if a husband abuses his wife, her kinsmen will intervene,
for she is still a member of her natal group.
36. Psychosomatic conditions have physical manifestations A. Body as machine
B. Objective research C. Mind-body dualism D. Specific etiology
THE BIOMEDICAL MODELS:
Mind-body dualism – formulated by Rene Descartes; everything is controlled by the mind and the
body just feels things
Mechanical metaphor – “body as a machine”; bodies tend to work like machines (defined as an
apparatus using or applying mechanical power and having several parts, each with a definite function and together performing a particular task)
Specific etiology – disease came from a specific disease causing agent; introduced by Koch Objective science/research – evidence based medicine
37. Koch’s postulate has popularized this. A. Body as machine
B. Objective research C. Mind-body dualism
D. Specific etiology (please refer to #36)
38. The hip joint, synovial fluid and cranial plates are associated with this biomedical model. A. Body as machine
B. Objective research C. Mind-body dualism D. Specific etiology (please refer to #36)
39. Becoming members of medical societies is essential to provide updates in the discipline. A. Medicalization
B. Professionalism of medicine C. Sick role
D. Objective research
40. The different specialties are divided into major categories: Clinical medicine and Surgical Medicine
A. Professionalism of medicine B. Medicalization
C. Functionalist theory
D. Symbolic interaction theory
41. A state of complete physical, mental, and social well-being and not merely the absences of disease and infirmity:
A. Health B. Wellness
C. Health education D. Health promotion
Health – a state of complete physical, mental, and social well-being and not merely the absence of
disease and infirmity
Wellness – integrated method of functioning which is oriented towards maximizing the potential;
continuum of balance and purposeful direction
Health education – communicating information, imparting and interpreting technical knowledge,
reinforcing positive lifestyles and exploring myths
Health promotion – combines the objective of disease prevention with techniques of health
education
42. Recommended lifestyle modifications for health promotion includes the following EXCEPT: A. Weight reduction
B. Salt restriction
C. Absolute restriction of alcohol intake D. Aerobic physical activity
HEALTH RISK APPRAISAL AND CONTROL:
Weight reduction
o Ideal body weight for female: 100 lb for first 5 feet + 5 lb per inch thereafter Diet
o DASH diet (Dietary Approach to Stop Hypertension) – rich in fruits and vegetables, low-fat dairy (low content of saturated & total low-fat), low sodium (≤ 100 mmol/day; 2.4 g sodium / 6 g NaCl)
Alcohol consumption
o Moderate alcohol consumption o Male: limit to ≤ 2 drinks/day
o Female and lighter weight persons: limit to ≤ 1 drink/day o 1 drink = 12 oz. beer / 5 oz. wine / 1.5 oz. 80% proof whiskey Physical activity
o Recommended aerobic exercises are brisk walking, ballroom dancing, biking, and swimming
o Target Heart Rate (THR) = (220–age) x __% activity No previous exercise = 60–65% activity
Minimal to some previous exercise = 70–75% activity Previous regular exercise = 80% activity
o 30 minutes / day most days of the week 43. Ideal body weight for males is computed as follows:
A. 100 lbs. for the first 5 feet then 5 lbs for every inch thereafter B. 100 lbs. for the first 6 feet then 6 lbs for every inch thereafter C. 106 lbs. for the first 5 feet then 6 lbs for every inch thereafter D. 106 lbs. for the first 6 feet then 5 lbs for every inch thereafter (please refer to #42)
44. Purpose of correlating the BMI with the waist circumference:
A. To weigh the risk or possibility of strokes and heart attacks among patients B. To determine baseline measurements for weight reduction programs
C. To determine increased BMI because of muscle enhancement versus adiposity D. All of the above
Obesity is usually measured using the body mass index (BMI). Waist circumference is a surrogate marker of visceral fat. Risk of co-morbidities are associated with different levels of BMI and waist circumference in Asian adults.
45. The South Beach diet espouses the following strategy: A. Increased carbohydrate diet
B. No carbohydrate
C. Choosing the right carbohydrates D. Carbohydrate replacement by protein
SOUTH BEACH DIET
Developed by Arthur Agaston, M.D.
