Mastering the medical long case : an introduction to case-based and problem-based learning in internal medicine PDF
Preview Mastering the medical long case : an introduction to case-based and problem-based learning in internal medicine
Mastering the medical long case A tribute to my parents and my family And to Hanna, with love S Rohan Jayasinghe MBBS (Honours Class 1) (Sydney), MSpM (UNSW), PhD (UNSW), FRACP Director of Cardiac Services and Cardiology, Gold Coast Hospital Professor of Cardiology, Griffith University School of Medicine Professor and Chair of Medicine, Bond University School of Medicine Queensland, Australia Sydney Edinburgh London New York Philadelphia St Louis Toronto Mastering the medical long case An introduction to case-based and problem-based learning in internal medicine Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 © 2009 Elsevier Australia Previously published by MacLennan & Petty, 1999 This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data _______________________________________________________ Jayasinghe, S. Rohan. Mastering the medical long case : an introduction to case based and problem based learning in internal medicine / S. Rohan Jayasinghe. 2nd ed. ISBN: 978 0 7295 3839 8 (pbk.) Includes index. Bibliography. Medical history taking. Diagnosis--Case studies. Medicine--Examinations, questions, etc. 616.0751 _______________________________________________________ Publishing Editor: Sophie Kaliniecki Developmental Editor: Sunalie Silva Publishing Services Manager: Helena Klijn Editorial Coordinator: Lauren Allsop Edited by Kay Waters Proofread by Pam Dunne Cover and internal design by Trina Mcdonald Typeset by TnQ Books and Journals Pvt. Ltd. Churchill Livingstone is an imprint of Elsevier Author’s note vii Preface viii Reviewers xii Acknowledgments xiii Part 1 Clinical assessments 1 Approach to the long case 3 2 Approach to various common symptoms 16 3 Cardiology 23 4 Respiratory medicine 51 5 Neurology 68 6 Nephrology 85 7 Oncology 96 8 Haematology 109 9 Endocrinology 130 10 Infectious diseases 147 11 Alcohol and hepatology 163 12 Gastroenterology 173 13 Rheumatology 186 Part 2 Clinical investigations and interpretations 14 Clinical investigations and interpretations 209 Part 3 Long case discussions 15 Long case 1. Themes: haematological malignancy, complications of chemotherapy 255 16 Long case 2. Themes: thrombocytopenia, acute myocardial infarction 261 17 Long case 3. Themes: ischaemic heart disease, diabetes, airways disease, chronic diarrhoea 267 Contents v CONTENTS vi 18 Long case 4. Theme: renal transplant 275 19 Long case 5. Themes: diabetes, obesity, obstructive sleep apnoea 282 20 Long case 6. Themes: chronic liver disease, chronic alcoholism, gastrointestinal bleeding, hepatitis C 290 21 Long case 7. Themes: rheumatoid arthritis, osteoporosis, chronic airways disease 297 22 Long case 8. Themes: HIV, immune deficiency, haemochromatosis 304 Appendix A: Discharge planning and community care 312 Appendix B: Internet directory of internal medicine 313 Index 315 This book is meant to be an examination aid and not a therapeutic manual. Clinical medicine as described here is what is practised in most leading teaching hospitals and tertiary referral centres in Australia, and relates to the experience of the author and es in Australia, and relates to the experience of the author and s in Australia, and relates to the experience of the author and colleagues. The author disclaims any legal responsibility associated with the application of the modalities of clinical management discussed here. Medicine is changing fast. fast.. Although every attempt has been made to provide accurate and complete information consistent with the practice of medicine at the time of publication, information given here may become outdated due to changes in medical science. Readers are advised to refer to therapeutic and clinical manuals for the practical application of the concepts discussed in this book. This book is an examination aid only. vii Author’s note Preface Primum non nocere. [First do no harm. First principle of medicine.] It is a great privilege to be invited to write this second edition of Mastering the medical long case. This endeavour has enabled this popular textbook to be made more compre- hensive and current. The management principles discussed here are in keeping with the latest evidence and trends in modern medicine. The fundamentals in the introduction I wrote for the first edition still hold true, no matter what developments have taken place in the science and technology of medical practice. The basics of clinical evaluation, beginning with the building of confidence and rapport, followed by thorough history taking and physical examination, cannot be replaced or bypassed. Mastering the medical long case is all about perfecting the practice of good and safe medicine. With the advancement of modern therapeutics, a demographic shift is taking place in the patient population. Patients are surviving longer and as a consequence tend to accumulate more diseases along the way. Their lists of medications keep getting longer and they have social, economic and occu- pational problems that also need addressing. This complexity in the management of patients is fast becoming the norm in clinical medicine, and it is not surprising that