Press the number of the question to get the answer

CONTENTS

MEQ1. EXAMPLE OF BAD ANSWER

MEQ2. Mrs. Sabreen is 40 years old, married and has no children. For the last 15 years she
has been trying to be pregnant, but all her trials ended by failure. This time she succeeds and
she became pregnant. She came to you for her first antenatal visit at 10 weeks gestation.

How are you going to conduct this consultation?

MEQ3. Two days later Mrs. Sabreen came to you complaining of vaginal bleeding.

Discuss your management of this situation.

MEQ4. Mr. Waseem is 28 years old, married, with 5 children. He works as a receptionist in a
very luxurious hotel. He noticed white spots spreading in his hands and trunk which was
diagnosed by a competent dermatologist as vitiligo, but Mr. Waseem did not accept the
diagnosis and he came to you asking for referral to another dermatologist.

1. What are the etiological factors for Mr. Waseem’s behavior?

2. How are you going to end this consultation?

MEQ5. You are assigned as doctor in-charge of a health center, you decided to start mini-clinics for
DM.

What are the issues raised by this decision?

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MEQ1. EXAMPLE OF BAD ANSWER

 I will establish good patient – doctor relationship

o I will say hello, how are you?
o I will shake hand with the patient.
o I will look to his eyes (eye contact).
o I will ask open - ended questions e.g. what can I do for you?

 I will find out the real reasons for his attendance & the effect of the problem
o His idea
o His concern
o His expectation
o I will take full history
o I will do general examination
o I will look for the differential diagnosis
 Is it physical?
 Is it social?
 Is it psychological?

 I will look for risk factors like smoking, obesity, hyperlipidemia, DM – hypertension,
asthma, drug, abuse, sedentary life …

 I will reach shared understanding of the problems.

 I will choose with the patient the appropriate action for each problem.

 I will involve patient in the management.

 I will use time & resources affectivity.

 Management option:

o Reassure the patient

o Advice the patient
o Prescribe medications
o Refer to hospital to social worker
o Investigation the patient
o Observe and give follow up appointment

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ANSWER MEQ2:
Mrs. Sabreen is 40 years old, married and has no children. For the last 15 years she has been
trying to get pregnant, but all her trials ended by failure. This time she succeeded and she
became pregnant. She came to you for her first antenatal visit at 10 weeks gestation.

How are you going to conduct this consultation?

 Establish Doctor – Patient Relationship

 Congratulate her for her pregnancy.
 Ask God to save it for her.
 Showing her extra care & empathy e.g. by treating
her very gently, give her enough time, put her at ease
and invite her to ask any question.
 Physical assessment :
 LMP and calculate EDD.
History:  Physiological changes of pregnancy e.g.
Tiredness, Nausea, Breast engorgement.
 Any complication of pregnancy:
Vaginal bleeding. Dysurea. Severe headache.
 Past medical history – chronic diseases e.g.
DM / Hypertension / Asthma
 Past OB history:
Abortion. / Ectopic pregnancy / Gynecological
operation / Drugs increase ovarian activity

Physical Examination:
General inspection:
Vital sign:
General examination:
OB examination:
 Psychological Assessment:
Patient ideas
 Pallor / Odema
 Pulse / BP
 Chest & CVS / Breast /Abdominal examination
 Vaginal examination if needed
 She may think she needs traditional healer to save her
pregnancy.
 She might think that this is afalse pregnancy or tumor
or ascitis, it is not a real pregnancy!
 She may be thinking it is a twin pregnancy because of
ovarian stimulant medications.

Patient concerns:  Possibility of congenital anomalies.

 Possibility of complications e.g. toxemia or death of the
fetus
 Possibility of complicated delivery e.g. bleeding or fetal
death.
 Worry about future e.g. is she young enough to take
good care of her baby?!

Patient  She needs reassurance that every thing is normal.

