Staff and Student Guide to Synchronous Learning in Year 4 2013

44 Pages·2013·0.41 MB·English

STAFF and STUDENT GUIDE to
Synchronous Learning in Year 4 2013

Introduction ................................................................................................................................................... 2
Purpose ........................................................................................................................................................ 2
Other relevant activities and resources ......................................................................................................... 2
Brief description of Year 4 Synchronous Learning programme ..................................................................... 2
Timing .......................................................................................................................................................... 3
Organisation ................................................................................................................................................. 3
Contact staff at sites ..................................................................................................................................... 3
Pedagogy ..................................................................................................................................................... 4
Outline of Synchronous Learning in 2013 ..................................................................................................... 5
Tutorial 1 Refresher of Clinical Methods ....................................................................................................... 7
Tutorial 2 Respiratory ................................................................................................................................... 8
Tutorial 3 Cardiology .................................................................................................................................. 11
Tutorial 4 Renal Medicine ........................................................................................................................... 13
Tutorial 5 Gastroenterology ........................................................................................................................ 17
Tutorial 6 Neurology ................................................................................................................................... 21
Tutorial 7 Endocrinology ............................................................................................................................. 23
Tutorial 8 Clinical Pathology ....................................................................................................................... 25
Tutorial 9 Rheumatology ............................................................................................................................. 29
Tutorial 10 Infectious Diseases (Medicine) ................................................................................................. 34
Tutorial 11 Haematological Cancer Presentations in the Community .......................................................... 36
Tutorial 12 Dermatology ............................................................................................................................. 40
Tutorial 13 Infectious Diseases (Surgery) ................................................................................................... 41
Tutorial 14 ORL .......................................................................................................................................... 42
Tutorial 15 Plastics ..................................................................................................................................... 44

Development of this Guide has been led by Prof Phillippa Poole in consultation with academic staff from the
Formal Learning Subcommittee and in the Departments of Medicine, Surgery, Clinical Pharmacology, and
Molecular Medicine and Pathology. Dr Susannah O’Sullivan has contributed significantly, especially to the
development of the Rational Management programme. If you have feedback or queries, please discuss
with the relevant academics or else directly with Prof Poole, email [email protected].
Details updated as at 22 July 2013

1
Introduction
The reinvigoration of the MBChB curriculum from 2013, and the cohorting of students at four clinical
campuses, each create opportunities for greater integration between formal learning activities and student
learning in clinical environments. The three Year 4 Medicine clinical attachments: General Medicine (6
weeks), Specialty Medicine (6 weeks), and Geriatrics (4 weeks), which run sequentially in one half of the
year for half the students at a clinical campus (and repeat in the other half year for the balance of the
students). For practical purposes this is labelled as the ‘Medicine’ half year. The other half of the year is
made up of attachments in Musculoskeletal (4 weeks), Emergency Medicine (3 weeks), General Surgery (6
weeks), Anaesthesiology (2 weeks), and Procedural Skills, and is labelled the ‘Surgery’ half year.

Formal Learning in Year 4 has strong horizontal links to clinical experiences in Year 4, and vertical links
with learning from earlier years, and to later medical practice. Further, Formal Learning has strong links to
the newly-developed suite of 189 Clinical Scenarios that define the core knowledge and skills to be
acquired in the programme. These may be found at http://mbchb.auckland.ac.nz/scenarios
There are three elements of Formal Learning:
1. Formal Learning Weeks on campus at Grafton
2. Asynchronous Formal Learning - modules for student to complete in their own time, and
3. Synchronous Formal Learning delivered at clinical campuses/ sites, involving a session for group (s)
of students at a particular campus at the one time.
Purpose
This Guide is written to facilitate the effective delivery of Synchronous Learning (SL) across all sites.
Other relevant activities and resources
MBChB Guidebooks, handbooks and other resources:
2013 MBChB Year 4 Guidebook
Year 4 Clinical attachment handbooks
Year 3 Clinical Methods handbook
SOM Clinical Teacher handbook being developed by Prof John Kolbe
The Clinical Scenarios (~ 189) that form a skeleton for learning in the MBChB programme
http://mbchb.auckland.ac.nz/scenarios
Phase 1 materials e.g. lecture notes and the North-Nanson Red Book