many authorities consider the long case the most significant component of their respective examinations. The clinical examinations of the Royal Australasian College of Physicians, undergraduate and postgraduate medical schools and postgraduate training authorities worldwide, have the long case examination or an equivalent in their assessment programs. Particularly with the Royal College of Physicians in Australia, the long case has become a significant parameter by which a physician’s competence is measured at the qualifying examination. With advances in global communication and the rapidity and ease of global travel, developments in medicine seem to spread to all corners of the earth very quickly. Accordingly, medical practice has become more or less uniform all over the world. During a discussion on the best way to prepare for the long case section of the physician’s examination, a reputed specialist at the Prince of Wales Hospital in Sydney (where I trained as a registrar) said that it is all about ‘just becoming really good at what you usually do in the wards with managing your patients’. This statement sums viii up the basic principle behind the required preparation for the medical long case. A very good physician trainee or a medical student needs to be able to assess patients with multiple serious medical problems thoroughly and systematically, analyse the issues involved, identify the problems in their order of priority (both medical and social), organise relevant investigations and formulate a comprehensive management plan. The candidate should do this with every patient they encounter in their daily clinical practice. So carrying out these daily tasks with diligence and curiosity may be all that is necessary to achieve long case mastery. A mere reproduction of this is all that is necessary at the examination to pass with flying colours! PRACTICAL TIPS Discuss your patients with your seniors and ask questions when you have any doubts. Do not be a passive participant. Always try to imagine what you would do if you were in charge. Take responsibility in the crucial decisions regarding the management of your patients. Look up the latest journals and publications to keep in touch with the most recent trends in diagnostics and therapeutics, and try to apply these in the care of your patients. Ask what your consultant thinks about the plan of management you propose. It is important to have worked with many different specialists in order to be experienced and comfortable with the management of patients with various disorders involving different organ systems. Specialties such as renal medicine and cardiology give the candidate or student exposure to the management of quite ill patients with many complicated medical and social problems. Oncology gives an opportunity to participate in making crucial decisions regarding active treatment and best palliation. All specialties have made tremendous progress in therapeutics in recent years, and the only way to learn the application of such modern therapeutics in the management of patients is to work with the relevant teams. As you can appreciate, the long case is essentially a process of gathering all the relevant information from the patient and bringing this together to understand what is happening with the patient at that precise moment. Once that objective has been achieved, the next step is to decide what needs to be done to tackle the various problems that have been identified. Decision-making is the key to the long case, and the candidate’s decisions (preferably judicious, mature and confident) can make the difference between passing or failing the exam. Be organised Although it is important to have a commanding knowledge of the various major medical conditions, this in itself is insufficient to be able to handle a long case confidently and competently. As the long case is an interplay between many serious and minor medical conditions, the candidate has to be able to apply his or her knowledge appropriately to understand how the combination of various diseases is affecting the patient. Direct application of the recommended therapy for a condition may not be feasible in the long case setting, due to the presence of complicating factors of other diseases and the potential for adverse reactions with multiple other medications. In addition, there may be psychological, social, financial and cultural issues that further complicate the case. For example, a patient who has ischaemic heart disease as well as asthma may not tolerate beta-blocker therapy well, while a patient who has ischaemic heart disease as well as migraine will not tolerate nitrate PREFACE ix therapy well. In such circumstances, candidates should be able to decide on the best combination of medications to treat one condition without exacerbating the other. Medicine ain’t just medicine In addition to the medical aspects of the long case, importance should be given to the social, financial and psychological aspects. Therapeutic decisions should be tailored to the patient’s context and needs. Active therapy, palliation and recruitment of research- based novel therapy may all be applicable in various situations. The candidate should be able to make a rational decision regarding the choice of therapy after taking into account all the important factors. The