12 Medicine Dr Jeffrey Rowland (21 Oct 09)

8/9/2019 12 Medicine Dr Jeffrey Rowland (21 Oct 09)

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CENTRE FOR INTERNATIONAL MEDICAL GRADUATESClinical Preparation Program 2009B

Workshop SummaryWednesday 21st October 2009

Medicine with Dr Jeffrey Rowland

Dear all,

What a great teaching session! I shall thank Dr Rowland sincerely on your behalf for such awonderful night. Dr Rowland said that YOU all have the knowledge, the CONTENT, however youneed to package yourselves, FORMAT andYOU, in order to pass this exam.

Dr Rowland provided you with some great advice and information.

This exam reflects real life

Dont kill your patient: always think about common thingsHe said: If it quacks like a duck, looks like a duck, then it is a duck = cases are common anddont think that you have a zebra when you have a horse

Ask yourself: Why is my patient seeing me today?

To diagnose dementia, you need:1. memory impairment2. cognition (one aspect of cognition)

AND these two factors impact on the patient to reduce capacity in terms of their function andinteractions socially

Know the Mini Mental State Examination; and how to interpret it

The mini-mental state examination (MMSE) orFolstein testis a brief 30-point questionnaire test that is used to screenfor cognitive impairment. It is commonly used in medicine to screen fordementia. It is also used to estimate the severityof cognitive impairment at a given point in time and to follow the course of cognitive changes in an individual over time,thus making it an effective way to document an individual's response to treatment.

In the time span of about 10 minutes it samples various functions includingarithmetic, memoryandorientation. This testis not the same thing as a mental status examination. The standard MMSE form which is currently published byPsychological Assessment Resources is based on its original 1975 conceptualization, with minor subsequentmodifications by the authors.

OR CONSIDER USING

the RUDAS (Rowland Universal Dementia Assessment Scale) This tool is not language oreducation dependent. www.rudas.com.au Attached is a two page summary FYI.

In Australia, officially people do not use the term nursing homes, but stay in

Residential aged care facilities: there are high and low care facilities available.

______________________________________________________________________________________________________________________ Copyright Centre for International Medical Graduates
http://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Dementiahttp://en.wikipedia.org/wiki/Arithmetichttp://en.wikipedia.org/wiki/Memoryhttp://en.wikipedia.org/wiki/Orientation_(mental)http://en.wikipedia.org/wiki/Mental_status_examinationhttp://www.rudas.com.au/http://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Dementiahttp://en.wikipedia.org/wiki/Arithmetichttp://en.wikipedia.org/wiki/Memoryhttp://en.wikipedia.org/wiki/Orientation_(mental)http://en.wikipedia.org/wiki/Mental_status_examinationhttp://www.rudas.com.au/


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BMI?On inspection (of the ear, chest, abdomen, right eye) what do I see?On auscultationOn palpation.On percussionAre there any investigations available (ECG? Chest Xray? Bloods? / Id order ( relevant)investigations?Thank your examiner

THANK YOU, DOCTOR

Physical Examination: Sensitive Examination

SPEAKING TO YOUR PATIENTI need to do an internal examination. Ill leave you in privacy to undress can I suggest you emptyyour bladder and there is a sheet to cover yourself with when youre ready, Ill come back in with achaperone.Is that OK with you? Ill put gloves on for the examination.

I need to do a vaginal/ rectal examination, Ill leave you in privacy to undress and when youre ready,

Ill come back in with a chaperone. Is that OK with you? Ill put gloves on for the examination.

SPEAKING TO YOUR EXAMINERGathering physical examination findings and investigations in the O&G stationsGeneral appearanceDoctor, whats the general appearance of my patient?VitalsWhats the BP? HR? Temp? BMI? Ward Urinalysis? Urine HCG?Physical ExaminationIll wash my hands before I begin.

Go to abdominal findings before a vaginal examinationOn inspection of the abdomen, what do I see? Is there any tenderness? Any masses? Lowerabdomen mass? Any fibroids? I will need to do a Vaginal Examination.

To do this, I would gain consent from my patient, ask her to empty her bladder, undress and providea sheet. I would ensure privacy, and bring a chaperone when I return. I would then use gloves forthe internal examination and a sterile, warmed and lubricated speculum.

On inspection of the external genitalia, what do I see?I would insert a sterile, warmed and lubricated speculum, what would I see?Are there any abnormal findings from this examination?

Thank you, doctor.

TASKS:Explain your management to your patient; Provide a treatment plan for your patient;Diagnose and manage this patient; Manage this patient appropriately.



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MANAGEMENT FORMAT

If you use this 5 Step Management plan or format, then you can attach any clinical scenario tothis. In exam situations, you will not forget vital information and detail

1. Tell the diagnosisIf the diagnosis is not possible, describe the problem

a. Establish the patients knowledgeYou MUST do thisSuggestions you could say for well-known diseases/ conditions?So, Marcia, what do you know about Diabetes?

Can you tell me what you understand about asthma?Suggestions for uncommon diseases/ conditionsHave you ever heard about Sjogrens Disease?

