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Simulated Clinic Tips and Pitfalls http://www.fayzarayes.com
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The Joint Program of Family and Community Medicine - Jeddah
70
Simulated Clinics Tips and Pitfalls
Contents:
Approach to Simulated Clinic Exam
The main skills assessed during simulated clinic exam
Possible difficulties and pitfalls in simulated clinic exam
Examples of Simulated Clinic checklists
(1) Approach to Patient with Chest Pain
(2) Approach to Patient with Cough
(3) Approach to Patient with Diarrhea
(4) Approach to Patient with Anemia
(5) Approach to Patient with Headache
(6) Approach to Patient with Acne
(7) Approach to Patient with Urinary Tract Infection
(8) Approach to Patient with Sore Throat
(9) Approach to Patient with Acute Otitis media
(10) Approach to Patient with Dyspepsia
(11) Approach to Patient with Irritable Bowel Syndrome
This is a part of Lecture Notes on Family Medicine Book
Written by the teaching staff of the family medicine department of the Joint Program of Family and Community Medicine in Jeddah
www.fayzarayes.com
The Joint Program of Family and Community Medicine - Jeddah
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5.
Approach to Simulated Clinic Exam F. Rayes
GoTo TOP
The main objective of the simulated clinic is to evaluate the candidate’s skills in
consultation. Accordingly, in preparation for simulated clinic exam, the candidate needs to
improve his/her knowledge and skills in consultation.
Some Important Consultation Models:
Byrne & Long (1976)
Doctor-centered consultation: the doctor was more likely to make decision for the
patient and instruct him to seek some service.
Patient-centered consultation: the doctor was more likely to seek the patient’s
views and permit him to make his own decision concerning the outcome.
Failure to explore the real reason of patient problem is the main reason of
consultation failure
Patient-Centered
Consultation
Doctor-Centered
Consultation
Use of patient’s
Knowledge and experience
Use of doctor’s
Special knowledge and experience
Silence Clarification Analyzing Gathering
Information Facilitation Interpretation Probing
Skills used by physician in patient-centered against
Doctor-centered consultation
Scott and Davis (1979) The Expanded Model of Consultation:
Management of Presenting Problem
Management of Continuous Problem
Modification of Help Seeking Behavior
Opportunistic health Promotion
Pendleton 7 Tasks (1982):
1. To define the real reasons for patient attendance;
2. To consider other problems;
3. To choose appropriate action for each problem with the patient;
4. To achieve a share understanding;
5. To involve patient in the management;
6. To use time and resources effectively;
7. To establish and maintain doctor-patient relationship
Neighbour (1992), The Inner Consultation:
Connecting (establishing relationship)
Summarizing (physical, social & psychological diagnosis)
Handing – over (management of presenting problem)
Safety – netting (Anticipatory care)
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GoTo TOP The main skills assessed during simulated clinic exam
Interview and history taking:
1. Introduces self to patients
2. Encourage patients to elaborate presenting problems fully
3. Identifies patients’ reasons for consultation
4. Listens attentively, Puts patients at ease
5. Recognizes patients’ verbal and non-verbal cues
6. Uses silence appropriately
7. Phrases questions simply and clearly
8. Considers physical, social and psychological factors as appropriate
9. Seeks clarification of words used by patients as appropriate
10. Elicits relevant and specific information from patients and/or their
records to help distinguish between working diagnoses
11. Exhibits well-organized approach to information gathering
Behavior and relationship with patients:
1. Conveys sensitivity to the needs of patients
2. Demonstrates an awareness that the patient’s attitude to the doctor (and vice versa)
affects management and achievement of levels of cooperation and compliance
3. Maintains friendly but professional relationship with patients
with due regard to the ethics of medical practice
4. Considers ethical issues in his practice, particularly patient confidentiality, and is
able to offer reasons for his action
Physical Examination:
1. Uses the instruments commonly used in general practice in selective, competent and
sensitively manner
2. Performs examination and elicits physical signs correctly and sensitively
Patient Management:
1. Formulates management plans appropriate to findings and circumstances in
collaboration with patients
2. Checks patients’ level of understanding
3. Makes discriminating use of investigations, referral and drug therapy
4. Arranges appropriate follow up
5. Demonstrates understanding of the importance of reassurance and
explanation and uses clear and understandable language
6. Is prepared to use time appropriately
7. Attempts to modify help-seeking behavior of patients as appropriate
Problem Solving:
1. Correctly interprets and applies information obtained from patient records, history,
physical examination and investigations
2. Generates appropriate working diagnoses or identifies problem(s) depending on
circumstances
3. Is capable of recognizing limits of personal competence
4. Seeks relevant and discriminating physical signs to help confirm or refute working
diagnoses
5. Is capable of applying knowledge of basic, behavioral and clinical sciences to the
identification, management and solution of patients’ problems
Anticipatory care:
1. Acts on appropriate opportunities for health promotion and disease prevention
2. Provides sufficient explanation to patients for preventive initiatives taken
3. Sensitively attempts to enlist the cooperation of patients to promote change to
healthier lifestyles
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GoTo TOP Possible difficulties and pitfalls in simulated clinic exam:
1) Common difficulties in communications:
Patient with hidden agenda: e.g. patient requesting vitamin or cough syrup or
patient showing certain non verbal cues
Aggressive and demanding patients e.g. patient may till you: “give me this
medication now!” or he may say: “Your colleague Dr. X is very rude”
Passive aggressive patient: e.g. patient may say: “yes, but!”
