CENTRE FOR INTERNATIONAL MEDICAL GRADUATES

Clinical Preparation Program 2009B

Workshop Summary
Wednesday 21st October 2009
Medicine with Dr Jeffrey Rowland

Dear all,

What a great teaching session! I shall thank Dr Rowland sincerely on your behalf for such a
wonderful night. Dr Rowland said that YOU all have the knowledge, the CONTENT, however you
need to package yourselves, FORMAT and YOU, in order to pass this exam.

Dr Rowland provided you with some great advice and information.

• This exam reflects real life
• Don’t kill your patient: always think about common things
He said: If it quacks like a duck, looks like a duck, then it is a duck = cases are common and
don’t think that you have a zebra when you have a horse
• Ask yourself: Why is my patient seeing me today?
• To diagnose dementia, you need:
1. memory impairment
2. cognition (one aspect of cognition)
AND these two factors impact on the patient to reduce capacity in terms of their function and
interactions socially

• Know the Mini Mental State Examination; and how to interpret it

The mini-mental state examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is used to screen
for cognitive impairment. It is commonly used in medicine to screen for dementia. It is also used to estimate the severity
of cognitive impairment at a given point in time and to follow the course of cognitive changes in an individual over time,
thus making it an effective way to document an individual's response to treatment.

In the time span of about 10 minutes it samples various functions including arithmetic, memory and orientation. This test
is not the same thing as a mental status examination. The standard MMSE form which is currently published by
Psychological Assessment Resources is based on its original 1975 conceptualization, with minor subsequent
modifications by the authors.

OR CONSIDER USING
• the RUDAS (Rowland Universal Dementia Assessment Scale) This tool is not language or
education dependent. www.rudas.com.au Attached is a two page summary FYI.
• In Australia, officially people do not use the term nursing homes, but stay in
Residential aged care facilities: there are high and low care facilities available.
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 Also Care in your own home: different packages available for different conditions
• You can’t use Occam’s razor in the elderly as the elderly have multiple problems
Occam’s principle states: if there are a number of explanations for observed phenomena, the
simplest explanation is preferred.
• Every single medication that your patient is on, needs to have a good reason for being on the
medication.
CONTENT
 Dementia, 69yo female:
Please look at this site www.rudas.com.au to assist your assessment of patients (instead of the mini
mental state examination). This test is excellent because it is not culturally or educationally
dependent)
 Abdominal pain, 65yo male
 UTI 84yo confused female: does she have a delirium?
 Dizziness 89yo female –you need to ask the patient about the presenting complaint –
what does dizziness mean to your patient?
 Confusion 79yo female

FORMAT: USE FORMATS

Task: Take a history/ take a focussed history/ take a history pertinent to the presenting
complaint.
HISTORY FORMAT
Presenting complaint
History of the presenting complaint: you need to find out what happened in what order
Pain history
Systems review
Past Medical history
Past Surgical history
Alcohol/smoking/ (recreational) drugs
Medications
Allergies
Social history
Is there anything that I have missed today, that you’d like to tell me?

CONSENT
You need to explain to your patient what you are going to do and consent your patient for the
physical examination
Norman, I need to have a listen to your chest, is that OK with you?

Task: Ask your examiner for physical findings

PHYSICAL EXAMINATION FORMAT

Doctor, What’s the general appearance of my patient?
(if applicable……….what’s the mental state of my patient?)
What’s the B.P?
Pulse?
Temperature?
Respiratory Rate?
Sats?

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BMI?
On inspection (of the ear, chest, abdomen, right eye) what do I see?
On auscultation
On palpation……….
On percussion
Are there any investigations available (ECG? Chest Xray? Bloods? / I’d order ( relevant)
investigations?
Thank your examiner
THANK YOU, DOCTOR

Physical Examination: Sensitive Examination

SPEAKING TO YOUR PATIENT

I need to do an internal examination. I’ll leave you in privacy to undress… can I suggest you empty
your bladder and there is a sheet to cover yourself with… when you’re ready, I’ll come back in with a
chaperone.
Is that OK with you? I’ll put gloves on for the examination.

I need to do a vaginal/ rectal examination, I’ll leave you in privacy to undress and when you’re ready,
I’ll come back in with a chaperone. Is that OK with you? I’ll put gloves on for the examination.

SPEAKING TO YOUR EXAMINER

Gathering physical examination findings and investigations in the O&G stations
General appearance
Doctor, what’s the general appearance of my patient?
Vitals
What’s the BP? HR? Temp? BMI? Ward Urinalysis? Urine HCG?
Physical Examination
I’ll wash my hands before I begin.
Go to abdominal findings before a vaginal examination
On inspection of the abdomen, what do I see? Is there any tenderness? Any masses? Lower
abdomen mass? Any fibroids? I will need to do a Vaginal Examination.

To do this, I would gain consent from my patient, ask her to empty her bladder, undress and provide
a sheet. I would ensure privacy, and bring a chaperone when I return. I would then use gloves for
the internal examination and a sterile, warmed and lubricated speculum.

On inspection of the external genitalia, what do I see?

I would insert a sterile, warmed and lubricated speculum, what would I see?
Are there any abnormal findings from this examination?
Thank you, doctor.

TASKS: Explain your management to your patient; Provide a treatment plan for your patient;
Diagnose and manage this patient; Manage this patient appropriately.