“a safe diet for the chronically overweight heart patient” NOT a low-carbohydrate diet, NOT a low-fat diet
Teaches patients to rely on the right carbohydrates and the right fats 46. The plate graphic illustrates the following:
A. More non-starch vegetables in the diet B. Matchbox-sized protein
C. No fruits allowed D. None of the above
47. The Filipino pyramid food guide differs from the rest of the international pyramid good guides in that:
A. The Filipino pyramid guide includes recommendation for fluid intake B. Carbohydrate requirement revised to 1 cup 2xday
C. Protein replacement through non-starch vegetables D. Low salt and sugar diet
FILIPINO PYRAMID FOOD GUIDE
Developed by Sanirose S. Orbeta, MS, RD, FADA o Drink a lot: water, clear broth
o Eat good: rice, root crops, corn, noodles, breads, cereals o Eat more: vegetables, green salads, fruits or juices
o Eat some: fish, poultry, dry beans, nuts, egg, lean meats, low fat dairy o Eat a little: fats, oils, sugar, salt
48. Formula for target heart rate in making our exercise prescription is as follows: A. THR = [(120-age) x % activity]
B. THR = [(220-age) x % activity] C. THR = [(250-age) x % activity] D. THR = [(320-age) x % activity] (please refer to #42)
49. Consequences of rubella infection for which rubella vaccination is strongly recommended: A. Cataracts, retinopathy, congenital glaucoma
B. Ventricular septal defect C. Down’s syndromes D. All of the above
HEALTH PROMOTION: Immunization Physical fitness Nutrition Stress awareness Environmental sensitivity
HEALTH PROMOTION THROUGH IMMUNIZATIONS
Rubella – occurrence of congenital defects is 50% or greater if infection occurs during the 1st month
of gestation, 20–30% if during the 2nd month, and 5% if during the 3rd or 4th month
COMMON ANOMALIES OF RUBELLA:
Cataracts, retinopathy, congenital glaucoma Patent ductus arteriosus
Sensorineural deafness Mental retardation
Hepatitis B – may result in severe disease in the mother and chronic disease in the newborn;
pregnancy is NOT a contraindication to immunization in women
Hepatits A – highly communicable
Tetanus – (immunization is for) prevention of neonatal tetanus
50. The following vaccines are NOT contraindicated in pregnancy: A. Rubella vaccination B. Hepatitis B vaccination C. Tetanus toxoid D. A & C only E. B & C only (please refer to #49)
51. Pap smear for screening for cervical cancer is what level of prevention? A. Primary
B. Secondary C. Tertiary D. A & B only
LEVELS OF PREVENTION:
Primary prevention – prevention of occurrence (e.g. immunization, lifestyle change, counseling,
genetic counseling, and public health services)
Secondary prevention – early intervention to detect and treat asymptomatic disease (e.g. colorectal
screening, cervical cytological testing, blood pressure screening, self-breast examination, medical and surgical therapy)
Tertiary prevention – settles established disease to avoid complications and disability and to assist in
rehabilitation
PERIODIC HEALTH EXAMINATION:
Health risk appraisal – detection of risk factors for disease and treatment of these factors that
predispose to disease; includes weight reduction, diet, moderate alcohol consumption and physical activity
Screening – use of presumptive methods to detect unrecognized health risks or asymptomatic
disease in apparently healthy individuals in order to permit prevention and timely intervention (WHO); cornerstone of disease prevention (e.g. screening for: hypertension [start screening at 18 y/o], cervical malignancy [cervical cancer screeing/pap smear], breast carcinoma, anemia)
Physical examination – e.g. digital rectal examination (DRE; for colorectal diseases and prostatic
hypertrophy [starting at 50 y/o in males]), breast self-examination (BSE) 52. Screening for hypertension according to JNC 7 should start at this age:
A. 15 years old B. 18 years old C. 21 y/o D. 35 y/o (please refer to #51)
A. 12 oz. beer, 5 oz. wine, 1.5 oz. 80 proof whiskey B. 12 oz. beer, 6 oz. wine, 1.5 oz. 80 proof whiskey C. 12 oz. beer, 5 oz. wine, 2.5 oz. 80 proof whiskey D. 12 oz. beer, 5 oz. wine, 3.5 oz. 80 proof whiskey (please refer to #42)
54. Cancers showing the most familial tendency: A. Breast CA
B. Lung CA C. Colon CA D. A & B E. A & C
RISK IDENTIFICATION FOR BREAST CARCINOMA:
Age (75% are found in women > 50 y/o)
Family history (increased for a woman whose if mother, sister or daughter has had the disease before she reached menopause)
Personal history (15% women treated for CA in 1 breast later on developed cancer in the other breast)
Menarche (at an early age) Late menopause
First child after 30 y/o or no children Hormonal exposure
55. Benign prostatic hyperplasia (BPH) may be screened clinically by doing the following: A. Pap smear
B. Lower abdominal ultrasound C. Direct rectal examination D. Abdominal palpation (please refer to #51)
QUESTIONS 56-65 CASE
A 22-y/o male first year medical student was seen for periodic health exam. He does not complain of any symptoms. He smokes around 3 sticks per day usually after meals and drinks alcohol on weekends. He sleeps 6 hours on most days of the week. Physical activity is limited to playing basketball twice per week. Family history is positive for diabetes and hypertension.
