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) (2) (3) (4) (5) (6) (7) (8) (9) Approach to Patient with Chest Pain Approach to Patient with Cough Approach to Patient with Diarrhea Approach to Patient with Anemia Approach to Patient with Headache Approach to Patient with Acne Approach to Patient with Urinary Tract Infection Approach to Patient with Sore Throat 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

71

5.

Approach to Simulated Clinic Exam

F. Rayes GoTo TOP

The main objective of the simulated clinic is to evaluate the candidates 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 patients 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 Use of patients Knowledge and experience Doctor-Centered Consultation Use of doctors Special knowledge and experience Silence Facilitation Clarification Analyzing Gathering Interpretation Probing Information 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)

The Joint Program of Family and Community Medicine - Jeddah

72

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 patients 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

The Joint Program of Family and Community Medicine - Jeddah

73

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 patients health beliefs Being very anxious and couldnt 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

The Joint Program of Family and Community Medicine - Jeddah

74

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 historyetc Speculate possible objectives from the given scenario, and at the same time be open minded and ready to conceder patients 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.: Suicidal risk factors in depressed patient or Risk factors in hypertensive patient Explore continuous problems e.g.: Chronic illness Continuous medications Smoking, obesityetc.

o o

o o o

The Joint Program of Family and Community Medicine - Jeddah

75

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. Questioning: Open-ended questions Facilitating verbal & non verbal Reflecting questions.

General Attitude: Patronizing Tenseness and nervousness Coldness and unfriendliness Defensiveness Appearance of too relax or casual Appear preoccupied Questioning: Direct questions, Why question, Suggestive question, Yes or No questions. Many questions at a time. 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.

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 Improve your explanation skills:

4)

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

The Joint Program of Family and Community Medicine - Jeddah

76

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: Take more history Discuss psychosocial component of the problem Perform physical examination Give health education Discuss health promotion issues Be flexible and respect of patient autonomy If patient is insisting make a contract of limited agreement Remember the basic skills for reassurance: Adult to adult relationship (Respect and honesty) Appropriate exploration of patients problem: Physical, social and psychological component of the problem Exploration of patient health beliefs about the problem Examination: Appropriate May be over doing some extra examination to show how much you care. Clear and objective explanation: Summarizing the problem Naming the diagnosis Prevalence of the problem (how common is this problem) Natural history (how rare are the complications) Management options (how they are safe and acceptable) Prognosis (how benign, treatable or at least controllable) Taking feed back: The patient understands the explanation The patient accepts the explanation Assurance of accessibility

o o o o o

6)

o o

o o

o o o o o o

o o

The Joint Program of Family and Community Medicine - Jeddah

77

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

The Joint Program of Family and Community Medicine - Jeddah

78

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 patients 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; doctors 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.

The Joint Program of Family and Community Medicine - Jeddah

79

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: Stages Stage I: Starting the interview Stage II: Hypothesis formation Your Main Tasks

Building effective relationship with the patient Prioritizing between patients problems Reaching a provisional diagnosis Excluding the differential diagnoses 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

The Joint Program of Family and Community Medicine - Jeddah

80

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 patients 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 patients 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 patients 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

The Joint Program of Family and Community Medicine - Jeddah

81

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. Non-compressible vascular puncture
o

See Data interpretation: ECG for more details

The Joint Program of Family and Community Medicine - Jeddah

82

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 patients 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, its 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

The Joint Program of Family and Community Medicine - Jeddah

83

Important diagnoses not to be missed in a childe presenting with cough: Differential features of Epiglottitis, Croup & Bronchiolitis

Epiglottitis 3 7 years Sudden onset, fulminating Dysphagia, drooling Fever Respiratory strider

Croup Childhood URTI problem 1-7 days No drooling Low grade fever or moderate Biphasic strider

Bronchiolitis 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

Muffled voice / cry Minimal cough Toxic appearance H. influenza Emergency protocol Avoid exam the pharynx Cefluroxime (150 mg/kg)

Hoarseness Barking spasmodic cough Nontoxic Para-influenza 1 Humidification (crouptent) IV fluid Antibiotic controversial

The Joint Program of Family and Community Medicine - Jeddah

84

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 patients cues Explore patients 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