Poor compliant patient: e.g. patient refusing your medication or investigation or
advice
Common pitfalls:
Use of open-ended question at the start only
Talking continuously and not listening
Forgetting to explore patient’s health beliefs
Being very anxious and couldn’t express any empathy
Being reactive and getting angry
Losing control.
2) Common difficulties in information gathering:
Atypical presentation of common disease: E.g. MI presenting as epigastric pain.
Indirect presentation: E.g. depressed patient present with backache.
Many problems at a time E.g. DM + infections + social problems, and difficulty in
prioritization
Multiple somatic complain E.g. somatization, masked depression or anxiety
Possible serious diagnosis: E.g. elderly patient with palpitation.
Common pitfalls:
Reaching final diagnosis from the first impression and ignorance to ask specific
questions to prove this diagnosis objectively
Disorganization and non-directive interview
No clear objectives
Failure to make use of preliminary information from the patient file
Repeating same questions in the same way
Wasting long time sticking to one issue
Ignorance of patient cues
Doctor-centered consultation
Thinking of one and only one possible diagnosis
Forgetting to ask about patient health beliefs
Forgetting to ask specific questions to rule out the possible differential diagnoses
Ignorance to ask specific questions for risk assessment and continues problem
No summarization of the history and no feedback from the patient.
Forgetting to conduct physical examination
Wasting long time in discussing irrelevant physical examination
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3) Common difficulties in management:
Controversial management issue
Complicated social problem
Complicated diagnosis
Uncertain diagnosis
Risk of complication e.g. ethical dilemma, marital problem, demented patient with
no family support,?? MI. !?? Ca.
Unhealthy life style, e.g. smoker or obese patient needing health education
Risk of complication, e.g. severely depressed patient at risk of suicide
Common Pitfalls:
Forgetting to discuss different management options
Forgetting to make use of other primary health care team members
Forgetting your limitation and to make good use of referral system
Helpful strategies in dealing with difficulties in simulated clinic exam:
1) Read the preliminary information carefully:
Concentrate on the key words, e.g.:
o Infrequent attender or
o DM+ high fasting blood sugar (FBS) or
o Medical student, Follow-up visit, Significant past history…etc
Speculate possible objectives from the given scenario, and at the same time be open
minded and ready to conceder patient’s objectives
2) Have systematic approach to your objectives:
Full focused history
Listen and watch carefully for any verbal or nonverbal cues
Use hypothetical deductive reasoning methods to test your hypotheses
Think loudly to give the examiner the chance to understand how you think, and
give you the desirable evaluation mark
Concentrate on your provisional hypothesis by asking relevant and specific
questions to reach clear and positive diagnosis
Remember: Psychological diagnosis by positive criteria not by exclusion
Eliminate possible deferential hypotheses by asking relevant and specific questions
Use open-ended questions when ever possible
Complete your exploration by asking specific questions
Assess the degree or risk (look for red flags) e.g.:
o Suicidal risk factors in depressed patient or
o Risk factors in hypertensive patient
Explore continuous problems e.g.:
o Chronic illness
o Continuous medications
o Smoking, obesity…etc.
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3) Remember the basic skills to obtain information and try to avoid habits which
block communication:
Basic skills to obtain information Habits which block communication
General Attitude:
Respect
Empathy.
Touch (if appropriate)
Eye contact.
Body language
Social smile.
Encouraging.
General Attitude:
Patronizing
Tenseness and nervousness
Coldness and unfriendliness
Defensiveness
Appearance of too relax or casual
Appear preoccupied
Questioning:
Open-ended questions
Facilitating verbal & non verbal
Reflecting questions.
Questioning:
Direct questions,
Why question,
Suggestive question,
Yes or No questions.
Many questions at a time.
Active listening:
Restatement
Classification and summarizing
Taking feedback
Empathy
Non-verbal awareness
Use of more advanced skills to
push for Resistant information:
Confrontation and probing
Reflection
Use of silence and use of touch
Thinking loudly and acknowledge
uncertainty
Asking for more clarification
Interpretations of...
o Non-verbal communication.
o Paralanguage
o Body language
Specific Behavior:
Use of Jargon
Inability to keep quiet
Unawareness of non-verbal cues.
Interrupting the patient
Controlling & inhibition of the
patient.
Lack of purposeful direction in the
interview.
Making assumption.
Giving advice too early.
Allowing personal emotions to get
in the way.
Talking too much continuously.
Inability to take feed back.
