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Since our first objective was to virus movie purchase ofloxacin from india develop a conceptual framework – delineating clinical indicators within the broader context of quality indicators – antibiotics in animals ofloxacin 200 mg on line, only articles containing empirical evidence or a theoretical discussion on generic issues in the use of quality indicators or clinical indicators were selected yeast infection 8 weeks pregnant purchase cheap ofloxacin on-line. Some articles about clinical indicator use in general practice were included (despite the fact that the scope of this research project are acute hospitals) antimicrobial agents order 200 mg ofloxacin otc, because they contained interesting theories about the development of clinical indicators, potentially applicable in a hospital setting. Also articles describing the reliability and validity testing of specific quality indicators were excluded because of a lack of theoretical discussion. These four countries have defined policies at the national level for the development and the use of quality indicators with the ultimate purpose to improve the quality of the health care system. The appendix 1 provides an overview of the main indicator sets of these countries (completed with important indicator sets from other countries). These indicators provide an overview of the performance of the Australian Health system (health status, determinants of health, health system performance and health inequalities). Many other agencies are involved in the measurement of the performance of health care organizations mainly for accreditation purposes. Recently, a unique set of clinical quality indicators has also been developed to measure the 13 quality in family practice. More recently, some other European countries developed quality policies incorporating the development and use of clinical indicators. These indicator sets are usually based on the experiences described above, but their use differs according to the health care 16, system. The scope of this framework is broader than the scope of the present report, and aims at international comparison. Information on clinical indicators in Belgium was gathered concerning general 6 practitioners’ initiatives, “colleges” of specialists and Flemish hospitals. The Federal government was also contacted to provide information on current initiatives. They finally selected commonly 158 abstracts focusing on the development and use of quality indicators. Specific articles were selected addressing methods and issues relevant for the development of the conceptual framework. The screening of the reference lists of these articles provided another 6 articles for inclusion. The search in the non-indexed literature yielded 28 articles, reports or websites. However, the definitions and underlying concepts differ between the authors and between the systems that use quality tools. The first part of this chapter describes the definition and underlying concepts of quality of health care, quality indicators, clinical quality indicators, and clinical indicator systems. Methodological aspects of quality and clinical quality indicators will be discussed in detail. The development and use of quality clinical indicators will be further analyzed together with the potential benefits and problems linked to their use. Because of the pure qualitative nature of the topic, mainly based on expert opinion, assessing the validity of the articles was difficult, making an objective selection of the soundest definitions hard. Donabedian, a pioneer in the theory and management of quality of health care, defined care of high quality as “that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the 20 balance of expected gains and losses that attend the process of care in all its parts”. The first component is related to the effectiveness of care, defined as the “ability to achieve the greatest improvement in health that science, technology and skills 21 can now offer”. According to Donabedian, quality of health care can be measured by observing its structure (organizational factors), processes (clinical care and inter 20 personal care) or outcomes (consequences of care). The terms used in this definition 10 deserve further attention : x ‘Health services’ refers to a wide range of settings of care (primary care, secondary and tertiary lines), a wide range of health professionals (physicians, nurses and paramedical workers) and many services affecting health. On the other hand, quality of care at the societal level is “the ability to access effective care on an efficient and equitable basis for the optimization of health benefit/well-being for the whole population”. The consistency with ‘current professional knowledge’ emphasizes the need for health care professionals to update their knowledge to maximize the likelihood of optimal outcomes for patients. Quality measurement is linked to the current scientific knowledge which expands rapidly. The ‘likelihood of desired health outcomes’ means that the practitioner has to take into account the values and preferences of the individual. Moreover the term ‘likelihood’ underlines that quality of care cannot be simply reduced to desired health outcomes. Effectiveness Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. Patient-centeredness Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. Timeliness Reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficiency Avoiding waste, including waste of equipment, supplies, ideas, and energy. Equity Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Dimensions Definitions proposed by other authors 25-27 Accessibility the services are accessible in terms of distance, time