N1

1. Biopsychosocial model of health and illness – main consideration

The biopsychosocial model views health and illness as the product of biological characteristics (genes),
behavioral factors (lifestyle, stress, health beliefs), and social conditions (cultural influences, family
relationships, social support).

2.Latency or school age: 7–11 years - motor development. Social and cognitive characteristics

A. Motor development. :- The normal grade-school child, 7–11 years of age, engages in complex motor
tasks (e.g., plays baseball, skips rope).
B. Social characteristics. The school-age child:
1. Prefers to play with children of the same sex; typically avoids and is critical of those of the opposite
sex.
2. Identifies with the parent of the same sex.
3. Has relationships with adults other than parents (e.g., teachers, group leaders).
4. Demonstrates little interest in psychosexual issues (sexual feelings are latent and will reappear at
puberty).
5. Has internalized a moral sense of right and wrong (conscience) and understands how to follow rules.
6. School-age children and younger children are typically interviewed and examined by the doctor with
the mother present.
C. Cognitive characteristics.The school-age child:
1. Is industrious and organized (gathers collections of objects)
2. Has the capacity for logical thought and can determine that objects have more than one property
(e.g., an object can be red and metal)
3. Understands the concepts of conservation and seriation; both are necessary for certain types of
learning
a. Conservation involves the understanding that a quantity of a substance remains the same regardless
of the size of the container or shape it is in (e.g., two containers may contain the same amount of water
even though one is a tall, thin tube and one is a sho rt, wide bowl).

b. Seriation involves the ability to arrange objects in order with respect to their sizes or other qualities

3. Preparatory activities for communicating bad news (1-3 steps)

Before starting to communicate any news, plan what will be discussed. Confirm the medical facts of the
case. Ensure that all the needed information is available. If this is an unfamiliar task, rehearse what you
will say. Don’t delegate the task. Create an environment conducive to effective communication

Start the discussion by establishing what the patient and family know about the patient’s health. With
this information, ascertain if the patient and family will be able to comprehend the bad news.
Occasionally a patient (or a parent if the patient is a child) will fall silent and seem completely
unprepared or unable to respond. To ease the situation and stimulate discussion, try to clarify what the
patient understands about his or her medical history and recent investigations

establish what and how much each patient, or parent if the patient is a young child, wants to know.
People handle information differently, depending on their race, ethnicity and culture, religion, and
ocioeconomic class. Each person has the right to voluntarily decline to receive any information and may
designate someone else to communicate on his or her behalf. Ask the patient and family how they
would like to receive information. If the patient prefers not to receive critical information, establish to
whom informationshould be given.
N2
1.Adolescence: 11–20 years – social and cognitive characteristics of early, middle and late adolescence.
A.Early adolescence (11–14 years of age)
1)Puberty occurs in early adolescence and is marked by
a)The development of secondary sex characteristics & increased skeletal growth First menstruation in
girls, which on average occurs at 11–14 years of age
b) First ejaculation in boys, which on average occurs at 12–15 years of age
c) Cognitive maturation and formation of the personality
d) Sex drives, which are expressed through physical activity and masturbation (daily masturbation is
normal)
2) Early adolescents show strong sensitivity to the opinions of peers but are generally obedient and
unlikely to seriously challenge parental authority.
3) Alterations in expected patterns of development (e.g., acne, obesity, late breast development in girls,
nipple enlargement in boys [usually temporary but may concern the boy and his parents]) may lead to
psychological difficulties.
B. Middle adolescence (14–17 years of age)
1) Characteristics

a) There is great interest in gender roles, body image, and popularity.

b) Heterosexual crushes are common.
c) Homosexual experiences may occur. Although parents may become alarmed, such practicing is part
of normal development.
d) Efforts to develop an identity by adopting current teen fashion in clothing and music, and preference
for spending time with peers over family are normal, but may lead to conflict with parents.
2) Risk-taking behavior
a) Readiness to challenge parental rules and feelings of omnipotence may result in risk-taking behaviour
(e.g., failure to use condoms , driving too fast, smoking).
b) Education about obvious short-term benefits rather than references to long-term consequences of
behavior is more likely to decrease teenagers' unwanted behavior . For example, to discourage smoking,
telling teenagers that their teeth will stay white if they don'tP.15smoke, or that other teens find
smoking disgusting, will be more helpful than telling them that they will avoid lung cancer in 30 years.
C. Late adolescence (17–20 years of age)
1 ) Development
a) Older adolescents develop morals, ethics, self-control, and a realistic appraisal of their own abilities;
they become concerned with humanitarian issues and world problems.
b) Some adolescents, but not all, develop the ability for abstract reasoning .
2) in the effort to form one's own identity, an identity crisis commonly develops.
a) If the identity crisis is not handled effectively, adolescents may experience role confusion in which
they do not know where they belong in the world .
b)Experiencing role confusion, the adolescent may display behavioural abnormalities through
criminality or an interest in cult

