Practical’s (Short Cases + Bio psycho social

assessment) of
Behavioral Sciences

Compiled by:

Dr. Muhammad Asif Mughal

MBBS, FCPS (Psychiatry)
Assistant Professor/HOD(Department of Psychiatry and Behavioral Sciences)
Bakhtawar Amin Medical College & Hospital, Multan

[1]
 Evaluation in Professional Examination
Obseved Strucured Practical Examination (OSPE)

TOTAL MARKS-----------------------90
Total NO of Stations-----------------06
Observed Stations-------------------------05/09 Marks Each (Total 45 Marks)
Rest Station.........................................................01

BIO Psycho Social Assessment Station/Table Viva

Total Marks................45 marks/20minutes

[2]
Demonstration Section
Sr.No: Topic Index Page#
1 Bio psychosocial Assessment 4
2 Communication Skills 15
3 Interviewing Techniques 19
4 Informational Care 21
5 Informed Consent 25
6 Psychosocial Aspects of Sleep 29
7 Psychosocial Aspects of Pain 31
8 Breaking The Bad News 33
9 Treatment Adherence / Compliance 36
10 Stress Management 38
11 Mini Mental State Examination 39
12 Progressive Muscle Relaxation 43
13 Confidentiality 45
14 Accepting gift from patients 47
15

[3]
 Psychosocial Assessment

Key for Psychosocial Assessment

Outlines
1. Demographic Details
2. Reason for Referral
3. Presenting Complaints
4. History of presenting illness
5. Treatment History
6. Past Medical, Surgical and Psychiatric history
7. Family History
8. Personal History
9. Pre morbid Personality
10. Health Belief Model

POINTS to be Remembered in History Taking

 Task is Assessment not Management (focus only on history

taking not management in exam)
 Systemic approach (avoids random questioning, follow the
systemic approach)
 Practice (Do practice with your colleagues as a mock patient/or
with real patient before appearing in exam)

[4]
 Case Scenario

A patient comes to you with Diabetes Mellitus

/Hypertension/Epilepsy/Depression/Drug addiction etc….Do the
detailed Bio Psychosocial assessment of the patient.

1. Demographic Details

 Name
 Age
 Gender
 Education
 Marital status
 Residence

2. Mode of referral

Emergency /OPD

3. Reason for Admission

4. History of presenting complaints

Mention the main problems with which the patient presented to

you in categorical manner with duration.

5. History of Presenting illness

(Includes both Physical as well as Psychological / Psychiatric problem)

 Main Problem
[5]
  Nature of problem
 Date of onset
 Duration
 Severity
Understanding of onset of problem:
 Was onset related to particular factor / event?
 If so detailed nature of event & its significance to the problem.
 How started
 When it become worse?
 Any change in? (Thought, emotion, behavior) due to said event.
 Course of illness ?(episodic or continuous course)
 Effects of illness on such activities including.
1. Work
2. Domestic tasks
3. Leisure activities
4. Sleep and appetite

1. Previous Medical & Psychiatric history and experience with treatment

Ask about past medical and psychiatric history

If the past history is significant then do detail account of

Previous diagnosis
Treatment given
Response to previous treatment
Any side effect of previous medication
Any drug allergy
Hospital admission

2. Family History

Including details about:

 Parents (alive or not, Occupation, overall health)
 Siblings (No,Occupation,Single/Married)
 Family support
 Relationship of the patient with parents as well as siblings
 Medical & Psychiatric history in family
[6]
  Housing
 Whether own or rented
 Social environment of the family
 Family structure
 Decision making in the family
 Interpersonal relationships
 Economic issues
 Overall financial status
 Positive support systems
 Economic support
 Psychosocial support
 Emotional support
4. Personal History
 Biological history
⚫ Pregnancy & Birth(any Birth Complications)
⚫ Early milestones of development
 Psychological history
⚫ Early neurotic traits
⚫ Any history of psychological trauma
⚫ Any history of child abuse & neglect
 Educational History
⚫ Schooling
⚫ Academic record
⚫ Extracurricular activities
⚫ Relationship with teachers, class fellows and peer groups
⚫ Psychosocial issues in educational history
 Occupational History
⚫ Nature of occupation /
job Work load / job stress
⚫ Job satisfaction
⚫ Relationship issues at job
Marital history
⚫ Duration of marriage
⚫ Arranged / love marriage

[7]
 ⚫ Relationship with spouse
⚫ Number of children

1. Any history of substance abuse

1. Smoking
2. Substance abuse (Occasional abuse / Addictions)
3. Resources involved
4. Relevant medi-colegal history if any

2. Legal / forensic Issues

1. Any offense & Imprisonment, Law suits etc.

⚫ Health belief models

⚫ Myths and misconceptions

⚫ Preference for any type of treatment (allopathic,
homeopathy)
⚫ Readiness for treatment
Questions to explore;

2. What do you call your problem? What name does it have?

3. What do you think has caused your problem?
4. How do you think it started and what course do you think will
it take?
5. What type of treatment do you think you should receive?
6. What do you think can the illness do to you and those
around you?

5. Premorbid Personality
 Personality profile / traits
 Lifelong coping resources
 Believes & moral standards
⚫ Religious & moral standards
 Habits

[8]
 Relationships
⚫ Ability to make friends
⚫ Ability to maintain relationships
 Hobbies & interests / life style

[9]
 ‫‪Psychosocial Assessment‬‬
‫)‪(As per UHS guidelines‬‬

‫‪Introduction‬‬
‫‪How to approach a patient:‬‬
‫‪ Maintain your safety first‬‬
‫‪ Always approach the patient from right side if on bed; otherwise sit on angle of 45 in the session‬‬
‫‪room.‬‬
‫‪ Greet the patient.‬‬
‫‪ Introduce yourself and others sitting/ accompanying you.‬‬
‫السالموعلیکم‬
‫‪.‬‬
‫ٹنہوں۔آپکیبیماریکےمتعلقکچھن‬ ‫‪.‬‬
‫‪.‬تکرنیہے۔امیدہےآپتعاون کریںگے۔‬ ‫نمڈاکٹرمیںتھرڈائیر‪ /‬فورتھائیر‪/‬فائنالئیرکامیڈیکالسٹوڈ‬ ‫می ار‬
‫ا ٓپکےمتعلقکیگئیتمامن‪.‬تیںمیرےاورا ٓپکےدرمیانرہیںگی۔اسلیےا ٓپتفصیلسےبتائیں۔‬
‫‪Demographic Details‬‬
‫ا ٓپکیبیماریکوجاننےسےپہلےہمکچھبنیادیمعلوماتلےلیتےہیں۔‬
‫‪.‬‬
‫‪ 1.‬آپکاکیا نمہے؟ ‪ 2.‬ا ٓپکیکتنیعمرہے؟‬
‫کتتعلیمحاصلکی؟‬ ‫‪3.‬‬
‫ا ٓپنےکہاں‬
‫‪ 4.‬ا ٓپکسشعبہسےتعلقرکھتےہیں؟ ‪ 5.‬آپشدیشدہہیں‬
‫¸‬
‫نغیرشدیشدہ؟ ‪ 6.‬ا ٓپکیرہائشکہاںہے؟‬

‫‪Chief Complaints‬‬

‫آپ مہرےن سکسمسئلےکےتحتا ٓئےہیں؟‬

‫‪History of Presenting Illness‬‬
‫اپنیاسکیفیتکےمتعلقتفصیلسےبتائیں؟ یہمسئلہکبسےہے؟ یہبیماریکیسےشروعہوئی؟‬
‫‪.‬‬
‫ا ٓپکے ند تاسکیوجوہاتکیاہیں؟ بیماریمسلسلرہتیہے نٹھیکبھیہوجاتےہیں؟‬
‫اسبیماریکےآپکیزندگیپرکیااناتمر ‪.‬نہوئےہیں؟‬
‫‪.‬‬ ‫ک‬

‫آپکوماضیمیںکبھیاسطرحکیعالماترہیہوں؟‬
‫ا ٓپکوماضیمیںکوئینفسیاتی نجسمانیبیماریرہیہو؟ اگرہاں‪ :‬توبیماریکیاتھی؟ بیماریکینوعیتکیاتھی؟‬
‫‪Past Medical / Psychiatric History‬‬
‫کیاعالجکیا؟‬
‫کونسیادو نتاستعمالکی؟ ادو‬
‫نتسکتنافائدوا؟‬
‫کیاادو نتاببھیجاریہیں؟‬

‫]‪[10‬‬
 ‫‪Family History‬‬
‫ابمیںآپکےخاندانکےمتعلقکچھسواالتکروںگا‪ /‬گی۔‬
‫‪ ‬اپنےوالدینکےن‪.‬رےمیںبتائیں؟‬
‫ا ٓپکےوالدینکیاکرتےہیں؟تفصیلسےبتائیں۔‬ ‫‪‬‬
‫‪ ‬والد‪ /‬والدہکیاکرتےتھے‪ /‬ہیں؟کسشعبےسےتعلقہے‪ /‬تھا؟‬
‫‪ ‬انکیشخصیتکیسیہے‪ /‬تھی؟‬
‫‪ ‬والدینکےآپسمیںتعلقاتکیسےہیں‪ /‬تھے؟‬
‫‪ ‬والدینکےا ٓپسےتعلقاتکیسےہیں‪ /‬تھے؟‬