4) Improve your explanation skills:
Ask the patient about what he already knows
Invite patient to ask questions
Continuously ask for feedback to make sure that you and the patient have a shared
understanding of the problem
Use simple language
Use varities of methods, e.g. demonstration or written materials
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5) Improve your negotiation skills:
Establish and maintain adult to adult relationship
Show good listening
Show empathy and care
Do logical analysis of the problem
Offer alternative solutions
Deviate the conversation to other issues; examples:
o Take more history
o Discuss psychosocial component of the problem
o Perform physical examination
o Give health education
o Discuss health promotion issues
Be flexible and respect of patient autonomy
If patient is insisting make a contract of limited agreement
6) Remember the basic skills for reassurance:
Adult to adult relationship (Respect and honesty)
Appropriate exploration of patient’s problem:
o Physical, social and psychological component of the problem
o Exploration of patient health beliefs about the problem
Examination:
o Appropriate o May be over doing some extra examination to show how much you care.
Clear and objective explanation:
o Summarizing the problem
o Naming the diagnosis
o Prevalence of the problem (how common is this problem)
o Natural history (how rare are the complications)
o Management options (how they are safe and acceptable)
o Prognosis (how benign, treatable or at least controllable)
Taking feed back:
o The patient understands the explanation
o The patient accepts the explanation
Assurance of accessibility
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7) Remember the comprehensive and holistic style of management in family
medicine:
Shared understanding
Comprehensive diagnosis (Physical, social & psychological)
Reassurance and explanation may be the only treatment
Appropriate use of nonpharmachological treatment
Appropriate prescribing: right drug and right dosage & right frequency
Explanation of effects and precautions of the medication
Modification of help seeking behavior
Awareness of limit of personal competence
Appropriate use of resources
Health promotion
Disease prevention
Appropriate follow-up arrangement
8) How to break bad news
(Dr. Hana Al Hajjar)
The setting:
Tell the patient when you are certain
No interruption
Comfortable physical setting
Family support
The patient:
Right to know
How much patient knows?
How much patient wants to know?
Encourage feelings expression
Listen to patient concerns
Beliefs & social background
The telling:
Warning shot, simple & honest
Eye contact, body language
Sympathy, encouragement, reassurance
Explain (diagnosis, prevalence, treatment and prognosis)
Reinforce & clarify frequently
Acknowledge your difficulties in breaking the news
Follow up:
See next day
Offer help to tell family & employers
Support groups
Documentation
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9) Strategies for dealing with some difficult patients:
Rambling, circumstantial patient: directed interview; closed questions;
permission at outset for frequent interruptions; frequent summarizations.
Threatening, aggressive patient: deflect anger; ally oneself with patient and
alliance position if seated; does not hem patient in; calm voice; reflect feeling of anger.
Violent, berserk patient: prevention: re-channel anger before it becomes
explosive; call for help, plenty of manpower – police if necessary; a show of force can be
reassuring to a person terrified of his own lack of control; not too close – do not violate
patient’s territory; interviewer closer to exit than patient; calm, comforting voice; sedative
chemicals, seclusion room, restraints may be needed.
Malingerer: confrontation usually ineffective; diagnosis by inconsistencies in
history and examination.
Seductive patient: deal with issue underlying seductiveness; what does patient
really want; be aware; doctor’s fantasy or needs for omnipotence.
Mute non-comatose patient: non-verbal communication is necessary (hold
hands); do not talk about mute patient in his or her presence; patient sometimes can
respond by nods or eyelid movements to closed questions.
Psychotic or thought disordered patient: closed questions; directed interview;
simple short sentences; concrete rather than abstract questions; avoid colluding with
patients about delusions or hallucinations (neither deny nor agree, if possible).
Organic brain impairment: as for (g); talk more slowly; give patient plenty of
time to respond.
Migrant: use interpreter; look at patient not at interpreter when talking; do not talk
loudly.
Elderly: if necessary ensure hearing aid or spectacles are available; talk more
slowly wait for replies; allow more time; sit face to face with patient; do not talk loudly; do
not patronize; touch can be reassuring.
Children: stay at some level as child with language and physically – do not sit at a
higher level; distraction or mutual task while talking can be helpful.
Doctor as patient /the very important patient (VIP): danger of interviewer not
asking certain questions or assuming the VIP will volunteer essential information; danger
of having strong, positive or negative feelings often unconsciously towards to VIP; danger
of managing VIP differently.
Own family: conscious and unconscious biases preclude the interviewer properly
assessing family members as patients.
Reference : Ken Cox, Christine E. Ewan. The Medical Teacher. Churchill Livingstone;
London 1988.
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10) Organization and time management in simulated clinic exam:
For organization and effective time management in simulated clinic exam, remember the
three stages of the consultation and the tasks you need to fulfill in each stage, and in each
consultation and according to the priorities distribute your time.
Take enough time in stage one (building good relationship), and do not forget to save
enough time for stage three (finishing the interview).
See the table below:
Stages of the consultation and your main tasks in each stage:
Your Main Tasks Stages
Building effective relationship with the patient
Stage I: Starting the interview
Prioritizing between patient’s problems
Reaching a provisional diagnosis
Excluding the differential diagnoses
Stage II: Hypothesis formation
Identifying factors that affect management and
prognosis
Explaining management options
Closing the encounter
Stage III: Finishing the Interview
“During training identify your difficulties and work on them specifically,
and if possible ask your trainer to help you to over come your difficulties”
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6.