2.Buckman’s step 6: planning and follow-up <N6-Q5>

3.Mature defense mechanisms: Humor, intellectualization, sublimation <N5-Q3>

N3
1. The toddler years: 15 months–2 1/2 years – motor and cognitive characteristics
Motor:- Throws a ball Stacks three blocks Climbs stairs one foot at a time Scribbles on paper. Kicks a ball
Balances on one foot for 1 second Stacks six blocks Feeds self with fork and spoon
Cognition:- Uses about 10 individual words Says own name, Uses about 250 words Speaks in two-word
sentences and uses pronouns
(e.g., "me do") Names body parts and objects

2.Buckman’s step 5: responding to feelings

Identify and acknowledge the patient’s reaction. The success or failure of the breaking-bad-news interview
ultimately depends on how the patient (or family member) reacts and how you respond to those reactions and
feelings.
• While this introductory exercise does not allow for an in-depth description of the issues involved in responding
to patients’ feelings, here are some points to consider when confronted by the patient’s feelings:
1. Patients respond to bad news in ways characteristic of their own coping strategies.
2. Their responses can be assessed by three criteria: • Social acceptability (set the limits generously) •
Adaptability: is this response helping the patient to cope? • Flexibility: if this is not helping, can you intervene to
help; if not, can someone else?
3. In the event of conflict, try to: • Step back and not be swayed by the conflict itself • Take action to bring
some resolution, do not wait and only react • Define areas that cannot be resolved

3. A “difficult’ patient - “frequent fliers.”

Big medical charts. may be lonely, dependent or too afraid or embarrassed to ask the questions.
“worried well” or misinformation
 Identify the underlying reasons for the frequent visits.
 Begin by acknowledging that you notice the pattern of frequent visits,
 Explain patients different reasons, eg. concern , reassurance, chronic pain relief or to talk.
 Showing understanding of the patient's reasons often will foster an open discussion of the
“reasons behind the reasons.”
 Contract with the patient for regularly scheduled return visits
 Use patient education and support personnel as needed.

N4
1.The preschool child: 3–6 years – general characteristics
1. The child's vocabulary increases rapidly.
2. The birth of a sibling is likely to occur in the preschool years and sibling rivalry may occur.
3. Sibling rivalry or other life stress, such as moving or divorce, may result in a child's use of regression, a
defense mechanism in which the child temporarily behaves in a "baby-like" way (e.g., starts wetting the
bed again)This is a normal reaction to life stress.
4. Children can distinguish fantasy from reality (e.g., they know that imaginary friends are not "real"
people), although the line between them may still not be sharply drawn.
5. Preschool children are normally active and rarely sit still for long.

2.Buckman’s step 5: responding to feelings < N3-Q2>

3.Immature Defense mechanisms: Denial, repression, regression, displacement
<N15-Q3>
.
N5
1.The toddler years: 15 months–2 1/2 years – social and verbal characteristics
Social:- Moves away from and then returns to the mother for reassurance (rapprochement)
Shows negativity (e.g., the favorite word is "no") Plays alongside but not with another child ("parallel play": 2–4
years of age)
verbal :- Uses about 10 individual words Says own name. in age of 2 years uses about 250 words Speaks in two-
word sentences and uses pronouns (e.g., "me do") Names body parts and objects

2.A “difficult” patient - grieving patients.

Recognising the effect of grief on some patients’ health requires familiarity with the normal stages of grief and
the cultural context in which it occurs. Look for vegetative signs of depression and maladaptive behaviours that
prevent progression through the normal grieving process, and treat them. Help grieving patients by validating
their emotional experience and making sure they understand that grief is a process that takes varying degrees of
time for different people. Encourage open communication, avoid inappropriate medication to suppress emotions,
and caution against major lifestyle changes too early in the process.