and social barriers. Continuity Delivery of care by the same healthcare provider throughout the course of care (when appropriate), and appropriate and timely referral and 25, 27 communication between providers. Acceptability Conformity to patient preferences regarding accessibility, the patients practitioner relation, the amenities, the effects of care, and the cost of care 28, 26. Comprehensiveness A range of services and care broad enough to meet all common needs as 25 they occur. Donabedian defines a care of high quality as “that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts”. The Institute of Medicine defines the quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. Many definitions of the term “quality indicator” have been proposed in the literature. Table 2 provides an overview of these definitions, however without taking into account the accompanying commentary of the authors. A common part of these definitions is that indicators are measurable elements of health care. Many definitions of clinical (quality) indicators are being applicable to quality indicators and vice versa. Few workable definitions were found delineating clinical quality indicators within the broader group of quality indicators (table 2). A major shortcoming of the definitions of clinical quality indicators is their lack of a description of ‘clinical’. For the development of the conceptual framework, special attention will be paid to develop a description of this concept ‘clinical’. The concepts underlying the term “clinical quality indicator” more often stress the 22, 29, 30, 15, 31, 8 relationship between the care provided (process) and the outcome of care. Some authors also mention the ability of clinical quality indicators to measure the appropriateness of care. As stated in the introduction, the scope of this project is clinical quality indicators and not performance indicators. Quality indicators and clinical quality indicators should be clearly distinguished from performance indicators, in that quality indicators infer a judgment about the quality of care, whereas performance indicators monitor care 33 without necessarily measuring the quality (figure 2). Its interest comes from its ability to support decisions and to highlight choices (for deciders, managers and health professionals). An indicator is a measurement of some point in an underlying process-outcome continuum. They are tools to assist in assessing whether or not a standard in patient care is being met. They can also refer to objective and measurable elements of acceptable practice that are applied consistently to the review of care by external reviewers. Finally, they can refer to appropriateness protocols (based on adherence to condition or procedure-specific standards) or to positive or negative health status outcomes. It is a screen that directs attention to specific performance issues that should be the subject of more intense review.

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These include joint replacements infection 8 weeks after giving birth order cheapest ofloxacin and ofloxacin, arthrodeses antibiotics for uti how long cheap ofloxacin 400mg otc, nerve decompressions antibiotic 2012 ofloxacin 200 mg generic, spinal decompression procedures no antibiotics for acne best order for ofloxacin, arthroscopic and open joint lavage, procedures for soft tissue problems in the hands, shoulders and knees. A new Speciality Certificate Examination is to be implemented from 2010 – see section 6 below. It is not expected that all competencies will be assessed and that where they are assessed not every method will be used. The overall aim is to develop the ability to perform a clinical assessment of patients with rheumatological disorders, select and interpret appropriate investigations and formulate a differential diagnosis and management plan. The trainee should be able to communicate their conclusions effectively to the patient and other clinical colleagues. Takes monitoring for treatment and disease-related responsibility for ensuring adequate complications follow up and monitoring Performs appropriate follow up medical services. This may include patient approach; respects the role of other self-help groups, social services, housing agencies; values the need for effective departments, Citizens advice bureaus, disablement communication with other agencies resettlement officers Rheumatology August 2010 Page 23 of 84 5. Soft tissue: Carpal tunnel, flexor and extensor tendon sheath soft tissue injections o Elbow: Joint: Elbow. Understand all aspects of a Develop a relationship that professional relationship facilitates solutions to patient’s Seek to identify the health such as the need to: problems. How to gain consent for a research project Outline situations where patient consent, while desirable, is not required for disclosure. Be willing to refer on to a Rheumatology August 2010 Page 42 of 84 colleague if conflict exists between personal values and those of the patient. Encourage patients to access: Management possible alternatives / Encourage questions. Discuss management plans and Patient support groups Be aware of management follow up arrangements strategies for rheumatological disease. Encourage participation in intervention o o Know principles of 1 & 2 appropriate disease prevention Encourage effective team prevention & screening. Define the local complaints procedureIdentify sources of help and support when a complaint is made about yourself or a. Roles & responsibilities of Respect skills and contribution Recognise own limitations. Seek feedback and audiences, small groups Select and use appropriate demonstrate a willingness to and clinic based teaching. Know the structure