They look so fashionable they must be great for the modern day medical student. Right?

We here at medicaleducator.co.uk are currently checking out he use of predominantly free iPhone apps on for medical students. So what we would like are three things. Why not email us at iphone@medicaleducator.co.uk if you have a point of view on any of our points below. We’re keen to supply our users with a free iphone guide once we know what’s worth checking out. So we have a few questions….

1. Have you been refused access to any iPhone health resource because you are ‘only a student’ ? (something we’ve heard is getting more common- and is perhaps a little frustrating [we know you need the information most!]
2. Any apps that are really worth their weight in gold to budding students out there?
3. Anything you think is not worth the free download time?
4. Any recommended top apps?
5. Overall as medical students do you think an iPhone is worth the money in terms of the benefit it gives you?

We;’ll be covering a feature on a few of some of the apps that we like, and are currently using in our day to day practice. We’ll leave you with this…

I was using my iPhone to check a patients disease activity score (DAS) to check their eligibility for anti-TNF therapy- a biologic agent that is a powerful treatment for rheumatoid arthritis.  I think the patient thought I  was checking my text messages! It took a careful explanation to avoid an embarrassing incident.

A free subscription to the user who sends us in the most detailed answer to any/ all of the above. And if you can make us laugh heartily you might get one too. Check out our user guide coming soon too!

At first, the students dont see themselves as Doctors but through the blogging process they become more reflective and get used to using the vernacular. From the article:

“When students from ethnic minority communities and disadvantaged economic backgrounds dream of becoming doctors, they sometimes struggle to envision themselves within that world. The contrasts between hometown, university, medical school, and hospital rounds can be overwhelming.”

“Weekly blogging is an integral part of my students’ pre-medicine internship. Through this creative, reflective process, they gradually see themselves as doctors and nurses, redefining their identities.”
Source: Arizona Daily Star

Its an interesting approach and yet another example of new technologies being used in learning and medical education. Have you got help from blogging your personal learning experiences? We’d love to hear from you.

Image source: Wikimedia Commons

The reality is simple. Poor handovers create discontinuities in care that can lead to adverse events and subsequent litigation. Poor handovers are associated with delayed diagnosis, medication errors, inaccurate diagnosis and increased length of stay.

A New Zealand study of clinical handovers in a tertiary hospital found that the majority of house officers encountered a clinical problem due to poor handover between 7 and 14 times in their previous three-month rotation. This was put down to inadequate systems, poor leadership and lack of specific handover locations.

It can be argued that good handovers have never been so important.

Last year the European Working Time Directive came into force, limiting the number of hours a doctor can work. It has posed major challenges to the way care is delivered. Many royal colleges have been outspoken about how the EWTD has disrupted the continuity of care patients are receiving, as more and more patients are handed over.

In the Casebook article “Dropping the baton” Sara Williams draws on the research that has been done by patient safety leads and practising clinicians to examine how a patient can be handed over effectively, highlighting the salient points that doctors need to bear in mind when handing over a patient.

Here's the original picture from the question. Thanks for tom for pointing out that we initially uploaded a picture of the left fundus, just to confuse you! The image above is from the original question, and is the right eye!

Well now we have the answer, lets go through it step by step. Remember this is from the perspective of a general medicine/ internal medicine doctor, NOT from that of an ophthalmologist, who may have all sorts of other interesting comments to make.*

*These comments are only likely to be interesting to other ophthalmologists

First the history: There is no history! There are no particular conditions which we would link to asthma and opthalmological problems. The blood pressure and observations are all normal.

A couple of caveats:

• in medical questions when you see asthma we always have ‘could this be alpha one anti trypsin deficiency and not asthma’ in the back of our minds
• The blood pressure bits always make us recap: could this be one of the primary causes of hypertension (e.g. phaeochromocytoma, where the blood pressure can be normal?

But… hang on a bit, the history suggests nothing of the sort. So we are left with the fundoscopy. Is it normal?

Lets start:

1. Which eye:  looking from the front, the optic disc is on the nasal half of the field, so this must be the RIGHT eye!
   

   Three quarters of you got the right eye, because yes, this is the 'right eye'. For the other 11%, don't worry, x-rays of the hands confuse us too...

2. Is the optic disc normal? Colour,  yes normal (it should be pale yellow: optic atrophy is one cause of a pale optic disc, and there are multiple causes for this (such as MS, ischameia etc). Shape yes, its spherical. Margins. Distinct-the pale yellow optic disc has nice clear margins here. Blurring of these margins may represent papilloedema, which is one sign of raised intra ocular pressure. This is a key finding in cases of headache as a ‘red flag’. You can also measure the optic cup to disc ratio, and we’re not going to into this now!
3. Vessels: Follow from the disc outwards. Which ones are arteries and which ones are veins? Easy- the arteries are the thinner ones that are often paler than the veins. Now check for common signs: ‘AV nipping’- in hypertension this is when an artery crosses a vein, the vein edges are squeezed in at this point. Its one of the signs of hypertensive retinopathy, or end organ damage caused by hypertension. There is nothing like that here.
4. Anything else on the retina? What about aneurysm formation or exudates (diabetic retinopathy) or dot and blot haemorrhages? nothing of the sort here, the discs otherwise look nice and clear. remember to check the macula area. Nothing to find here suggesting any of these problems.