Often your patients will express an attitude to their diagnosis-listen to your patient and respondto their feelings and fears. Your patients will let you know.Patient: Depression. No. Thats a girls disease.Doctor: Thats not quite right, Tony. Depression affects both men and women, all ages and alljobs. In fact, I would be treating more men right now in my practice than women.

b. Correct any misinformationSo, doctor, you say Ive got measles, eh? I probably got that from playing netball lastweekend in the rain.Well, Sally, you didnt catch measles from playing in the rain but you couldve caught themeasles from one of your team mates. Measles is a very contagious and serious viralillness so well need to let your team mates know.

c. EducateDraw if you think that this helps your patient. Use patient language. If you draw you need topractise talking whilst you are drawing- quick sketches in context for your patient are wonderful.

2. Immediate ManagementWhat are you going to do now to manage this patient?

3. Referrals/ involvement of othersWho does my patient need to see? A senior colleague? A diabetes educator? Podiatrist?Endocrinologist?And involvement of others: Does my child patient attend childcare? School? Work? Partner(for cooking and diet involvement); Are there elderly parents living with my patient?

4. Long term Management/ Prevention

5. Follow upWhat does my patient need to do next? When do I need to see my patient again?


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YOU

Be professional

Manage your tasks and time well Use formats

Clarify with your examiner and patient anything you do not understand.

Establish good rapport with your patient, including introductions to your patient. Use yourpatients names. Take care with saying your name and your position. Dont say your namequickly.

Start all history with an open question. How can I help you today?Be quiet, listen and allow your patient to tell their story. Address your patients concerns eg ifyour patient tells you she is more concerned about her baby rather than herself, then you needto address this. You cannot avoid this.

Do not use technical languageRespond and address your patients addressing your patients concerns.Patient: Im so worried about Jack. Is he going to die?Doctor: This is a severe reaction, Suzie, and it will affect his heart and his breathing. Wehave stabilised him now but we will need to monitor him.

Be clear with explanations (1) Youre having a heart attack. This means that oxygen is notgetting to all parts of your heart because there is a clot. What we need to do is to give yousome medicine to dissolve this clot.Patient: What about my baby, doctor?Doctor: Nicole,what I think is going on is that you have a ruptured ectopic pregnancy. Whatdo you know about this type of pregnancy?

Patient: Ive heard the word but I dont know. Will my baby be OK, doctor?Doctor: Nicole,an ectopic pregnancy is not a normal pregnancy and unfortunately your babywill not survive. Sometimes this pregnancy sits outside the uterus, sometimes the pregnancyis in the tubes.

Do NOT use these expressions Better ways of expressing yourself

Are you able to pass winds at themoment?

Do you pass wind?

Senile dementia Dementia is from a disease NOT old aged so please donot use this expression.

The elderly An older personYour electrolytes are deranged. Your electrolytes are out of balance.

You cant remember when did youhave them?

Do you remember when you had them?

Do you feel like you want to pewk? Do you feel like you want to vomit?

Do you have sputum coming out? Do you bring up phlegm?

Do you take alcohol? Have you takenalcohol before?

Do you drink?

Some expressions used last night



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Expression Meaning

I stuck aroundin medicine. I kept working in medicine.

I play soccer. I play left right out. Out of the team. This is a joke

I live with the missus. The kids haveflown the coup.

Left home.

You need to pull the stuff out of thehistory.

To ask information from a good history.

The mini mental state examinationcosts a dollar a pop.

A dollar for each.

Before you start sticking her with pins,what questions do you want to ask her.

Doing any investigations on her.

How do I say this so I dont piss offthe examiners?

annoy

The other thing that sends them offis.constipation.

Leads to

Your patient may use a stick or arollator

Walking stick

Its barn door stuff. Its very common.

If you have a patient that is called Iris,then she is in her 80s or 90s. Butthese names are coming back. All ofthe flower names are coming back.

The younger generation are being called these names.Flower names are very popular for children eg Rose, Lily,Pansy, Iris, Holly, Daisy.

Dont back yourself in a corner withyour history taking. You need to bevery broad.

Dont put yourself in a position where you have no whereto go.You need to think broadly when you approach all patients

Brain mets is not the first thing that youthink about when someone rocks upwith dizziness.

comes

Theyre very thingyabout this Theyre very particular about this.Apparently she thinks that herneighbour is snoopy or nosy

Always

Carer stress and burden Stress on those people who care for others usually thosewho are physically or mentally

If you cant get a history, then you needto be like a vet, perform physicalexaminations.

Veterinarian

If your patient is 8 years down thetrack, and is aspirating, and unable tofeed.

In the future

We look forward to seeing you all next week,

28th October: Paediatric Emergencies: Dr Zaahid Pandie4th November: Paediatrics: Dr Margot Bosanquet11th November: Safe Prescribing scenarios: Professor Charles Mitchell Senior AMC Examiner18th November: TBC25th November: Paediatrics2nd December: Psychiatry

Take care and with warm regards



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your CIMG TeamVickie, Diane, Gail and Jenny


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12 Medicine Dr Jeffrey Rowland (21 Oct 09)