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228 Cards in this Set

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woman w/ anxiety about gyn exam is told to relax and imagine going through the steps of the exam. What process does this exemplify
systematic desensitization
65 y/o man is dx w/ incurable pancreatic adenocarcinoma. His family asks you, the doctor, not to tell the pt. What do you do?
assess whether telling the pt will negatively affect his health. If not, tell him
Man admitted for chest pain is medicated for ventricular tachycardia. The nexxt day he jumps out of bed and does 50 push ups to show the nurses he did not hav a heart attack. What defense mechanism is he using
denial
you find yourself attracted to your 26 y/o pt. What do you say.
nothing! be professional. It is not acceptable to have a relationship with your pts.
large group of people is followed over 10 years. Every 2 years. It is determined who develops heart dz and who does not. What type of study?
cohort study
girl can groom herself, hop on one foot and has an amaginary friend. How old is she?
4 y/o
man has flashbacks about his girlfriends death 2 mo. ago follwooingt a hit-and-run accident. He often cries and wishes for the death of the culprit. What is the dx?
normal bereavemnt
36 y/o woman with strong family hx of breast CA refuses mammogram because she heard it hurts. What do you do?
discuss the risks and benefits of not havign a mammogram. Each pt must give her own informed consent to each procedure; if the pt refuses, you must abide by her wishes.
4 y/o girl complains of burning feeling in her genetalia; otherwise she behaves and sleeps normally. Smear of the discharge shows N. gonorrhea. How was she infected
sexual abuse
72 y/o man insists on stopping tx for his heart conditon because it makes him feel "funny" What do you do?
encourage pt to take his meds but pt has final say in his tx regimen. Investigate the "funny" feeling and determine if there are drugs available that don't elicit this particular side effect.
This is an observational study. The sample is chosen based on presence (cases) or absence (controls) of dz. Info is collected about risk factors. It is often retrospective
case control study
this is an observational study. Sample is chosen based on presence or absense of risk factors. Subjects are followed over time for development of dz. Often prospective
cohort study
Framingham heart study is an exampel of this type of study
cohort study
This involves pooling data from several studies (often via a literature search) to achieve greater statistical power.

Limitations of individual studies prevail
meta-analysis
this is an experimental study. It compares the terapeutic benefits of 2 or more tx or tx & placebos
clinical trial
highest quality clinical trials are double ______
blind
this negative study finding occurs when 1 outcome is systematically favored over another.
bias
this type of bias is a nonrandom assignment to a study group
selection bias
this type of bias occurs when knowledge of the presence of a disorder alters recall by the subjects
recall bias
this type of bias occurs when subjects are not representitive; tehrefore results are not generalizable
sampling bias
this type of bias occurs when information is gathered at an inappropriate time
late-look bias
Give 4 ways to reduce bias:
1) blind studies (single/double)
2) placebo responses
3) crossover studies (each subject acts as own control
4) randomixation
this describes total cases in population at a given time over total population
prevalence
this describes new cases in population over a given time over total population at risk during that time
incidence

mneu: incidence is new incidents.

note: when calculating incidence, don't forget that people previously positive for dz are no longer considered at risk
this is approximately equal to the incidence multiplied by the dz duration
prevalence
what is greater for chronic dzs like diabetes. prevalence or incidence
prevalence.
which is greater for acute dzs like the common cold. prevalence or incidence
they are equal
this describes the number of true positives divided by the number of all the people with the dz. It is the probability a positive test, given a person has the desease
sensitivity
sensitivity rules ______
out

mneu: SNOUT
this is equal to 1-sensitivity
false negative
high sensitivity is desirable for this type of test
screening
This is the number of true negatives divided by number of all people without the desease. It is the probability of a negative test given taht a person is free of the dz.
specificity.
specificity rules _____
IN

mneu: SPIN
this is equal to 1-specificity
false positive rate
high specificity is desirable for this type of test
confirmatory test
This is the number of true positives divided by number of people who tested positive for the dz.

It is the probability of having a condition given a positive test
positive predictive value (PPV)
This is the number of true negatives divided by number of people who tested negative for the dz.