So, all in all from this quick check we can see nothing up! This is a normal fundoscopy. So…

35 % of you were correct: The answer is to reassure the patient that the examination is normal! No other scans or referrals are needed on the basis of this history and examination.

35% of you got this right at last check on the 21st of January!

To recap the question see below…. or click the link here. Please add any comments or questions!

A medical student is practising for her OSCE exams on the ward…

She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.

The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.

BP 128/70

Pulse  98 regular

Fingerprick blood glucose 8.3

Oxygen Sats 97% on Air

She performs a cardiovascular and opthalmological examination.

Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.

Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…

Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!

Why not have a go at the questions below? We’ll put up the answers in a couple of days…

What is the correct course of action?

• Reassure the patient (35%)
• Request a CT Brain (24%)
• Refer opthalmology: check intra-ocular pressure (24%)
• Repeat blood pressure (12%)
• Request neurology/ clinical geneticist review (5%)

By the way, which eye is shown?

• Right eye (71%)
• Left eye (18%)

I’m not sure I get like this with x-rays of hands too… (11%)

To recap, here is our 36-year old’s patient 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 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 examination findings every time

Practice this, it is the same every time. For the above 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.

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 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 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!

She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.

The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.

BP 128/70

Pulse  98 regular

Fingerprick blood glucose 8.3

Oxygen Sats 97% on Air

She performs a cardiovascular and opthalmological examination.

Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.

Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…

Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!

Why not have a go at the questions below? We’ll put up the answers in a couple of days…

In the waiting room, the patient’s family members circled a Blackberry. About every 15 minutes, Dr. Carlos Wolf of Miami Plastic Surgery gave them a few keystrokes of information about how the patient was doing.

“M is asleep,” one of Wolf’s nurses typed at 9:13 a.m. on June 3. “We will start surgery soon.”

Less than an hour later, the nose job was complete.

“Beautiful,” the nurse typed. “She’s going to love it.”

From the Miami Herald

Although this may seem absurd, the use of social networking tools is now commonplace in personal circles and businesses are starting to take note. Over the last 6 months we have seen an explosion in professional networking and knowledge share sites, meaning it is quicker and easier to get in touch and share information.

The example in the article later goes on to describe how surgeons used Twitter to report the account of an operation to remove a kidney tumour, and how anyone with web access could tune in to a webcast to watch a knee ligament being repaired live.

These are all great advances and examples of people using the technology well to further professional learning. Here at Medical Educator it’s what we are good at, our niche is medical students.

Has anyone else got any good examples of how web 2.0 has helped their professional lives? We’d love to hear your comments.

We took a straw poll of our colleagues and friends who will be at work over the Christmas period: this will give some insight for those students who may not be too far away from the coal face:

Mistletoe can have unpredictable effects when placed in or around gatehrings of medical students. Under no circumstances should you approach a medical student with mistletoe, there may be unpredictable results...

Internal Medicine

Working up to the new year and its full steam ahead with our rolling rota. No breaks over the Christmas period sees me working the weekend but not Christmas day, so it will simply be time with the family

Medical Specialities

Ill be working the Christmas weekend (Saturday 26th and Sunday 27th) but not on the big day, which makes a change from night shifts! Had some fun teaching some of the students from Keele University on the Musculoskeletal Examination, makes you hark back to the days of having to know a little bit about everything… I wish I was breaking up for a couple of weeks though…

One of our Students:

Ill be doing absolutely no work over the Christmas period, watching lots of Tv, watching lots of TV and watching lots of TV. My Iphone should be arriving too which will be nice. Exams on return, have about 6 weeks off.

Anaesthetics:

Our Anaesthetic contributor was unavailable for comment after going in to work this morning on his day off, much to his disgust…He does have Christmas off though…

General Practice:

Well the surgery is shut, so even if I wanted too i won’t be working. As ever there is an out of hours service, but its supplied through an agency, so none of the other GPs will be contributing to the out of hours work. Its lucrative for those who don’t mind putting in a few shifts.

Accident and Emergency:

Too busy to comment. Period.

Our Verdict…. Its a bit of a lottery, unless you’re in General Practice, in which case you have already won the festive lottery!

We reckon most medical students will be taking things pretty easy up until the post new year time-frame, then the roll into the busy exam period starts. Stick to questions about naming all eight of Santa’s original reindeer, watch Rage Against the Machine parodies on YouTube and enjoy the festive break!

Tchestito Rojdestvo Hristovo, God jul, dah Saidan Wa Sanah Jadidah, Feliz Navidad y próspero Año Nuevo,Nadolig Llawen a Blwyddyn Newydd Dda, Have a merry Christmas from the Medical Educator Team.

Now check your hypothesis against the clinical signs:

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