pcl 2 - case 7: case of michael phillips michal zacharzewski. (2011). last man standing [online...
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PCL 2 - Case 7: CASE OF MICHAEL
PHILLIPS
Michal Zacharzewski. (2011). Last Man Standing [Online image]. Retrieved from http://www.sxc.hu/photo/1330435
Request Student Volunteer to interview patient Introduce the Standardized Patient Instructions for Student Volunteer:
During the interview you may take “time out” and ask questions
Student Leader/Tutor may interrupt to help facilitate the interview.
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INSTRUCTIONS
Case 7: Michael PhillipsPart 1: Interview (SP)
Go To Problem List
Go To Clinical Notes
What do you think?
Go to Problem List and Clinical Notes to begin the Differential Diagnosis
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INSTRUCTIONS
Case 7: Michael PhillipsPart 1:
Go To Problem List
Go To Clinical Notes
Problem List Learning ObjectivesDDx
Go to Clinical Notes
CC: (Chief Complaint/Concern):
HPI: (History of Present Illness):
PMH: (Past Medical History):
Clinical Notes:
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Past Surgical History:
Go To Problem List
FH: (Family History): Medications:
Allergies:
Clinical Notes:
SH: (Social History):
Go To Problem List
Clinical Notes:
Assessment & Plan:
Labs: Review of Systems:
Physical Exam:
Go To Problem List
*** Distribute Handout 1***
Background Information Physical Exam & Lab Results
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Case 7: Michael PhillipsPart 1: Background
Go To Problem List
Go To Clinical Notes
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Case 7: Michael PhillipsPart 2: Two Days Later
Go To Problem List
Go To Clinical Notes
Lab results show Michael Phillips has inflammation of the liver.
Doctor calls Michael Phillips and informs him he has hepatitis and recommends to “give the liver a rest” and asks Mr. Phillips to abstain from alcohol.
Michael schedules an appointment to follow up inone week.
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Case 7: Michael PhillipsPart 2: FRAMES Intervention
Go To Problem List
Go To Clinical Notes
One Week Later: Doctor meets with Michael Phillips to review his case.
FRAMES Intervention: Doctor (Student Leader) conducts “FRAMES” intervention using the AUDIT Questionnaire. (Script & Questionnaire on Blackboard)FRAMES Intervention:• Feedback• Responsibility• Advice• Menu of Options• Empathy• Support
AUDIT Questionnaire:• Alcohol Use Disorders
Identification Test (AUDIT)
*** Distribute Handout 2***
Handout 2: “Future Course of Patient’s Life”
Class review and discuss1) Pathway One2) Pathway Two
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Case 7: Michael PhillipsPart 2: Background
Go To Problem List
Go To Clinical Notes
(These Will Not Be Tested as Part of PCL)Clinical Problem Solving
List the differential diagnosis of abdominal pain in the setting of alcohol use
Basic and Clinical Sciences Review alcohol metabolism Review pathophysiology of alcohol related liver disease
(These Will Be Tested as Part of PCL)
Psychosocial, Behavioral, and Developmental Issues Recognize the role of standardized screening tools such as
AUDIT in evaluating alcohol usage Be familiar with validated brief intervention tools such as
FRAMES Recognize the impact of alcoholism to all the components in a
patient’s life.12
Case 7: Michael PhillipsLearning Objectives:
Go To Problem List
Go To Clinical Notes
NEXT WEEK: Readings
Required Reading: Mailliard M.E., Sorrell M.F. (2012). Chapter 307. Alcoholic Liver Disease. In D.L.
Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison's Principles of Internal Medicine, 18e. Retrieved January 26, 2012 from http://www.accessmedicine.com/content.aspx?aID=9134918.
Supplemental Readings: Fagbemi, K. (2011). QWhat
is the best questionnaire to screen for alcohol use disorder in an office practice? Cleveland Clinic Journal of Medicine, 78(10), 649-651.
Fiellin, D. A., Reid, M. C., & O'Connor, P. G. (2000). Screening for alcohol problems in primary care: A systematic review. Archives of Internal Medicine, 160(13), 1977-1989.