of the appraisal interview Rheumatology August 2010 Page 56 of 84 4. Trainees should become generally conversant with several of the scientific methods which are used in rheumatological research. There should be active involvement with research projects throughout the training period. Ability to frame questions to be needed to follow a project Completed Know how to use answered by a research project. Humility and the proposals and Know the principles of Obtain ethical committee acknowledgement of the grant research ethics and the role approval for a research contribution of others. Be active in research and mistakes, errors and procedures, audit authority and Research and development. Critically appraise medical Recognise the importance implementation Understanding Integrated care data research. Share best practice with patient might Evidenced based Aim for clinical effectiveness others. Willingness to cultivate a expect from Clinical Educate self, colleagues and questioning approach to Clinical effectiveness. Be able to handle and deal motivation to make environment To define the with complaints in a focused improvements. Take appropriate action if you suspect you or a colleague may not be fit to practice. Knowledge of risk assessment, perception and relative risk Know the complications and side effects of treatments. Evidence of principles of care groups, Trusts Develop leadership skills to management management and Hospital Trusts. Show respect for others, ensuring Directors, Clinical Be able to build a business equal opportunities. To acquire the management Demonstrate a willingness to Know the role of skills relevant to participation assume managerial responsibilities. To Recognise the importance of just societies, the royal achieve this the trainee will be allocation of healthcare resources colleges and the required to demonstrate general medical  Effective time Recognise the role of physicians as council. Be willing to offer advice to and for own projects and Access relevant web sites lay person on access to personal initiatives in and specialist databases to appropriate Internet sources development. To understand the confidentiality and their implications of the implementation in terms of Data Protection Act clinical practice in the for patient context of information confidentiality. The sequence of training should ensure appropriate progression in experience and responsibility. The training to be provided at each training site is defined to ensure that, during the programme, the entire curriculum is covered and also that unnecessary duplication and educationally unrewarding experiences are avoided. However, the sequence of training should ideally be flexible enough to allow the trainee to develop a special interest. The core learning method for training in Rheumatology will be work-based experiential learning supported by independent self-directed learning and by a formal education programme run regionally or sub-regionally for rheumatology trainees. Key to the success of the work-based learning will be appropriate clinical and educational supervision. This will be overseen by the named educational supervisor but will also involve other consultants and clinicians with appropriate expertise. Clinical skills acquisition will be predominantly by supervised work-based learning, supported where appropriate by skills laboratory activities. Skills competence will be assessed by means of directly observed, on-the-job activities, using the workplace-based assessments. It will allow the opportunity for collaborative learning between trainees and trainers. Additionally, in some cases, trainees may embark upon a relevant formal Masters programme to develop aspects of their knowledge and skills, both clinical and otherwise. Trainees will also attend other off-site educational activities, in agreement with their educational supervisor. Attitudinal development will be fostered by appropriate behaviours in the workplace, in addition to individual (with and without the educational supervisor) and group reflections. Professionalism will be assessed in the workplace by means of multi-source feedback. Rheumatology August 2010 Page 68 of 84 Although acting up often fulfills a genuine service requirement, it is not the same as being a locum consultant. Doctors in training acting up will be carrying out a consultant’s tasks but with the understanding that they will have a named supervisor at the hosting hospital and that the designated supervisor will always be available for support, including out of hours or during on-call work. The trainee will be based in different centres within the region, typically for periods of 12-18 months. Placements in the different training centres will be allocated to ensure that the trainee is exposed to the case mix of patients and experiences relevant to covering the learning outcomes of the programme. Thus specific opportunities in a given clinical centre will be mapped against the curriculum learning outcomes. Programme directors will then allocate trainees in a blueprinting exercise so that there is opportunity to cover all core learning outcomes during the trainee’s individual programme. This is because more experienced trainees will be better placed to maximise such a learning opportunity and will also be more prepared to deal with patients with such complex conditions. In some circumstances, trainees may spend time in a department outside of their own region. This will be by agreement with the programme director and will have a clear purpose in terms of developing defined learning objectives. Trainees will learn from practice, clinical skills appropriate to their level of training and to their attachment within the department.

