Archive for the 'Clinical Case Histories' Category
June 28th, 2012
Photo by US Army AfricaGuest blogger Joanne Peel shares her own insights from her experience of taking this Diploma.
I completed the Diploma in Hygiene and Tropical Medicine at the London School of Hygiene and Tropical Medicine (LSHTM) from January to March 2012.
This is a diploma for anyone with a recognized medical degree who has an interest in working in the tropics or developing countries. Applicants can be from any country, and the diversity of students who attend is a particular feature of the course. There are usually around 25 different countries represented on the course. Students also range in experience from recently qualified junior doctors to specialist infectious disease physicians with several years of experience.
Aims and content of the course
The course aims to teach doctors the knowledge and skills required to understand, diagnose, treat and prevent diseases especially prevalent in tropical and developing countries. The course is also very useful for doctors who have previously worked abroad to update their knowledge, and consolidate and share their experiences.
Over three months the course in taught through lectures, seminars, and laboratory practicals. Lectures cover epidemiology, causative organisms, clinical features, diagnosis, management and prevention of parasitic and communicable diseases prevalent in the tropics. The importance of social, cultural and economic factors when implementing health services and prevention programmes is also discussed in depth.
Seminars are often discussions with tropical disease consultants of cases, (usually ones seen at the Hospital for Tropical Diseases) centred on a particular disease or group of diseases.
The Diploma in Tropical Medicine & Hygiene is recognised by the Royal College of Physicians and receives up to 360 CPD points. Completion of a Diploma in Tropical Medicine is a necessary pre-condition for those UK physicians who intend to complete clinical training in Tropical Medicine.
My advice for anyone interested in this course is to apply early, there are only 70 spaces, and these fill up very quickly, around a year in advance, (for the London course). You don’t have to pay anything to apply, so it’s worth it, even if you’re considering other things.
The course was definitely worth both the money and time I dedicated to it. I did the course as I have a strong desire to work in developing countries, and I also want to specialise in HIV and sexual health, topics which were covered very well on the course.
I feel I now have a great knowledge base which has given me the confidence to persue this interest, and it is also possible to arrange placements via contacts from the course. Lecturers are very keen to get you involved in projects going on all over the world. Career fairs are held during the course to help you find out more information about specialising in tropical medicine, and how to work with organisations such as the Red Cross and Médecins Sans Frontières.
The other very valuable experience of the course was meeting other likeminded doctors, with similar interests in working abroad, and learning from the vast experiences of those doctors who have already taken on this challenge.
London School of Hygiene and Tropical Medicine, 020 7636 8636
May 28th, 2012
The Olympic Games is fast approaching and more than 5,000 doctors have already offered their services as medical volunteers. However, as a recent Casebook article points out, not all doctors can apply to volunteer at the Games.
Photo by Peter KonneckeIn the article “Olympic Dilemmas” Dr Iain Barclay, Head of Medical Risk and Underwriting at MPS, explains why foundation doctors are not eligible to volunteer in a medical capacity at this year’s Olympic Games.
According to Dr Barclay, MPS has been approached by a number of foundation doctors who were hoping to volunteer. Unfortunately, owing to statutory restrictions, F1 and F2 grade doctors are unable to work at the Olympics as it is not an approved practice setting.
However, this does not mean that should a medical emergency arise that foundation doctors should not provide assistance by way of a good Samaritan act. A good Samaritan act is one where a doctor provides medical assistance in a bona fide medical emergency upon which they may chance, in a personal as opposed to a professional capacity. For a doctor attending the Games as a spectator, assisting a fellow spectator would be an example of a good Samaritan act.
What should you do?
When called into action while off duty, you must remember to:
- Only intervene if the situation is an emergency
- Assess your own competence in handling the situation – for eg, you may be under the influence of alcohol – and proceed accordingly
- Make a full clinical record after treatment, and give your contact details to the appropriate official.
There will be millions of people at the Games and any situation that would normally be beyond your competence may still benefit from your input, to a degree. For example, you can use your clinical skills to:
- Take a history
- Make an examination to reach a preliminary assessment
- Give an indication of the likely differential diagnosis and suggest options for the management of the situation pending arrival of support.
In the unlikely event that legal proceedings follow a good Samaritan act, MPS members are entitled to apply for assistance, no matter which country the legal proceedings are commenced in, this is important as many spectators will be drawn from around the world.
Whilst London 2012 is a once in a lifetime experience, the medicolegal risks remain the same as any other clinical encounter. By following the above advice, you will contribute to making the 2012 Olympics a safe and enjoyable event.
Read Olympics Dilemmas in the latest issue of Casebook.
January 13th, 2011
As a doctor, the ward is full of potential dangers, risks and potential for cock-up. Avoiding pitfalls are a daily event for many junior doctors! But things were a lot worse many years ago. In the January edition of Casebook Sarah Whitehouse trawls through the medicolegal archives for some historical horror stories to see what doctors used to get away with.
1. Using acid to cure a skin infection
Thomas S Fletcher was a surgeon at the Bromsgrove Workhouse, Worcestershire. One of his patients, young Henry Cartwright, died in 1842 after being immersed in potassium sulphate – in an attempt to cure “the itch”, or scabies.
2. Mistaking Tincture of Opium for Rhubarb
Mrs Elizabeth Galloway was suffering from inflammation of the bowels. To aid her recovery, she was given a tincture of rhubarb … Unfortunately, the druggist mixed up the wrong remedy; the cup contained laudanum [Tincture of Opium] rather than rhubarb. Mrs Galloway immediately worsened and the doctor was called… she later died.
