simulated clinic tips and pitfalls

The Joint Program of Family and Community Medicine - Jeddah

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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

http://www.fayzarayes.com/


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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:




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:


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.





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:


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.





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.





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


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





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





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)


90

GoTo TOP (8) Approach to Patient with Sore Throat F. Rayes

The following items need to be considered in managing any episode:




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


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


91

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


92

GoTo TOP (9) Approach to Patient with Acute Otitis media

F. Rayes

The following items may be considered in managing any episode:




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 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 !


93

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



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


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


94

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


95

GoTo TOP (11) Approach to Patient with Irritable Bowel Syndrome

F. Rayes

History:

Establish doctor-patient relationship



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 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


96

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

simulated clinic tips and pitfalls

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