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NBME 23 Answers

nbme23/Block 4/Question#35 (reveal difficulty score)
A 17-year-old girl with type 1 diabetes ...
Acknowledge the patient's reasons for missing insulin injections ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
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 +5  upvote downvote
submitted by โˆ—niboonsh(409)
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One of the questions in the uworld practice test 2 actually touched on this.

motivational interviewing: indication
  • substance use disorders
  • other behaviors in patients who are not ready to change
principles
  • acknowledge resistance to change
  • address discrepancies between behavior and long term goals
  • enhance motivation to change
  • nonjudgmental
Technique (OARS)
  • Ask Open-ended questions (encourage further discussion)
  • Give Affirmations
  • Reflect and Summarize main points
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 +4  upvote downvote
submitted by emh(11)
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You need to acknowledge and discuss the reason for missing. Some people - young women mostly, intentionally restrict insulin therapy to lose weight. It's called diabulimia. They manage their glucose levels right before the blood draw so that their glucose is normal on the labs, but the HA1c doesn't lie.

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rozeng  But didn't he acknowledge already by asking her and getting also a relatively relevant response? +



 +1  upvote downvote
submitted by โˆ—hopsalong(32)
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I get this is a fluffy question and acknowledging the patient's reasons for missing insulin injections is the cuddliest, but I feel like this answer tows the line a bit. You don't want to say that missing doses is ok, but you also don't want to be mean to patient either. I thought this answer (A) was condoning her missing the injections, so I picked (C). In retrospect, I guess acknowledge means talk about/focus the conversation around.

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dentist  I would say: "I understand why you are missing injections, but you're going to have a BAD TIME IF YOU KEEP MISSING INJECTIONS" +4
alexxxx30  @dentist, I was searching for that answer as well, but it wasn't there so I picked C ahahaha +
123ojm  you would definitely do C as well. key word is "initial step" +
meja2  I believe that C is wrong since data suggests that teenagers tend to focus on the current situation, rather than long term, so if you want to initiate a change in behaviour its best to discuss how the behaviour affects their CURRENT situation. Option C would be to discuss long term effects. +1
fatboyslim  I think by acknowledging the patient's reasons they mean to say something like "yeah it's not always easy to remember to take ur insulin on time every day, especially when you don't immediately feel the effects of not taking the insulin" etc. In contrast to saying they are right about it. It's just about telling the patient "I hear you and I know it can be difficult". I think this concept applies to any non-compliant patient. +



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