‫‪In case of separation / divorce‬‬

‫‪ ‬علیحدگیکتناعرصےپہلےہوئی؟‬
‫‪ ‬علیحدگیکیوجہکیابنی؟‬
‫¸‬
‫انکیعلیحدگیکےا ٓپپرکی اناتہوئے۔‬ ‫‪‬‬
‫والدینمیںسےکسیکوذہنی‪ /‬جسمانی‪ /‬نفسیاتیبیماریہے‪ /‬تھی؟‬ ‫‪‬‬
‫‪ ‬اگرہاںتوتفصیلسےبتائیں۔‬
‫‪ ‬اپنےبہن‪ /‬بھائیوںکےن‪.‬رےمیںبتائیںتفصیلسے‬
‫¸‬
‫‪ ‬کتنےہیں؟کیاکیاکرتےہیں؟شدیشدہ‪ /‬غیرشدیشدہ؟‬
‫)‪(Note down demographic details of siblings in birth order‬‬
‫آپکےبہن‪ /‬بھائیسےکیسےتعلقاتہیں؟‬ ‫‪‬‬
‫‪ ‬انمیںسےکسیکوذہنی‪ /‬جسمانیبیماریہے‪ /‬تھی؟‬
‫اگرہاںتوتفصیلسےبتائیں۔(کیابیماریتھی؟کوئیدورہ‪ /‬مرگی؟خودکشیکیکوشش؟خودکشیکی؟بیماریکےلیےکیاعلاجکروا ن؟کہاںسےکروا نوغیرہ؟(‬ ‫‪‬‬
‫‪ ‬خاندانمیںکسیاورکوکوئینفسیاتی‪ /‬ذہنیبیماریہے‪ /‬تھی؟‬
‫اگرہاںتوتفصیلسےبتائیں۔ )‪(same detailed questions‬‬ ‫‪‬‬
‫‪ ‬ا ٓپکےگھرکاماحولکیساہے؟تفصیلسےبتائیں؟‬
‫‪ ‬بچپنمیںکیساتھا؟ابکیساہے؟‬
‫‪ ‬بہنبھائیوںک ا ٓپسمیںرویہ؟‬

‫‪Personal History‬‬ ‫‪ o‬کوئیمالیمشکلات؟‬

‫کتکےموجودہحالاتپرمشتملہوںگے۔یہسوالاتا ٓپکیبیماریکوبہترطورپرسمجھنےکےلیےضروری‬
‫یں‬ ‫ابمیںا ٓپکیذاتیزندگیکےمتعلقکچھسوالاتپوچھوںگا‪ /‬گی؟جوکہا ٓپکیپیدائشسےلےکرا ٓج‬
‫‪ ‬اپنیپیدائشکےن‪.‬رےمیںبتائیں۔‬
‫‪ ‬کبہوئیپیدائش؟کہاںہوئی(ہسپتال نگھر(‬
‫‪.‬‬
‫‪ ‬نرملڈلیوریہوئی؟ نا ٓپریشنسے؟‬
‫‪ ‬حملکےدورانکوئیپیچیدگیتونہیںہوئی؟‬
‫پیدائشکےبعدابتدائیا تدوسالوںمیں‬

‫]‪[11‬‬
‫‪Behavior during childhood‬‬

‫‪.‬‬
‫‪ ‬سکولجا نکبشروعکیا؟‬
‫‪ ‬پڑ‪Ø‬ئیمیںکیسےتھے؟‬
‫‪ ‬سکولاورپڑ‪Ø‬ئیکیطرفرویہکیسارہا؟‬
‫کھیلکوداورغیرتعلیمیسرگرمیوںمیںحصہلیتےتھے؟‬ ‫‪‬‬
‫سکولکےعلاوہکوئیدینیتعلیموغیرہحاصلکی؟اگرہاںتوتفصیلسےبتائیں۔‬ ‫‪‬‬
‫‪Adolescence and Occupation‬‬

‫‪ ‬کیاکامکرتےہیں؟‬
‫‪ ‬جہاںا ٓپکامکرتےہیںوہاںلوگوںکےساتھکیسےتعلقاتہیں؟‬
‫‪ ‬کامکیطرفکیسارویہہے؟(مطمئنہیں؟(‬

‫‪Marital History‬‬ ‫¸‬

‫‪ ‬شدیشدہہیں؟‬
‫¸‬
‫‪ ‬اپنی شدیشدہزندگیکےن‪.‬رےمیںبتائیں۔‬
‫¸‬
‫‪ ‬کتنےسالکیعمرمیں شدیوئی؟‬
‫‪ ‬پسندکیہوئی نوالدینکیمرضیسے؟‬
‫‪ ‬خاندانمیںہوئی نخاندانسےن‪ .‬مہ؟‬

‫‪ ‬شر تحیاتکےن‪.‬رےمیںکیاخیالہے؟‪ /‬میاںبیویکےن‪.‬رےمیںبتائیں۔‬

‫‪ ‬انکےساتھرویہکیساہے؟‬
‫‪ ‬انک ا ٓپکےساتھرویہکیساہے؟‬
‫کسیقسمکےخاصمسائلکاسامناہے؟اگرہاںتوتفصیلسےبتائیں۔‬ ‫‪‬‬

‫‪Children‬‬
‫‪ ‬بچوںکیپیدائشکےن‪.‬رےمیںبتائیںتفصیلسے‬
‫‪ ‬کتنےبچےہیں؟‬
‫‪ ‬بچوںکیعمریںکیاہیں؟‬
‫‪ ‬کیاکرتےہیں؟‬
‫بچوںکےحملکےدورانبچوںکیکوئیپیچیدگیہوئیاگرہاںتوتفصیلسےبتائیں۔‬ ‫‪‬‬
‫بچوںکیذہنی‪ /‬جسمانیصحتکیسیہے؟‬ ‫‪‬‬
‫‪‬‬
‫‪Drug History‬‬
‫ٹن‬
‫‪ /‬نسوار‪/‬حقہپیتےہیں؟‬ ‫کی ا ٓپسگر‬ ‫‪‬‬
‫‪ ‬کی استعمالکرتےہیں‪،‬یہکیسےشروعہوا؟‬
‫کسمقدارمیںشروعہوا؟مقدارمیںکتن اضافہہو ابکتنیمقداراستعمالکرتےہیں؟‬ ‫‪‬‬
‫کیسےپیتےہیں؟کسیچیزمیںملاکرپیتےہیں؟‬ ‫‪‬‬
‫‪. .‬جلیتےہیںتوکیسامحسوسکرتےہیں؟‬ ‫‪‬‬

‫]‪[12‬‬
 ‫¸‬
‫نشہکرنےسےا ٓپکیزندگی(گھریلو‪،‬کامکی‪،‬ازدواجی‪،‬معاشرتی نتفریحی‪social‬پرکی ا نپڑاہے؟‬ ‫‪‬‬
‫¸‬
‫نشہکرنےسےا ٓپکیصحت(جسمانی‪،‬ذہنی نقانونیمسائل( پرکوئیا ناتہوتے‪/‬ہوئےہیں؟‬ ‫‪‬‬
‫‪ ‬یہنشہکہاںسےملتاہے؟کیسےملتاہے؟‬
‫ک‬
‫‪ ‬اسپرکتناخچہونہے؟یہلینےکےلیےپیسےوغیرہکہاںسےآتےہیں؟‬
‫‪.‬‬ ‫ٹن‬
‫نکچھملاکے‪(،‬‬ ‫‪ ‬اسکےعلاوہاورکوئیچیز‪/‬نشہاستعمالکرتےہیں؟(سادہسگر‬
‫کنکیاہو کنہے؟‬ ‫‪‬‬
‫اگرنشہ ہنملے‬
‫‪ ‬کبھینشہچھوڑنےکےن‪.‬رےمیںن‪.‬رےمیںسوچاہے؟‬
‫‪ ‬کبھیاسسوچپرعملکرنےکیہے؟ نعملکیاہے؟‬
‫‪.‬‬
‫‪ ‬اگرچھوڑاتوکتنیمقدارمیںچھوڑا؟کیوںچھوڑ نچاہتےہیں۔‬
‫¸‬
‫‪ ‬کمکرنے‪ /‬چھوڑنےپرکی ا نہوا؟‬
‫کیاعلاماتا ٓئیںاورانکےلیےکیاکیا؟‬ ‫‪‬‬
‫چھوڑکردون‪.‬رہشروعکیاتوکیاوجہتھی؟‬ ‫‪‬‬
‫‪Forensic History‬‬
‫کبھیکوئیایسامسئلہدرپیش ٓا نجسکےلیےپولیس‪ /‬کورٹکیمددکیضرورتپڑیہو؟‬ ‫‪‬‬
‫‪.‬‬
‫کبھیکسیمسئلےکےلیےتھانےکچہریکاسامناکر نپڑا؟اگرہاںتوتفصیلسےبتائیں۔‬ ‫‪‬‬
‫‪ ‬کبھیکسیغیرقانونیسرگرمیمیںملوثرہے؟‬
‫‪ ‬اگرہاںتوتفصیلسےبتائیں۔‬
‫‪Housing & Social History‬‬
‫‪ ‬کسعلاقےمیںرہتےہیں‪ /‬کہاںرہتےہیں؟‬
‫‪ ‬اپنیگھرکےن‪.‬رےمیںبتائیں۔تفصیلسے‬
‫‪ ‬اپناگھرہےٹ نکرایےکا؟‬
‫‪ ‬گھرمیںٹوٹکتنےلوگرہتےہیں؟‬
‫کنہے؟‬
‫‪ ‬گزارہکیسےہو ‪ /‬مالیحاالتکیسیں؟‬
‫کوئیمالیمشکلاتکاسامناہے؟‪/‬کوئیمالیدشواریہے؟‬ ‫‪‬‬