3.Mature defense mechanisms: Humor, intellectualization, sublimation

Humor:- Expressing personally uncomfortable feelings without causing emotional discomfort
Intellectualization:- Using the mind's higher functions to avoid experiencing emotion
Sublimation:- Expressing a personally unacceptable feeling (e.g., rage) in a socially useful way

N6
1.Infancy: birth to 15 months - characteristics of the infant
1. Reflexive behavior. At birth, the normal infant possesses simple reflexes such as the sucking reflex,
startle reflex (Moro reflex), palmar grasp reflex, Babinski reflex, and rooting reflex. All of these reflexes
disappear during the first year of life.
2. Motor, social, verbal, and cognitive development
a. Although there is a reflexive smile present at birth, the social smile is one of the first markers of the
infant's responsiveness to another individual.
b. Crying and withdrawing in the presence of an unfamiliar person (stranger anxiety) is normal and
begins at about 7 months of age.
1. This behavior indicates that the infant has developed a specific attachment to the mother and is able
to distinguish her from a stranger.
2. Infants exposed to many caregivers are less likely to show stranger anxiety than those exposed to few
caregivers.
c. At about 1 year the child can maintain the mental image of an object without seeing it ("object
permanence").

2.Buckman’s step 6: planning and follow-up

a. Establish a plan for the next steps. This may include gathering additional information or performing further
tests. Treat current symptoms. It may include helping parents to tell their child about their illness and what
treatment will be like for them. Arrange for appropriate referrals. Explain plans for additional treatment. Discuss
potential sources of emotional and practical support, eg, family, significant others, friends, social worker,spiritual
counselor, peer support group, professional therapist, hospice, home health.agency, etc. Discuss sources of
support for an ill child’s siblings.

B.Reassure the patient and family that they are not being abandoned and that the physicianwill be actively
engaged in an ongoing plan to help. Indicate how the patient and familycan reach the physician to
answer additional questions. Establish a time for a follow-up appointment.Ensure that the patient will
be safe when he or she leaves. Is the patient able to drive home alone? Is the patient distraught, feeling
desperate or suicidal? Is there someone at home to provide support?At future visits, elements of this
protocol may need to be revisited. Many patients and families require repetition of the news to gain a
complete understanding of their situation
3.Immature Defense mechanisms: Denial, repression, regression, displacement
Denial:- Not accepting aspects of reality that the person finds unbearable
Repression:- The person forces the unacceptable or threatening feeling out of awareness to a point where he/she
becomes unaware of it
Regression :- Reverting to behavior patterns like those seen in someone of a younger age
Displacement:- Moving emotions from a personally intolerable situation to one that is personally tolerable

N7
1. Adulthood: stages, characteristics, responsibilities and relationships
1.) Early Adulthood: 20–40 Years
A. Characteristics
1. At about 30 years of age, there is a period of reappraisal of one's life.
2. The adult's role in society is defined, physical development peaks, and the adult becomes independent.
B. Responsibilities and relationships
1. The development of an intimate (e.g., close, sexual) relationship with another person occurs.
2. According to Erikson, this is the stage of intimacy versus isolation; if the individual does not develop the ability
to sustain an intimate relationship by this stage of life, he or she may experience emotional isolation in the future.
4. During their middle 30s, many women alter their lifestyles by returning to work or school or by resuming their
careers.
2.) MIDDLE ADULTHOOD: 40–65 YEARS
A. Characteristics.
The person in middle adulthood possesses more power and authority than at other life stages.
B. Responsibilities.
The individual either maintains a continued sense of productivity or develops a sense of emptiness (Erikson's
stage of generativity versusstagnation).
C. Relationships
1. Seventy to eighty percent of men in their middle 40s or early 50s exhibit a midlife crisis. This may lead to
a. A change in profession or lifestyle
b. Infidelity, separation, or divorce
c. Increased use of alcohol or drugs
d. Depression
2. Midlife crisis is associated with an awareness of one's own aging and death and severe or unexpected lifestyle
changes (e.g., death ofa spouse, loss of a job, serious illness).