Brief description of Year 4 Synchronous Learning programme
The SL programme is comprised of 15 two-hour sessions. Twelve of these are broadly ‘medical’ and three
broadly ‘surgical’. Each session is delivered twice - to half of the students in the first six months, and to the
other half in the second six months. This is for two reasons: to keep group sizes manageable; and to
maximise the link between synchronous learning and clinical attachments.
Broadly, the format for the tutorials needs to be followed. Each tutorial has been developed by named lead
staff in disciplines within the Departments of Medicine, Surgery, Clinical Pharmacology, and Molecular
Medicine and Pathology, in conjunction with staff on the Formal Learning Subcommittee of the Board of
Studies. The format takes into account prior learning, pedagogy, curriculum goals, and feasibility. This
programme replaces the previous Core Topic teaching in the General Medicine attachment, some tutorials
in Specialty Medicine, plus some Therapeutics and Lab Medicine teaching previously done in Campus
Learning Weeks. It does not preclude other tutorials being offered at sites, provided these Synchronous
Learning sessions are delivered as a priority.

2
Timing
It has been agreed that default day for SL is a Tuesday afternoon. There may be a short break between
sessions. On Tuesdays when there is no SL scheduled, this time is designated for students to use for other
learning activities such as Asynchronous Learning and assignments, as part of the weekly student study
half day.
At Waikato SL will be held on a Wednesday morning.
At Waitemata, SL sessions will start at 1.30pm; at Auckland from 1.00pm- 3.30pm.
Organisation
Student numbers for 2013 are:
Year 4 Site in 2013 Each half year Total
Auckland 37 74
Middlemore 30 60
Waitemata DHB 25 50
Waikato/Rotorua 10 20
Total 102 204

There is an academic coordinator at each site in charge of SL, who may come from the Department of
Medicine, given the number of ‘Medicine’ tutorials, and who is supported by a professional administrator.
Between them, the coordinator and administrator:
• Confirm the programme with tutors. Tutors will mainly be on-site, but on occasions, a tutor may
deliver at more than one site. Tutors at the sites need not necessarily be subspecialists, and should
act as facilitators;
• Confirm the days, times, topics and location of SL and promulgate a detailed timetable to staff and
students. Note: if resources allow, smaller groups may be employed.
• Confirm local timing of tutorial in week of 28th October; which can’t be on Tuesday (Progress Test)
• Ensure rooms are booked (2.5 hours minimum);
• Allocate two students to lead each SL session;
• Provide the model answers to tutors if requested, NOT students;
• Check sessions are delivered, and deal with feedback from staff and students, channelling it where
appropriate;
• Work closely with coordinators of clinical attachments to make sure students are able to attend SL;
• Liaise with the lead academic for the topic, or HOD, if there are issues with content or difficulty
getting staff for delivery.
Contact staff at sites
Waitemata
Academic: Prof Martin Connolly / Dr Vinod Singh (Medicine), Mr Jonathan Koea (Surgery)
Professional: Mere Vercoe
South Auckland
Academic: Dr Roger Reynolds (Medicine), Mr Andrew MacCormick (Surgery)
Professional: Maria Vitas
Auckland
Academic: Prof Phillippa Poole (Medicine), Prof Bryan Parry (Surgery)
Professional: Lindsay Richdale (Medicine), Christine Ganly (Surgery)
Waikato / Rotorua
Academic: AProf John Conaglen (Medicine)
Professional: Raewyn Wooderson