formulated plan of management should be effective, safe, practical and financially feasible. The candidate has to be able to defend his or her approach when questioned by the examiners. It is not wise to change your plan to any significant extent when challenged, because you are expected to make firm and well-informed decisions from the outset. Remember that the examiners don’t necessarily challenge your decision because it is wrong, but because they want to make sure that you are confident, convinced and clinically mature enough to stand by your decision. The all-important final thrust Another key aspect in the long case—the ‘final thrust’ at the examination—is the presentation. A good style of presentation will certainly impress the examiners. Clear organisation of the information, demonstration of empathy and a broad understanding of all areas of concern to the patient are important aspects of a good presentation. Pres- entation skills are acquired only through constant practice. Learn to speak clearly, at a reasonable speed. Sit relaxed, with your head held high. Maintain eye contact with the examiners at all times. Listen carefully when the examiners speak or ask questions. Do not interrupt examiners, and never criticise an examiner! Some candidates audio- or even video-record their long case presentation, to review and correct mistakes. MEDICAL STUDENTS Mastering the medical long case gives medical students an ideal opportunity to see how the various therapeutic concepts discussed in textbooks are put into practice. You may discover that not everything in the textbook is directly applicable to the practical setting, because diseases don’t always present as well-demarcated, separate entities. Medical students should try to undertake terms in all medical specialties, to gain experience in dealing with patients suffering from diseases of different organ systems. Try to spend as much time as possible in the wards and participate in the ward rounds, ward meetings and teaching sessions. Talk to patients, allied health professionals and patients’ relatives; you will learn a lot and improve your communication skills. Listening to registrars presenting long cases to consultants will be an enriching educational experience. Establish a good rapport with your registrar and politely request permission to be present when she or he presents a long case. After the case presentation, discuss with the registrar the areas of the case that were unclear to you. Each long case can be considered a short textbook on the relevant medical conditions. You can learn your medicine by doing long cases. Consider each patient you see in the ward, emergency department and outpatients clinic as a long case. Take the most detailed history you can, do the most detailed but relevant physical examination, and devise the best plan of management after much thought and consideration. Try not to PREFACE x cut corners. Spend time sorting out patients. As you become more experienced with handling the long case, your speed will improve. And if you cultivate a real enthusiasm to learn from the cases you see, you will begin to enjoy them. Good luck with your long cases, both at the examination and in your clinical career! Rohan Jayasinghe Surfers Paradise Summer 2008 PREFACE xi Reviewers I would like to offer my sincere gratitude to the following experts, who kindly reviewed and provided advice, corrections and suggestions on the relevant sections and the long cases of this book. I would also like to thank those whose work was instrumental in the development of the first edition of this book. Responsibility for any errors, omissions and inaccuracies in the information lies with the author. xii Dr Balaji Hiremagalur FRACP, MMedStat, Director of Nephrology Gold Coast Health Service District Gold Coast Dr Jagadeesh Kurtkoti MD Senior Registrar in Renal Medicine Gold Coast Hospital Gold Coast Dr Vance Manins MBBS, FRACP Heart Transplant Fellow Royal Perth Hospital Perth Dr Jenny Ng MBBS, FRACP Consultant Rheumatologist Gold Coast Hospital Gold Coast Dr George Ostapowicz MBBS, FRACP Senior Gastroenterologist Head of Gastroenterology Gold Coast Hospital Gold Coast Dr David Platts MBBS, FRACP Cardiologist Prince Charles Hospital Brisbane Dr Arman Sabet MD Senior Staff Neurologist Gold Coast Hospital Gold Coast Dr Siva Sivakumaran MBBS, FRACP Director of Rspiratory Medicine Gold Coast Hospital Gold Coast Dr Thomas Titus MBBS, MD, MRCP, PhD Staff Specialist in Nephrology Gold Coast Hospital Gold Coast Dr Jeremy Wellwood MBBS, FRACP Director and Senior Haematologist Gold Coast Hospital Gold Coast Acknowledgments Michael Trikilis, Chief Radiographer, Cardiac Catheterisation Laboratory, Gold Coast Hospital, for coronary angiography images Michael May and Vivek Kulkarni, echo technicians at the Gold Coast Hospital, for cardiac echo images Radiology Department at Gold Coast Hospital for abdominal ultrasound images Radiology Department at Prince Charles Hospital for cardiac MRI images Radiology Department at Westmead Hospital for radiographic images I am indebted to Developmental Editor Sunalie Silva and the staff at Elsevier for their tremendous support and facilitation in making this second edition a comprehensive and high quality product. xiii This page intentionally left blank
The list of books you might like
