eric niederhoffer siu-som channeling a clinician: design and construction of clinical scenarios for...
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Eric Niederhoffer
SIU-SOM
Channeling a Clinician:
Design and Construction of Clinical Scenarios for
Teaching and Assessment
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Outline
• USMLE style scenario template• Resources for clinical information• Single or multiple disciplines• Discuss example designs
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USMLE Style Scenario Template• A n-year-old (Age) boy/girl/man/woman (Gender) comes/is
brought to the physician/emergency department (Site of Care) for evaluation of/with a problem (Presenting Complaint including Duration and Patient/Family History).
• Physical examination shows some combination of pertinent findings (Height/Weight/BMI/Percentile, Temperature/Heart Rate/Breathing Rate/Blood Pressure).
• Laboratory studies show some combination of test results (Reference Ranges provided for non-adult age groups/special tests).
• Which drug, toxic exposure, diet; predict physical findings, lab findings, sequelae; identify underlying cause/mechanism/diagnosis, cause of drug response, drug to administer (Questions)
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Resources for Clinical Information
• Height/weight for children (growth charts)/adultshttp://www.babycenter.com/average-fetal-length-weight-chart
http://pediatrics.about.com/cs/growthcharts2/l/bl_ibw_rslts.htm
http://www.cdc.gov/growthcharts/charts.htm
https://www.nhlbi.nih.gov/health/resources/heart/latino-weight-html/need
• Heart/respiration rate, blood pressure for childrenhttp://www.emedicinehealth.com/pediatric_vital_signs/article_em.htm
• Physical exam/heart/lung soundshttp://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/contents.htm
http://www.med.umich.edu/lrc/psb_open/repo/primer_heartsound/primer_heartsound.html
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Reference RangesSerum Arterial Blood Gases
Na+ 135-147 mEq/L pH 7.35-7.45K+ 3.5-5.0 mEq/L Pa.CO2 (PCO2) 33-44 mm HgCl- 95-105 mEq/L Pa.O2 (PO2) 75-105 mm HgHCO3
- 22-28 mEq/L HCO3- 22-28 mEq/L
Ca2+ 8.4-10.2 mg/dL O2 saturation 96-100%Urea nitrogen 7-18 mg/dL Anion gap (no K+) 8-16 mEq/LGlucose, fasting 70-110 mg/dL with K+ 12-20 mEq/LCreatinine 0.6-1.2 mg/dL Bicarbonate gap -6-+6 mEq/LPhosphorus 3-4.5 mg/dL BloodTotal CO2 24-30 mEq/L Hemoglobin, male 13-16 g/dLTotal protein 6-7.8 g/dL female 12-15 g/dLAlbumin 3.5-5.5 g/dL Hematocrit, male 42-50%Osmolality 275-295 mOsm/kg water female 40-48%Uric acid 3-7 mg/dL O2 binding capacity 1.34 mL O2/g Hb
Lipids UrineTotal cholesterol <200 mg/dL Creatinine clearance 90-140 mL/minLDL <130 mg/dL Osmolality 50-1400 mOsm/kg waterHDL >40 mg/dL Specific gravity 1.003-1.030Triglycerides <160 mg/dL Protein <150 mg/24 h
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Potential DiseasesDisease
Anemia
Chronic obstructive pulmonary disease
Diabetes
Down syndrome
Gout
Lactase deficiency
Marfan syndrome
5,10-Methylenetetrahydrofolate reductase deficiency
Minimal change disease
Mixed acid-base disorders
Muscular dystrophy
Parkinson disease
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Potential Concepts
Concept
Protein/enzyme structure/function in health/disease
DNA structure/function, transcription/translation in health/disease
Signal transduction mediated cellular responses
Protein/enzyme small molecule interactions in health/disease
Regulation of metabolic flux
Serum chemistries (anion/bicarbonate gap) as marker for organ function/disease
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Example of Single Discipline Question
A 3430 g (7 lb 9 oz) infant delivered at 42 weeks gestation to a primigravida woman shows a positive result for newborn screening of hemoglobin disorders. A complete blood count shows:
Hemoglobin 17.0 g/dL
Hematocrit 49%
Mean corpuscular volume 72 fL
Hemoglobin electrophoresis shows 80% HbA, 5% HbA2 and 15% HbF. A defect in which of the
following globin genes is most likely in this patient?
A. Alpha
B. Beta
C. Gamma
D. Delta
E. Epsilon
F. Zeta
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Example of Multiple Discipline Question
A 51-year-old woman with a history of diarrhea poorly controlled with medication comes to the physician for evaluation of food intolerance. She is 170 cm (5 ft 7 in) tall and weighs 69 kg (152 lb); BMI is 24 kg/m 2. Her temperature is 37.5°C (99.5°F), pulse is 72/min, respirations are 22/min and blood pressure is 120/80 mm Hg. A complete blood count, serum studies, and hemoglobin electrophoresis show:
Hemoglobin 12.4 g/dL Albumin 2.8 g/dL HbA 93%
Hematocrit 37% CO2 content 22 mmol/L HbA2 5%
Mean corpuscular volume 72 fL HbF 2%
Serum iron concentration is within the reference range. All other values are within the reference ranges. A peripheral blood smear shows microcytosis. Additional laboratory studies show increased concentrations of tissue transglutaminase–immunoglobulin A and tissue transglutaminase–immunoglobulin G. Which of the following changes in globin expression is most likely in this patient?
A. Decreased post-translational modification of zeta globin gene product
B. Decreased transcription of alpha globin gene
C. Decreased translation of beta globin gene
D. Increased post-translational modification of zeta globin gene product
E. Increased transcription of alpha globin gene
F. Increased translation of beta globin gene
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Let’s Discuss What We Have Designed
• Is the presenting complaint/situation clearly defined?
• Dpes the physical examination data make sense?
• Do the laboratory testing results allow students to exclude differentials
and/or focus on the primary concern (how bad is the condition)?
• Can students understand the problem by using the information or is it
recall?
• How can the scenarios be improved or altered to fit the educational need
(ask for a clinician’s assistance)?