It is the probability of not having the condition given a negative test
negative predictive value (NPV)
unlike sensitivity and specificity, predictive values are dependent on this
prevalence of the dz

the higher the prevalence off the diz the higher the positive predictive value of the test.
p. 63 predictive value graphic
--
this descrives the odds of having a dz in the exposed gorup divided by the odds of having dz in unexposed group.
odds ratio (OR)
how are odds are calculated within a group
as number with dz divided by number without the dz
if the prevenance of the dz is not too high the OR approximates this
relative risk
OR is used in this type of study
case-control
this describes the disease risk in exposed group divided by dz risk in uneposed gorup
relative risk (RR)
how is relative risk calculated within a group
number with dz divided by total number of people in the gourp.
relative risk is used for what type of studies
cohort studies
graphic odds ratio v. relative risk p. 63
--
the consistency and reproducibility of a test (reliability)

the absense of random variation in a test
precision
the trueness of test measurements (validity)
accuracy
random error leads to reduced this in a test
precision
systematic error leads to reduced this in a test
accuracy
image p. 64. Accuracy and Precision
--
In a normal /Gaussian/Bell shaped statistical distribution curve, How are the mean, median, and mode related
equal to each other
bimodal distribution means
2 humps
This type of skew describes tail on the right. The mean>median>mode
positive skew
This type of skew describes tail on the left. The mean<median<mode
negative skew
this describes a hypothesis of no difference. E.g., there is no association between the dz and risk factor in the population
null hypothesis (Ho)
this describes a hypothesis that there is some difference (e.g., there is some association between the dz and the risk factor in the population
Alternative hypothesis (H1)
image - statistical hypothesis p. 64
--
This type of error is stating that there IS an effect or difference when none exists (to mistakenly accept the experimental hypothesis and reject the null hypothesis).
Type I error (α)
ρ is judged against α, a preset level of significance (usually <0.5). ρ=
probability of making a type I error
if ρ < .05 then
there is less than a 5% chance that the data will show something that is not really there
α=
you saw a difference that idd not exist--for example, convicting an innocent man
This type of error states that there IS NOT an effect or difference when one exists (to fail to reject the null hypothesis when in fact Ho is false.
type II error (β)
β=
the probably of making a type II error

you did not "see" a difference that does exist--for example, setting a guilty man free
This is the probability of rejecting a null hypothesis when it is in fact false.
power (1-β)
Power depends on:
1) total number of end points experienced by population
2) difference in compliance b/n tx groups (differences in the mean values between groups)
3) size of expected effect
what is the most common way you can increase the power of the study
increase sample size

mneu: there is power in number
n=
sample size
σ=
standard deviation
SEM=
=standard error of the mean

=σ√n
SEM is __ than σ

SEM ______ as n increases
less than

decreases
this describes the range of values in which a specified probability of the means of repeated samples would be expected to fall
confidence interval (CI)
CI=
range from [mean-Z(SEM)] to [mean + Z(SEM)].
what CI is often used
95% (corresponding to p=.05)
what is the Z for 95% CI
Z=1.96
If the 95% CI for a mean difference between 2 variables includes 0, then
there is no significant difference and Ho is not rejected
If the 95% CI for odds ratio or relative ris includes 2, Ho is _____
not rejected
this type of test checks the difference between the means of 2 groups
t- test

mneu: Mr. T is MEAN
this checks the difference between the means of 3 or more groups
ANOVA

mneu: ANalysis Of VAriance of 3 or more variables
this checks the difference between 2 or more percentages or proportions of categorical outcomes (not mean values)
χ^2
always between -1 and 1. Absolute value indicates strenghth of correlation b/n 2 variables
coorelation coefficient
r^2
coefficient of determination
Describe primary, secondary, and tertiary dz prevention
primary-prevent dz occurance (e.g., vaccination)

secondary-early detection of dz (e.g., Pap smear)

tertiary- reduce disability from dz (e.g., exogenous insulin for dbts

mneu: PDR (prevent, detect, reduce disability)
Given the risk factor give the important prevention services:

dbts
eye, foot exams, urine test
Given the risk factor give the important prevention services:

drug use
hepatitis immunizations, HIV, TB tests
Given the risk factor give the important prevention services:

alcoholism
influenza, pneumococcal immunizations, TB test
Given the risk factor give the important prevention services:

overweight
blood sugar tests for dbts
Given the risk factor give the important prevention services:

homeless, recent immigrant inmate
TB test
Given the risk factor give the important prevention services:

High risk sexual behavior
HIV, hepatitis B, syphilis, gonorrhea, clamydia tests.
Give the reportable dzs
Hep B
Hep A
Salmonella
Shigella
Syphilis
Measles
Mumps
AIDS
Rubella
TB
Chickenpox
Gonorrhea

mneu: B.A. SSSMMART CHICKEN or you're Gone
leading causes of death in US of infants
congenital anomalies, short gestation/low birth weight, SIDS, maternal complications of pregnancy, rspiratory distress syndrome
leading causes of death in US of children 1-14
injuries, Cancer, congenital anomalies, homocide, heart dz
leading causes of death in US of people 15-24
injuries, homocide, suicide, cancer, heart dz
leading causes of death in US of people 25-64
Cancer, heart dz, injuries, suicide, stroke
leading causes of death in US of people 65+
heart dz, cancer, stroke, COPD, pneumonia, influenza
Medicare and medicaid are federal programs that originated from amendments to the social security act.

MedicarE is for ________
MedicaiD is for ________
Elderly
Destitute
medicare part A pays for _____
medicare part B pays for ____
A=hospital
B=doctor bills
this describes the obligation to respect pts as individuals and to honor their preferences in medical care
autonomy
informed consent legally requires these 3 things
1) discussion of pertinant information
2) pts agreement to the plan of cre
3) freedom from coertion
in informed consent pts must understand these 3 things
risks, benefits, and alternatives (including no interventions)
Give the 3 exceptions to informed consent
1) pt lacks decision-making capacity (not legally competent)
2) implied consent in an emergency
3) therapeutic privilage (withholding info when disclosure would severely harm the pt or undermine informed decision-making capacity
4) waiver (pt waves rights)
pts decision making capacity depends on these 5 things
1) pt makes and communicates a choice
2) pt is informed
3) decision remains stable over time
4) decision is consistant w/ pts values and goals
5) decision is not a result of delusions or hallucinations
T or F. Pts family cannot require that a doctor withhold info from the pt
T
Describe what an oral advance directive is
when an incapacitated pts prior oral statements are used as a guide. Problems arise form variance in interpretation. If pt was informed, directive is specific, pt made a choice, and decision was repeated over time, the oral directive is more valid.
this is when a pt directs physician to withold or withdraw life-sustaining tx if the pt develops a terminal dz or enters a persistant vegitative state
living will
this is when a pt designates a surrogate to make medical decisions in the event that the pt loses decision-making capacity. Pt may also specify decisions in clinical situations. Surrogate retains power unless revoked by pt. More flexible than a living will, supersedes living wil if both exist
durable power of atterney
"do no harm". However, if benefits of intervention outweigh the risks, a pt may make an informed decision to procede
nonmaleficence
Physicians have special ethical responsibility to act in the pts best interest (physician is a fiduciary"). Pt autonomy may conflict.
beneficence
respect for the pts privacy and autonomy. Disclosing info to family & friends should be guided by pts wishes. Pts may wave rights
confidentiality
Give the 2 exceptions to confidentiality
1) harm to others
2) harm self
duty to break confidentiality because of potential to harm others can take several forms. Give 3 examples
1) infectious dzs- duty to warm public officials and identifiable people at risk
2) Child/Elder abuse
3) Impared auto drivers
what landmark decision involved a psychiatrist who did not break confidentiality to warn apotential homocide victem
Tarasoff decision
Civil suit under negligence requires these 3 things
1) Dereliction- Physician breach of duty to patient
2)Damage--pt suffers harm
3) Direct- breach of duty causes harm