2. A “difficult’ patient - manipulative patients.

These patients use guilt, rage, and threats of legal action or suicide in impulsive attempts to get what
they desire. In these patients, it can be difficult to differentiate between manipulative tendencies and
borderline personality disorder. With manipulative patients, it is important to set limits, say “no” when
you have to, remain cognizant of your own emotions, and understand the patient’s expectations, which
can, in fact, be reasonable despite their actions

3. Freudian topographical model of the mind < same as N12- Q3>

N8
1. Cognitive and psychological changes of aging

a. -Although learning speed may decrease, in the absence of brain disease, intelligence remains
approximately the same throughout life.
b. -Some memory problems may occur in normal aging (e.g., the patient may forget the name of a new
acquaintance). However, these problems do not interfere with the patient's functioning or ability to live
independently

2.Role of defense mechanisms. <N13- Q3>

3. Fatigued or harried physicians.

The three diagnostic symptoms:

1) Exhaustion:
Physician and emotional exhaustion to the point where a little voice in your head might say something
like, "I'm not sure how much longer I can keep going like this."

2) Cynicism, Sarcasm, Compassion Fatigue:

You are frustrated, bothered and snarky about patients and their families. You may even find you need
to "vent" just to keep going.

3) You begin to doubt that you are making a difference

Dr. Maslach called this "lack of efficacy". You may notice the little voice in your head saying things like,
"what's the use". Or it might say "I am concerned that if things don't change, I am going to make a
mistake and someone is going to get hurt."

N9
1. Postpartum maternal reactions - duration of symptoms, characteristics
A:- Postpartum blues ("baby blues") onset symptoms Within a few Days after delivery Up to 2 weeks
after Delivery …. Exaggerated emotionality And tearfulness Interacting well with friends and family Good
grooming
B:- Major depressive episode :-> onset Within 4 Weeks after delivery, Up to 1 year without treatment;
3–6 weeks with treatment… Feelings of hopelessness and helplessness Lack of pleasure or interest in
usual activities Poor self-care May include psychotic Symptoms ("mood disorder with Psychotic
features"), e.g., hallucinations and delusions When psychotic, mother may harm infant
C:- Brief psychotic disorder (postpartum onset):-> Within 2–3 Weeks after Delivery Up to 1 month
Psychotic symptoms Not better accounted for by Mood disorder with psychotic Features Mother may
harm infant

2. Buckman’s step 4: sharing the information

-Deliver the information in a sensitive but straightforward manner. Say it, then stop.
-Avoid delivering all of the information in a single, steady monologue.
-Use simple languagethat is easy to understand.
-Avoid technical jargon or euphemisms.
-Pausefrequently. Check for understanding.
-Use silence and body language as tools to facilitatethe discussion.
-Do not minimize the severity of the situation. Well-intentioned efforts to“soften the blow” may lead to
vagueness and confusion

3. Freudian structural model of the mind

In the structural theory, the mind contains three parts: the id, the ego, and the superego
i.) Id – Unconscious - Present at birth ---Contains instinctive sexual and aggressive drivesControlled by
primary process thinking Not influenced by external reality
ii.) Ego -- Unconscious, preconscious, conscious -- Begins to develop immediately
after birth --- a. Controls the expression of the id to adapt to therequirements of the external world
primarily by the use of defense mechanisms
b.Enables one to sustain satisfying interpersonal relationships Through reality testing
(i.e.,constantly evaluating what is valid and then adapting that to reality), enables one to maintain a
sense of reality about the body and the external world
iii.) Superego - Unconscious, preconscious, conscious - Begins to develop by about 6 years
of age Associated with moral values and conscience Controls the expression of the id

N10
1. Leading causes of infant mortality
1. Birth defects.
2. Preterm birth and low birth weight.
3. Maternal pregnancy complications.
4. Sudden infant death syndrome.
5. Injuries (e.g., suffocation).