56. What is the ideal body weight? A. 155 – 165 lbs
B. 156 – 166 lbs C. Both A & B D. Neither A nor B (please refer to #42)
57. Physical examination revealed the ff: 5’10”, weight = 185 lbs. What is the BMI? A. 25
B. 26
C. 27 (if not rounded off before dividing weight from height, but rounding off at the final answer [26.60 ≈ 27])
D. 28 (if rounded off before dividing weight from height)
BMI COMPUTATION: weight (kg) / height (m)2 5 ft = 1.524 m 1 in = 0.0254 m 1 kg = 2.2 lb BMI CLASSIFICATION: underweight: < 18.5 normal range: ≥ 18.5 – 22.9 overweight: ≥ 23 at risk: 23 – 24.9 obese I: 25 – 29.9 obese II: ≥ 30
58. What is the classification of BMI according to WHO? A. Normal
B. Overweight C. Obese I D. Obese II (please refer to #57)
59. If you give an exercise prescription, what would be the target heart rate? A. 135 – 145
B. 136 – 146 C. 137 – 147 D. 138 – 148 (please refer to #42)
60. If you will recommend aerobic exercise that the student can easily integrate in his daily activities, which one would you recommend?
A. Biking
B. Ballroom dancing C. Swimming
D. A & C
61. As far as proper diet is concerned, what would you recommend? A. Increase fluid intake (water, milk, soda)
B. Low fat dairy (low content of unsaturated fats) C. Low sodium (5 grams sodium)
D. Increase fiber intake (fruits, vegetables) (please refer to #s 42 and 47)
62. Aside from diet and exercise, what other intervention would you recommend that can prevent diabetes and hypertension?
A. Stress management
B. Sleep minimum of 8 hrs/day
C. Social networking most days of the week D. All of the above
(please refer to #49)
63. What procedures would you recommend to screen for heredo-familial diseases? A. Blood pressure monitoring
B. Blood sugar determination C. Chest X-ray
D. A and B
64. Primary level of intervention in this case would generally consist of: A. Immunization
B. Low fat, low salt diet C. Smoking cessation D. All of the above (please refer to #51)
65. Health promotion activities that the student can engage in are the following: A. Membership in fitness center
B. Joining a travel club C. Consulting a dietician D. A and C
66. A patient informed you that she had a disease that could not be cured by conventional medicine and like to consider the use of complementary and alternative therapies for which no proof of efficacy exists. As the attending doctor what should be the best advice you can give.