Examples of Simulated Clinics F. Rayes, N. Dashash, H. Hajjar, M Alatta, A. Assaggaf & A. Al Harthy
The following are examples of common simulated patient’s presentation in exam and the
possible approach to them in the form of checklists. However, candidate should not follow
these checklists strictly, he/she need to be flexible, and always conducts patient-centered
consultation, starting the consultation by exploration of simulated patient’s ideas, concerns
and expectations, he also should be sensitive to any verbal or nonverbal cues and respond
to them appropriately and immediately.
GoTo TOP (1) Approach to Patient with Chest Pain F. Rayes
Causes include musculoskeletal, gastrointestinal, neurological, functional, cardiac and
pulmonary.
The following items may need to be considered.
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Look for recent precipitating event
History of pain: onset, duration and radiation of pain
Characteristics of pain
Aaaociated symptoms: e.g.
o Cough
o Breathlessness or sweating
o Gastrointestinal symptoms
o Palpitations or anxiety
Social and psychological context of the problem
Precipitating factors, e.g. fears or exertion
Relieving factors: rest, medications
Smoking habit
Examination:
Pulse, blood pressure
Cardiovascular system
Chest
Chest wall
Abdomen
Management:
Share diagnosis and share prognosis
Agree management: behavior, drugs or referral
Reassurance and follow-up arrangement if necessary
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Management of acute MI Rapid history and physical examination IV access Administration of oxygen
Cardiac monitor: ECG Blood studies Aspirin, 1 tablet crushed & swallowed Morphine sulfate, 2-4mg IV every 15-20 min. Transfer to hospital.
Indication to Thrombolytic Therapy o Within 12 hrs. onset of chest pain lasting for at least 30 min.
o ECG changes of ST elevation at least 1 mm in two, Or more contiguous leads of
left bundle branch block.
Contraindications to thrombolytic therapy o A history of active GIT bleeding within 2 months.
o Uncontrolled hypertension.
o CVA having occurred within the last 6 m.
o Recent history of serious injury within 1month.
o Non-compressible vascular puncture
See Data interpretation: ECG for more details
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GoTo TOP (2) Approach to Patient with Cough. A. Assagga , A. Al Harthy & F. Rayes
Causes include infection (URTI or pneumonia), inflammation (including smoking),
asthma, cardiac failure, chronic chest disease, foreign body, and malignancy.
The following items may need to be considered:
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Duration of complaint
Predisposing factors (night-time, exercise)
Clarification of the symptom:
o Is the cough tickle in the throat or from the chest, it’s onset and course
(Continuous or intermittent, at daytime or at night).
Associated symptoms:
o Wheezing,
o Chest pain
o Shortness of breath, or orthopnea
o Fever, night sweating, weight loss
o Heamoptysis.
Presence of sputum: From throat or chest, quantity, color, relation to position.
Past history of similar problem or T.B.
Family history of T.B. or bronchial asthma.
Continuous problems & at risk factors: bronchial asthma, DM or heart disease
Social history & occupation.
Allergy history
Drug history
Smoking habit
Therapies already tried
Social & psychological context of the problem
Examination:
Examination of respiratory system
Examination of cardiovascular system
Peak flow, before and after Beta agonist
(If the patient is a child exam his throat and ears)
Possible investigations:
Chest X-ray
Sputum culture
Specific investigations according to the differential hypotheses, e.g. TB skin test
Management:
Share diagnosis and share prognosis
Advise against smoking
Use of medication:
Cough suppressant or expectorants, antibiotics, brochodilators or steroids.
Agree referral if indicated
Arrange follow-up if indicated
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Important diagnoses not to be missed in a childe presenting with cough:
Differential features of Epiglottitis, Croup & Bronchiolitis
Epiglottitis Croup Bronchiolitis
3 – 7 years
Sudden onset, fulminating
Dysphagia, drooling
Fever
Respiratory strider
Muffled voice / cry
Minimal cough
Toxic appearance
H. influenza
Emergency protocol
Avoid exam the pharynx
Cefluroxime (150 mg/kg)
Childhood
URTI problem 1-7 days
No drooling
Low grade fever or
moderate
Biphasic strider
Hoarseness
Barking spasmodic cough
Nontoxic
Para-influenza 1
Humidification (crouptent)
IV fluid
Antibiotic controversial
0-2-years
May be insidious or acute
or progressive
Fever
Noisy breathing,
Expiratory wheezing,
Inspiratory crackers,
Intercostals retractions.
Cough
May be cyanosis
RSV or parainfluenza
Fluid maintenance
Bronchodilator
Oxygen
For infant: inhaled antiviral
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GoTo TOP (3) Approach to Patient with Diarrhea F. Rayes
Causes include infection, food intolerance, inflammatory, obstruction, functional.
The following items may need to be considered:
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Explore patient’s ideas, believes, expectations and concerns about the diagnosis,
o E.g.: Worms or food poisoning
o Cholera or dysentery
o Cancer or HIV
o Request for investigations or drug treatment or admission to hospital.
Details of the complain:
o Duration of complaints
o Frequency and consistency of stool
o Associated blood and mucus.
o Associated symptoms: E.g. fever, vomiting, abdominal pain, weight loss, fatigue
nervousness.
o Recent events or foreign travel
o Dietary indiscretion
o Family contact, occupation
o Drug history e.g. laxative, antacid, endomethacin diuretics, theophylline or
colchicin.