Expectations:  She may need more information about pregnancy at
age of 40 years and possible complications.
 She may ask for referral to a special care center to take
maximum care of her pregnancy.
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 Psychological  Degree of anxiety about her pregnancy.
symptoms:  Her mood & interest

Social support: 
Relationship with her husband & his attitude towards
this pregnancy.
 The condition at work (if she is working) and if there is
any risk needing to be avoided e.g. heavy work.
 Management options :
Reassurance:  Patient needs explanation & reassurance that she is in good hands
and if any problem raised it will be diagnosed early and she will got the
maximum treatment available.

Advice:  General advice:

 Avoidance of medications
 Diet – high quality vitamin and iron
 Rest – enough sleep
 Hygiene and care for breast
 Specific advice:
 Signs of complication e.g. abdominal pain, vaginal bleeding, severe
headache.
 May she need amniocentesis at 18 weeks because of her age.
 She may need referral to a radiologist for detailed U/S for early
diagnosis of any fetal abnormality.
Prescribing:  Iron and Folic acid
 May be calcium if her dietary intake is not enough.

Referral:  To OB specialist because she is high risk pregnancy.

 May be a genetic counselor if there is any indication e.g. hereditary
disease.
 She may need tertiary care center if she develops any complications.
Investigations:  CBC
 RBS
 Urine culture & sensitivity
 Urine dip stick
 U/S

Observation:  To be seen after the result of her investigation are ready

or after 2 - 4 weeks
 Self awareness
My feelings:  I may feel anxious in dealing with high risk pregnancy lady like this
patient.
 How can I help her if she lost this pregnancy, she might become
depressed and angry from me.
 I will feel very sad if she lost her pregnancy

Possible ways to deal with my feelings:

 Express my feeling by showing to her extra care and empathy.
 I may discuss her problem with her OB specialist, this may give me
some satisfaction.

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ANSWER MEQ3:
Two days later Mrs. Sabreen came to you complaining of vaginal bleeding. Discuss your
management of this situation.

 Maintaining Doctor – Patient Relationship :

 Treat her energetically to show how much I care?
 Show empathy (I understand how much it is important to
you to save this pregnancy).
 Help her to lay down on the examination couch if this is
more comfortable for her.
 Assess vital signs immediately while taking history,
because she might need resuscitation (hypovolemic shock
because of bleeding).
 Physical assessment :
History :  Nature of the bleeding:
Heavy or just drops or full fetus with clot
 Onset & duration of the vaginal bleeding.
 Any associated symptoms:
Abdominal pain /Fever / Severe headache
 Possible causes for abortion:
Infectious disease /Trauma / Congenital disease

Examination :  General appearance: Pallor / Exhaustion

 Vital signs: Pulse / BP / Temperature
 Abdominal examination:
Tenderness in the lower abdomin or Mass
 Vaginal examination:
Amount of bleeding
Fetal parts
Cervix: closed or open

Differential  If drop of blood & no abdominal pain, it is most probably

diagnosis: threatened abortion.
 If heavy bleeding & the cervix is open, may be it is
incomplete abortion.
 If heavy bleeding but the cervix is closed, it might be
complete abortion.
 Psychosocial assessment:
Patient ideas :  It is only local problem and nothing to do with her
pregnancy (denial).
 She may think she lost her baby and this is her last
chance of pregnancy.

concerns :  About her future trial of pregnancy (is it worthwhile).

 About her husband, he may look for another wife.
 About her future life, she will be lonely lady with no
children and no husband.
 About her health deterioration because of this bleeding.
 About her mother in law will stigmatize her for being a
hopeless infertile lady.

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 Expectations :  Treatment to stop this bleeding and save her pregnancy.
 D & C because she might think she already lost the baby.
 Referral to a special center to do anything to save her
pregnancy.
 Sick leave to give her a chance for complete bed rest.
Social resources :  Family support by her husband or mother or sisters or
friends.
 Support at work because she is physically & psychologically
fragile.

Risk assessment : 
Symptoms of depression e.g. her mood and interest in life.