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 MANAGEMENT FORMAT

If you use this 5 Step Management plan or format, then you can attach any clinical scenario to
this. In exam situations, you will not forget vital information and detail

1. Tell the diagnosis

If the diagnosis is not possible, describe the problem

a. Establish the patient’s knowledge

You MUST do this
Suggestions you could say for ‘well-known diseases/ conditions?
So, Marcia, what do you know about Diabetes?
Can you tell me what you understand about asthma?
Suggestions for uncommon diseases/ conditions
Have you ever heard about Sjogren’s Disease?

Often your patient’s will express an attitude to their diagnosis-listen to your patient and respond
to their feelings and fears. Your patients will let you know.
Patient: Depression. No. That’s a girl’s disease.
Doctor: That’s not quite right, Tony. Depression affects both men and women, all ages and all
jobs. In fact, I would be treating more men right now in my practice than women.

b. Correct any misinformation

So, doctor, you say I’ve got measles, eh? I probably got that from playing netball last
weekend in the rain.
Well, Sally, you didn’t catch measles from playing in the rain but you could’ve caught the
measles from one of your team mates. Measles is a very contagious and serious viral
illness so we’ll need to let your team mates know.

c. Educate
Draw if you think that this helps your patient. Use patient language. If you draw you need to
practise talking whilst you are drawing- quick sketches in context for your patient are wonderful.

2. Immediate Management
What are you going to do now to manage this patient?

3. Referrals/ involvement of others

Who does my patient need to see? A senior colleague? A diabetes educator? Podiatrist?
Endocrinologist?
And involvement of others: Does my child patient attend childcare? School? Work? Partner
(for cooking and diet involvement); Are there elderly parents living with my patient?

4. Long term Management/ Prevention

5. Follow – up
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What does my patient need to do next? When do I need to see my patient again?
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 YOU

• Be professional
• Manage your tasks and time well
• Use formats
• Clarify with your examiner and patient anything you do not understand.
• Establish good rapport with your patient, including introductions to your patient. Use your
patient’s names. Take care with saying your name and your position. Don’t say your name
quickly.
• Start all history with an open question. How can I help you today?
Be quiet, listen and allow your patient to tell their story. Address your patient’s concerns eg if
your patient tells you she is more concerned about her baby rather than herself, then you need
to address this. You cannot avoid this.
• Do not use technical language
Respond and address your patient’s addressing your patient’s concerns.
Patient: I’m so worried about Jack. Is he going to die?
Doctor: This is a severe reaction, Suzie, and it will affect his heart and his breathing. We
have stabilised him now but we will need to monitor him.
• Be clear with explanations (1) You’re having a heart attack. This means that oxygen is not
getting to all parts of your heart because there is a clot. What we need to do is to give you
some medicine to dissolve this clot.
Patient: What about my baby, doctor?
Doctor: Nicole, what I think is going on is that you have a ruptured ectopic pregnancy. What
do you know about this type of pregnancy?
Patient: I’ve heard the word but I don’t know. Will my baby be OK, doctor?
Doctor: Nicole, an ectopic pregnancy is not a normal pregnancy and unfortunately your baby
will not survive. Sometimes this pregnancy sits outside the uterus, sometimes the pregnancy
is in the tubes……….

Do NOT use these expressions Better ways of expressing yourself

Are you able to pass winds at the
moment?
Senile dementia
The elderly
Your electrolytes are deranged.
You can’t remember when did you
have them?
Do you feel like you want to pewk?
Do you have sputum coming out?
Do you take alcohol? Have you taken
alcohol before?
Do you pass wind?
Dementia is from a disease NOT old aged so please do
not use this expression.
An older person
Your electrolytes are out of balance.
Do you remember when you had them?
Do you feel like you want to vomit?
Do you bring up phlegm?
Do you drink?

Some expressions used last night

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 Expression Meaning
I stuck around in medicine. I kept working in medicine.
I play soccer. I play left right out. Out of the team. This is a joke
I live with the missus. The kids have Left home.
flown the coup.
You need to pull the stuff out of the To ask information from a good history.
history.
The mini mental state examination A dollar for each.
costs a dollar a pop.
Before you start sticking her with pins, Doing any investigations on her.
what questions do you want to ask her.
How do I say this so I don’t piss off annoy
the examiners?
The other thing that sends them off Leads to
is……….constipation.
Your patient may use a stick or a Walking stick
rollator
It’s barn door stuff. It’s very common.
If you have a patient that is called Iris, The younger generation are being called these names.
then she is in her 80s or 90s. But Flower names are very popular for children eg Rose, Lily,
these names are coming back. All of Pansy, Iris, Holly, Daisy.
the flower names are coming back.
Don’t back yourself in a corner with Don’t put yourself in a position where you have no where
your history taking. You need to be to go.
very broad. You need to think broadly when you approach all patients
Brain mets is not the first thing that you comes
think about when someone rocks up
with dizziness.
They’re very thingy about this They’re very particular about this.
Apparently she thinks that her Always
neighbour is snoopy or nosy
Carer stress and burden Stress on those people who care for others usually those
who are physically or mentally
If you can’t get a history, then you need Veterinarian
to be like a vet, perform physical
examinations.
If your patient is 8 years’ down the In the future
track, and is aspirating, and unable to
feed……………….

We look forward to seeing you all next week,

28th October: Paediatric Emergencies: Dr Zaahid Pandie

4th November: Paediatrics: Dr Margot Bosanquet
11th November: Safe Prescribing scenarios: Professor Charles Mitchell – Senior AMC Examiner
18th November: TBC
25th November: Paediatrics
2nd December: Psychiatry

Take care and with warm regards

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your CIMG Team
Vickie, Diane, Gail and Jenny

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