Other affected family members
Occupation, e.g. food worker
Examination:
General impression
Signs of dehydration
Examine abdomen
Per rectum examination may be indicated, if serious diagnosis is suspected
Possible Investigations: Stool analysis
Culture faeces: if specific infection is suspected
Fecal occult bloods: if malignancy is suspected
Blood tests: for evaluation of general well being of the patient
Barium studies or endoscopy: for chronic diarrhea
Management:
Share diagnosis and share prognosis
Advise about diet and fluids
Use of medication:
o Electrolyte replacement (rehydration solution)
o Anti-diarrhea agents?!
o Antibiotics?!
Specific therapies
Referral if indicated
Follow-up arrangements if indicated
* See traveler advice for more details in management of diarrhea
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GoTo TOP (4) Approach to Patient with Anemia F. Rayes
Causes include nutritional, hemolytic, chronic GIT bleeding, or chronic diseases.
The following items may need to be considered:
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Look for possible complications of anemia:
o Dyspnoea, palpitation, heart failure, or fainting attack (in case of acute internal
bleeding)
Look for possible causes of anemia:
o Family history of anemia, e.g. thalassemia, G6PD or sickle cell anemia
o Drug (NSAIDs, Steroids)
o Blood per rectum / Black stool
o Dyspepsia (bleeding peptic ulcer)
o Hemoptasis, hematuria or menhorragia
o Regular blood donor
o Past history of chronic disease e.g. TB, Chronic UTI, RA, SLE or subacute
bacterial endocarditis
o Alcoholism
Explore patient ideas believes and expectation
Examination Pallor: (Conjunctive, Lips, Nails)
Nails changes, e.g. Koilonychia (chronic severe anemia)
Evidence of haemoragic talangectasia
If anemia is severe or acute, look for evidence of heart failure.
Abdominal examination:
o Epigastric tenderness
o Renal tenderness
o Mass (cancer)
o Rectal examination:
o Piles or melena
Management and Education:
According to the type and the etiology of the anemia
Explanation and reassurance
Step-care investigations in patient with anemia:
Confirmatory test CBC Findings Suspected anemia
Low serum iron
Low transferin saturation
Low ferritin
Microcytic hypochromic
anemia
Iron deficiency anemia
Low serum iron
Normal ferritin
Microcytic hypochromic
anemia
Anemia of chronic
disease
Normal serum iron
Haemoglobin electrophorisis
Micricytic or normocytic
Hypochromic anemia
Beta thalassemia
Serum B12 level
And/ or serum Folic acid
Macrocytic anemia B12 or Folate deficiency
* For more details see (Data Interpretation: Lab Tests)
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GoTo TOP (5) Approach to Patient with Headache H. Al Hajjar, M Alatta & F Rayes
Causes include tension headache, migraine, referred - pain (e.g. sinus, teeth, cervical
spine). Intracranial pressure (hypertension, tumor, meningitis), temporal arteritis.
The following items may need to be considered:
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Identify the characteristics of pain (Classical history of pain)
o Onset & time, duration, site of pain and nature of pain.
o Continues or intermittent.
o Course (severity &, frequency)
o Triggering or aggravating factors and reliving factors.
o General health and well-being
Ask specific questions: e.g.
o Prodrome, aura of migraine, e.g. visual or sensory aura,
o Respiratory tract infection in sinus pain…
Associated symptoms, e.g. neurological symptoms, fever, eye symptoms, nausea,
vomiting…
History of head trauma or history of lumbar puncture.
ENT problem, any dental or vision problem, e.g. acute viral infection, COPD
Drug history:
o For the headache.
o For other medical causes.
Effect of the headache on patient’s life.
Psychosocial problems:
o New stressful events.
o Marital problems or problems at work.
Family history.
Exploration of any continues problems.
Exploration of patient’s concerns, worries, ideas and expectations.
Examination:
Blood pressure
Local possible sources of pain:
E.g. sinuses, temporal arteries, teeth, cervical spine, ears
Neurological examination
Management and education
Share diagnosis and share prognosis
Discussion of self-help, e.g. relaxation
Use of medication:
o Analgesics, anti-migraine or anti-depressant
o Specific medication for primary cause
Agree referral if indicated: “Counselor or specialist”
Follow-up arrangements if indicated
Possible investigations:
o Blood tests, e.g. erythrocyte sedimentation rate
o X-ray chest, cervical spine or CT scan
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Factors in the development of chronic daily headache from episodic migraine
o Analgesic/ergotamine overuse
o Abnormal personality profile, including depressive trait
o Stress
o Traumatic life events
o Non-headache medications, including sex hormones
Alarm symptoms pointing to more serious disease headache
o Aura symptoms associate always with the same body side or with acute onset
without spread, or having either very brief (<5min) or unusually long (>60min)
duration
o Sudden change in migraine characteristics or a sudden substantial increase in attack
frequency
o Headache emerging after exercise (may indicate subarachnoid hemorrhage)
o Onset above age 50 (migraine and cluster headaches are not usually late onset)
o Aura without headache
o High fever
o Abdominal pain (could suggest acute ketoacidosis)
o Recurring neurological symptoms between headaches
o Abnormal neurological examination
o Increase intensity after 24 hours from onset.
o Change in cognition, level of consciousness or focal neurological findings.
o Neck rigidity.
o Abnormality in vital signs
Differential Diagnosis of headache
Tension Headache Migraine Subarchinoid Hge Cluster headache
- Young adult and
middle age
- Recurrent
- Almost daily
- No significant
associated
symptoms
- Trigger factors
-Normal
examination
- Common in
young adult
- More in female
- Recurrent
- Once a week
- Lasting from 8
to 12 hours
- Left side of the
head.