A. Yes. Go ahead and try it.
B. No, it has no therapeutic claims. C. Give me the details I’ll search on it. D. Sorry, I don’t know.
E. None of the above.
67. The reason for the above choice is/are:
A. To analyze patient’s choice of types of therapy including Complementary Therapy
B. Analyze the benefits and risks of Complementary Therapy for patients with life threatening illness
C. Analyze role of Complementary Therapy in practice D. A & B
E. All of the above
68. The following belongs to Non-Toxic Therapies. A. Meditation
B. Positive thinking
D. All of the above
TOXIC THERAPIES:
Surgery – does not necessarily affect the rest of the body Radiation – damage can be localized
Chemotherapy – affects many areas
NON-TOXIC THERAPIES: Meditation Dietary considerations Positive thinking Immunological stimulants Vitamin/mineral therapy
Wide range of so-called alternative therapies Complimentary and Alternative Medicine (CAM)
69. The following are the so-called Conventional Therapies EXCEPT: A. Surgery
B. Chemotherapy C. Radiation therapy
D. Immunological stimulants (please refer to #68)
70. The most common reason why patients with life-threatening condition would consider the use of CAM is/are.
A. Prolong their survival
B. Alleviate the side effects of conventional cancer treatments C. Detoxify their bodies
D. Boost immunity
E. Enhance their overall quality of life [NOTE: Since all the choices are reasons (basing on the study), I chose the one that Dra. Bausa noted in her conclusion. ]
Most participants self-treated with CAM and perceived CAM modalities as complementary rather than alternative to conventional cancer treatments.
Within this context, this group of people used CAM to prolong their survival, palliate their symptoms or
alleviate the side effects of conventional cancer treatments, detoxify their bodies, boost immunity
and enhance their overall quality of life.
Patients with cancer want to know more about how to maintain or improve their quality of life during and after surgery, radiation or chemotherapy. (from Dra. Bausa’s conclusion about a study trying to identify in detail the reasons for using CAM among patients with advanced cancer)
71. During patient-physician encounter, physician as part of good clinical practice should: A. Foster an open non-judgmental communication with patients
B. Clinicians need to be aware of what their patients are doing and their rationale for doing so.
C. Screeening for physical, emotional, and spiritual discomfort associated not only with the disease
D. A & B
E. All of the above
Clinicians need to be aware of what their patients are doing and their rationale for doing so. Screening for physical, emotional, and spiritual discomfort associated not only with the disease but with some of the cancer treatment needs to be given a prominent place in the clinical encounter.
Fostering an open nonjudgmental communication with patients is part of good clinical practice.
72. In patients using CAM, physician should take into account all but most especially the ____________: A. Benefit
B. Cost and the potential harm C. Patient’s choice
D. Physicians choice E. All of the above
CAM
Supporting patient’s choices is an important part of palliative care. It is challenging to be providing care when patients use complementary therapies. There are issues relating to cost, and the potential
for harm that need to be taken into account.
73. Role of Health Care Professional in patients considering CAM: A. Help the patients to make their own decisions
B. Listening to the patient
C. Finding information and asking questions D. Navigate information overload
E. All of the above
ROLE OF HEALTH CARE PROFESSIONALS
In helping patients to make decisions as health professionals our roles are to help them to make their
own decisions. This involves listening to the patient, finding information and asking questions. We may
often be called upon to help navigate the “information overload” of very variable quality that is out there on the internet.
74. Which of the following describe CAM:
A. Alternative medicine is frequently grouped with Complementary Medicine or Integrative Medicine
B. Refers to the interventions when used in conjunction with mainstream techniques under the umbrella term complementary and alternative medicine
C. Both D. Neither
COMPLEMENTARY MEDICINE
Complementary – preferred terminology to describe therapies used in conjunction with conventional
treatments
Alternative therapy – “umbrella term” used in the United States to describe unproven remedies and
techniques; carries the implication of use instead of conventional treatment; frequently grouped with complementary medicine or integrative medicine
Integrative medicine – refers to the same interventions when used in conjunction with mainstream
75. Patient seek and are attracted to CAM due to which factor/s: A. Dissatisfaction with conventional therapies
B. Hope and self-empowerment
C. Feel helpless in the face of disease progression
D. Gain control over what is happening [NOTE: Since in Dra. Bausa’s conclusion she said that patients are increasingly asserting their right to choose their own therapy, this MIGHT be the best answer.]