‫‪Pre morbid Personality‬‬

‫‪Personality: personality refers to individual difference in characteristic patterns of thinking, feeling‬‬
‫‪&believing‬‬
‫”‪Premorbid: ask about “before the onset of illness” and “in between the episodes‬‬
‫‪This area of history requires information to be taken from other reliable informants as well as the patient‬‬
‫‪himself.‬‬
‫کل‬
‫بیماریسےپہلےکیحا ‪/‬شخصیتکےن‪.‬رےمیںبتائیں۔‬ ‫‪‬‬
‫کس‪،‬گھروالے‪،‬کاموالے‬
‫( آپکوکوکیسےبیانکرتےہیں؟آپکےن‪.‬رےمیںکیاکہتےہیں؟‬ ‫لوگ(آپکےدو‬ ‫‪‬‬
‫بیماریسےپہلےلوگوںکےساتھرویہ‪/‬سلوککیساتھا؟‬ ‫‪‬‬
‫‪ ‬اپنیچندخوبیاںاورکمزور نںبتادیں؟‬
‫‪.‬ینکےنرےمیںکیارحجانتھا؟‬ ‫د‬
‫¸ئ‬ ‫‪‬‬
‫‪ ‬کتنےدوسہیں‪ /‬کتھے؟کوئیخاصدوس نہمراز کہےجسسےا ٓپدلکین‪.‬ت شکرتےہوں؟‬

‫]‪[13‬‬
 ‫کنتھا؟ ‪. .‬‬ ‫‪.‬‬
‫بیماریسےپہلے ماجکیسارتاتھا؟(ز ندہغصہ ٓا نزک ماجتھے‪F‬سطبیعتتھی؟(‬ ‫‪‬‬
‫‪ ‬کوئیمشاغلوغیرہہیںتوبتائیں۔‬
‫کنتھاتواسکوکیسےہینڈل‬
‫‪ /‬حلکرتےتھے؟‪capability) coping (Stress‬‬ ‫بیماریسےپہلےکوئیمسئلہ‪ /‬دن‪.‬ؤہو‬ ‫‪‬‬

‫‪Health Belief Model‬‬

‫‪ ‬ا ٓپکےخیالمیںا ٓپکوکیابیماریہے۔‬
‫‪ ‬ا ٓپکےخیالمی ںاسبیماریکیوجہکیاہے؟‬
‫ا ٓپکےخیالمیںیہبیماریکیسےشروعہوئی؟‬ ‫‪‬‬
‫ا ٓپکےخیالمیںاسبیماریکاعلاجکیاہے؟‬ ‫‪‬‬
‫¸‬
‫‪ ‬ا ٓپکوکیالگتاہےکہا ٓپکیبیماریکیوجہسےا ٓپکےاردگردموجودلوگکیسےمتا نہورہےہیں؟‬

‫]‪[14‬‬
 OBSERVED STATION (1)
Communication Skills
Definition:-
“The use of different ways and tools to transmit information, thought or feeling
so that it is satisfactorily received or understood.”
In doctor-patient relationship,
The responsibility of effective communication lies with the physician.

Tools of Effective Communication

1. Attending & listening:

It is an art involves a conscious effort on the part of the doctor to keep himself
aware of what the patient is saying and trying to imply. This should be done in a
setting of exclusivity.
2. Active listening:-
It is a complex process that goes beyond merely hearing and making notes of
what the patient says. It has three aspects.
a. Linguistic aspect
b. Para- linguistic aspect
c. Non-verbal cues
A. Linguistic Aspect:-
It involves a focus on the words including linguistic or verbal aspect of
speech.
B. Para-linguistic Aspect:-
It involves paying attention to other features of speech such as timing,
volume, pitch, accent, fluency, pauses, “ums” and “errs” which indicate as to
how the person is feeling beyond the words.
c. Non-verbal cues:-
⚫ Body language refers to the way a patient expresses himself through the
use of non-verbal cues such as facial expression, proximity to the doctor,
use of gestures, body position, movements and eye contact.
⚫ These are only cues not “clinical signs”
3. Verbal Techniques :
These are vital skills for the doctors involves following

[15]
Six com ponents.
1. Questions
2. Funneling
3. Paraphrasing
4. Selective reflection
5. Empathy building
6. Checking for understanding
1. Questioning
Types of questions:-
1. Open-ended Question
2. Close-ended Question
3. Leading Question
1. Open Ended Questions
Are those that do not elicit a particular answer?
Example:
What brings you here?

2. Closed Ended Question

is one that elicit a yes, a no or a similar response
Example:
What is your name?

3. Leading Questions
Are questions that contain an assumption by the interviewer and
lead the doctor towards diagnosis?
Example:
Don’t you think your chest pain radiates into the left arm.

2. Funneling
It refers to the use of questions to guide the conversation from a broader area to a
more specific area.
3. Paraphrasing
It is a process of,
1. repeating the last few words the patient has said.

[16]
 2. Validating what the patient has communicated so for, in order to
encourage him to say more.
4. Selective Reflection
It is a technique to bring out the feelings attached to various symptoms/
problems. It refers to the method of repeating back to the client a part
of something that he said which was emotionally charged.
5. Empathy Building
It refers to the statements by the interviewer that makes the patient understand
that his feelings have been well understood and the doctor would have felt same
if he was in his place.
6. Checking for understanding
For checking the patient’s understanding, doctor should summarize time to time
what patient has stated or ask the patient to comment on the summary or confirm
about anything left.

[17]
 Case Scenario (1)
Communication Skills
Miss , a 22 years old lady from a distant village presented to you
with complaints of fever for last one week. She is going to take up her B.A Exam
after two days. She is worried about that. Talk to the patient using;
• Funneling
• Paraphrasing
• Selective reflection
• Empathy building
• Summarizing
! ıJ l:l
!fls:ç
?(clsťl llclD:l
u@c lslç clD:ç
lбSuèyls(ysťí.SfslanTl ç:l
? T .y.sl JJ y.sl?(cNTJuD l T
uJy.sl:ç
5UST κf:l
uy.dsT cŨlcDlsllã%:ç
 ?  lssldTd ?slTasfS l?uØlãT %ċ:l
?/l  d lcfslTS
ldébl :ç
lSls ?//S(usTUlxçc.STκfsll:l
?
sl5lsslS/:ç
?Ģ d 5uţsu:l
auţsslyd uEUdlTA/l d 5fcD:ç
(Funneling)  sldJǴfdslzf 
(Paraphras ?uØ lSls  slS/d % ċ:l
ing)
Ø :ç
(Selective Reflection)
?yŨl:l
uy.dc.lsl5Ø Aslbl :ç
Tc Ũllsl (usTE /l asĩsl5Tu.( :l
(Empathy Building)

bl:ç
bTκDĩElxTcsl lasfSl:l
(Sum
marization)  aYa.slslluØTsl
bl

[18]
 Practical Station (2)
INTERVIEWING TECHNIQUE

While interviewing the patient following three parameters should be kept in

mind
1. SEATING ARRANGEMENT
2. INITIATON OF INTERVIEW
3. ENDING THE INTERVIEW

1) SEATING ARRANGEMENT

Patient is always on your right side at one arm distance and on 45 degree angle.