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Bronchiolitis obliterans syndrome after allogeneic hematopoietic sct: Phenotypes and prognosis antibiotic medical abbreviation 400 mg ofloxacin fast delivery. Bronchiolitis obliterans after allogeneic hematopoietic stem cell transplantation antibiotics brands buy ofloxacin with visa. National institutes of health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: V antibiotics long term order ofloxacin 200mg with visa. Bergeron A antibiotic not working for uti cheap ofloxacin, Chevret S, Chagnon K, Godet C, Bergot E, Peffault de Latour R, Dominique S, de Revel T, Juvin K, Maillard N, Reman O, Contentin N, Robin M, Buzyn A, Socie G, Tazi A. Budesonide/formoterol for bronchiolitis obliterans after hematopoietic stem cell transplantation. Fluticasone, azithromycin and montelukast therapy in reducing corticosteroid exposure in bronchiolitis obliterans syndrome after allogeneic hematopoietic sct: A case series of eight patients. Christian Rose, Olivier Ernst, Bernard Hecquet, Patrice Maboudou, Pascale Renom, Marie Pierre Noel, Ibrahim Yakoub-Agha, Francis Bauters, Jean Pierre Jouet. Quantification by magnetic resonance imaging and liver consequences of post-transfusional iron overload alone in long-term survivors after allogeneic hematopoietic stem cell transplantation. High Prevalence of Iron Overload in Adult Allogeneic Hematopoietic Cell Transplant suvivors. Frequent severe liver iron overload after stem cell transplantation and its possible association with invasive aspergillosis. Lucarelli G, Angelucci E, Giardini C, Baronciani D, Galimberti M, Polchi P, Bartolucci M, Muretto P, Albertini F. Martin Wermke, Anne Schmidt, Jan Moritz Middeke, Katja Sockel, Malte von Bonin, Claudia Schönefeldt, Sabine Mair, Verena Plodeck, Michael Laniado, Günter Weiss, Johannes Schetelig, Gerhard Ehninger, Igor Theurl, Martin Bornhäuser and Uwe Platzbecker. Iron Overload in Allogeneic Hematopoietic Cell Transplantation Outcome: A Meta Analysis. Biology of Blood and Marrow Transplantation, Volume 20, Issue 8, 1248 1251 9. Emanuele Angelucci, Pietro Muretto, Guido Lucarelli, Marta Ripalti, Donatella Baronciani, Buket Erer, Maria Galimberti, Claudio Giardini, Djavid Gaziev, Paola Polchi and the Italian Cooperative Group for Phlebotomy 102 Treatment of Transplanted Thalassemia Patients. Phlebotomy to Reduce Iron Overload in Patients Cured of Thalassemia by Bone Marrow Transplantation. Evaluation of cardiac status in iron loaded thalassemia patients following bonew marrow transplantation: improvement in cardiac function during reduction in body iron burden. Kinetics of iron removal by phlebotomy in patients with iron overload after allogeneic hematopoietic cell transplantation. The impact of desferrioxamine postallogeneic hematopoietic cell transplantation in relapse incidence and disease-free survival: a retrospective analysis. Carlos Vallejo, Montserrat Batlle, Lourdes Vázquez, Carlos Solano, Antonia Sampol, Rafael Duarte, Dolores Hernández, Javier López, Montserrat Rovira, Santiago Jiménez, David Valcárcel, Vicente Belloch, Mónica Jiménez, Isidro Jarque. Erythrocytapheresis compared with whole blood phlebotomy for the treatment of hereditary haemochromatosis. Cooperative Group for the Study of Immunoglobulin in Chronic Lymphocytic Leukemia. Intravenous immunoglobulin for the prevention of infection in chronic lymphocytic leukemia. The National Institute of Child Health and Human Developments Intravenous Immunoglobulin Study Group. Intravenous immune globulin for the prevention of bacterial infections in children with symptomatic human immunodeficiency virus infection. Intravenous immunoglobulin therapy for prevention of infection in high-risk premature infants: report of a multicenter, double-blind study. A multicenter, randomized, double-blind comparison of different doses of intravenous immunoglobulin for prevention of graft-versus-host disease and infection after allogeneic bone marrow transplantation. Intravenous immunoglobulin: appropriate indications and uses in hematopoietic