3
Pedagogy
Having one designated study half day per week, every week, should make it easier for students to prioritise
clinical, formal and individual learning activities during Year 4. Students are expected to attend SL
sessions, to have read the materials and the scenarios prior to the tutorials, and be prepared to engage
fully in the tutorial. SL sessions are, however, not compulsory.
The main aim of the SL sessions in Year 4 is to enable students to learn to apply their knowledge in clinical
reasoning or problem solving. Clinical reasoning has been defined by K. Eva (2007) and others as “the
ability to sort through a cluster of features presented by a patient and assign accurate diagnostic label/s so
as to develop an appropriate management plan, including treatment.” Specifically, the focus of these
sessions is largely on the diagnosis and management of common and important clinical conditions students
will meet and manage as doctors. In general, they cover topics in only two of the Auckland MBChB
curriculum domains, viz. Applied Science for Medicine, and Clinical and Communication Skills. Thus, they
are largely clinical science tutorials. Please note that the Clinical Scenarios outline the broader context of
this learning through inclusion of another three domains viz. Personal and Professional Skills, Hauora
Māori and Population Health.
These are not to be didactic sessions. To aid application and deep learning, there is a student-led
component to most tutorials. The nominated students should do any preparation necessary for the tutorials
(e.g. check session details, find and present cases if needed, organise allocation of problems to fellow
students, be prepared to propose or answer questions, review the relevant MBChB Clinical Scenarios, and
liaise with tutors about aspects they want to cover in the session).
The tutor is largely to act as a facilitator and resource person, and is not expected to prepare a formal talk,
except where specified. The tutor should familiarise themselves with the topics in the session, the model
answers (available from lead academic or professional staff at sites), and ideally with the Clinical
Scenarios; being prepared to point these out to the students. These scenarios detail the knowledge and
skills expected by graduation in all domains.
Format
The formats of the tutorials vary slightly. Many for organ systems follow the format below:
First Hour – Clinical Reasoning
The two nominated students at the site will be pre-allocated the tasks of:
1. Each finding and presenting a case with (that specialty) problem, from their ward experiences;
2. Compiling questions from students relating to the cases or that specialty.
Students will need to communicate with each other in order to prepare for the tutorial.
After the presentation of the two patient vignettes (max 15 minutes), the remainder of the hour will be spent
on:
1. discussing relevant aspects of the two cases and covering student queries;
2. clinical reasoning in that specialty:
a. how typical or atypical were the presentations;
b. specific history and exam findings, and techniques;
c. common differential diagnoses;
d. red flags, pitfalls;
e. the role and interpretation of common investigations;
f. choosing treatments/ delivery mechanisms.
3. addressing the broader curriculum domains of Hauora Māori and Population Health
4. covering other specific case-based topics raised by students.
Second Hour – Rational Management
Students will work through paper cases and answer questions that illustrate important diagnostic and
therapeutic principles in medical specialties.

For other sessions such as Rheumatology and Clinical Pathology, the format for both hours is based on
paper cases. It is suggested there is a short break between the two sessions.
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Outline of Synchronous Learning in 2013
The generic programme is outlined below. The Tuesday dates have been added as the default time for SL
is Tuesday afternoon. An early session of the year (Tut 1) is a refresher of the Clinical Method for all
students, and may be combined for all students in Week 2 at smaller sites. After that, sites may vary the
order of the other sessions depending on staff and room availability, and, if necessary alter day of the
week.
Please NOTE:
• Waikato sessions will be run on a Wednesday.
• At Auckland, tutorials start at 1300; at Waitemata they start at 1330.
• *There is a clash with the Progress Test on October 29th for Tuts 11 and 13 in the second half of the
year. Sites need to confirm own arrangements, with options being a time on Wednesday, Thursday
or Friday that week.
For students starting on the ‘Medicine’ half year
SL Medicine Topic Format
Tut 1 Clinical Methods
Tues 19 Feb revision
Tut 2 Respiratory Clinical Reasoning 2 students allocated to present
Tues 26 Feb Rational cases
Management
Tut 3 Cardiology Clinical Reasoning 2 students allocated to present
Tues 5 Mar Rational cases
Management
Tut 4 Renal Clinical Reasoning 2 students allocated to present
Tues 12 Mar Rational cases
Management
Tut 5 Gastroenterology Clinical Reasoning 2 students allocated to present
Tues 2 Apr Rational cases
Management
Tut 6 Neurology Clinical Reasoning 2 students allocated to present
Tues 9 Apr Rational cases
Management
Tut 7 Endocrinology and Clinical Reasoning 2 students allocated to present
Tues 16 Apr Diabetes Rational cases
Management
Tut 8 Clinical Pathology Common problems 2 students allocated to organise
Tues 23 Apr students to focus on each
problem.
Tut 9 Rheumatology. Paper patients, plus 2 students allocated to organise
Tues 28 May a Quiz. students to focus on each
problem.
Tut 10 ID (Medicine) Common problems 2 students allocated to organise
Tues 4 Jun students to focus on each
problem
Tut 11 Haematology / Haematological 2 students allocated to organise
11 Jun Oncology Cancer: students to focus on each
Presentations in the problem
community
Tut 12 Dermatology Dermatology 2 students allocated to present
Tues 18 Jun treatments, Clinical cases
Reasoning
Followed by
SL Surgery Topic Format
*Tut 13 *ORL Patient-centred presentations
Week 28th
Oct
5
Tut 14 Plastics 1 hr burns and 1 hr flaps and principles of plastic
Tues 5 Nov surgery
Tut 15 ID (Surg) Common problems 2 students allocated to
Tues 12 Nov organise students to focus on
each problem
For students starting on ‘Surgery’ half year
SL Surgery Topic Format
Tut 1 Clinical Methods
Tues 26 Feb revision
Tut 13 ORL Patient-centred presentations
Tues 5 Mar
Tut 14 Plastics 1 hr burns and 1 hr flaps and principles of plastic surgery
Tues 12 Mar
Tut 15 ID (Surg) Common problems 2 students allocated to organise
Tues 9 April students to focus on each problem
Then
SL Medicine Topic Format
Tut 2 Respiratory Clinical Reasoning 2 students allocated to present
Tues 16 Jul Rational Management cases
Tut 3 Cardiology Clinical Reasoning 2 students allocated to present
Tues 23 Jul Rational Management cases
Tut 4 Renal Clinical Reasoning 2 students allocated to present
Tues 30 Jul Rational Management cases
Tut 5 Gastroenterology Clinical Reasoning 2 students allocated to present
Tues 6 Aug Rational Management cases
Tut 6 Neurology Clinical Reasoning 2 students allocated to present
Tues 10 Sept Rational Management cases
Tut 7 Endocrinology and Clinical Reasoning 2 students allocated to present
Tues 17 Sept Diabetes Rational Management cases
Tut 8 Clinical Pathology Common problems 2 students allocated to organise
Tues 24 Sept students to focus on each problem.
Tut 9 Rheumatology. Paper patients, plus a 2 students allocated to organise
Tues 15 Oct Quiz. students to focus on each problem.
Tut 10 ID (Medicine) Clinical Reasoning 2 students allocated to organise
Tues 22 Oct students to focus on each problem
*Tut 11 *Haematology / Haematological Cancer: 2 students allocated to organise
Week 28th Oct Oncology Presentations in the students to focus on each problem
community
Tut 12 Dermatology Dermatology treatments, 2 students allocated to present
Tues 5 Nov Clinical Reasoning cases