2. Preparatory activities for communicating bad news (1-3 steps) < same as N1- Q3>

3.A “difficult’ patient – physician factors

1. If the doctor is hungry, angry, late, or tired (HALT).
2. Personal factors could be a distraction for some doctors,
3. The doctor’s personality traits could clash with those of the patient
4. Doctor’s lack of experience
Common physician factors include negative bias toward specific health conditions, poor communication
skills, and situational stressors

N11
1. Infancy: birth to 15 months - theories of development

1. Chess and Thomas showed that there are endogenous differences in the temperaments of infants
that remain quite stable for the first 25 years of life. These differences include such characteristics as
reactivity to stimuli, responsiveness to people, and attention span.
a. Easy children are adaptable to change, show regular eating and sleeping patterns, and have a positive
mood
b. Difficult children show traits opposite to those of easy children.
c. Slow-to-warm-up children show traits of difficult children at first but then improve and adapt with
increased contact with others.
2. Sigmund Freud described development in terms of the parts of the body from which the most
pleasure is derived at eachstage of development (e.g., the "oral stage" occurs during the first year of
life).
3. Erik Erikson described development in terms of critical periods for the achievement of social goals; if
a specific goal is not achieved at a specific age, the individual will have difficulty achieving the goal in the
future. For example, in Erikson's stage of basic trust versus mistrust, children must learn to trust others
during the first year of life or they will have trouble forming close relationships as adults.
4. Jean Piaget described development in terms of learning capabilities of the child at each age.
5. Margaret Mahler described early development as a sequential process of separation of the child from
the mother or primary caregiver.

2. A “difficult’ patient - situational factors

• Language and cultural differences. An inability to communicate directly is inherently frustrating, but there are
ways to break down these barriers. Try to be sensitive to different beliefs about health, illness, gender issues, and
religion.
• Multiple people in the exam room. When patients bring companions to the exam, speak directly to the patient,
avoid taking sides in any conflict, and confirm all parties understand the care plan.
• Environmental issues. Noise, chaos in the clinic, or a lack of privacy can all contribute to a difficult encounter.
Try to minimize distractions in the clinic where possible.
• Breaking bad news. When you have to give patients bad news, make sure you’re well-prepared for the
questions that will likely arise, give the news directly, and then allow adequate time for patients to process the
information and their emotions.

3.Freudian structural model of the mind <same as N9- Q3>

N12
1. Cognitive and psychological changes of aging <N8-Q1>

2.Buckman’s step 4: sharing the information

-Deliver the information in a sensitive but straightforward manner. Say it, then stop.
-Avoid delivering all of the information in a single, steady monologue.
-Use simple languagethat is easy to understand.
-Avoid technical jargon or euphemisms.
-Pausefrequently. Check for understanding.
-Use silence and body language as tools to facilitatethe discussion.
-Do not minimize the severity of the situation. Well-intentioned efforts to“soften the blow” may lead to
vagueness and confusion
3. Freudian topographical model of the mind
In the topographic theory, the mind contains three levels: the unconscious, preconscious, and conscious.
1. The unconscious mind contains repressed thoughts and feelings that are not available to the
conscious mind, and uses primary process thinking.
a. Primary process is a type of thinking associated with primitive drives, wish fulfillment, and pleasure
seeking, and has no logic or concept of time.
Primary process thinking is seen in young children and psychotic adults.
b. Dreams represent gratification of unconscious instinctive impulses and wish fulfillment.
2. The preconscious mind contains memories that, while not immediately available, can be accessed
easily.
3. The conscious mind contains thoughts that a person is currently aware of. It operates in close
conjunction with the preconscious mind but does not have access to the unconscious mind. The
conscious mind uses secondary process thinking (logical, mature, time-oriented) and can del ay
gratification.

N13
1. Special issues in child development: illness, death, mental retardation and adoption.
A. Illness and death in childhood
A child's reaction to illness and death is closely associated with the child's developmental stage.
1. During the toddler years (15 months–2.5 years) hospitalized children fear separation from the parent more
than they fear bodily harm, pain, or death.
2. During the preschool years (2.5–6 years) the child's greatest fear when hospitalized is of bodily harm.
B. Adoption
1. An adoptive parent is a person who voluntarily becomes the legal parent of a child who is not his or her genetic
offspring.
2. Adopted children, particularly those adopted after infancy, may be at increased risk for behavioral problems in
childhood and adolescence.
3. Children should be told by their parents that they are adopted at the earliest age possible to avoid the chance
of others telling them first.
C. Mental retardation---(also referred to as intellectual and/or developmental disability)
a. The most common genetic causes of mental retardation are Down syndrome and fragile X syndrome.
b. Other causes include metabolic factors affecting the mother or fetus, prenatal and postnatal infection (e.g.,
rubella), and maternal substance abuse; many cases of mental retardation are of unknown etiology.
c.The Vineland Social Maturity Scale can be used to evaluate social skills and skills for daily living in mentally
retarded and other challenged individuals.

