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iTeach "Clinical Skills"

iTeach "Clinical Skills"

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iTeach "Clinical Skills"

4.5/5 (4 valutazioni)
121 pagine
1 ora
Aug 31, 2014


The book will help develop skill to perform clinical examination. It is meant for undergraduate medical students, junior doctors and post-graduate doctor preparing for college examination.

Aug 31, 2014

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Anteprima del libro

iTeach "Clinical Skills" - Dr Kyaw Sanhla


I. Introduction

Meeting with year 5 medical students from the Australian Medical School (AMS)

K: Good morning. I′m K; I′ll be your supervisor for this medical rotation.

S: Hi. I′m Student A (SA). The others are Student B (SB) and Student C (SC); the three of us will be with you for eight weeks.

K: Nice to meet you. So, what are your expectations during this rotation?

S: We have already heard from other students that you are a keen teacher of clinical skills. We would like to improve our clinical skills during this rotation.

K: Fantastic! As you know, there are stages in developing clinical skills.

S: Tell us.

K: First and foremost, you learn the technical skill - going through the routine and doing each component correctly. You all have been doing this part so far and I expect you are expert with the routine.

S: Well, I doubt it.

K: The next stage is to appreciate that clinical examination has a purpose beyond technical skills.

S: What is it? I′ve never thought of it that way!

K: The ultimate aim of a clinical examination is to get a physical diagnosis - i.e. what is going on structurally? After each finding, you need to appreciate its value and decide what else to do next. So your examination becomes a thoughtful act instead of mindless routine.

S: How can you achieve that?

K: That is exactly what we are going to do here - to develop an insight into why you do what you do and which part of the examination is most important in a given situation.

S: Sounds good. Do you mean we don′t need to follow the routine all the time?

K: In a way. I don′t want you to follow the routine mindlessly. I want you to do the physical examination with a purpose.

S: But how?

K: Well, that′s what you are going to learn with me. For your part, I expect you to do more practice to pick up abnormal physical signs and you must learn to evaluate the findings.

S: What do you mean by evaluate the findings?

K: The physical examination is, technically speaking, a test. When you order a test you know the value of a test in terms of sensitivity and specificity. And to interpret the result you must have an idea of pre-test probability.

S: I know all these buzzwords but I don′t think they have anything to do with the physical examination.

K: Yes, they do. Before telling how, do you mind if I beat around the bush first?

S: Go on, we have all the time in the world.

K: As you know, the individual component of the physical examination was developed a long time ago, before the technology was developed. For example, auscultation of the heart was started by Laennec two hundred years ago and we still continue learning and teaching this skill.

S: Is it really necessary to learn the examination of the heart when the echo can tell you everything?

K: Advanced technology is not everything. I′ll tell you more when we do neurology. I agree that there is a lot in the physical examination that is not very useful. But there are components of the physical examination which can change your management. The real problem is that we perform the physical examination without an idea of how much faith to put into what we find.

S: You hit the nail on the head.

K: That′s why I talked about evaluation of the component of the physical examination in terms of its accuracy and validity. I′m afraid there is not much information in this area. I would like you to read Steven McGee′s Evidence-based Physical Diagnosis¹. You can get this book from the library. It will give you an insight into the component of physical examination that you do. I also would like to recommend that you read the Rational Clinical Examination series from JAMA.

S: I’ll do that. So, what is your plan for us to develop our clinical skill?

K: There will be one bedside teaching session with me every week. I′ll identify a suitable patient for you to examine. I′ll be watching while you examine without interruption. Then we will go to the meeting room and talk about what you do, why you do it and what you get out of it. The idea is that you not only learn the technical skill but also something above and beyond it.

S: I′m excited!

K: Just one thing. Don′t expect me to tell you everything. What I normally do is pick up some skill which I think is important and we work on it together. You have learnt the basics and already have some skills. Most importantly, you must re-read the textbook on clinical examination as well as Evidence-based Physical Diagnosis after my teaching. You will understand more that way.

S: Thanks. We′ll follow your advice as best we can.

Message Box:

II. Auscultation of the Chest

K: Today we are going to learn listening to the chest. Most clinicians still carry the stethoscope and listen at the bedside.

S: And not just clinicians. Nurses and allied health people also carry stethoscopes and listen at the bedside.

K: I agree. That′s even more reason for us to be skilful with the use of stethoscope – it’s not just a status symbol. Anyway, when you listen to the chest, what do you listen for?

S: Breath sounds, of course.

K: Generally speaking, yes. But technically we use the terms (a) breath sounds and (b) accompaniments or added sounds with different meanings. Let′s start with breath sounds. How many types of breath sounds are there?

S: Three, I think.

K: Tell me.

S: One, vesicular breath sound; two, bronchial breath sound; three, a mix of these two.

K: Actually, there are only two types of breath sounds. You will hear either vesicular type or bronchial type of breath sound at any one area. There is no such thing as mixed or in-between. You have to make up your mind between the two.

S: But how?

K: It is easy. Learn to recognise the "bronchial breath

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