Webb, G., Shakeshaft, A., Sanson-Fisher, R., & Havard, A. (2009). A systematic review of work-place interventions for alcohol-related problems. Addiction, 104(3), 365-377.
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Case 7: Michael PhillipsSession 1: Wrap Up
Go To Problem List
Go To Clinical Notes
NEXT WEEK: Management of Session 2
Begin with an oral presentation of the case (Oral Presentation: See PowerPoint on Blackboard & Handout #4)
Student Presentations
Appoint a new scribe to keep track of the discussion
Review USMLE sample questions
Appoint a student leader for the next case
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Case 7: Michael PhillipsSession 1: Wrap Up
Go To Clinical Notes
Go To Problem List
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End of Session 1
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PCL 2 Case 7: Michael Phillips
Michal Zacharzewski. (2011). Last Man Standing [Online image]. Retrieved from http://www.sxc.hu/photo/1330435
MANAGEMENT OF SESSION 2:
Begin with an oral presentation of the case
Student Presentations
Appoint a new scribe to keep track of the discussion
Review USMLE sample questions
Solicit and provide Feedback on the session
Appoint a student leader for the next case
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Case 7: Michael PhillipsSession 2: Management
Go To Clinical Notes
Go To Problem List
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USMLE Questions
USMLE QUESTIONS
QUESTION 1: A 50-year-old male alcoholic presents with cirrhotic liver disease and chronic pancreatitis. He has been nauseated for the past several days, and not eating. Blood glucagon levels are elevated with which of the following results? A. Stimulation of glycogenolysis in muscleB. Inhibition of insulin secretionC. Stimulation of gluconeogenesis in the liverD. Inhibition of adenylate cyclaseE. Inhibition of phospholipase C
(All Practice questions were retrieved from USMLEasy Web site.) USMLEasy: Home Retrieved 1/25/2012, from http://www.usmleasy.com/
USMLE: 1
ANSWER:C
EXPLANATION: The primary action of glucagon is to increase blood glucose concentration, which it accomplishes by promoting gluconeogenesis and glycogenolysis in the liver but not in muscle. These effects are mediated by cyclic AMP, which is produced by hepatic adenylate cyclase following interaction of glucagon with its plasma membrane receptor. Interaction of glucagon with different hepatic plasma membrane receptors activates phospholipase C, which results in a rise in concentration of intra-cellular Ca2+, which further stimulates glycogenolysis. Although glucagon opposes the action of insulin, it does not directly affect insulin secretion.
USMLE QUESTIONS
USMLE:
(All Practice questions were retrieved from USMLEasy Web site.) USMLEasy: Home Retrieved 1/25/2012, from http://www.usmleasy.com/
USMLE QUESTIONS
QUESTION 2 : A 42-year-old woman presents with an acute onset of fever, jaundice, tender liver enlargement, and ascites. Liver biopsy reveals histological features of scattered foci hepatocytes undergoing swelling and necrosis, with neutrophilic infiltration around the affected cells, and sinusoidal and perivenular fibrosis. This is most suggestive of which of the following? A. Acetaminophen overdoseB. Acute fatty liver of pregnancyC. Alcoholic hepatitisD. Budd-Chiari syndromeE. Pyogenic liver abscess
King, M. W. (2008). Lange Q & A. USMLE step 1 / [edited by] Michael W. King. New York : McGraw-Hill Medical, c2008.
USMLE: 2
USMLE QUESTIONS
USMLE:
ANSWER:C
EXPLANATION: Alcoholic hepatitis (also called acute sclerosing hyaline necrosis of the liver) usually occurs acutely following an alcoholic binge superimposed on steatosis (fatty liver) or cirrhosis. Variable degrees of liver cell necrosis are present with corresponding clusters of neutrophils and frequent accompaniment of pericellular and perivenular fibrosis. Intracellular Mallory bodies are common. Alcoholic hepatitis may range from asymptomatic to fulminant hepatic failure. Symptoms, which may persist for weeks or months, include upper abdominal pain, anorexia, fever, tender hepatomegaly, and jaundice. Sever disease may cause encephalopathy and death.
King, M. W. (2008). Lange Q & A. USMLE step 1 / [edited by] Michael W. King. New York : McGraw-Hill Medical, c2008.