2. Preparatory activities for communicating bad news (1-3 steps)

Step 1:- setting up the interview

Preparation ,Plan, Privacy, Significant others, Sitting, Non Verbal Behaviour, Time
Step 2:- Assessing the patients’s perception
Gather Patient’s knowledge, expectations and hopes
What do they understand about the situation? Unrealistic expectations?
What is their state of mind? Hopes?
Opportunity to correct misinformation and tailor your information
Step 3:– Obtaining the patient’s invitation
Gather before you give
How much does the patient want to know?
 Coping strategy?
Answer questions, offer to speak to another

3. Role of defense mechanisms

Defense mechanisms are behaviors people use to separate themselves from unpleasant events, actions, or
thoughts. These psychological strategies may help people put distance between themselves and threats or
unwanted feelings, such as guilt or shame

N14
1. Biopsychosocial model of health and illness – main consideration

The biopsychosocial model views health and illness as the product of biological characteristics (genes), behavioral
factors (lifestyle, stress, health beliefs), and social conditions (cultural influences, family relationships, social
support).

2. Stages of dying and death

According to Elizabeth Kübler-Ross, the process of dying involves five stages: denial, anger, bargaining,
depression, and acceptance (DAng BaD Act). The stages usually occur in the following order, but also may be
present simultaneously or in another order.
A. Denial.
The patient refuses to believe that he or she is dying. ("The laboratory made an error.")
B. Anger.
The patient may become angry at the physician and hospital staff. ("It is your fault that I am dying. You should
have checked on me weekly.") Physicians must learn not to take such comments personally .
C. Bargaining.
The patient may try to strike a bargain with God or some higher being. ("I will give half of my money to charity if I
can get rid of this disease.")
D. Depression.
The patient becomes preoccupied with death and may become emotionally detached. ("I feel so distant from
others and so hopeless.")
E. Acceptance.
The patient is calm and accepts his or her fate. ("I am ready to go now.")

3. Angry or defensive physicians.

Angry or defensive physicians. An angry physician can derail a visit just as quickly as an angry patient.
When you’re stressed or burned out, it’s easy to become angry. Be mindful of your emotions going into
an exam, and keep an eye out for things you know can trigger your anger during the visit. Recognizing
the source of the emotion can help you manage it.

N15
1. Normal and abnormal grief reactions
Normal Grief Reaction (Bereavement)
Minor weight loss (e.g., < 5 pounds)
disturbances.
Mild guilty feelings.
Illusions.
Attempts to return to work and social activities. Resumes few, if any, work or sociaactivities
Cries and expresses sadness.
Severe symptoms resolve within 2 months.
Abnormal/Complicated Grief Reaction (Depression)
Significant weight loss (e.g., > 5% of body Minor sleep
Significant sleep disturbances
Intense feelings of guilt and worthlessness
Hallucinations and delusions
Considers or attempts suicide
Severe symptoms persist for > 2 months

2. Breaking bad news.

Step 1: Getting started, Create an environment conducive to effective communication.
Step 2: Finding out what the patient knows 5. Start by establishing what the patient and family know about the
patient’s health.
Step 3: Finding out how much the patient wants to know out what the patient wants to know.
Step 4: Sharing the information, Deliver the information in a sensitive but straightforward manner.
Step 5: Responding to patient and family feelings,Outbursts of strong emotion are an expected component of
information sharing. Learn how to cope with this.
Step 6: Planning, follow-up,Establish a plan for next steps.When language is a barrier Verify that translators will
be comfortable and sufficiently skilled in translating the news you are about to give.

3. Immature Defense mechanisms: Denial, repression, regression, displacement

Denial-the person doesn't acknowledge the validity of the matter but acknowledge it's presence.they oppose
force with force. According to Freud 3types of denial- simple denial, minimisation, projection
Repression-unconcious blocking of unacceptable thoughts,the person forces unacceptable feeling out of
awareness to a point where he/she is unaware of it.
Regression - when adult defence mechanismstop working for us we regress to a personality we had at childhood
.in the face of threat one may retract to an earlier pattern of adaption possibly a childish or primitive one
Displacement Moving emotions from a personally intolerable situation to one that is personally tolerable