- Associated with
malaise, nausea,
vomiting and
photophobia.
- Normal
examination
- Severe headache
(the worst headache
of patient’s life)
- Associated with
exertion & vomiting
- ECG: similar to
IHD
- CT scan then LP
presence of blood
- Common in
middle age
- More in male
- Recurrent, may be
every 4 weeks
- Awaken from
sleep
- Every night
- Same time
- Lasting one
hour.
- Deep burning
sensation
- Associated with
lacrimation flushing,
nasal discharge and
conjunctivitis.
- Ptosis & popullary
constriction.
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GoTo TOP (6) Approach to Patient with Acne N. Dashash
The following items may need to be considered:
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Identify the present complaint “Acne”
When has it started? Why now (E.g. preparation for social event)?
Is there any aggravating factor (E.g. stress, exams)
Previous treatments:
What sort of treatment? How long was each one used? Compliance?
Patient ideas: what he/she knows about “acne”
Patient concerns and fears:
(E.g. losing friends, scars, discolored skin, not getting married.)
Expectations: (E.g. referral to a dermatologist)
Effect of Acne on the patient (E.g. Relationship with friends)
Exploration of continuous problems:
DM, asthma, smoking …
Examination:
Inspection of the face, shoulders, back, upper arms and chest looking for acne
Management:
Shared understanding of the problem:
Summary of what the doctor understood
Shared management & health education:
o Acne is a common problem, up to 80% of people had acne sometime in their life
o What is acne? Enlargement of the sebaceous gland (oil producing gland in the
skin), with blocking of its outlet and over growth of bacteria.
o It has no relation with being clean or not
o Chronic problem, needs patience in and tolerating the treatments
o It increases at times of stress such as exams, and is related to hormonal changes
(seen in women)
o Black heads and white heads are not dirt
Appropriate prescribing:
o Discussion of options: e.g. Topical: Retin – A and/or Benzoil peroxide and/or
Systemic antibiotics e.g. minocyclin
o Explaining side effects and precautions.
Patient with such mild complain, may present with special communication problem, e.g.
requesting referral to a dermatologist or requesting special medications.
Candidate needs to show skills in dealing with demanding behavior:
o Empathy and caring attitude
o Logical negotiation of advantages and disadvantages of patient’s demand (referral
or medications)
o Nonjudgmental attitude
o Flexibility and respect of patient autonomy
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o
GoTo TOP (7) Approach to Patient with Urinary Tract Infection F. Rayes
The following items may need to be considered:
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Explore the nature of symptoms:
o dysuria
o frequency and pattern
o Haematuria
o Pain
o Fever
General well-being
Recurrent symptoms?
Symptoms in sexual organs or pain related to sexual activity
Examination:
Palpate kidneys and lower abdomen
Vaginal examination may be indicated
Investigations:
Urine dipstick nitrite
Urine bacteriology (MSU)
Vaginal swabs
Renal x-ray ultrasound
Blood creatinine
Management and education:
Alternative diagnosis
E.g. atrophic vaginitis, urethral syndrome, vaginal discharge
Use of:
o Antibiotics
o Analgesics
o Treatment of associated cause
o Referral
o Prophylaxis
Discuss nature and prognosis of complaint
Discuss management plan
Check self-care and lifestyle
o Adequate fluid intake
o Voiding after intercourse
Follow-up arrangements if necessary
Presentation of UTI in children:
Failure to thrive, fever, enuresis, frequency and dysuria
Management and follow -up:
MSU 2-4 days after starting antibiotic, if positive, patient need urgent referral for
possible obstruction
MSU 2 weeks after antibiotic, if positive repeat the course of antibiotic
MSU 3 months late if positive, patient need maintenance of antibiotic
All proves UTI in children under 5 should be referred for further investigations.
For more details see (Data Interpretation: Lab Tests)
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GoTo TOP (8) Approach to Patient with Sore Throat F. Rayes
The following items need to be considered in managing any episode:
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Explore the nature of the complaint:
o Duration
o Associated symptoms: fever, malaise, rash
o Prior medication
o Smoking habit
o Immunocompromised?
o Relevant past history or family history of rheumatic fever
Explore the patient’s concerns, worries, ideas and expectations.