The Joint Program of Family and Community Medicine - Jeddah

85

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 patients 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: Suspected anemia CBC Findings Iron deficiency anemia Microcytic hypochromic anemia Anemia of chronic disease Beta thalassemia B12 or Folate deficiency Microcytic hypochromic anemia Micricytic or normocytic Hypochromic anemia Macrocytic anemia

Confirmatory test Low serum iron Low transferin saturation Low ferritin Low serum iron Normal ferritin Normal serum iron Haemoglobin electrophorisis Serum B12 level And/ or serum Folic acid

* For more details see (Data Interpretation: Lab Tests)

The Joint Program of Family and Community Medicine - Jeddah

86

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:

o o o o o

Establish good rapport Encourage patient contribution Respond to patients cues Identify the characteristics of pain (Classical history of pain) Onset & time, duration, site of pain and nature of pain. Continues or intermittent. Course (severity &, frequency) Triggering or aggravating factors and reliving factors. 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 patients life. Psychosocial problems: o New stressful events. o Marital problems or problems at work. Family history. Exploration of any continues problems. Exploration of patients 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

The Joint Program of Family and Community Medicine - Jeddah

87

o o o o o

Factors in the development of chronic daily headache from episodic migraine Analgesic/ergotamine overuse Abnormal personality profile, including depressive trait Stress Traumatic life events 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 - Young adult and - Common in middle age young adult - More in female - Recurrent - Recurrent - Almost daily - Once a week - No significant - Lasting from 8 associated to 12 hours symptoms - Left side of the - Trigger factors head. - Associated with malaise, nausea, vomiting and photophobia. -Normal - Normal examination examination

Subarchinoid Hge - Severe headache (the worst headache of patients life)

- Associated with exertion & vomiting

- ECG: similar to IHD - CT scan then LP presence of blood

Cluster headache - 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.

The Joint Program of Family and Community Medicine - Jeddah

88

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 patients 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 patients demand (referral or medications) o Nonjudgmental attitude o Flexibility and respect of patient autonomy

The Joint Program of Family and Community Medicine - Jeddah

o

89

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 patients 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)

The Joint Program of Family and Community Medicine - Jeddah

90

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 patients 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 patients 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 patients 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

The Joint Program of Family and Community Medicine - Jeddah

91

Possible serious differential diagnosis: Comments 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.

Possible Diagnosis o Epiglottitis o Meningitis o Quinsy o Streptococcal sepsis. o Rheumatic fever o Palatal cellulitis

Facts about use of antibiotic in tonsillitis: o o o o o 20-40% of sore throat caused by GABHS Incidence of rheumatic fever has no correlation with the use of antibiotic Rheumatic fever runs in family, more in low social class 50% of +ve culture for GABHS have no serological evidence of infection (Carrier) Treatment shorten the duration of illness by 24 hr & prevent supportive complications. o Antibiotic does not prevent development of glomerulonephritis

o o o o o

Indications for antibiotics GABHS more likely Peritonsillar abscess Sinusitis Prophylaxis in case of associated chronic diseases e.g. 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

The Joint Program of Family and Community Medicine - Jeddah

92

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 patients 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 Downs syndrome, o Immunocopromised Explore the patients 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 !

The Joint Program of Family and Community Medicine - Jeddah

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 Encourage patient contribution Respond to patients 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

The Joint Program of Family and Community Medicine - Jeddah

94

o o o o o o o o o o

Advice in peptic ulcers: Stop smoking Avoid drugs like NSAIDs (explain) Cola, coffee & tea with moderation and avoid alcohol Milk & diary product with moderation Inform patient about warning sign in PU e.g. black stools Insure patients acceptance & understanding of your advice Explain others management options e.g. (Medications, dosage, frequency, side effect and any relevant precautions). Reassurance: It is common disease and treatable 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 patients symptoms change, possibly indicating a new pathology or malignancy. o Failure of empirical treatment

The Joint Program of Family and Community Medicine - Jeddah

95

GoTo TOP

(11) Approach to Patient with Irritable Bowel Syndrome

F. Rayes

History: Establish doctor-patient relationship Encourage patient contribution Respond to patients 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 patients 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 Dont 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

The Joint Program of Family and Community Medicine - Jeddah

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 Drug Treatment For diarrhea: o Cholestyramin, Imodium orlomotil

With Upper Abdominal Pain: o PU o Cholelithiasis o Chronic pancriatitis

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