2) INITIATON OF INTERVIEW
1. Greeting
2. Introduction
3. Concern of language
4. Consent/Permission
5. Purpose of interview
6. Approximate Duration
7. Offering the opportunity for questioning
8. Privacy
9. Confidentiality

10. Empathy

11. Nature of questions

3) ENDING THE INTERVIEW

 QUERY FOR INFORMATION LEFT
 INVITATION FOR QUESTIONS
 FOLLOW UP VISIT (IF NEEDED)
 GOOD BYE

[19]
 Interviewing Technique
A 22 year old woman out of blue gave history of tearfulness, apprehension,
associated with shortness of breath and pounding of heart which last for half an
hour. She feared that she has some cardiac problem and is going to die. She
rushed to cardiac emergency. however baseline reports and rest of her history
and physical examination was also normal.
Talk to the patient keeping in view the following instruction.
• Seating Arrangement

• Initiation of interview

• Open ended, close ended and leading questions

• Ending of interview

! ıJ l:l

!fls:ç
?(clsťl llclD:l
çclD:ç
бSuèyls(ysťí.SfslanTlç:l
? T.y.slJJy.sl?(cNTJuD l Tl
uJy.sl:ç
Open Ended 5UST κf:l
Question
ċcsSUsl ыøylsSl  D.bl:ç
ylGlscDl
Close Ended ?çd5TT:l
Question
ç5Td%  ç
?ss/T:l
dGcDb ćSsslcы Øl:l%.ss/%ss5TdTκfyl:ç
a
d %5T sllds sl.E ċ:l
Leading Question ?As. .

s.:ç
aYa.slsll uØTsl SĖ:l
bl

[20]
 Practical (3)
Information Care (IC)

Definition: It is defined as provision of information to patients (using principles

of communication) regarding the disease, the drugs and the doctor (the 3 Ds),
that concern him or her. This is to help fill the gap in the patient’s knowledge and
understanding in these areas, using the language that the patient understands.
Seven Questions
1. What is wrong with me (the patient seeks the diagnosis)?
2. Why have I developed this disease (what is the etiology)?
3. Is there any effective treatment to my problem? Is the treatment
safe? Are there any serious or dangerous side effects?
4. How long will I take to recover (what is the prognosis?)
5. Is there a Perhez (restrictions)?
6. Is there a risk of illness being spread to those around me or passing it
on to my offspring?
7. How will the illness and the treatment effect or influence my
functioning? (Can I continue to work or rest? What will happen to my
sleep, appetite etc?)
Seven Essentials in Informational Care
The physician must set aside certain tie within a consultation to give
a reasonable level of information to the patient and his family about
the disease and the treatment.
i. The IC session must take place in the language that the patient can
understand.
Ii. It must start with parent's knowledge, understanding and expectations.
Iii. The doctor must then remove any myths and misconceptions that the
patient mentions in his description.

[21]
Iv. The task of giving information should be professionalized, meaning
thereby that evidence based facts are provided without fear of causing
a negative reaction in patient or the relatives.
v. Both aspects of the disease and treatment negative and positive should be
communicated to the patient.
Vi. Use of simple figures, diagrams and sketches are often very helpful to
enhance the patients understanding
Vii. The IC session ends with the patient briefly summarizing his new
understanding of the 3DS. This helps to evaluate how much of the
information has been retained?

[22]
‫‪Clinical Scenario‬‬
‫‪Informational Care‬‬
‫‪20 years old Mr.Ahmad comes to you with pain in left lower jaw. He is having this pain for‬‬
‫‪last one week. Detailed history revealed he is fond of sweats and pan. Premorbidly he was‬‬
‫‪sensitive and use to chew pan under stressful situation.‬‬
‫‪His mother is illiterate and there are frequent quarrel between parents. Being the eldest‬‬
‫‪among his siblings, he used to remain under stress most of the time. On examination his oral‬‬
‫‪hygiene is very poor. You have diagnosed him as a case of Dental Caries.‬‬
‫‪Task:‬‬ ‫‪Provide informational care to the gentleman :‬‬

‫ڈاکٹر‪ :‬السالموعلیکم!‬
‫مریض‪ :‬وعلیکمالسالم!‬
‫‪.‬‬ ‫‪.‬‬ ‫‪.‬‬
‫ڈاکٹر‪:‬میرا نمڈاکٹربمشرکی آپاپناتعارفکروا نپسندکریںگے؟ مریض‪ :‬جیمیرا نماحمد‬
‫‪.‬‬
‫کرازمیںرکھنےکان بندو اںٓپگفتگویمںکسیکوشملکر نچاہیںگے؟‬ ‫ڈاکٹر‪ :‬جیاحمدآپکیاجازتسآپکیموجودتکلیفاورعالجکمتعلقچندن‪.‬تیںکریںگے۔امیدہےآپتعاونکریںگے۔پیشہورانہتقاضوںکےمطابقمیںاسگفتگوکو‬
‫کیاآپاردوزن‪.‬نآس انیسےسمجھسکتہیں نکسیاورزن‪.‬نمیںن‪.‬تکریں؟‬
‫مریض‪ :‬جیمیںاردوزن‪.‬نسمجھسکتاہوں۔‬
‫‪.‬‬
‫ڈاکٹر‪. :‬سسےپہلےمیںیہمعلومکر نچاہوںگاکہآپکےخیالمیںآپکیتکلیفکسنوعیتاورشدتکیہےاورکسوجہسےہے؟‬
‫کنہے۔اوراسوجہسےمیںبہتز‬ ‫کنہےلیکندرددون‬
‫ند‬ ‫‪.‬رہشروعہوجا‬ ‫مریض‪ :‬پچھلا تہفتہسےمیںدانتوںکیتکلیفمیںمبتالہوں۔دردکیدواسےکچھد نآفاقہہوجا‬

‫‪ .‬ک ‪.‬‬ ‫پر ی ش انہوں ۔‬

‫ڈاکٹر‪ :‬میںآپکیتکلیفسمجھسکتاہوں۔معائنہاورآپکیعالماتکےمطابقمیںاسنتیجےپرپہنچاہوںکہآپکےدانخابہورہےہیںمسوڑھوںمیںبہتز ندہسوزش‬
‫کنہےاوربعد‬ ‫ہےجسکیوجہسےدردرہتاہے۔سائنسیمعلوماتکےمطابقیہتکلیفدانتوںمیںپلنےوالےچند‬
‫‪.‬خاثیموںکیوجہسےہوتیہےاسمیںدانتوںمیںخلاہوجا‬

‫)‪(Diagnosis‬‬ ‫¸‬
‫عبنتیہے۔ مریض‪ :‬ڈاکٹرصا‬ ‫پپڑجاتیہےجوکہدردکان‪.‬‬ ‫ازاں‬
‫‪.‬جمیریاسبیماریکیوجہکیاہے؟‬
‫ٹن‬
‫نمیٹھیچیزوںکاز ندہاستعمالکرتےہیں۔‬ ‫ڈاکٹر‪ :‬یبیماریانلوگوںمیںز ند ہوتیہےجودانتوںکیصفائیکاخیالنہیںرکھتےاورن ن‪،‬تمباکو‪،‬سیگر‬
‫)‪(Etiology‬‬
‫مریض‪ :‬اسکاعلاجکیسےممکنہے؟‬
‫¸ ‪ .‬کنہوں‬ ‫‪.‬‬ ‫ے‬ ‫لی‬‫ے‬‫ک‬‫ے‬‫کوکچھعرص‬‫ٓپ‬ ‫ا‬‫ہ‬ ‫کنچلوںک‬
‫‪.‬خاثیمکشادو نتک استعمالکر نہوگا۔جوسوزشاور پکوختمکرنےمیںمددگار ن‬ ‫ٖڈٖڈاکٹر‪:‬عالجکےسلسلےمیںمیںآپکوبتا‬
‫)‪(Treatment‬‬ ‫گی۔اورمسوڑھوںکادردختمکریںگی۔‬
‫¸‬
‫¸‬ ‫مریض‪ :‬اندواؤںکےکوئیمضراناتبھیہوتے ہیں؟‬
‫‪.‬‬
‫‪.‬سردو‬ ‫ڈاکٹر‪ :‬جیبعضاوقاتاندواؤںکیوجہسےپیٹکیخابی نمتلیکیکیفیتہوسکتیہے۔لیکناگرادو نتکے ‪.‬نےاناتا ٓپکےساتھہوںتوادو نتکےمنا‬
‫)‪(Side effects‬‬ ‫بدلسےانکوکنٹرولکیاجاسکتاہے۔‬
‫]‪[23‬‬
 ‫مریض‪ :‬ڈاکٹرصا ‪.‬جمجھےاحتیاطیتدابیرکےن‪.‬رےمیںبتائیں۔‬
‫ک‬
‫ٹناورن‬
‫نک استعمالنککردیں۔علاوہازیںکھانےکےبعددانتوںکیصفائیاپنامعمول‬ ‫ڈاکٹر‪ :‬پرہیزکےسلسلےمیںاولتومیٹھیچیزوںکااستعمالکمسےکمکریںاورسیگر‬
‫بنائیں۔)‪(Precaution‬‬
‫مریض‪ :‬میںٹھیکتوہوجاؤںگا؟۔اوراسمسئلےکےساتھمیںاپنےروزمرہکےکامکاجکرسکتاہوں؟‬
‫ڈاکٹر‪ :‬جین‪.‬لکلا ٓپکامسئلہدواؤںسےٹھیکہونےوالاہےاوراگرضرورتپڑیتوہمیںدانتوںکیصفائیکرنیپڑےگی۔علاوہازیںاسکےساتھا ٓپاپنےروزمرہکےکام‬
‫کستکیہں۔‬
‫)‪(Effects on daily life‬‬ ‫ٓاس انیکر ‪.‬ن‬
‫مریض‪ :‬میرییہبیماریمیریوجہاورلوگوںمیںپھیلسکتیہے؟‬
‫(‪)Contagiousness‬‬ ‫ڈاکٹر‪ :‬نہیںایسانہیںہے۔‬
‫‪.‬‬
‫مریض‪ :‬شکریڈاکٹرصا ‪.‬ج خاحافظ‬
‫‪.‬‬
‫ڈاکٹر‪ :‬آپدوہفتےیہادو نتاستعمالکریںاورپھردون‪.‬رہ چاپکےلیےتشریفلائیں۔ خاحافظ‬

‫]‪[24‬‬
 Practical (4)
Informed Consent
CONSENT
It is acceptance of or agreement to something proposed or desired by another.
INFORMED CONSENT.
Consent is the agreement of the patient to an examination, procedure, treatment
or intervention. Validity of the informed consent depends upon
1. Capacity of the person.
2. Information given.
3. Voluntarily acceptance.