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Tutorial 1 Refresher of Clinical Methods
Lead academic advisor:
Assoc. Prof Geoff Braatvedt email [email protected]
Resources and revision:
North-Nanson Red Book
Green handbook from Year 3 Clinical Methods
Background
In Years 2 and 3 the students had regular instruction in examination techniques from AProf Andy Wearn in
the Clinical Skills Resource Centre. In Year 3 Semester 2, the students took the Professional, Clinical and
Communication Skills course (PCCS) with three major components:
• A weekly bedside tutorial in a hospital setting (MMH, NSH, Waitakere or Auckland) for ten weeks.
These tutorials followed a syllabus that included history taking, general exam and then CVS,
Respiratory, Abdominal and CNS examination techniques. The students had a history taking
assessment and an end-of-year clinical ‘must pass’ OSCE. After each tutorial, the students went to
see patients on their own. At least three case reports were marked.
• Concurrently, they had a series of whole class lectures that covered history taking (including two
sessions where a patient unknown to the lecturer was interviewed in front of the class), how to
generate a problem list, ethics, communication skills, etc.
• Small group activities with a tutor covering topics such as history taking, death and dying, ethics,
sensitive history taking, clinical reasoning (chest pain, abdo pain and SOB).
Aim for Year 4 Refresher of Clinical Methods
In preparation for clinical attachments:
1. revise purpose, structure and documentation of patient history and examination, summary, problem
list and differential diagnosis;
2. practice systematic clinical examinations;
3. orientate to writing in admission-to-discharge planners and case notes;
4. Revise resources available and how to get the most out of clinical attachments.
Suggested format
• Brief verbal reminder of the ideal structure of interview (Presenting Complaint, Past Medical History,
Medications, Allergies, Family History, Social History, Systems Enquiry), examination, problem list
and differential diagnosis. Show how this is documented on local admission-to-discharge forms.(20
min)
• Real patient interview (best with a patient not known to the teacher to make it real and a typical
‘general medical’ type scenario). Followed by discussion. (45 min)
• Demonstration of exam technique (could use actor/patient).(20 min)
• Generate a summary and problem list for the patient just seen and document this.(25 min)
• Discuss how to write in hospital case notes (SOAP framework) (10 mins)

