TRAINING IN RUSSIA: WHAT ARE WE MISSING OUT?Alan Na, KSMU 2011

FUTURE DOCTORS PROGRAM

MSA, KURSK

PROGRAM ITINENARY

2

Time Itinerary5.00-5.40 PM:

[PRESENTATION] Training in Russia – What are we missing out? By Alan Na.

5.40-6.00 PM

Break

6.00 – 6.15 PM

[GROUP ACTIVITY] Physical Examination Mastery.

6.15 – 6.30 PM

[GROUP ACTIVITY] Solving Tasks.

6.30 – 7.00 PM

Group Presentations

3 ASPECTS

3

Procedural skills

Case presentation

History taking & Physical

examination

THE OSCE

Objective Structured Clinical Examination

ComponentsHistory TakingPhysical ExaminationCommunication SkillsoExplaining ProceduresoExplaining to a newly diagnosed patient.oBreaking bad news, etc.

4

RELEVANCE

5

OSCE

USMLE

PLAB

AMC

POST-GRADUATE STUDIES

6

OSCEMRCP

MRCS MRCOG

LOCAL MASTER

S PROGRA

M

Long CaseA component of the examination where the

students are given ONE hour to examine a patient and he/she is required to present the case to the examiners.

After that, 30 minutes with 2 lecturers. They may bring you to see the patient, ask you to perform examination.

Cases are from Major postings: Internal Medicine, O&G, Paediatrics, Surgery.

7

Short CaseA component where students are evaluated on

the skills in physical examination, history taking, procedural skills, etc.

Virtually anything under the sun can be tested, from Urinary catheter insertion to performing ERPOC to calling the consultant to report a case.

4 stations : 1 Internal Medicine, 1 Surgery or 0rthopaedics, 1 O&G and 1 Miscellaneous ( includes Psychiatry, Paediatrics, ENT, Opthalmology).

10 minutes each station.8

THE PHYSICAL EXAMINATION

9

CLINICAL EXAMINATIONA Systematic Guide to Physical DiagnosisNicholas J. Talley, Simon O’Connor

The Physical Examination of the Cardiovascular System

10

11

GI

HANDS

BP

FACE BACK

AUSCULTATION

PRECORDIUM

NECK ABDOMEN

LEGS

OTHERS

GENERAL INSPECTION (GI)

12

Marfan's, Turner's, Down syndromeRheumatological disorders, e.g. ankylosing

spondylitis (aortic regurgitation)Acromegaly etcDyspnoea

HANDS

13

Radial pulses-right and leftRadiofemoral delayClubbingSigns of infective endocarditis-splinter

haemorrhages etcPeripheral cyanosisXanthomata

BLOOD PRESSURE (BP)

14

HypertensionWide pulse pressure – Valvular pathology.

FACE

15

EyesoSclerae-pallor, jaundiceoPupils-Argyll Robertson (aortic regurgitation)oXanthelasma

Malar flush (mitral stenosis, pulmonary stenosis)

MouthoCyanosisoPalate (high arched-Marfan's)oDentition

NECK

16

Jugular venous pressureCentral venous pressure heightWave formCarotids-pulse character

PRECORDIUM (ANTERIOR CHEST)

17

InspectoScars-whole chest, backoDeformityoApex beat-position, characteroAbnormal pulsations

PalpateoApex beat-position, characteroThrillsoAbnormal impulses

NB: Beware of dextrocardia

AUSCULTATION

18

Heart sounds (4 point auscultation)MurmursPosition patientoLeft lateral positionoSitting forward (forced expiratory apnoea)

NB: Palpate for thrills again after positioningDynamic auscultationoRespiratory phasesoValsalvaoExercise (isometric, e.g. hand grip)oCarotids

BACK (SITTING FORWARD)

19

Scars, deformitySacral oedemaPleural effusion (percuss)Left ventricular failure (auscultate)

ABDOMEN (LYING FLAT – 1 PILLOW)

20

Palpate liver (pulsatile etc.), spleen, aortaPercuss for ascites (right heart failure)Femoral arteries-palpate, auscultate

LEGS

21

Peripheral pulsesCyanosis, cold limbs, trophic changes,

ulceration (peripheral vascular disease)OedemaXanthomataCalf tenderness

OTHERS

22

Urine analysis (infective endocarditis)Fundi (endocarditis)Temperature chart (endocarditis)

23

X’Press Revision in Short CasesDr. Chew Nee KongUniversity of Malaya Press

24

Physical and Examination at a GlanceJonathan Gleadle

25

26

The Big Picture

27

HISTORY TAKING

PHYSICAL EXAMINATION

PRIMARY DIAGNOSIS

HISTORY TAKING

28

1. Presenting (principal) symptom (PS)

2. History of presenting illness (HPI)

3. Past history (PH)

4. Social history (SH)

5. Family history (FH)

6. Systems review (SR) – Often done after HPI.

The systems review

29

Enquire about common symptoms and three or four of the common disorders in each major system listed in the next slide.

Not all these questions should be asked of every patient.

Adjust the detail of questions based on the presenting problem, the patient's age and the answers to the preliminary questions.

30

1. Gen: appetite, weight change, fevers night sweats

2. Head: headache, loss of consciousness, seizures, trauma

3. EENT: blindness, hearing loss, tinnitus, vertigo, otitis, sinusitis, frequent sore throats, oral sores, epistaxis

4. Resp: hemoptysis, cough, dyspnea, wheezing, pleurisy

5. CV: chest pain, dyspnea, palpitations, known murmur, edema, claudication

6. GI: hematemesis, melena, hematochezia, abdominal pain, dysphagia, change in bowel habits, jaundice

7. Menses: menarche, amount, irregularity, menopause, post menstrual bleeding

8. Rheum: pain, swelling, stiffness, locking of joint

9. Endo: polyuria, polydipsia, heat or cold intolerance

10. Hemat: prolonged bleeding, easy bruising, known anemia

11. Derm: rashes, pruritus, prior removal of mole or tumor

12. Neuro: paralysis, weakness, numbness, involuntary movements

An example

31

•Chest Pain, Dyspnea

COMPLAINTS/PS

•SOCRATES

HPI

•HTN, Hyperlipidemia

PAST HISTORY

SOCIAL HISTORY

FAMILY HISTORY

SYSTEM REVIEW

• Smoking, Drinking

• Father passed away due to MI (1986)

• CVS: Orthopnea, Edema, IC• Resp: Nil• GIT: Nil

32

GENERAL PHYSICAL EXAMINATION (Head to Toe)

CARDIOVASCULAR PHYSICAL EXAMINATION

PRIMARY DIAGNOSIS

[VIDEO] PHYSICAL EXAMINATION OF THE CARDIOVASCULAR SYSTEM.

33

34

“the key to success is

CONFIDENCE,

the key to confidence is

PREPARATION”

thank you