The informed consent can be given orally, by signing a form, a written statement or
simply agreeing by a gesture.

1: CAPACITY OF A PERSON

The capacity is the ability of a person to make a decision. It depends upon

a. Ability of a person to understand facts
b. Ability to know the consequences of not accepting the treatment.
c. Ability to process that information to reach decision.

The capacity of person is affected by

1. Impairment of mind as in dementia, delirium, learning disability.
2. Impairment of judgment as in psychosis.
3. Legal impairment as in minors that is less than 16 years of age.

The capacity can be checked by asking about

A. Orientation
Orientation to time, place and person can be checked as
1. Asking the person what is the time
2. Who is with you
3. Where are you

B. Attention Concentration
Checked by serial 7 test/ or days of week in reverse order.

C. Memory
Registration ----- name and address---- 7 +/- 2 3 attempts.
Short term-------- after 5 min-------7 +/- 2
Long term---------war, earth quake etc

D. Intelligence and General Knowledge

1. Simple additions and subtractions.
2. Who is President

[25]
 3. Provinces of Pakistan.
4. In which district you are living.

E. Insight and judgement

Insight
1. Whether you are ill.
2. Nature of illness.( physical/ mental )
3. Need of treatment.
4. Nature of treatment.
Judgment
Simple task of ID card.

INFORMATION

1. Patient must be offered all the available information.

2. Information should be according to educational and socio cultural back ground of
patient.
3. Information should be given after establishing a good rapport.

THE MINIMUM INFORMATION REQUIRED IS

a. Possible diagnosis
b. Purpose of treatment
c. Nature of treatment
d. Benefits and risks
e. Prognosis
f. Alternative if any

VOLUNTARILY ACCEPTANCE.

1. Message given should be free from any threat

2. Factual knowledge should be given regarding proposed treatment and alternatives.
3. Person should be free in choosing the alternatives
4. During procedure , the person has the right to withdraw his consent regarding rest of
treatment

[26]
 ‫‪Clinical Scenario‬‬
‫‪All three parameters ie capcity of the person,information given and‬‬
‫‪voluntarily acceptance will be assed in the given scenario to make‬‬
‫)‪consent valid.‬‬
‫‪Informed Consent‬‬

‫‪40 years old Mr. Owais comes to you with pain in left lower jaw. He is having‬‬
‫‪this pain for last one week. You have tried antibiotics for control of infection‬‬
‫‪and now decided extraction of left lower molar tooth. Considering him a fully‬‬
‫‪capable person how you will get the informed consent.‬‬

‫ڈاکٹر‪ :‬السالموعلیکم!‬
‫مریض‪ :‬وعلیکمالسالم!‬
‫‪.‬‬ ‫‪.‬‬ ‫‪.‬‬
‫ڈاکٹر‪:‬میرا نمڈاکٹرتحسینہے۔کی ا ٓپاپناتعارفکروا نپسندکریںگے؟ م ر ی ض ‪ :‬جیم یر ا نماویسہے۔‬
‫‪.‬‬
‫ک نچاہیںگے؟کیاآپاردوزن‪.‬نآس انیسےسمجھسکتہیں‬‫ڈاکٹر‪ :‬جیاویسا ٓپکیاجازتسےا ٓپکیموجودہتکلیفاورعلاجکےمتعلقچندن‪.‬تیںکریںگے۔امیدہےا ٓپتعاونکریںگے۔پیشہورانہتقاضوںکےمطابقمیںاسگفتگو کورازمیںرکھنےکان بندہوں۔ا ٓپگفتگومیںکسیکوشملکر‬
‫نکسیاورزن‪.‬نمیںن‪.‬تکریں؟‬
‫مریض‪ :‬جیمیںاردوزن‪.‬نسمجھسکتاہوں۔‬
‫ڈاکٹر‪ :‬ا ٓپکنعلاماتکےساتھتشریفلائےہیں؟‬
‫‪.‬‬
‫مریض‪ :‬ڈاکٹرصا ‪.‬جمیںا تہفتہپہلےآپکےن س ٓا نتھامجھےدانتوںمیںشد یدردتھاآپنےمجھےکچھ ‪.‬خاثیمکشادو نتتجو نکیتھیں۔انکےاستعمالسےدردکچھکم ہواہےلیکنمکملٹھیکنہیںہورہا۔‬
‫کن‬ ‫ڈاکٹر‬
‫‪ :‬پہلےہمنےکوششکیکہدواؤںسےا ٓپکیمرضکاعلاجکیاجائےلیکندواؤںسےا ٓپکوخاطرخواہفائدہنہیںہورہ اسلیےمیںنےیہنتیجہنکالاہےکہا ٓپکادا‬
‫‪.‬‬ ‫‪ .‬کنکہا ٓپکیتکلیفکامکملتدارکہوسکے۔اسکےلیےقانو ‪.‬‬
‫یجہہوسکتند‪،‬اعہے؟اقلاورن‪.‬لغا نندےسکتا ہے۔اسلےآپکوچندسوالاتکیزحمتدینیہے۔‬
‫تہےمگرینہکرہاواجانےزکاتصکریفاانت تہوشم‬‫ر‬‫و‬‫یضر‬ ‫ک‬ ‫ت‬‫ز‬ ‫ا‬ ‫ج‬
‫ککقکہاںپرہیںاورعلاج‬‫ا‬ ‫ی‬‫ک‬ ‫ٓپ‬ ‫ا‬‫ًن‬ ‫ککقہواہے؟‬ ‫نکالد نجائے‬
‫‪Person) of (Capacity‬‬ ‫ٓاپاسو‬ ‫یہبتائیںکہ ٓاپکیعمرکتنیہے؟انداز ًاکیاو‬
‫ک کقمیںہسپتالمیںہوں۔علاجنہکروانےکیصورتمیںمیریتکلیف‬
‫‪.‬نٹھےگیاورمیرے کامکاجکرنےمیںدشواریہوگی۔‬ ‫مریض‪ :‬میریعمر‪۴۰‬سالہے۔ابھیانداز ًادوپہرکے ‪۱۱‬بجےہیںاوراسو‬
‫کجکردوں۔اب کتکےمعائنہاورایکسرےکےنتیجےمیںیہپتاچالہےکہآپکےدا کنمیںشد‬
‫یانفیکشنکیوجہسے دانجڑسےخابہوچکاہے۔منا ‪.‬سیہیہےکہاسکونکالد نجائے۔نکہ‬ ‫ڈاکٹر‪:‬ابمیںآپکوڈاکٹروںکےنقطہنظرکیوضا‬
‫ک‬ ‫‪.‬‬ ‫‪.‬‬ ‫‪ . .‬ک‬
‫خاثیمدوسردانتوںمیںنپنچجائیںیعملچندمنٹوںمیںمکملوجائگامتان‬
‫ک ک‬ ‫‪ .‬ک‬ ‫‪.‬‬ ‫¸‬
‫کنلگاکراسکو‬ ‫کننکالنےپرہونےواالخال‬
‫ُ نکیاجاسکتاہے۔دا ‪.‬‬ ‫ُ ‪.‬نامعلومہوگا۔لیکناسکےبعدمصنوعیدا‬ ‫مسوڑھےکو ُسکرنےکےبعددانکونکالدیںگے۔ا ٓپکوکچھوقکےلیےدردرہےگا۔اورخونک اخاجبھیہوگا۔جسکوادو ‪.‬نتسےکنٹرولکیاجاسکتاہے۔علاوہ ازیںدا‬
‫‪.‬‬ ‫کننکلوانےکےبعدچندگھنٹےآپٹھوسغذااستعمالنہیں‬
‫)‪(informational care given‬‬ ‫کرسکیںگے۔‬
‫‪ .‬کنمیںمتا ¸‬ ‫‪.‬‬
‫نہوجائیں۔آپاسچیزکےلیےخودمختیارہیںکہجوعالجچاہیںاختیاکرلیں۔‬ ‫آپمجوزہعالجنہکروا نچاہیںتوہمکوششکریںگےکہ ‪.‬خاثیمکشادو نتکےذریعےا ٓپکیبیماریکوکنٹرولکیاجاسکےاسخطرےکابہرحالاحتمالرہےگاکہدوسرے دا‬