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Tutorial 2 Respiratory
Lead academic advisor:
Prof Harry Rea email: [email protected]
Resources and revision:
Clinical Scenarios as below http://mbchb.auckland.ac.nz/scenarios
Phase 1 materials e.g. from Cardiorespiratory course
Year 4 Respiratory Teaching from Formal Learning Weeks
First hour – Clinical Reasoning
Two nominated students in each cohort will have the tasks of:
• Each finding a case with a respiratory problem, from their ward experiences. Present key
features to group (suggest 0-4 Powerpoint slides maximum.).
• Compiling questions from students relating to the cases or respiratory medicine.
Students will need to communicate with each other in order to prepare for the tutorial.
After the presentation of the two patient vignettes (max 15 minutes), the remainder of the hour will be spent
on:
• discussing relevant aspects of the two cases and covering student queries
• clinical reasoning in respiratory medicine:
a. how typical or atypical were the presentations;
b. specific history and exam findings, and techniques;
c. common differential diagnoses;
d. red flags, pitfalls;
e. the role and interpretation of common investigations;
f. some specific treatments / delivery mechanisms.
• addressing the broader curriculum domains of Hauora Māori and Population Health
• covering any other specific topics.
Second Hour - Rational Management
Case 1 (relates to Sudden onset shortness of breath [Resp4])
A 17 year old woman brought into the Emergency Department after becoming suddenly short of breath.
She is very distressed and is rushed into the resuscitation room. Her usual medication is inhaled
fluticasone 250mcg b.d. and inhaled salbutamol 2 puffs p.r.n. She normally uses her salbutamol once or
twice daily. Over the last week she has had increased cough with green sputum, she has been using her
salbutamol 6-8 times a day and she has been waking at night. By the time she arrives at hospital she is
breathless at rest.
Questions
1. How do you assess the severity of her asthma?
2. What are your initial investigations?
3. What is your initial treatment (specify the dose and frequency of medicines that you would use)?
4. If she does not respond to the initial treatment, what would you do next?
If she were regularly using salbutamol 6-8 times a day,
5. What factors might be contributing?
6. How could you improve her management?
Case 2 (relates to Chronic shortness of breath [Resp2])
A 74 year old woman presents to the Emergency Department with worsening shortness of breath. She is
well known to the department, needing hospital admissions around two to three times per year. She says
that she is always short of breath and has difficulty getting to the shops but things are currently much worse
than usually. She says she is breathless just lying on the bed. Her usual medication is inhaled salbutamol 2
puffs prn and theophylline (Nuelin SR) 250mg twice daily. On examination she has a temperature of 37.8°C
and a respiratory rate of 28 per minute. Pulse oximetry (while breathing air) shows a saturation of 87%.
Questions
1. Are there any other investigations that you would request?
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2. How would you manage her exacerbation of COPD?
After she recovers from her exacerbation she is reviewed by her GP. She wants to know whether she
should be treated with inhaled fluticasone (her son is on treatment with fluticasone for asthma).
3. How would you respond to her question?
4. Are there any other treatments (either pharmacological or non-pharmacological) that you should
consider for the ongoing management of her COPD?
Case 3 (relates to Pneumonia [Resp5])
You visit a 98 year old woman in a private hospital where she has been a resident for the past three years.
In the past she has had a stroke that has affected her ability to swallow. She has a fever of 37.8°c and is
coughing up purulent sputum. On examination she has poor dentition, crackles throughout the left side of
her chest posteriorly and dullness and decreased air entry at the left base. You send her to the local
Emergency Department. A chest X-Ray at the Emergency Department shows left upper lobe consolidation
and large left pleural effusion.
1. What is the likely diagnosis?
2. You aspirate some pleural fluid. What tests do you request on the pleural fluid?
After aspirating the pleural fluid you commence her on treatment.
3. What is your initial treatment?
4. How would the results of your investigations influence your management?
You successfully treat the pleural effusion and she initially shows a marginal clinical improvement (but
never complete apyrexia). However, over the next few days her fever gradually worsens, the cough
becomes productive, and her lung function deteriorates. Chest CT scan reveals spread of the existing