Look for possible hidden agenda
Explore continues problems: e.g.
o DM, asthma or malnutrition vaccination coverage …
Examination:
Inspect neck and throat
Palpate cervical glands
Other examinations:
o E.g. rash and spleen (Infectious mononucleosis)
Investigations:
Throat swab rarely indicated
Infectious mononucleosis blood test if it is highly suspected
Complete blood count may be indicated
Management and Education:
Use of:
o Analgesics: use enough dose and right frequency
o Antibiotics if bacterial infection is highly suspected
o Encourage symptomatic home remedies
Discuss disease and its cause
Discuss patient’s concerns (sick leave, wary about possibility of rheumatic fever)
Discuss management plan
Follow-up arrangements if necessary
Usually simulated patients with minor illness appear in the exam for testing certain skills,
E.g.:
Patient demanding referral for tonsillectomy
Patient with mild pharengitis demanding antibiotic
Simulated patient is a smoker and need counseling
Simulated patient has a hidden agenda, E.g. marital problem or parent may be using
the child as presenting complain
Malingering patient requesting sick leave
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Possible serious differential diagnosis:
Possible Diagnosis Comments
o Epiglottitis
o Meningitis
o Quinsy
o Streptococcal sepsis.
o Rheumatic fever
o Palatal cellulitis
o Ashen color, Drooling (children)
o Meningism (child. & young adult)
o Voice change, Trismus (all ages)
o Unstable vital sign (all ages)
o Murmur, Heart failure (Rare)
o Unilateral swelling, Marked tenderness.
Facts about use of antibiotic in tonsillitis:
o 20-40% of sore throat caused by GABHS
o Incidence of rheumatic fever has no correlation with the use of antibiotic
o Rheumatic fever runs in family, more in low social class
o 50% of +ve culture for GABHS have no serological evidence of infection (Carrier)
o Treatment shorten the duration of illness by 24 hr & prevent supportive
complications.
o Antibiotic does not prevent development of glomerulonephritis
Indications for antibiotics
o GABHS more likely
o Peritonsillar abscess
o Sinusitis
o Prophylaxis in case of associated chronic diseases e.g.
o DM, Asthma or cystic fibrosis.
Indications for tonsillectomy and admission
Tonsillectomy:
o Grossly enlarged tonsils with sleep apnoea.
o History of peritonsillar abscess.
o Frequent tonsillitis with otitis media.
Admission:
o Airway obstruction
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GoTo TOP (9) Approach to Patient with Acute Otitis media
F. Rayes
The following items may be considered in managing any episode:
Establish good rapport
Encourage patient contribution
Respond to patient’s cues
Explore the nature of complaint:
o Pain , discharge from ear, and/or fever
Recent upper respiratory tract infection
Frequency of episodes
Hearing between episodes
At risk factors:
o Age or Down’s syndrome,
o Immunocopromised
Explore the patient’s concerns, worries, ideas and expectations.
Explore continues problems: e.g.
o DM, asthma or malnutrition, vaccination coverage …
Examination:
Examine both tympanic membranes
Examine nose and throat for congestion
Assess level of distress
Investigation:
Bacteriology swab if discharge
Management and education:
Prescribe antibiotic and pain killer
Discuss disease and its course
Discuss immediate concerns
Discuss current management
Follow-up arrangements made
Advise lifestyle and self-care: water and swimming
Management of Acute Otitis Media
o Amoxicillin 5-14 days
Review in 48 hours. if symptomatic :
o Insure compliance
o Exclude complications
o Change antibiotic.
If asymptomatic:
o Review in 4 days, in 30% of the patient the tympanic membrane will be normal
o The remaining 70% of the patient, they need to be reviewed every 3 months
o 10% persistent of the patient will continue to have persistent effusion and they will
need referral to ENT
Management of recurrent otitis media
Treat each episode with antibiotics
Use long term low dose antibiotic prophylaxis !
Insert ventilating tubes (grommets) !
Perform adenoidectomy !
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GoTo TOP (10 )Approach to Patient with Dyspepsia F. Rayes
Dyspepsia is a vague term; patient may has upper abdominal pain, heartburn, anorexia,
nausea, vomiting, flatulence and/or dysphagia. It includes a wide spectrum of differential
diagnosis, starting from functional disorders to malignant disorders
History:
Establish doctor-patient relationship
Encourage patient contribution
Respond to patient’s cues
Explore the nature history of the problem:
o Onset of dyspepsia;
o Chronic: most probably benign etiology
o Site of pain and radiate
o Frequency: cyclic (reflux or ulcer), continuous (dismotility)
o Severity and nature of pain: dull ache, colicky or staping
o Timing: worse at night or hungry (PU)
o After heavy meal or fatty meal: dysmotility or biliary colic.
o Continuous: could be malignancy
o Relieving factors: antacid, rest, strong analgesia, eating
Associated features:
o Reflux: cyclic, retrosternal pain, heartburn, regurgitation, water brash, weight gain
o IBS: change bowel habit, lower abdominal pain
o Dysmotility: ulcer like symptom (epigastric pain associated with meal or hunger
pain,
o Biliary colic: severe require strong analgesia
o Respiratory infection: cough
o Angina: dyspnoea, relieved by rest
o Depression: loss of interest and low mood
o Cancer: weight loss, dysphagia, vomiting
Drugs history: aspirin, steroids, NSAID, antacid or tagamet.