‫]‪[27‬‬
 ‫‪.‬‬ ‫‪.‬‬
‫)‪(voluntarily acceptance‬‬ ‫مریض‪ :‬ڈاکٹرصا ‪.‬جمیںا ٓپکےتجو نکردہعلاجسےمطمع نہوںاوراسکیاجازتدیتاہوں۔‬
‫‪.‬‬
‫ڈاکٹر‪ :‬جوکچھا ٓپنےموجودہگفتگومیںسمجھ اپنےالفاظمیںد مہادیںاورکوئیسوالہوتوپوچھلیں۔دئیےگئےفارمپرآپکااجازت نمہہےاسےبغورپڑھلیںاوراگرمتفق ہیںتواسپردستخطکردیں۔‬
‫مریض‪ :‬جیڈاکٹرصا ‪.‬جآپعالجشروعکریں‬

‫]‪[28‬‬
 Clinical Scenario 5
Sleep Hygiene

A 33 year old Banker comes to you with complaints of irritability, lack of

concentration and disturbed sleep for last few days. He is not willing to take
medication for sleep disturbances .what suggestions you would like to give the
patient regarding sleep hygiene?
Elaborate
1. PRINCIPLES OF SLEEP HYGIENE.
2. SLEEP INDUCING TECHNIQUES

!fl
 clsťl --------------------------------------------lclD
y.slysťí.STUbanSTl
T: nlćUS;JT.y.slJ
SalldT %CTUlx
slT.s/ TT:?UĖT: ?y.c.STUSċxl:
s: ?TUSċxslSċd?aldylTťsl:
?Lrκal:ª.rċx ?Ģa/dċx?
ŚTUSċxTťslSċxS:lPT.lS:
TUSċdLSssl.:N ds l1sNUĖ
Lrκal: lasfcdslċdç:
xlSls:ċJ.ulSċUlT:l
DylslFTťslSslċx
lUTslcª dTťslSNr
ssSyv
s(2ť.T
rбlØćfi sNssxa
DylslFTUSċd
y.lslsy/Tżsl y.T D
y.y/sslalTrκSċxr
bl øEĩlxT

[29]
Sleep Inducing Techniques

ASċU

ĩby/:y/sTżLjcslD:S.
J. Aż
allыl.a;c/sslJţl.Psl UÀdalSκ
dťslSscA/.yT lll  l lыlcll 
..TJlØ l DA l/.SclĩćJćyl s ldc l
 κAċl/

2./SċAíØ 2ćfi lclTJl

 xu l/TJSċsl 

[30]
 Practical 6
PSYCHO-SOCIAL ASPECTS OF PAIN

PSYCHOLOGICAL MANAGEMENT OF PAIN

ASSESSMENT:
 Establish the primary cause.
 Explore the Bio-Psycho-Social factors.
 Establish the relationship of factors with illness.
MANAGEMENT:
 Verbalize & ventilate the feelings of distress.
 Relaxation techniques.
 Operant techniques

Cognitive strategies.
 Social skills training
 Assertiveness training.
 Coping strategies.

[31]
 Clinical Scenario: 6
A 45 years old post menopausal is admitted in the ward with complaint of
chronic back pain for the last five years. She is c/o persistent pain which gets relieved
whenever some pain killers are used. However, the quantity of medicine is gradually
increasing. She demands pain killers whenever she feels pain and the time interval between
intakes of drugs is decreasing.
Task:
• Using principles of Operant Conditioning how will you counsel this lady in
medication reduction training?
• Explain any one of the cognitive strategies to control the pain.

!f
Tl(clsťl-------------------------------------lclD
y.sl(ysťí.STUbanS
T.y.slJ
dTslċsã/ BċssSl
b/T.lTslçucĖlsll
SsasTlaSTslsTsl
STslslsdcUαlTlSTslSdlls
uyçTllc.
yls.øyysuTslTD)l
.
yćblюaslsuy.T..  lsSTslys/(u
yysl
lsly.UÀdTdlSκsly.c/allĩ/ls.Sl
(ysťí y.sp MdslJċĩ/
l/sløEĩlxTl
bl

[32]
 Practical: 7
Breaking the Bad News

Definition:

Any news that adversely and seriously affects an individual’s view of his or her future.

Following points should be keep in mind while breaking the bad news keeping in mind
Bio Psycho Social Model.
1) Sitting and setting

2) Perception

3) Invitation

4) Knowledge

5) Empathy

6) Summarize

7) Plan of action

1. Seating and Setting Arrangements

 Privacy

 Involve significant other

 Seating arrangements

 Look attentive and calm

 Listening mode

 Availability

2. Perception

 Assess patient’s perceptions regarding Medical Situation.

 Assess language and vocabulary patients are using.

 Assess gap between patient perception and actual medical situation.

 Assess denial.

3. Invitation

[33]
  Get permission about extent of information.

 Involve family member if allowed

 Invite questions

4. Knowledge

 Warn PT. before giving bad news.

 Avoid scientific knowledge.

 Give information in small chunks.

 Ensure understanding.

 Acknowledge emotions and respond to them.

5. Empathy

 Give factual knowledge.

 Empathic response.

6. Summarize

7. Plan of action

[34]
 Clinical Scenario

Mr. Arafat, a 48 years old shopkeeper, has been under your care for last one month in dental out
door. He presented to you with ulceration of tongue for the last six months. Ulcer was
initially painless; it gradually became painful with foul smelling discharge. On examination
you found a foul smelling ulcer with averted margins. Biopsy was taken one week ago and
you have received laboratory report indicating squamous cell carcinoma. Mr. Aziz is
accompanied by his brother.

Task:

How will you break this bad news to the patient?

[35]
 Practical: 8
Compliance
Compliance is the degree to which a patient carries out the clinical recommendations of treating physician.

IT INCLUDES

1 Keeping Appointments
2. Entering and completing the treatment

3. Taking medicine correctly.

4. Following the recommended change in behavior.

FACTORS AFFECTING COMPLIANCE

(A) PATIENT FACTORS

LACK OF INSIGHT/JUDGMENT

DENIAL

MISCONCEPTIONS

(B) FAMILY FACTORS

POOR FAMILY SUPPORT

STIGMATIZATION

MYTHS

SOCIO-ECONOMIC STATUS

POOR UNDERSTANDING

(C) TREATMENT RELATED FACTORS

POOR RAPPORT

SIDE EFFECTS OF MEDICINES

POOR AVAILABILITY OF MEDICINE

UNAVAILABILITY OF HEALTH FASCILITY

PRPLONGED DURATION OF TREATMENT

COMPLICATED DOSAGE SCHEDULE

POOR UNDERSTANDING OF PATIENT

[36]
 Clinical Scenario
Mr. Aslam, 30 years old, laborer with no formal education from distant village, presented
to you with H/O continuous fever, cough with blood in sputum, gradual weight loss and poor
oral intake for past 2 month. After complete investigations he was diagnosed as a case of
Pulmonary Tuberculosis. Appropriate treatment was advised by Pulmonologist. He
discontinued treatment after few days and started visiting a Hakeem on advice of his
paternal uncle as he perceives these medicines are “garam”and have serious side effects.

Task:

Assess the cause and talk to the patient to improve compliance(Address myths and
misconceptions associated with treatment)

!f
clsťl---------------------------------------lclD
y.slysťí.SfslanTl
T.y.slJ
.
T Slucaé  b.arS fsl.
ysťlCTUlx
S?JTţslsl?Tl?ĖS
cṷa.fAJ ?cAfd
Sc.SfAfillasfSl?fus.rlsã fil
?íysťS()Sf y.κ)qĩTT
SţгlTsċfSSL
?Jldu s.rlssJTţsl
asfSlus.rlsslld ss.rTus.rlsTţs  S
/TllSu s.rlsT.STã.u .lsS
lsl(бSlus.us.rls
Tť a.sYlSsfaĩuluss.r
bl øEĩlxT

[37]
 Practical :9 (Case Scenario)
Stress Management
DEFINITION
THE CUMULATIVE EFFECT OF PHYSIOLOGICAL CHANGES IN THE BODY
RESULTING FROM ANYSTIMULUS PLAYING UPON THE BODY.
COPING WITH STRESS
One of your class fellows is really stressed due to upcoming professional exams and some
family issues how you would help him in giving tips about stress management

Task:
HOW WILL YOU APPROACH THIS PT,& WHAT ADVICE WOULD YOU GIVE HER

!fl
clsťl -----------------------------------------------l clD
y.slysťí.STUbanSTl
lsDlSTκf PT LT.y.slJ
żSTκfÙ5T.Sċlç Ù slćU
cκl .żã(.d lT.ls  .
 .ż asfSl .dS/sljl øl
dTκfÙylUJĩslJGċdll sSy l
.SylyTylTκfsTţsasssls
y
uṷl3ż Ǿsl .blsyŨldusª SS L
ĩs.lSTťslslsrκlª.rċ Eť.ylNгl
Jb
S Ø3 lyŨl ª Sdd Ǿcª lD rκ
J )JT/sSss
DȦċl.Tssanlcª fiSl.sscª cª.r s
s .
s )Susnª.rcldT/lb  . ĩ
pT  l3yl sª.rċ Eť.c Slçll
slx y.Sĩcª pl pyTl3ylslU
l

[38]
 Practical 10
Mini Mental State Examination

• The Mini-Mental State Exam (MMSE) is the most widely used

standardized instrument for cognitive impairment in the world. Cognitive
functions are compromised in the patients with Dementia and Learning
Disability(Mental Retardation)

• The Mini-Mental Status exam created by Folstein in 1975.