E. All of the above
COMMON CRITICISMS ON CONVENTIONAL THERAPIES:
“they told me they cannot do any more” focuses on disease instead of health focuses on doctor instead of patient paternalistic
practitioners are too busy therapies are harmful
undervalues social, psychological and spiritual aspects practiced by doctors who are poor role models for health
part of a conspiracy (e.g. cancer cures are kept secret in order to maintain pharmaceutical companies profits)
As part of a general cultural change, patients are increasingly asserting their right to choose their own therapy, whether their doctors approve or not (from Dra. Bausa’s summary)
76. The purpose of having knowledge of Long Term Care Services is to: A. To have an idea of the continuum of long term care services B. To know the specific services provided within the continuum C. Identify patients who need and use long term care
D. B & C
E. All of the above
Long term care services – includes a broad spectrum of care generally utilized by individuals with
severe medical and social problems that limit normal residential living; armada of services, both related and social, that are needed to help individuals who are fully or partially impaired in their conduct of daily living activities; continuum of care
TARGET GROUPS
Disabled – may be due to physical or mental health problems; restriction/prevention of
performance; long term care services include emotional support services as well
o Impairment – permanent or transitory psychological, physiological or anatomical loss or abnormality of structure or function
o Handicap – disability that constitutes a disadvantage for a given individual in that it limits or prevents the fulfillment of a role that is normal depending on age, sex, social and cultural factors of that individual
o A physical disability or health impairment is not a handicap unless it limits the
individual’s participation in routine activities.
Elderly – long term care is used primarily by frail elderlies who because of reduced physical
vigor (may or may not involve loss of mental acuity) can no longer be solely responsible for their own maintenance and functioning
o Incompetent (Alzheimer’s, multi-infarct dementia, geraitric depression, benign forgetfulness of senescence)
o Immobile (arthritis)
o Incontinent (urge incontinence: bladder inhibition, SC lesion, neurogenic bladder [presents with the severe urge to void that cannot be controlled]; stress incontinence: damage/dysfunction of bladder sphincter, leakage of urine when intra-abdominal pressure increases [presents with incontinence in coughing or sneezing]; overflow incontinence: bladder outlet obstrution or detrussor failure, bladder unable to empty normally, overdistention, leakage [presents with urgency, feeling of inability to void, small amount of urine]; reflex incontinence; functional incontinence: immobility/severe cognitive impairment [presents with unawareness that he/she voided])
o Iatrogenic disease (doctor/nurse induced; medications)
o Impaired homeostasis (heat fatigue, hypothermia, dizziness, anemia, nutritional deficiency)
Partially impaired/handicapped – permanent/transitory
Chronically and terminally ill – with genetic illnesses, terminal patients
Acute care Inpatient units
Psychiatric care Rehabilitation
Ambulatory care Outpatient clininic
Adult day care Mental health care
Alcohol and substance abuse
Extended Skilled nursing facilities
Step down units
Wellness and health promotion Educational program
Recreational and social support Volunteer programs
Meal programs
Outreach linkage Screening
Information/referral Telephone contact Emergency assistance Transportation
Housing Continuing care communities
Congregate care Assisted living
Home care Hospice care
Home health
Homemaker and personal care 77. The following is/are the scope of hospice care EXCEPT:
A. Home Care B. Out-Patient C. Acute Care D. In-Patient
Hospice care – active total care of patients and their families by the multi-professional team when
the patient’s disease is no longer responsive to curative treatment (WHO); consists of palliative and supporting services
GOALS OF PALLIATIVE CARE:
Achievement of the “best quality of life” For patients and their families
Interdisciplinary
Admission through “bereavement” Available at all times
Many aspects apply earlier in the course of illness
COMPONENTS OF HOSPICE PALLIATIVE CARE:
In-patient units – to control pain and other sx difficult to manage at home, provide respite for
fatigued family members, and provide for training goods
Home care – stresses that home is the primary “venue of care” particularly necessary for px
who are non-ambulatory o Care includes:
Management and control of px physical sx
Provision of psycho-emotional and social support to px and families
Provide information and training to the px family at home to attend to the other needs of the cancer px
o Team unit consists of: Doctors
Nurses
Social workers Pastors
Family caregivers
Community health workers Volunteers
Out-patient consultation clinic – center-based, community-oriented, geographic catchment
area with personnel who are trained in palliative care, px, and family counseling
Day care – px diversion and activity
Bereavement support – for families of px after the death of px
Counseling – both psychosocial and spiritual