stem cell transplantation [Review]. Immunomodulatory and antimicrobial efficacy of intravenous immunoglobulin in bone marrow transplantation. A controlled trial of long-term administration of intravenous immunoglobulin to prevent late infection and chronic graft-vs. Biology of Blood and Marrow Transplantation, Volume 24, Issue 5, 909 913 Hyperlipidemia: 103 References: 1. Efficacy and safety of fluvastatin therapy for hypercholesterolemia after heart transplantation. Simvastatin initiated early after heart transplantation: 8-year prospective experience. Effect of fluvastatin on cardiac outcomes in renal transplant recipients: a multicenter, randomized, placebo-controlled trial. The effects of hyperlipidemia on graft and patient outcome in renal transplantation. Pravastatin therapy is associated with reduction in coronary allograft vasculopathy in pediatric heart transplantation. Atorvastatin treatment for hyperlipidemia in pediatric renal transplant recipients. Association between different lipid-lowering treatment strategies and blood pressure control in the Brisighella Heart Study. Hepatitis Viruses and Hematopoietic Cell Transplantation: A Guide to Patient and Donor Management. Biliary obstruction in hematopoietic cell transplant recipients: An uncommon diagnosis with specific causes. Hepatitis C virus infection after bone marrow transplantation: A cohort study with 10 year follow-up. Gastrointestinal, hepatobiliary, pancreatic, and iron-related diseases in long term survivors of allogeneic hematopoietic cell transplantation. Flowers Bone Loss and Avascular Necrosis of Bone After Hematopoietic Cell Transplantation. Evaluate skin thickness by clinical palpation: 0 = normal skin thickness 1 = mildly increased skin thickness 2 = moderately increased skin thickness 3 = severely increased skin thickness (inability to pinch skin into a fold) B. Crystalloid solutions are distinguished by the relative tonicity (before infusion) in relation to plasma and are categorized as isotonic, hypotonic, or hypertonic. Isotonic solutions Isotonic solutions have a concentration of dissolved particles similar to plasma, and an osmolality of 250 to 375 mOsm/L. These fluids remain within the extracellular compartment and are distributed between intravascular (blood vessels) and interstitial (tissue) spaces, increasing intravascular volume. Document baseline vital signs, edema, lung sounds, and heart sounds, and continue monitoring during and after the infusion. Initially dilutes osmolality of (D5W) extracellular fluid (hypotonic); once cell has used dextrose, remaining saline and electrolytes act isotonic, expanding the 253 mOsm/L extracellular compartment. PlasmaLyte Electrolyte composition similar to plasma; can be infused with packed red blood cells. Hypotonic solutions Hypotonic solutions have a concentration of dissolved particles lower compared to plasma and an osmolality < 250 mOsm/L. Hypotonic fluids lower serum osmolality within the vascular space by causing fluid to shift out of the blood into the cells and tissue spaces. Typically used to treat conditions causing intracellular dehydration, such as diabetic ketoacidosis and hyperosmolar hyperglycemic states. Hypertonic solutions Hypertonic solutions have a concentration of dissolved particles higher than plasma and an osmolality > 375 mOsm/L. A higher solute concentration causes the osmotic pressure gradient to draw water out of cells, increasing extracellular volume. These fluids are often used as volume expanders and may be prescribed for hyponatremia (low sodium). Additional Hypertonic Solutions: 20% Dextrose in water (D20W): Acts as an osmotic diuretic, causes a fluid shift between various compartments. Also known as volume/plasma expanders, colloids expand intravascular volume by drawing fluid from the interstitial space into the vessels through higher oncotic pressure. Colloids are indicated for patients in malnourished states and patients who cannot tolerate large infusions of fluid. Used for moderate protein replacement, and to achieve hemodynamic stability in shock states.