• Quick to administer = 10 min or less

• Items could be administered with additional equipment at patients’ bedside like

Watch, Paper & Pencil.

1. Orientation (score 1 if correct ……….. total score 10)

• What is the (year) (season) (date) (day) (month) is it? (5)

• Where are we (state)(country)(hospital)(floor) ( 5)

2.Registration (score 1 for each……total score 3)

Nam e 3 objects (Ball, Car, and Man), 1 second to say each .Then ask the patient all 3 after
you have said them. Give one point for each correct answer. Then repeat them until he /she
learns all 3.Count trials and record. (Record trials).

3.Attention and calculation:(max.score 5)

– Serial Sevens (Subtract 7 from 100 in serial fashion to 65)

4. Recall (total score 3)

– Ask for name of 3 objects learned in Q2

– Give one point for each correct answer.

5. Naming (total score 2)

Point to a pencil and a watch.

Have the patient name them as your point.

6. Repetition(total score 1)

Repeat what I say: 1

“No ifs, ands, or buts”

[39]
 7. Read and Obey (total score 1 )
Have the patient read and obey the following:

“CLOSE YOUR EYES”

8. writing a sentence (total score 1)

• Please write a sentence and sentence must make sense and contain a subject and
verb to score a point.

• If they can’t write a sentence, can they write a dictated sentence?

9. Comprehension (total score 3 )

Have the patient follow a three stage command:

Take a the paper in your right hand,

Fold it in half,

And put the paper on the floor.

• 10. Drawing / Visuo-spatial Task:(total score 1)

Please copy this design

2 intersecting pentagons

Score

• Widely accepted cutoff of 24/30 for MMSE.

• 27-30: Normal

• 21-26: Mild Cognitive Impairment

• 11-20: Moderate Cognitive Impairment

• 0-10: Severe

[40]
‫‪Mini Mental State Examination‬‬

‫‪1. Orientation‬‬
‫‪Time‬‬ ‫‪.‬‬
‫یہکو نسالہے؟‬ ‫‪‬‬
‫‪.‬‬
‫یہکو نموسمہے؟‬ ‫‪‬‬
‫‪.‬‬
‫یہکو نمہینہہے؟‬ ‫‪‬‬
‫کنریخہے؟‬ ‫‪‬‬
‫آجکونسی‬
‫‪.‬‬
‫فتکاکو ندنہے؟‬ ‫‪‬‬

‫‪Place‬‬
‫‪.‬‬
‫کو نملکہے؟‬ ‫‪‬‬
‫‪.‬‬
‫کو نصوبہہے؟‬ ‫‪‬‬
‫‪.‬‬
‫کو نشہرہے؟‬ ‫‪‬‬
‫ک کقکسجگہموجودہیں۔‬ ‫‪‬‬
‫ہماسو‬
‫‪ ‬اسعمارتکیکونسیمنزلپرہیں؟‬
‫‪2. Registration‬‬
‫‪.‬‬
‫ابمیںا ٓپکوتینچیزوںکے نم ندکراؤںگا۔ا ٓپنےانہیں ندرکھناہے‪،‬کچھد نبعدمیںا ٓپسےسنوںگا۔(کرسی‪،‬میز‪،‬قلم(‬
‫‪3. Attention and calculation:‬‬
‫کتمیںا ٓپکونہروکوں۔‬
‫‪ ۱۰۰‬میںسے‪7‬نفیکریں۔جوجوابا ٓئےاسمیںسے‪7‬نفیکریںاسیطرحنفیکرتےجائیں ‪. .‬ج‬
‫‪ Recall‬‬
‫‪.‬‬ ‫‪.‬‬
‫‪ ‬جنتینچیزوںکے نما ٓپکوبتائےتھےانکے نممجھےبتائیں۔‬
‫‪ Sentence repetition‬‬

‫‪ ‬جومیںکہوںاسےد مہائیں۔نہیںاگراور نلیکن۔‬

‫‪‬‬ ‫‪Read and obey‬‬
‫‪.‬‬
‫‪ ‬میںجوکچھلکھوںا ٓپنےکرکےدکھا نہے۔(اپنیا ٓنکھیںبندکریں(‬
‫‪ Writing a sentence‬‬

‫‪ ‬ا تن‪.‬معنیجملہلکھیں۔‬
‫‪‬‬ ‫‪Comprehension‬‬

‫‪ ‬ابا ٓپنےاپنےدائیںہاتھسےا تصفحہاٹھائیں۔‬

‫]‪[41‬‬
 ‫‪ ‬اسصفحےکوموڑیںاورنیچےمیزپررکھدیں۔‬

‫‪• Drawing / Visuo-spatial Task:‬‬

‫اسطرحکیتصو نبنائیں۔‬

‫]‪[42‬‬
 Practical 11
Progressive Muscle Relaxation (PMR)

Key:

In progressive muscle relaxation technique, each muscle or group of muscle is tensed for 5 to
7 seconds and then relaxed for 20 to 30 seconds. Repeat the cycle

Four major muscle groups are covered in this order:

(A) Hands, Forearms and Biceps.

(B)Head, Face, Throat and Shoulders.

(C) Chest, Abdomen and Lower Back.

(D)Thighs, Buttocks, Calves and Feet.

1. Practice progressive relaxation by lying down or seated in chair with feet firmly on
the floor.

2. Begin active progressive relaxation by tightening the right fist for 5 to 7 seconds and
paying attention to the stiffness. Then allow the muscle of same right fist to gradually relax
for 20 to 30 seconds, while noticing the pleasant/soothing effect.

3. Do the same with left fist, tensing and relaxing and feel the difference.

4. Follow the same procedure for forearms (tensing and relaxing), then for the biceps,
remembering to feel the difference in sensation between tensed and relaxed muscles.

5. Progress through the next major group..Head, Face, Throat and Shoulders.

6. Move to the third major muscle group, Chest, Abdomen and Lower back.

7. End with the fourth major muscle group…Thighs, Buttock, Calves and Feet.

[43]
 ‫‪Clinical Scenario:‬‬
‫‪Question:‬‬

‫‪A patient has come to you with severe symptoms of anxiety and restlessness. Using the guidelines for‬‬
‫‪progressive muscle relaxation, guide the patient through the steps.‬‬
‫‪.‬‬ ‫‪.‬‬ ‫‪.‬‬ ‫‪.‬‬ ‫میںا ٓپکوجسمانیسکونکیا‬
‫تمشقکراؤںگا۔یہمشقجسمکےتماماع ضاءپرمشتملہے۔جسعضوکیمشقکرنیہےپہلےاسمیںن نچسےساتسی ک یدکے لیےتناؤپیداکر نہے۔پھربیسسےتیسسیکنڈکےلیےڈھیلاچھوڑدیناہے۔جسعضوکیمشقکرنیہےتناؤصرفاسیمیںپیداکر نہے۔‬
‫کسکتہیں۔‬ ‫کلمیںرہےگا۔اگرکسین‬
‫‪.‬تکیسمجھنہا ٓئےتوا ٓپدون‪.‬رہپوچھ‬ ‫اورن‪.‬ق یتمام جس مس کون کیحا‬
‫‪. .‬جا ٓپنےمشقکرنیہےتوا ٓرامدہپرسکونجگہہونیچاہیے۔‬
‫‪ ‬اپنےدونوںن‪.‬زووںکوسامنےکیطرفسید‪Ø‬کریںاوردونوںہاتھوںکیمٹھیوںکوزورسےدن‪.‬ئیں۔‬ ‫ہاتھاورن‪.‬زو‬
‫اپنےدونوںن‪.‬زووںکوسامنےکیطرفسید‪Ø‬کریںاوردونوںہاتھوںکیمٹھیوںکواوپرکیطرفدن‪.‬ئیں۔‬ ‫‪‬‬
‫اپنےدونوںن‪.‬زووںکوسامنےکیطرفسید‪Ø‬کریںاوردونوںہاتھوںکیمٹھیوںکوپیچھےکیطرفدن‪.‬ئیں۔‬ ‫‪‬‬
‫‪.‬‬
‫اپنیدونوںکہن وںکواندرکیطرفموڑیں۔‬ ‫ی‬ ‫‪‬‬
‫کتلگائیںاورپھرڈھیلاچھوڑدیں۔‬ ‫‪‬‬
‫اپنےکندھوںکوکانکیلو‬
‫‪ ‬اپنیگردنکودائیںطرفموڑیں‬ ‫گردن‬
‫‪ ‬اپنیگردنکون‪.‬ئیںطرفموڑیں‬
‫اپنےسرکوپیچھےکیطرفلےجائیں۔‬ ‫‪‬‬
‫¸‬ ‫‪.‬‬ ‫‪‬‬
‫اپنیٹھوڑیکو یسپ لرگائیں پ ن‬ ‫پ ¸‬
‫اپنی شانیپرجھرنںلائیں‬ ‫‪‬‬ ‫ن شانی‬
‫اپنیا ٓنکھوںکوزورسےبندکریں۔‬ ‫‪‬‬ ‫آنکھوں‬
‫اپنےدونوںجبڑ‪.‬وںکوملائیںاورجبڑےکوا تطرک‬
‫فسےن‪ .‬مہکیطرفزورلگائیں۔‬ ‫‪‬‬ ‫جبڑ‬
‫‪.‬‬ ‫ٓم ٓ‬
‫اپنےنککےزریعےاتگہرالمباسانسلیں‪،‬سانسکوروکیںاوراہستہاہستہننچتگنتیگنیںاورپھرسانسکونہ‬ ‫‪‬‬ ‫سینا‬
‫نکالیں۔‬
‫‪ ‬اپنےپیٹکواندرکیطرفزورلگائیں‬ ‫پیٹ‬
‫‪ ‬اپنےٹپیٹکون‪ .‬منکالیں‬
‫ٹ‬
‫‪.‬‬
‫‪ ‬اپنیننگوںکوسید‪Ø‬کریں‬ ‫نؤں‪،‬نن‪،‬کولہے‬
‫‪.‬‬
‫‪ ‬اپنےن ؤںکواوپرکیطرفزورلگائیںاورپھرنیچکیجا ‪.‬نکریں۔‬
‫‪.‬‬
‫‪ ‬اپنےن ؤںکیانگلیوںکواوپراورنیچےکیجا ‪.‬ن زورلگائیں۔‬
‫‪.‬‬
‫دیگرتجاون‬
‫کنہےتوپٹھوںکوکھینچیںاوراسےمساجکریں۔‬ ‫‪1.‬‬
‫آپاپنےپٹھوںپرالگوہونےوالیکشیدگیکیمقدارمیںبتدریجاضافہکرتےہیں۔ ‪ 2.‬اگردردہو‬