Exploration of patient ideas, concerns, expectations and believes
Examination:
o Abdominal examination: may be mild tenderness
Management and Education:
Work-up strategy based on risk stratification:
o Patient judged to be low risk: start empirical treatment
o Patient judged to be high risk: refer the patient for investigation
Advice in Reflux:
o Stop smoking and
o Life style modification
o Lose of weight if overweight
o Eat small frequent meals and avoid bedtime snacks
o Avoid late night eating
o Raise the head of the bed
o Avoid foods that upset you & avoid tight-fitting clothes
o Elevate head of bed may help
Advice in dysmotility:
o Small frequent meal
o Semi-liquid meals to avoid distension
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Advice in peptic ulcers:
o Stop smoking
o Avoid drugs like NSAIDs (explain)
o Cola, coffee & tea with moderation and avoid alcohol
o Milk & diary product with moderation
o Inform patient about warning sign in PU e.g. black stools
o Insure patient’s acceptance & understanding of your advice
o Explain others management options e.g.
o (Medications, dosage, frequency, side effect and any relevant precautions).
o Reassurance: It is common disease and treatable
o Availability of the doctor (you) for any problem or any questions any time.
Arrange for follow up
Drug treatment in patient with peptic ulcer
H2 - antagonist e.g. Cimetidin 800 mg at night, 400 mg BD.
Or Proton Pump Inhibitors
e.g. Omeprazole 200 mg OD
Or Sucralfate 1 g before each meal and at night
Antacid 30 - 45 mmol QSD after meals.
Management of dysmotility
8 weeks course lead to healing of 95% peptic ulcer Drug treatment in patient with dysmotility:
o Metoclopramete: Short term Or Cisapride
o Antiulcer treatment might be tried but for a limited time and not to continue if
symptom fail to resolve Drug treatment in gastro- esophageal reflux disorder
o Mild disease:
Antacid after meal & at bedtime
H2 - antagonist e.g. Cimetidine 400 mg QID
Or Ramtidine 300 mg BD (3 months)
o Resistant cases:
Omeprazol 20-40 mg OD / 8 weeks
Maintenance treatment H2 - antagonist
o In case of failure of medical treatment, refer patient for surgery
Indication for referral & investigations:
o If diagnosis is in doubt
o If malignancy need to be excluded, e.g. patient has weight loss, dysphagia, vomiting
o Patient age over 45 years
o The patient’s symptoms change, possibly indicating a new pathology or malignancy.
o Failure of empirical treatment
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GoTo TOP (11) Approach to Patient with Irritable Bowel Syndrome
F. Rayes
History:
Establish doctor-patient relationship
Encourage patient contribution
Respond to patient’s cues
Explore the nature history of the problem
o Abdominal distention
o Pain eased after bowel movement
o Altered stool frequency, alter stool form and alter stool passage
o Urgency and feeling incomplete evacuation
o Passage of mucus
Risk assessment:
o Pain awaken from sleep or change of pain
o Onset at elderly
o Weight loss
o Rectal bleeding
o Steatorrhea and fever
o History of steadily worsening symptoms
Explore the patient’s concerns, worries, ideas and expectations.
Explore any continues problems: e.g. psychosocial problem
Examination and Investigation:
o Abdomen and per rectum examination
o Sigmoidscopy may be needed
Management:
o Develop effective Pt-Dr Relationship
o Acknowledgment of pain and treat with empathy
Reassurance:
o prevalence is 10-20% of adult population
o It is not progressive to a serious disease or develop complications
o 30% of the patient became symptomatic over time
Don’t overreact & set reasonable treatment goal
Negotiate treatment & know your limitation
Education and counseling:
o Explain the diagnosis:
o The intestine squeeze food too hard or not hard enough to cause food to move too
fast or too slowly.
o Advice patient to increase high-fober foods like vegetables and fruits, whole grain
braed and cereals
o Drink plenty of water
o If gas is a problem to avoid beans, cabbage and some fruits
o Avoid food that increase the symptom, if milk and other dairy product bothers, the
patient may have lactose intolerance
o Stress management
Follow up arrangement
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Differential Diagnosis of IBS
With Diarrhea And/or Constipation:
o Colorectal Cancer
o Polyps
o Inflammatory bowel disease
o Chronic intestinal infection(e.g.
giardiasis)
o Coeliac disease
With Upper Abdominal Pain:
o PU
o Cholelithiasis
o Chronic pancriatitis
Drug Treatment
For diarrhea:
o Cholestyramin, Imodium orlomotil
For pain:
o Antispasmodic e.g. Mebeverin (Colofac) 135 mg TDS 30 min before meal.
o Pepperpment oil ( Colpermin, Mintec) .2 - 0.4 ml TDS 30 min before meal.
o Tricyclic antidepressant. Ametriptyline 25-75 mg.
For constipation:
o Osmotic laxative (Duphalac)10 mg TDS
For bloating:
o Low residue diet (low fiber)
o Peppermint oil. Cisapride 10 mg TDS.)
Risk of Colorectal Cancer
It is the second most common cancer in both males and femals
Risk factors :
o Familial adenomatous polyposis
o IBD > 20 Years
o Family history of colorectal cancer
Risk of colorectal cancer with an affected first -degree relative :
o One relative: risk 1 in 17
o Two relatives: risk 1 in 6
o Three relatives: risk 1 in 2