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However bacteria quotes discount 400 mg ofloxacin free shipping, severe mental disorders pose serious threats to infection 2 hacked generic ofloxacin 200 mg with visa the health and safety of the patient antimicrobial insoles ofloxacin 200mg on-line, and sometimes to antibiotic beads for osteomyelitis order cheap ofloxacin on-line the well-being of others. Physical and mental disorders often coexist sometimes coincidentally but more often as cause and effect. For example, a severe infection may precipitate delirium (an acute confusional state), while intravenous drug abuse may result in the patient acquiring infections. Consequently the prevalence of mental disorders (particularly organic brain disorders, mood illnesses and substance misuse disorders) is even greater among the physically ill, and affects mortality and morbidity. Because of these considerations all clinicians should be competent at basic psychiatric assessment of a patient. Assessment interviews usually do have to cover background personal and social factors to establish an understanding of how the illness evolved and to guide management, but the focus, as in all history taking, is the presenting problem and its solution for the patient. Additionally, it is helpful to establish whether: the patient knows about and accepts the referral the patient is able to understand and communicate the patient wishes to be seen alone or with somebody else there is an element of danger behavioural disturbance or other impediments to interview are likely. Otherwise, the interview follows conventional procedures: Put the patient at ease. Allow breaks and digressions (within reason) if the patient requires these notably with sensitive topics or when distress emerges. Concentrate on the presenting complaint, using a technique of nested, open questions to explore the key elements. Once the presenting situation is clear, the patient is settled and rapport permits, take greater control of the interview content through focused questioning and greater use of closed questions. Content the content of a psychiatric history is as follows: Reason for referral Presenting complaint(s) History of presenting complaint(s) Family history (including psychiatric disorders specifically) Personal history childhood; education; occupational history; sexual and marital history; children; current social circumstances Past medical/psychiatric history Prescribed medication; other remedies Psychoactive substance use, including alcohol, tobacco and caffeine Forensic history Premorbid personality. Some aspects of psychiatric history taking differ from standard medical interviewing, and merit further consideration. Risk assessment Mental disorders can be associated with danger: classically depression with harm to self, and paranoid states with harm to others. Whenever the presentation suggests such hazards may be a possibility, then inquiries about thoughts, impulses and actions concerning suicide or violence must be made. How and when this is broached during the interview depends on cues: generally it is best left until rapport is firmly established, as patients often find these matters difficult to reveal. Many patients are relieved to be able to confide what is frightening to them and unacceptable to share with their family. Sensitive issues There are other themes that can be tricky for the patient and doctor during an interview, notably sexual matters and criminal activities. The sexual history is a component in a standard psychiatric history, the forensic history is another, while illicit drug-taking is part of the history of psychoactive substance use. It is far more important to build an effective relationship than to obtain a complete account at the expense of alienating the patient. Enquiring about sensitive matters can and sometimes should be omitted from initial psychiatric history taking unless the presenting problem is such that there is an obvious relevance which the patient can understand, or it is essential for establishing management. Such topics can be returned to if necessary at later interviews when rapport will enable the patient to divulge such material more comfortably (and probably more accurately too). Premorbid personality Assessment of premorbid personality is, by convention, the last section in the psychiatric history. Assessing premorbid personality involves evaluating what kind of person the patient was before the illness emerged and because of this, it is the one section of history for which an informant who knew the patient well is essential. It is helpful to summarize premorbid personality under these subheadings: interests and hobbies social activities, friendships and other relationships moral/religious beliefs predominant mood coping strategies and reactions to stress and setback strengths, weaknesses, basic character. One useful approach is to start by asking patients how they might have spent an average week in their life before they became ill. Other sources of information In psychiatric assessment, information obtained from other sources is usually necessary, sometimes vital and occasionally the only available history. Background medical information will be available in the case records of known patients and from the general practitioner. With inpatients, speaking to ward nurses informs about aspects such as sleep pattern, hallucinatory activity and cooperation. The content and extent of the physical examination