Volunteer program and training – for caregivers
78. Target groups for Long Term Care Services A. Handicap, elderly
B. Young, bedridden with spinal cord injury C. Chronic and terminally ill
D. A & C
E. All of the above (please refer to #76)
79. Element/s of Long Term Care Services: A. Specific target groups
B. Appropriate to patient’s situation
D. A & C
E. All of the above
Long term care is a variety of services that includes medical and non-medical care to people who have chronic illneses or disability (specific target groups). Long term care helps meet health or personal needs (appropriate to px’s situation). Most long term care is to assist people with support services (appropriate to px’s situation) such as activities of daily living like dressing, bathing and using
the bathroom. Long term care can be provided at home, in the community, in assisted living or in
nursing homes (provided in patient’s own home or community). (manual)
80. Disabled patient needs care because of: A. Temporary or permanent disablement B. Maybe cause mental problem
C. Performance of ADLs
D. Emotional & physical support E. All of the above
(please refer to #76)
81. Special concerns among Elderly, EXCEPT: A. Incompetence B. Immobility C. Cancer D. Incontinence E. Iatrogerlic (please refer to #76)
82. Categorized as Wellness and Health Promotion Programs A. Educational program
B. Recreational and Social Support C. Volunteer Programs
D. A & B
E. All of the above
83. Most important team member in Home Care. A. Registered Nurse
B. Physical Therapist C. Medical Social Worker D. Dietician
E. Physician
The core palliative care team should consist of nurses and physicians with special training as a minimum, supplemented by psychologists, social workers and physiotherapists if possible. Other professionals can be members of the core team, but more frequently will work in liason. (manual) 84. An option for management of a patient who is in pain, too old and bedbound, with infection that
is too infectious that there is greater risk for spread to other patients with consideration to cost and harm/effectiveness is to:
B. Admit to ICU C. Home care
D. None of the above
85. Reason to admit a terminally ill patient to a hospital is/are: A. Family meeting when house is too far
B. Terminal care C. Respite care D. A & B
E. All of the above
DIRECTION: Match SET A and SET B in COLUMN I with the common COMPLEMENTARY AND ALTERNATIVE THERAPIES in COLUMN II.
COLUMN I COLUMN II
86. Vitamins C A. Manipulative Therapies
87. Yoga B B. Mind Body Interactions
88. Massage A C. Biologically Based Approach
89. Naturopathy E D. Energy Therapies
90. Qigong D E. Alternative Medical Systems
Choices of CAM:
Biologically based approaches – diets, herbs, vitamins
Energy therapies – Reiki, magnets, Qigong
Alternative medical systems – hemeopathy, naturopathy, Ayuverda
Mind-body interventions – yoga, spirituality, relaxation
Manipulative and body-based therapies – massage, chiropractic, osteopathy
DIRECTION: Write A if the patient needs referral and B if not.
91. Patient shows lack of confidence in the diagnosis or management. A
92. The doctor is unsure of the diagnosis. A
93. Patient has controlled blood pressure with the med given by the doctor. B 94. Hypertensive patient who complains of blurring of vision. A 95. Patient with gall bladder stone but is asymptomatic. A
Referral – implies a transfer responsibility to another physician for the care of a specific problem;
usualy involves one physician requesting the services of another for a particular purpose and for a limited time; transfer of responsibility from family physician to another physician is never total (family physican retains an overall responsibility for the patient’s welfare
DIFFERENT TYPES OF REFERRAL:
Internal referral – px referred for complete care for a limited period; referring physician has no
responsibilities during this period (eg. referral of px for a major surgery or major medical illness)
Collateral referral – referring physicial retains overall responsibility but refers the patient for
care of some specific problem; may be long term (chronic glaucoma) or short term counseling for a psychological or social problem)
Cross-referral – px adviced to see another physician, and the referring physician accepts no
because it is 1) wasteful of resources, 2) demoralizing for the patient, and 3) alienating for the family physician
Split referral – takes place under conditions of multispecialist practice, when responsibility is
divided more or less evenly between two or more physicians (px is a diabetic and also has an
ischemic heart disease); disadvantage: nobody knows who has overall responsibility for the px
WHEN TO REFER:
Px or family expresses doubt or shows lack of confidence in the diagnosis or management o Readiness of physican to consult is a sign of maturity and self-confidence
Family physician himself is dissatisfied with the px’s progress or is unsure of the diagnosis
RESPONSIBILITIES OF THE REFERRING PHYSICIAN:
Selection of the consultant Adequate transfer of information Patient preparation and compliance Evaluation of information
Feedback consultant
DIRECTION: The kinds of team in IDA and types of referral are written on the lettered choices. Match them with the numbered items. Write the letter of the best answer.