mneu: 3 Ds
what is the most common factor leading to litigation
poor communication between physician and patient
In a criminal suit the burdenof proof is "beyond a reasonable doubt", the burden of proof in a malpractice suit is ___________
"more likely than not"
Given the situation, give the appropriate response:
pt is noncompliant
work to improve the physician-pt relationship
Given the situation, give the appropriate response:
pt has difficulty taking medications
provide written instructions. Attempt to simplify tx regimens
Given the situation, give the appropriate response:
family members ask for info about a pts prognosis
avoid discussing issues w/ relatives w/out the permission of the pt
Given the situation, give the appropriate response:
17 y/o girl is pregnant and requests an abortion
many states require parental notification or consent for minors for an abortion. Parental consent is NOT required for emergency situations, tx of STDs, medical care during pregnancy, prescriptions for contraceptives, and management of drug addicition
Given the situation, give the appropriate response:
A terminally ill pt requests physician assistance in ending his life
in the overwhelming majority of states, refuse involvement in any form of physician assisted suicide. Physician may, however, prescribe medically appropriate analgesics that coincidentally shorten the pts life.
Given the situation, give the appropriate response:
pt states that he finds you attractive
ask direct, closed-ended questions and use a chaperone if necessary. Romantic relationships with pts are NEVER appropriate.
Given the situation, give the appropriate response: Pt refuses a necessary procedure or desires an unnecessary one.
attempt to understand why the pt wants/does not want the procedure. Address the underlying concerns. Avoid performing unnecessary procedures
Given the situation, give the appropriate response: Pt is angry about the amount of time he spent in the waiting room
apologize to the pt for any inconvenience. Stay away from efforts to explain the delay
Given the situation, give the appropriate response: Pt is upset with the way he was treated by another doctor
suggest that the pt speak directly to that physician regarding his concerns. If the problem is with a member of the office staff, tell the pt you will speak to that indiviedual.
Given the situation, give the appropriate response: A child wishes to know more about his illness
Ask waht the parents have told the child about his illness. Parents of a child decide what info can be relayed about the illness
Given the situation, give the appropriate response: Pt continues to smoke, believing that cigarettes are good for him
Ask how the pt feels about his smoking. Offer advice on cessation if the pt seems willing to make an effort to quit.
How is APGAR scored and what does the APGAR SCORE stand for
scored 0-2. 10 is a perfect score.
Appearance (color) [blue, trunk pink, all pink]
Pulse [0,<100,100+]
Grimace [0,grimace, grimace+cough]
Activity [no tone, some, active]
Respiration [0,irregular, regular]
<2500g. Associated with greater incidence of physical and emotional problems. Caused by prematurity or intrauterine growth retardation. Complications include infections, respiratiory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and persistent fetal circulation.
low birth weight
long-term deprivation of affection results in these 7 things
1) decreased mm tone
2)poor language skills
3)poor socialization skills
4)lack of basic trust
5) anaclitic depression
6) weight loss
7) physical illness
severe deprevation can result in infant dealth

