| | SMOKING CESSATION
Doorway information about patient
The patient is a 55-year-old woman who comes to the clinic for counseling on smoking cessation
Vital Signs
. Temperature : 36.7’C
. Blood pressure : 122/80 mmHg
. Pulse : 70/min
. Respirations : 14/min
Approach to patient
1 Precontemplation : Not really to change : patient does not acknowledge negative consequences
. Encourage patient to evaluate consequence of current behavior
. Explain & personalize the risk
. Recommending actions is premature
2 Contemplation : Think of change : patient acknowledge consequences but is ambivalent
. Encourage evaluation of pros & cons of behavior change
. Promote new, positive behaviors
3 Preparation : Ready to change : patient decides to change
. Encourage small initial steps
. Reinforce positive - outcome expectations
4 Action : Making change : patient makes specific , overt changes
. Help identify appropriate change strategies & enlist social support
. Promote self-efficacy for sealing with obstacles
5 Maintenance : Changes integrated : into patient;s life ; focus on relapse prevention
. Follow-up support; reinforce intrinsic rewards
. Develop relapse prevention strategies
6 Identification : Behavior is automatic : changes incorporated into sense of self
. Praise to change
The initial assessment in smoking cessation can be summarized with the “5 As” :
. Ask about smoking at each visit
. Advise and encourage patient who smoke to quit
. Assess willingness to quit (stage of change)
. Assist with smoking cessation , including counseling and possible drug therapy
. Arrange follow-up (unperson or by phone ) to reinforce the behavior chanegs
Most agent who smoke desire to quit and may have attempted it many times. In light of this , it is important to be patient , empathetic , and nonjudgemental when interviewing a patient who smokes. Lectures or glib pronouncements (eg, “if you don’t stop song you are going to kill yourself”) are rare helpful.
Differential diagnosis
The diagnosis of nicotine abuse is not usually doubt . however , be alert for other substances abuse disorders (eg, alcohol, illicit drugs ) and psychiatric illness (eg, depression , anxiety disorder ) that may complicate management.
HISTORY AND PHYSICAL EXAMINATION
History
history of present illness
. When did you start smoking ?
. How many cigarettes do you smoke in an average day? In the past , did you smoke more or less than you do now?
. What were the circumstance that cause you begin smoking ?
. Do you enjoy smoking ?
. Are there any situations (eg, morning coffee times at work ) that tend to reinforce your smoking ?
. Have you tried to quit before ? How did it go ?
. Are you concern about your health?
. Is stress or depression a reason for your smoking ?
. Have you ever had any smoking -related complications such as heart or lung problems ?
Past medical history
. Do you have nay otters medical problems (eg, cancer, cardiovascular disease )?
. Have you had depression or other emotional problems ?
Social history
. What kind of work do you do ?
. Who lives was home with you ?
. Are there any other thinks in your life that are adding to your stress?
. Do you drink alcohol ? How much & how often?
. have you used recreational drugs ?
They physical examination may be very limited . However , you should make observations about the patient’s psychological states (eg, mood/affect , alertness , psychomotor activity) during the interview .A brief cardiopulmonary examination may also be appropriate , in addition to examination of any symptomatic body system.
Closing the encounter
Motivation Interviewing
1 Indications
. Substance sue disorder
. Other behaviors in patients who are not ready to change
2 Principles
. Acknowledge resistant to change
. Address discrepancies between behavior & long-tern goals
. Enhance motivation to change
. Nonjudgemental
3 Technique (OARS)
. ask “O”pen-ended questions (encourage further discussion)
. give “A”ffirmations
. “R”eflect & “S”ummarize main points
Treatment is not tested as part of the USMLE Step 2 CS exam. However , a brief counseling intervention regarding quitting is appropriate. Help patient identify factors that might make quitting more or less difficult .Allow them to express any preference on quitting strategies and treatments (eg,prescription medications). Be positive and encouraging about their desire to quit.
If the patient is ready to quit , encourage setting a “quit date”. The idea quit date is a low -stress day (eg, a weekend ) with no significant social engagement that might make patient’s first day without nicotine more difficult . the date should be soon enough that the patient dose not lose motivation but still has adequate time to prepare (eg, purchase nicotine patches) without feeling rushed.
Diagnostic studies
Diagnostic studies testing is not often needed in smoking cessation . You can consider basic screening tests for any significant complications you suspect (eg. chest x ray , spirometry for chronic obstructive pulmonary disease), but these should be kept to a minimum . Toxicology testing (eg, urine nicotine or cotinine levels 0 is not usually helpful. If no tests are necessary , write “No studies indicated “ in the Diagnostic Studies section of your documentation.
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2018/05/11 08:19pm 
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