A. Intervention-Oriented C. Service-Oriented
B. Crisis-Oriented D. Client-Oriented
96. It is an organized, highly sophisticated team equipped to save or prolong life. B 97. The aim of this team is to improve the life of the patient. D 98. This team is organized around the effort to reach certain specific population at risk. A 99. This team is organized around the delivery of a group of health care services. C
100. This team is focused on problem solving. D
KINDS OF TEAM:
Crisis-oriented – organized around saving or prolonging lives; highly sophisticated;
technologically equipped; clear roles (e.g. cardiac arrest team)
Client-oriented – organized around individual health care; problem-solving; more
life-improving than life-saving (e.g. comprehensive patient care: family health care)
Intervention-oriented – organized around the effor to reach certain specific population at risk
(e.g. health team for the aged, alcoholics, STD)
Service-oriented – organized around the delivery of a group of health care services (e.g.
maternal/child care, family planning)
A. Split Referral C. Cross Referral
B. Collateral Referral D. Internal Referral
101. The danger of this type of referral is that nobody knows who has overall responsibility for the patient. A
102. A hypertensive patient was admitted by a Family Medicine Specialist. While in the ward, the patient developed sudden severe chest pain. The FM’s impression was Myocardial Infarction. The patient was referred to a Cardiologist for ICU admission. D
103. Dr. Cruz was taking care of a 7-year-old patient since birth and was in optimal health. Until, one day, the patient was brought by his mom because he did not want to go to school. He was a
victim of bullying. He was referred to a FMS for counselling but Dr. Cruz retains overall responsibility. B
104. The patient was advised to see another physician and the referring physician accepts no further responsibility for the patient’s care. C
105. A patient came to the clinic of a FMS because he wanted to have one doctor to whom he can visit every time he feels ill. He informed the FMS that he has a Diabetologist who takes care of his Diabetes, a Cardiologist who manages his heart disease and a Gastroenterologist for his Acid Peptic Disease. A
(please refer to #s 91–95) CASE
Maria is a married, 32 y/o mother of three. She has been discharged from the hospital against medical advice after a 3-day stay with a medical diagnosis of diabetes mellitus and fracture of the left proximal humerus. She had initially gone to the emergency room of the hospital for treatment of her “broken arm” after a “fall down the basement stairs.”
During her stay in the hospital, Maria appeared depressed and sullen, avoided eye contact, and answered all questions with one or two words. It was also noted that she had not any visitors during her stay. It was decided that a home care follow-up was indicated because Maria seemed to be vague and insecure about her condition even though she verbalized a complete understanding of her diet and medications.
During the first home visit by the FHC team (family health care) the house appeared cluttered but was relatively clean. Empty beer bottles were noted. Maria appeared tense and agitated. Maria told the FHC team, “Let’s get this over with fast before my husband arrives. He does not want strangers in the house.”
Maria revealed that she has an 8-y/o daughter who is her biggest help. Her other children are a 6-y/o son and a 5-y/o daughter. She never mentioned her husband. When probed about it, she averted her eyes and looked fearful. Maria said, “He is a wonderful father and husband when he is not drunk. We just have to act better so he’ll love us enough to stop drinking.”
DIRECTION: Write the letter of the BEST answer.
106. In the assessment phase of the family health care process, what tools were used by the FHC team to gather data about the family?