mneu: The 4 Ws: Weak, Wordless, Wanting (socially), Wary
deprevation for greater than how long can lead to irreversible changes
6 mo
this describes depression in an infant owing to continued separation from caregiver--can result in failure to thrive. Infant becomes withdrawn and unresponsive.
anaclitic depression
children often due this when they are under stress-physical illness, punishment, birth of a new sibling, tiredness. An example is bed-wetting in a previously toilet-trained child.
regression to younger behavior
give some signs of physical abuse
healed fractures on x-ray, cigarette burns, subdural hematomas, multiple bruises, retinal hemorrhage on detachment
what is the abuser profile of a physical abuser
usally female and the primary caregiver
how many deaths occur each year in the US from physical abuse
~3000
give some signs of sexual abuse
genital/anal trauma, STDs, UTIs
Give the profile of a sexual abuser
usaually male and known to the victem
what is the peak age incidence of sexual abuse
9-12
3 mo motor milestones
holds head up, Moro reflex disapears
3 mo cognitive/social milestone
social smile
4-5 mo motor milestones
rolls front to back, sits when propped
4-5 mo cognitive/social milestone
recognizes people
7-9 mo motor milestones
sits alone, crawls
7-9 mo cognitive/social milestones
stranger anxiety, orients to voice
12-14 mo motor milestones
upgoing babinski disappears
15 mo motor milestones
walks
15 mo cognitive/social milestones
few words, separation anxiety
12-24 mo motor milestones
climbs stairs, stacks 3 blocks
12-24 mo cognitive/social milestone
object permanance
18-24 motor milestones
stacks 6 blocks
18-24 cognitive/social milestone
rapproachement
24-48 mo cognitive/social milestone
parallel play
24-36 cognitive/social milestone
core gender identity
30-36 mo motor milestones
stacks 9 blocks
30-36 mo cognitive/social milestones
toilet training
3 yrs motor milestones
rides tricycle, copies line or circle drawing
3 yrs cognitive/social milestone
group play
4 yrs motor milestones
simple drawing (stick figure), hops on 1 foot
4 yrs cognitive/social milestone
cooperative play, imaginary friends
6-11 yrs motor milestones
reads; understands death
6-11 yrs cognitive/social milestone
development of conscience (superego), same-sex friends, identification with same- sex parent
11 y/o girls
13 y/o boys
abstract reasoning (formal operations), formation of personality
does sexual interest decrease with age
no
describe sexual changes that occur in men in elderly
slower erection/ejaculation, longer refractory period
describe sexual changes that occur in women in elderly
vaginal shortening, thinning, and dryness
describe changes in sleep patterns in the elderly
decrease REM
decrease slow wave sleep
increase sleep latency,
increase awakinings during the night
common medical conditions occuring in the elderly
arthritis, hypertension, heart dz, osteoporosis
In the elderly psychiatric problems (e.g., depression become more prevalent. T or F
T
suicide rate increases in elderly. T or F
T
does intellegence decrease w/ age
no
in the elderly mm mass ___, and fat ___
decreases
increases
normal bereavement is is characterized by
shock, denial, guit, and somatic symptoms, sometimes may experience illusions.
how long does normal bereavmant usually last
6 mo to 1 yr
Describe pathological grief
includes excessively intense or prolonged grief or grief that is delayed, inhibited, or denied. May experience depressive symptoms, delusions, and hallucinations
Give the Kubler-Ross grief stages
Denial, Anger, Bargaining, Grieving, Acceptance

mneu: Death Arrives Bringing Grave Adjustments

note: stages do not necessarily occur in this order and >1 stage can be present at once.
Give 5 effects of stress
induces production of free fatty acids, 17-OH corticosteroids, lipids, cholesterol, catecholamines; affects water absorption, muscular tonicity, gastrocolic reflex, and mucosal circulation. May exacerbate certain physical disorders (including CHF, dbts, RA, IBS, gastric ulcer).
give the DDX of sexual disfunction
1) Drugs (e.g., antihypertensives, neuroleptics, SSRIs, etoh)
2) Diseases (e.g., depression, dbts)
3) psychological (e.g., performance anxiety)
this is the measure of weight adjusted for height
BMI
BMI=
=weight in kg/height in m^2
BMI underweight
<18.5
BMI normal
18.5-25
BMI overweight
25-30
BMI obese
>30
give 2 famous IQ tests
Stanford-Binet & Wechsler
this IQ test calculates IQ as mental age/chronological age x 100
stanford-Binet
this IQ test uses 11 subtestes (6 verbal, 5 performance)
Wechler Adult Intelligence Schale
what is the mean IQ test and standard deviation
mean=100
SD=15
mental retardation
IQ<70
severe MR
IQ<40
profound MR
IQ<20
IQ scores are correlated w/ genetic factors and are hightly correlated w/ school achievement. T or F
T
IQ tests are objective (not projective) tests. T or F
T
this describes learning in which a natural response (e.g. salvation) is elicited by a conditioned, or learned, stimulus (bell) that previously was presented in conjunction with an unconditioned stimulus (food)
classical conditioning