pneumonia and development of multiple cavitating lesions with air-fluid levels.
5. What is the likely diagnosis and how would you manage her?
6. If the CT showed persistent pneumonia but no cavitating lesions, what would be your approach to
management?
Case 4 (relates to Deep vein thrombosis [Blood3] and Sudden onset shortness of breath [Resp4])
A previously fit 30 year woman presents with sudden onset of breathlessness and pleuritic chest pain. She
is a non-smoker, regularly exercises and has not previously been limited by breathlessness. She is on
treatment with the combined oral contraceptive but takes no other medication. Two weeks ago she flew
from Los Angeles to Auckland. On examination she is afebrile. Her blood pressure is 120/70, her heat rate
is 105 per minute and her respiratory rate is 24 per minute. On auscultation, her chest is clear. Her left calf
is swollen. A CXR shows no abnormality.
Questions
1. What is the differential diagnosis?
2. What other investigations would you request?
3. If the suspected diagnosis is confirmed, how would you treat her?
4. Is there any other advice you should give her?
Additional Cases
These may be covered if sufficient time or as SDL.
Case 5 (relates to Haemoptysis and abnormal chest X-ray [Resp6])
A 65 year old man returns to the GP clinic where you are on your attachment. He has had a prolonged
cough and the GP arranged a chest X-Ray; this has shown a left hilar mass. He has come back for the
result and reports that he coughed up some blood recently. He is a long term smoker. Clinically he is
clubbed. Laboratory investigations show only mild hypercalcaemia. You suspect he has a primary bronchial
carcinoma.
Questions
1. What tests would you consider in order to obtain a definite pathologic diagnosis?
2. What additional tests would you routinely undertake in order to determine the patient’s suitability for
surgical resection?
3. What is the possible significance of the hypercalcaemia?
Six months later the patient re-presents with a one month history of worsening lower thoracic back pain.
Radiology shows a lytic lesion in T12 consistent with a metastasis.
4. What would be your management of this problem?
9
5. List community-based services that you might now enlist to assist in management of this man in his
own home.
Case 6 (relates to Worsening shortness of breath [Resp8])
A 67 year old man presents with slowly progressive shortness of breath on exertion. He has a history of
working in mines in Western Australia during his 20s and 30s but has subsequently worked in office jobs.
His chest radiograph shows evidence of diffuse lung disease (consistent with pulmonary fibrosis).
Questions
1. What findings do you expect on auscultation?
2. With regards to aetiology of his lung disease, what other points in the history would you explore and
why?
He develops oxygen desaturation on exercise.
3. Describe the likely pathophysiologic mechanism.
4. Describe the likely pattern of abnormality on spirometry.
5. Describe the likely abnormalities on arterial blood gases.
Case 7 (relates to Daytime sleepiness [Resp9])
A 52 year old man comes to your clinic due to worsening snoring, sleep fragmentation, unrefreshing sleep
and excessive daytime sleepiness. He says he spends 9 hours a night in bed and sleeps for at least 7
hours a night. He says he occasionally wakes gasping for breath, and he gets up 2 or 3 times a night to
pass urine. He complains of morning headache. He scores 18/24 on the Epworth Sleepiness scale (upper
limit of normal 9/24) and this is causing problems at his work. His partner says that he frequently stops
breathing and thrashes around during sleep. His past medical history includes current diagnoses of Type 2
diabetes, gout, hypertension, dyslipidaemia and he is on appropriate drug therapy. He denies symptoms of
angina, TIA or stroke. Physical examination reveals a tired-looking but not overtly sleepy, morbidly obese
man with a BMI of 48. The neck is short with increased circumference. The nose is patent. On examination
of the oral cavity the tongue is large (Malampati score is 4), tonsils are symmetrically mildly enlarged
(Grade 1/4), and the oropharyngeal structures appear generally erythematous and swollen. Blood pressure
is 130/85, Pulse 88 bpm regular, SpO2 95%. Cardiovascular, Respiratory and Neurological examinations
are otherwise normal. He proceeds to a home overnight oximetry study. A 7 hour recording looks to be of
good quality on manual review. It shows multiple discrete dips in oxygen saturation occurring throughout
the recording period at a rate of 62/hour (for >4% dips). The average SpO overnight is 90.1%, lowest is
2
63%. Average desaturation is 13.9%.
Questions
1. What is the likely diagnosis?
2. What is the best treatment for this man at this time, and why?
3. What other treatments should or could be advised?

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