‫]‪[44‬‬
 Practical :12
Confidentiality
Confidentiality means keeping information’s given by or about an individual in the course of
a professional relationship secure and secret from others.
1. It applies to all forms of transmission, verbal, written, digital, manual or hardcopy
record, videos and illustrations etc.
2. It also applies to fellow professionals and medical students.
Breaching confidentiality

Confidentiality is an absolute but there are certain situations in which confidentiality can be
breached.

Encourage the client to break the confidentiality but if he is reluctant to disclose the
information then treating doctor can make decision in best interest of patient and concerned
person (public).

It can be breached in following situations:

1. The patient is seeking employment or 2nd opinion.

2. When information’s is to be shared within healthcare system in best interest of patient.
3. Issuing a driving license( reporting Night Blindness,colour Blindness, Epilepsy or
illicit substance use ).
4. For research purpose but only as anonymous data.
5. In reporting infectious diseases (like small pox, cholera, plagiue, veneral diseases etc )
6. Sexually transmitted diseases (Hepatits, HIV)
7. For Forensic reporting (like gunshot wounds )
8. Reporting Abuse (physical sexual and emotional abuse).
9. Noticing imminent harm to self or others by a psychiatric patient under the care of
psychiatrist or psychologist.

[45]
 ‫‪Clinical Scenario‬‬
‫‪You are treating a young male with schizophrenia. His marriage has been arranged and will happen‬‬
‫‪next month. His in-laws visited your clinic asking about the diagnosis of your patient. You have denied at‬‬
‫‪first but the family insists that you have a responsibility since their daughter's life hangs in the balance.‬‬

‫?‪Can confidentiality be breached in this case? How would you counsel the family‬‬

‫ڈاکٹر‪ :‬السالموعلیکم!‬

‫مریض‪ :‬وعلیکمالسالم!‬
‫‪.‬‬ ‫‪.‬‬
‫ڈاکٹر‪:‬میرا نمڈاکٹراحمدکیاآپاپناتعارفکروا نپسندکریںگے۔‬
‫‪.‬‬
‫مریض‪ :‬میرا نمسلماناورمیںا تمریضکےحوالےسےا ٓپسےکچھمعلوماتلیناچاہتاہوںجوا ٓپکےز نعلاجہے۔ ڈاکٹر‪ :‬جیبتائیںا ٓپکامریضسےکیارشتہہے؟‬
‫‪.‬‬
‫مریض‪ :‬جیڈاکٹرصا ‪.‬جہماپنیبیٹیکارشتہانکےساتھکر نچاہرہےہیں۔اورمیںبیٹیکاوالدہوں۔ہمیںپتہچلاہےکہوہا تنفسیاتیبیماریکاشکار ہے۔اورکافیعرصہسےا ٓپکےز نعلاجہے۔‬
‫کیونکہیہمیریبیٹیکیزندگیکامعاملہہےاگرمجھےانکیبیماریاورعالجکےحوالےسےرہنمائی‬
‫کسکتہیں۔‬ ‫کردیںگےتو مہرےلیےفیصلہلیناآس انہوجائےگااورہماپناآگ‬
‫‪.‬ہمیمشورہسےطےکر‬ ‫عملن‬ ‫ہ‬‫کاالئح‬ ‫ے‬

‫کنہوں۔مگرمیراپیشہمجھےکسیکارازکسیاورکوبتانےکیاجازتنہیںہے۔ہاںاسکیا‬ ‫‪.‬‬
‫تصورت‬ ‫‪.‬‬
‫ڈاکٹر‪ :‬میںآپکے ‪ .‬خن تاورا‪F‬ساتکیقدرکر‬

‫ہوسکتیہےکہاگرمریضخودمجھےا ٓکرا ٓپکوبتانےکاکہےگاتومیںا ٓپکوبتادوںگالیکناسکےلیےمریضسےاجازتلینابہتضروریہےاورمیںپیشہ ورانہتقاضوںکومدنظررکھتےہوئےاسن‪.‬تکان بندہوںکہمریضکیکوئین‪.‬تاسکیاجازتکےبغیرکسیکونہبتاؤں۔‬

‫‪.‬‬
‫ا ٓپکےیہاںا ٓنےکابہتبہتشکریہ۔ خاحافظ‬

‫]‪[46‬‬
 Practcal :13
Accepting Gift from patient
Some safe recommendations :
i. Accept the parting gift at the end of successful treatment.
ii. Gift should be less expensive (like bouquet of flowers or box of sweets).
iii. A gift during treatment may be an expression of patients need for more
than usual attention or care.
iv. Extravagant or expensive gifts must never be accepted (it means patient is
putting you under heavy obligations).

V. Refusal should be polite as:

I am unable to accept this gift as it is against my professional ethics .My
concerns will be always for your betterment in future. I will accept the parting gift but not
the expensive one.

Clinical Scenario
One of your regular patients came to you with very expensive gift as a token of gratitude for his full
recovery from a severe illness .He insisted that the gift should be accepted .As a medical professional
What you should do and how should you deal with the situation?

!‫ السالموعلیکم‬:‫ڈاکٹر‬
!‫ وعلیکمالسالم‬:‫مریض‬
. . .
‫ میرا نماسلم‬:‫میرا نمڈاکٹربزیرکیآپاپناتعارفکروا نپسندکریںگے۔ مریض‬:‫ڈاکٹر‬
.
‫ جیبتائیںکیسٓا نوا‬:‫ڈاکٹر‬
.
‫نی فماکراسےقبولکرلیں۔‬.‫ میرابیٹاآپکےز نعلاجہےاسک ا ٓپنےبہتخیالرکھاہےاورا ٓپکےعلاجسےاسکیطبیعتکافیبہترہوگئیہے مہراپوراخاندانآپ کاشکرگزارہے۔میںآپکےلیےا تتحفال نہوں۔ا ٓپمہرن‬:‫مریض‬
‫کنہوں۔مگرمیراپیشہمجھےکسیسےقیمتیتحفہلینےکیاجازتنہیںدیتا۔مگرا‬ .
‫ٓپ مہگزیہنہسوچیں‬ ‫ساتکیقدرکر‬F‫تاورا‬.‫ خن‬. ‫ میںآپکے‬:‫ڈاکٹر‬
. .
‫ جبھیآئیںگآپکمریضکیدیکھبھالکر نمیرا فض‬. . ‫کہتحفےسےمیںآپکےمریضکاعالجز ندہبہتراندازمیںکروںگا نتحفہنہلینےسےمیںا ٓپکےمریضکاعلاجاچھےسےنہیںکروںگا۔ایساکچھنہیں وگاآپ‬
‫ا ٓپکےیہاںا ٓنےکابہتبہتشکریہ۔‬
.
‫خاحافظ‬

[47]