note: Pavlov's classical experiments w/ dogs--ringing the bell provoked salivation
This describes learning in which a particular action is elicited because it produces a reward
operant conditioning
in operant conditioning, this describes when a desired reward produces action (e.g., mouse presses button to get food)
positive reinforcement
in operant conditioning, this describes when removal of aversive stimulus increases behavior (mouse presses button to avoid shock)
negative reinforcement

note: do not confused w/ punishment
this determines how quickly a behavior is learned or extinguished
Pattern of reinforcement
this type of reinforcement schedule describes when a reward is received after every response. It is rapidly extinguished.
continuous

note: Think vending machine-- you stop using it if it does not deliver.
this type of reinforcement schedule describes when a reward is received after random number of responses. It is slowly extinguish
variable ratio

note: think slot machine--continue to play even if it rarely rewards
this occurs when pt projects feelings about formative or other important persons onto physician (e.g., psychiatrist=parent)
transference
this describes when doctor projects feelings about formative or other important persons onto patient
countertransference
describe Id
primal urges, sex, and aggression (I want it.)
describe Superego
Moral values, conscience. (YOu know you can't have it)
describe Ego
Mediator between the unconscious mind and the external world (Deals with the conflict)
In the topographic theory of the mind this describes what you are aware of
conscious
In the topographic theory of the mind this describes what you are able to make conscious with effort (e.g., your phone number)
preconscious
In the topographic theory of the mind this describes what you are not aware of; the central goal of Freudian psychoanylysis is to make the pt aware of what is hidden in his/her unconscious.
unconscious
this describes repressed sexual feelings of a child for the opposite-sex parent, accompanied by rivalry with same-sex parent. First described by Freud.
Oedipus complex
these are automatic and unconscious reactions to psychological stress
ego defences
give the mature ego defenses
sublimation, altruism, suppression, humor

mneu: MATURE women ware a SASH
altruism
guilty feelings alleviated by unsolicited generosity towards others

e.g., mafia boss makes large donation to charity
humor
appreciating the amusing nature of an anziety-provoking or adverse situation

e.g., nervous medical student jokes about the boards
sublimation
process whereby one replaces an unacceptable wish with a course of action that is similar to the wish but does not conflict with one's value system.

e.g., aggressive impulses used to succeed in business ventures
suppression
voluntary (unlike other defenses) witholding of an idea or feeling from conscious awareness

e.g., choosing not to think about the USMLE until the week of teh exam
acting out
unacceptable feelings and thoughts are expressed through actions

e.g., tantrums
dissociation
temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress

e.g.,exteme forms can result in multiple personalities (dissociative identity disorder)
denial
avoidance of awareness of some painful reality

e.g., a common reaction in newly diagnosed AIDS & CA pts
displacement
process whereby avided ideas and feeligns are transferred to some neutral person or object

e.g., mother yells at child because she is angry at her husband
fixation
partially remaining at a more childish level of development

e.g., men fixating on sports games
identifications
modeling behavior after another person who is more powerful (although not necessarily admired).

e.g., abused child becomes an abuser
isolation
separation of feelings from ideas and events

e.g., describing murder in graphic detail with no emotional response
projection
an unacceptable internal impulse is atttributed to an external source

e.g., a man who wants another woman thinks his wife is cheating on him
rationalization
proclaiming logical reasons for actions actually performed for other reasons, usually to avoid self blame

e.g., saying the job was not important anyway, after getting fired.
reaction formation
process whereby a warded-off idea or feeling is replaced by an (unconsciously derived) emphasis on its opposite

e.g., a pt w/ libidinous thoughts enters a monastery
regression
turning back the maturational clock and going back to earlier modes of dealing with the world

e.g., seen in children under stress (e.g., bed-wetting) and in pts on dialysis (e.g., crying)
repression
involuntary witholding of an idea or feeling from conscious awareness. The basic mechanism underlying all others.
Splitting
belief that peoplea re either good or bad

e.g., a pt says that all the nurses are cold and insensitive but that the doctors are warm and friendly.