depend on the history and likely diagnosis; usually general observation, coupled with basic cardiovascular and neurological examination will suffice. Like a physical examination, it is systematic with the aim being to elicit signs of disorder. The main areas are: appearance behaviour speech mood thought content perception cognitive functioning insight. This will be channelled by the history and potential diagnoses so, for example, when an organic brain disorder is suspected, more thorough assessment of cognitive functioning is required, while for depression the assessment of mood is central. Behaviour Cooperation/reaction to the interview/eye contact/rapport Level of consciousness Social behaviour Motor overactivity includes hyperkinesis (a disorder of children), restlessness, agitation, compulsions and rituals Motor underactivity includes stupor, slowing (retardation) and poverty of movement (akinesis) Motor abnormality includes involuntary movements and mannerisms. Speech Rate includes pressure of speech and slowing Quantity includes mutism, poverty of speech and pressure of speech Articulation includes stammering, stuttering and dysarthria Form covers the way in which a patient speaks rather than the content: flights of ideas: where ideas flow rapidly but remain connected although sometimes by unusual associations. Subjective mood Subjective mood is established by inquiry, introduced by an open question. Dysphoric (abnormal) mood states take two forms: abnormal pervasive mood abnormal expression of mood. Abnormal pervasive mood states occur in many types of mental disorder, but are the central feature of: depression, when there is sustained low mood which may include sadness, tearfulness, hopelessness, despair and, in severe illness, loss of emotion such that the patient feels nothing mania, when the patient feels elated or euphoric anxiety, when worry, apprehension and tension feature. Abnormal expression of mood includes: labile mood, when emotions are superficial, rapidly changing and poorly controlled; extreme lability is sometimes emotional incontinence (associated with multi-infarct dementia) incongruous mood, when the emotional expression is inappropriate for the thought blunting, when normal expression of mood is diminished or lost (sometimes termed flattening of affect). Incidentally, the terms mood and affect are often used interchangeably, but they are subtly different. Mood refers to the pervasive emotional state, whereas affect is the observable expression of emotions, which is variable over time. Thought content this is a central part of the mental state examination, and is primarily based on the history the patient has provided. Preoccupations Preoccupations include: Ruminations: repetitive ideas or themes on which the patient broods. Suicidal or homicidal ruminations are particularly important to establish and evaluate (Table 1. Hypochondriasis: a specific, unjustified preoccupation with having a serious disease. Obsessional thoughts: a form of rumination that involves senseless preoccupation with a topic from which the patient cannot desist in spite of realizing it is irrational. Instead of feeling compelled to think or do something, the phobic patient feels compelled to avoid a situation, object or activity because of an irrational fear. Typical preoccupations associated with mood disorder Anxiety state Anxiousness, worry, fear, apprehension, doubt, uncertainty Depressive disorder Loss of self-worth, confidence, ability Guilt, burden, failure, catastrophe, hopelessness Death, suicide Unlovable, unlikeable, self-denigration Table 1-23. Questions to ask to determine the possibility of suicidal thoughts in a patient How have you been feeling recently? Abnormal beliefs Abnormal beliefs are subdivided into overvalued ideas and delusions. They are beliefs that are held, expressed and acted on by the patient about matters which are of particular importance to them but to a degree that others from the same culture would regard as unreasonable. A delusion is a false belief which is held with total conviction, which is not shared by others from the same culture and which is maintained in spite of proof or logical argument to the contrary. Primary delusions, which are characteristic of schizophrenia, are fully formed de novo. Secondary delusions, which can occur in various mental illnesses, can be understood to have arisen in a context of another mental process usually an abnormal mood state or abnormal perceptions. The content of delusions can give a clue to the nature of the mental illness for instance, grandiose delusions are associated with mania, nihilistic delusions with depression, and paranoid delusions with delirium and schizophrenia. When delusions are bizarre their recognition is easy, but delusions may seem quite ordinary ideas. When conducting a psychiatric interview it is inappropriate to ask routinely about delusions: such inquiries will upset many patients and damage rapport, while deluded patients are unlikely to give a straight answer anyway. Questions usually have to be focused on information the patient has provided, or sometimes other information brought to your attention. Technique generally involves greater use of closed questions to pin down the beliefs. Abnormal experiences may be referred to: the environment, which includes illusions, hallucinations and derealization the patient, which includes somatic hallucinations and depersonalization.

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