3. Choosing the wrong bottle
Mary Ramshaw was knocked down and severely fractured her thigh. Dr Lumley was called, and prescribed both a mixture to take and an embrocation. Mrs Ramshaw’s daughter unfortunately administered the medicine from the wrong bottle and Mrs Ramshaw instantly began to convulse. Ten minutes later, she died. The embrocation she had accidentally been given contained belladonna (deadly nightshade).
You can read about more deadly disasters in the full article here.
The MPS regularly publish case reports as an aid to its members, to alert them to pitfalls that have caught their colleagues unawares.
Have you been privy to any first-term disasters? We would love to hear about them.
January 17th, 2010
Earlier in the week we posted the first 5 of our 10 most important things you need to focus on for your medical clinical cases examination OSCE technique. Here are the final 5.
To recap, here is our 36-year old’s patient clinical cases of history and findings:
“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so from that side I’m pretty happy.”
- Hands Normal.
- Pulse 80.
- No Signs in the face.
- BP 182/92 Pan systolic murmur left sternal edge.
- Otherwise NAD.
Tip 6. Group your thoughts logically every time
a) By the most likely causes
“The differential includes the following:…”
b) By the problem that’s causing the issue:
“Based on the limited information from the history the differential would include infections (viral: T cell disorder seroconversion illness) Bacterial (bacterial endocarditis, bronchopneumonia, abscess etc), fungal (less likely but consider underlying immunosupression), malignancy…”
Tip 7. Let the examiners know you are finished examining the clinical cases every time
Once you’ve finished or exhausted all the possible causes, let your examiner know! “Causes of a pan systolic murmur include… they are the main causes that I know.” This is vital and stops you looking stupid standing around.
Tip 8. Acknowledge what you don’t know
If you’re asked a question you don’t know the answer to, be prepared to tell the examiner in a clear way i.e. “I cant recall that at this time, I don’t know the answer to that question”. This saves valuable time, and is refreshing for examiners to get clear, honest responses, which is what they require from junior doctors.
Tip 9. Have a set way of presenting clinical case examination findings every time
Practice this, it is the same every time. For the above clinical case here would be our example:
“No stigmata of cardiovascular disease in the hands, pulse 80 and regular in terms of rate and volume, hypertensive with a blood pressure of 182/92. No stigmata of CVSD disease in the face. Apex beat palpable 5th intercostal space, mid clavicular line, normal character. The first heart sound is normal. The second heart sound is normal. There is a pan systolic murmur, best heard with the diaphragm, at the left sternal edge that is non-radiating. JVP not elevated, no peripheral oedema.”
If you do this the same every time it will stop you making mistakes.
Tip 10. Thank and ‘look after’ your exam patient (and the examiners).
This is vital. Your duty is first to the patient. When you have finished examining, show the patient the dignity and respect they deserve, cover up exposed areas, and express thanks. The patient has volunteered most likely to do the exam! Thanking both is important, and professional.
We hope this has helped, remember there are over a thousand questions, dozens of videos and downloads to help you with your exams in the student login area.
January 11th, 2010
One topic that continually crops up in medical student questions is clinical cases exam technique, and issues that can revolve around it. For this reason we have produced a list of the most important things you need to know.
This is based on common errors in exam/ OSCE techniques that crop up in medical examinations from our experience.
Here are the first 5 tips for preparing for your verbal examinations, the next follow soon.
Let’s consider the following features and clinical examination…
A 36 year old male gives the following history:
“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so form that side I’m pretty happy.
Your Examination Findings are:
- Hands Normal.
- Pulse 80.
- No Signs in the face.
- BP 182/92 Pan systolic murmur left sternal edge.
- Otherwise NAD.
Tip 1. Look professional
Dress smartly and conservatively, in accordance with the accepted policy for dress and infection control. We think this means, white shirts (ironed!), smart black shoes, trousers or dress.
Tip 2. Organise your presenting posture to minimise nerves
This is it. Hands behind your back. Head up. Speak clearly and decisively. By organising your posture fidgeting with your hands (common in stressful situations) will not be possible. Standing with an open posture (feet apart, slightly out turned) is a common technique used in business, and will help you present in an organised fashion.
Tip 3. Structure your presentation of medical terminology
This needs to be structured in the same was that you elicited the clinical case history. PC, HPC PMHx, for example:
Mr X is a 36 year old male with a background of intravenous substance use, who presents with a 6 week history of malaise, retired office worker presents with a three week history malaise, night sweats, dyspnoea and anorexia…
Note the use of medical terminology to describe symptoms. This is not the same as describing clinical signs in the history, which you should not do!
Tip 4. Interpret as you go
Don’t be afraid to explain your interpretations of the clinical cases as you assess the situation. For example with history: “The history importantly raises concerns: substance misuse (introducing a blood borne infection, other viral infections and T cell Disorders transmitted by IV drug use), symptoms that suggest a systemic illness/ infection (fevers, malaise, anorexia) that would have a wide differential based on this information that would include….”
Tip 5. Learn to summarise in one sentence
Floundering, being vague, or summarising in a small essay just won’t do. Be clear and to the point – for example “36 year old male, current problem of intravenous substance misuse with 6 weeks of symptoms that include anorexia night sweats and general malaise.”
We hope this helps some of you student doctors in preparing for your OSCEs…. view the final 5 tips here!