A. Interview B. Home visit
C. Ocular inspection D. A & C
E. A, B, C
THREE PRIMARY RESPONSIBILITIES DURING ASSESSMENT PHASE:
Develop a trusting, therapeutic relationship o Describe the FMC and what it has to offer o Explain the purpose for the home visit
o Facilitate the sharing of thoughts, feelings and data
o Set time parameters for evaluation, frequency and length of visits o Share with patient and family their rights and responsibilities
o Informed consent
Collect data in a variety of ways and from multiple sources o Sources:
Primary – data obtained from the patient and his family or from what one sees,
hears, feels or smells in the patient’s environment
Secondary – data obtained from a variety of sources (e.g. significant others,
personnel from health or social agencies, attending physician, spiritual leaders, health record
o Methods:
Observation – taking note of how a px behaves; observing grossly; primary
Interview – most important; primary
Inspection – physical examination (e.g. auscultation, palpating); difficult to do
because violation of privacy can be violated; primary
Review of records – secondary
Assess all parameters of family functioning o Health status o Family dynamics o Physiologic data o Psychologic data o Sociocultural data o Environmental data
o Preventive health practices
107. Which one of the following Maria’s medical problems and objectives is/are correct? A. Depression – to improve mood and well-being
B. Diabetes – to maintain blood sugar to normal level of < 100mg/dl C. Fracture – to improve motor function of the injured arm
D. B & C E. A, B & C
108. Which one of the following is the appropriate secondary level of prevention for the identified medical problems of the patient?
A. Fracture – x-ray of the injured arm and physical therapy B. Depression – antidepressant and counselling
C. Diabetes – diabetic diet and anti-diabetic drug D. B & C
E. A, B & C (please refer to #51)
109. In the evaluation of the chosen treatment plan for the medical problems, what are you going to look for?
A. Diabetes – blood sugar level of < 100mg/dl B. Fracture – improved motor function
C. Depression – improved mood and well-being D. A & B
E. A, B & C
Evaluating – a continuous concurrent process used to critique each component of the health care
Methods:
o Feedback from px and family
o Consult with peers, supervisors, and other health care professionals (e.g. conferences, chart rounds, ask experiences improves interaction with px)
o Summarize records o Conduct case audit
Identify the results of intervention activities taken by the px, family, physician, and other health care professionals involved in the case
Modify the management plan when appropriate
o Reasons why the px and the family are not reaching their goals: Data base inadequate to identify actual needs
Goals and objectives too broad
Goals and objectives not mutually established
Family priorities in relation to goals and objectives not ascertained Family energies depleted
Barriers to care not identified
Diagnoses, goals and objectives not revised as the family situation changes Intervention strategies not appropriate
Coordination of care among the health professionals involved is neglected 110. What is/are the psychosocial problem/s considered to be the immediate cause of the patient’s
hospitalization?
A. Dysfunctional marital relationship
B. Family violence [NOTE: Since only the IMMEDIATE cause for hospitalization is being asked, then Maria’s broken arm after “falling down the basement stairs” (indicative of violence) should be the answer.]
C. Substance abuse D. A & B
E. A, B & C
111. Which among the following levels of intervention for the psychosocial problem is correct? A. Secondary: mental health assessment of family members
B. Secondary: family and individual counselling C. Tertiary: rehabilitation of husband
D. A & B E. A, B, & C (please refer to #51)
112. In implementing your plans, what are the things you have to consider to ensure success? A. Periodic evaluation
B. Work within limitations C. Case consultation
D. Modify intervention when needed E. All of the above
IMPLEMENTATION:
Demonstrate awareness of proper timing when carrying out intervention activities Adapt or modify intervention strategies when client situation changes
Recognize social, cultural, economic, and environmental barriers, and work within these limitations
Carry through with planned interventions
Base intervention activities on scientific principles and knowledge o Review literature
o Consult with peers, consultants, and other health professionals
113. In evaluating your casework with the family, the following methods can be used EXCEPT A. Feedback from patient
B. Consultation with supervisors C. Case audit
D. A & B
E. None of the above (please refer to #109)
114. What are the indications for terminating the patient, family and physician therapeutic relationship?
A. Objectives have been achieved B. Patient wants to end relationship C. Intervention not effective
D. A & B E. A, B & C
INDICATIONS OF TERMINATION:
Px wants to change doctors or end relationship Address of px changes
Achievement of objectives Ineffective intervention 115. BONUS – shade A
