A 74 year old retired GP, Dr Wallis comes to see you.His wife reports that his memory is not ‘as it was’  however the retired GP dismisses this as ‘nonsense’ and proceeds to tell you about his early research on the use of anti tuberculous medications. His wife is concerned that he may have a brain tumour. The concern about this is that she has read brain tumours can cause memory problems.

Dr Wallis is frustrated by his wife’s concerns about his memory and mentions she is always meddling in his affairs. In his history his wife tells you he has put on a stone in weight, and fractured an ankle when being run over by a car 12 months ago.

PMHx

Previous history of skin psoriasis, treated with topical preparations only.

Drug history

Vitamin D tablets ordered over the internet (patient unsure of strength, wife believes it to be 1000 international units a day)

Examination

You proceed to examine Dr Wallis to evaluate him for any neurological problems. The examination is as follows.

Observations normal. Normal Cardiovascular, Respiratory and Gastrointestinal Examination

Neurology:

Cranial Nerve Exam

Normal. Fundoscopy normal.

Mental Test Score:

Adapted from Hodkinson HM. “Evaluation of a mental test score for assessment of mental impairment in the elderly.” Age and Ageing 1972;1:233-8

Recent blood tests

What is the most likely diagnosis is this just ‘old age’, and does the patient require any other investigations? You can pick a maximum of 5 answers.

A free subscription is on offer for what we judge as the best ‘free text’ answer to this question!

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!

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…

The answer is….. b. Warfarin

Based on NICE Guidance 36 (AF) and the CHADS 2 scoring system.

The CHADS2 score is an excellent aide memoir to anticoagulation in AF. It is based on:

SCORE

• 2 or over=Warfarin
• 1= Warfarin or aspirin
• 0=aspirin

This means our chap here will score:

• 1 for being >75
• 1 for being hypertensive

This means he should be treated with warfarin (assuming he has no contraindications)

A link to the original publication citation in circulation is available here. (link will open in a new window)

Get more questions like this in our free trial. ]]> http://medicaleducator.co.uk/answer-to-question-of-the-day-atrial-fibrillation.html/feed 1 http://medicaleducator.co.uk/question-of-the-day-atrial-fibrillation.html http://medicaleducator.co.uk/question-of-the-day-atrial-fibrillation.html#comments Fri, 26 Jun 2009 08:05:10 +0000 admin http://medicaleducator.co.uk/?p=427 A 76 year old man presents with atrial fibrillation which is permanent. He is lucid and has specifically made an appointment with you to discuss the best way of stopping him “dying ” as a result of the AF.

PMHx:
Hypertension (treated), Mild COPD. Nil else of note.

DHx
Verapamil (as treatment for AF)
Amlodipine
Simvastatin
PRN inhalers

SHx
Lives alone. Independent. Can carry out all ADL’s (activities of daily living)

What is the anticoagulation schedule you would recommend to prevent stroke?

a. Clopidrogel
b. Warfarin
c. Aspirin
d. No anticoagulation
e. Warfarin and Aspirin

At Medical Educator we are always looking to push the boundaries of what we can do on the web to further medical student e-learning in preparation for medical student finals.

We’re pretty excited about the potential our new technology (in collaboration with the kind folks at iSpring) has to offer medical students an even richer learning experience.

Have a go at our free interactive MCQ picture quiz above to get a feel of the kind of things we will be producing in future – that’s ontop of our established base of over 1000 MCQs for medical students, practical video guides for medical finals, podcasts, and one-minute revision downloads!

Trying to cater for the 140 countries that use the site and our growing list of >1000 registered users can at times be difficult. We asked one of our contributing registrars to comment on the forms of assessment:

Its a very interesting question if a single site can provide enough different content to suit the needs of different medical students. I think the best approach is to remain diverse in your tutorial and assessment methods on the site, which is something that medicaleducator manages to do. Obviously there’s a number of domains which could be improved, and that’s the big challenge.

When asking a newly qualified doctor about their own experiences we got a slightly different answer:

I dont think it makes any difference what you do, as long as you have some practice in the assessment method- I mean if you’re doing an MCQ, then that’s fine, you should have had some MCQ practice, same goes for an OSCE, but the knowledge you get from sites like these about key important things, that you might not understand, really helps you to get an overall grasp of whats going on.

One of the qeaknesses of assessment methods is the opportunity to use exam technique to help students perform well in OSCEs. James Bateman, one of the key contributors to the site has his own view:

I do see exam technique as an important issue, but for a different reason to many doctors.

An example of the format of the answers used in the site.

I’ve helped a large number of doctors (>20) sit complicated clinical examinations in tutorials of up to 3 doctors (for entry to specialist training). Its actually problems in techniques in fielding and answering questions that leads to the main problem, i.e. the doctors are being penalised for problems in the way that they answer questions.

Its a shame to see people not maximise their potential because of nerves. I do think that assessment methods used are robust (the evidence from the literature supports this), I do think that web based learning on the site will help people learn (as the meta-analysis by Cook DA et al in JAMA suggests).

So our reasons are as follows

1. Evidence based medical knowledge is transferable across continents in terms of pathophysiology, clinical assessment investigation, and treatment approaches
2. Almost all assessment by medical schools involve MCQ based assessments, a strong component of our approach. This can be useful practice, and any essay format or long answer question will still revolve around key medical facts.
3. Clinical examination skills as taught by a video format can help in both clinical and written examinations. Our questions also highlight clinical connundrums based on different clinical findings
4. A wide variety of delivery formats will help to provide students with the capacity to learn from multiple different domains
5. Detailed clinical answers to MCQ and EMQ question format will help in medical written assessments and other viva situations by providing the students with key clinical facts.

Medical Educator hopes to publish some interviews with UK based and US based medical students in the coming weeks, to see how their needs differ. We already have some US contributors. If you’re a student, and you’re like to get invovled in this, or are interested why not email interviews@medicaleducator.co.uk for further details.

Further Reading:

Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Internet-based learning in the health professions: a meta-analysis. JAMA. 2008;300(10):1181-1196 Full text here.

So far all of our users polled have supported the need for mobile friendly web material: that’s exactly what you’ll find on our site.

We’re driven by our own desire to make the content usable on a mobile phone, not just in the UK. We haven’t tested the mobile version of the site in anywhere other than the UK and we’d be pleased to hear any comments from our international users…

Do you have a web enabled mobile phone? If so then you can use it to revise when you’re on the move. Do our our questions, videos and PDF guides from your mobile phone. It couldn’t be easier.

Our pictures should appear as normal, and you can select the answers just like you did before.

Want to try it? Just register (this is easier on the main site) and browse away from your phone. Once you’ve registered for full membership or our free trial you can try it out.