July 13, 2010

Patient based learning

In order to make medicine more enjoyable, it is good to learn it by seeing patient and relate it to your study syllabus.

In order to be able to do it, you must have a curiosity to find out what actually happen to your patient once they are presented to you.

Whenever you encounter the case, please bear all this question in your mind after seeing the patient. Please be aware that you should not only manage the symptoms of the patient but to manage them as a whole.

So, this are the question that should arise in your mind.

1) What is actually this patient suffered from (correct diagnosis)

2) How do I prove my diagnosis (you are thinking about physical examination and investigation)

3) How did the disease occur and develop (you are thinking about pathogenesis and Pathophysiology)

4) What are the risk factor of the condition (it will affect your management because you are looking for modifiable vs non modifiable risk factor)

5) What complication do you expect to occur to this patient

6) What are you going to do next? (how to manage this case)

7) How do you manage the patient if the complication occur or your diagnosis is wrong?

8) What is the best treatment for the patient (you may require evidence based approach for this item)

9) Additional knowledge that you would like to gather from the case

For the purpose of learning, you can divide the question listed above into a “three step approach of learning”

1) First approach (Question 1 to 4)

2) Second approach (Question 5 to 6)

3) Third approach (Question 7 to 9)

For examples;

22 years old Malay gentleman, smoker presented to emergency department after complaining shortness of breath associated with musical breathing.

So the key point here is a young smoker who presented with dyspnoe and additional breath sound.

First approach

1) Correct diagnosis

a) What can cause the shortness of breath

b) What is the term musical breathing means? Is it only related to one disease only or it is general?

c) Definition of the disease that you put as a diagnosis

2) Investigation

3) Pathogenesis and Pathophysiology

4) Risk factor.

Next, now you are deciding to put asthma as your provisional diagnosis, therefore you have to support it with patient presentation. In this case, asthma is the most likely diagnosis since young patient, smoker, having shortness of breath, wheezing.

Therefore, first you need to know what is the definition of the diagnosis that you made. In this case, asthma is defined as chronic inflammation of the airway leading to hyper responsiveness of airway to multiple insult and characterized by triad of dyspnoea, wheezing and cough.

Then you may touch on pathogenesis and Pathophysiology related to this disease as it all will give you an idea on how to manage this patient.

For example, you know that asthma involves inflammation which causing vasoconstriction of the airway. Therefore, to treat it, you need to tackle these problem by giving anti inflammation and bronchodilator.

From the pathogenesis, you also may find that smoking can be a trigger for asthmatic attack. Therefore, you can use this knowledge to ask the patient to stop smoking in which it is a modifiable risk factor.

You also need to exclude other causes of shortness of breath which presenting with wheezing like congestive cardiac failure, upper airway obstruction, Bronchogenic carcinoma with obstruction or metastasize carcinoma.

To prove that this is asthma, you may do the physical examination to look for sign of respiratory distress, mental status, speech, rhonchi. This will be proceed with or without investigation depending on patient condition like vital sign, pulse oxymetry, peak flow meter, relevant blood investigation and relevant radiological investigation.

Second approach

This section will enhance your thinking about complication that may arise from this problem, how do you manage the case.

Before knowing about the complication, you should know first how bad did the disease affect the patient. For example, is by using the classification system. As for acute exacerbation of asthma, you may classify it into mild, moderate, severe and respiratory arrest.

Complication that may arise could be status asthmaticus, respiratory failure, hernia (long term complication due to chronic cough).

As for the management, like what I have mentioned earlier, it can be achieve via understanding of the pathogenesis and Pathophysiology.

Third approach

This step is to prepare you to become an excellent doctor whereby you are able to manage the each complication of the patient and provide the best treatment to the patient.

This require an experience in handling the patient. As for a student or new doctor, it can be achieved through vast reading for example from journal.

Apart from that, you may gather additional info related to asthma for example recent research to find the cure for asthma, the level of asthma control, immunology behind the asthmatic attack.

To know briefly about it is more than enough for student. Do not stress yourself to put everything inside your head as it will come slowly throughout your career.

1 comment:

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