Symptoms of pathological anxiety e.g. palpitation and
dyspnea.
 Bereavement (state of shock & denial).
 Immediate Managements :
Management options:
Reassurance :  Explanation of the findings and reaching
shared understanding of the situation: If it is
threatened, complete or incomplete abortion.
Investigations :  CBC to assess the degree of chronic bleeding
 Urgent US to establish the diagnosis of
abortion
 HCGT if low it may indicate abortion
Specific Treatment :
threatened  Bed rest may help but there is no Evidence
abortion : Based Medicine supporting this advice (EBM).
 Hormonal treatment may help, but there is no
Evidence Based Medicine supporting this
treatment.
 Grate proportion of patient with threatened
abortion can complete there pregnancy to the
end.

incomplete  She will need Dilatation & Curettage

abortion
complete abortion  Reassurance & bed rest
:
Referral & Observation :
 Mrs. Sabreen need urgent referral to hospital
for evaluation and may be for admission or D&C
 According to degree of bleeding and my
preliminary assessment, she may need referral
by ambulance after IV line insertion & supply of
oxygen
 A nurse or paramedic or even a doctor may
need to accompany her in the ambulance if the
bleeding is severe
 Long Term Managements :

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 Anticipatory Care :  If Mrs. Sabreen lost her pregnancy, she will
need close observation during bereavement for
early diagnosis of abnormal bereavement
reaction & appropriate intervention, e.g. Referral
to psychiatry
 If the diagnosis is threatened abortion, she
need social support & reassurance from her
husband and /or relatives to complete her
pregnancy
 Self awareness:
My feelings :  I may feel anxious in dealing with life threatening
situation (bleeding)
 I may feel depressed if Mrs. Sabreen lost her pregnancy
 I may feel helpless if the diagnosis is threatened abortion
and there is no effective (EBM) treatment which I can offer

Dealing with my  I will try to act promptly and be very cautions in my

feeling: decision e.g. I may accompany Mrs. Sabreen in the
ambulance if needed
 I may talk to her obstetrician to discuss the situation ,
this may give some relieve

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ANSWER MEQ 4:
Mr. Waseem is 28 years old, married, with 5 children. He works as a receptionist in a very luxurious
hotel. He noticed white spots spreading in his hands and trunk which was diagnosed by a competent
dermatologist as vitiligo, but Mr. Waseem did not accept the diagnosis and he came to you asking for
referral to another dermatologist.

1. What are the etiological factors for Mr. Waseem’s behavior?

 Patient factors:
Patient Ideas:  Vitiligo is an infectious disease & it may affect his
family.
 It is an acute illness and he will find radical treatment
for it by an expert dermatologist.
 It is a very serious illness & may progress to skin
cancer.

Patient Concerns:  He may loss his wife because of this disease and also
his friends.
 Losing his job in that luxurious hotel.
 He cannot find another job because no body likes his
appearance.
 The treatment is expensive and he can not afford its
cost.
 The disease may be hereditary & it will affect his
children.
 His daughters will be stigmatized and no body will
come to marry them.

Patient Expectations:  He needs more explanation about vitiligo.

 He wants more investigation to confirm the
diagnosis.

 Family factor :  His wife is pushing hem to ask for a second

opinion.
 Dermatologist :  His appointment system makes it difficult to see
him.
 May be he did not convince Mr. Waseem about
the diagnosis.
 May be he advised him to see another
dermatologist.
May be Mr. Waseem had difficulty in communicating
with him and needs to see another dermatologist.

 Doctor factor :
 The PHC physician may not have enough time to
discuss his worries with him.
 Lack of trust between the patient and his PHC
physician.
 Dependent Dr – Pt relationship makes the patient
think he can ask for anything any time.

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  The health care system :
 Flexibility of the referral system allows multiple referral.
 Different hospitals have different resources so the patient is asking for a
better hospital with more resources e.g. not every hospital has laser
treatment.

2. How are you going to end this consultation?

 Maintaining Doctor–Patient relationship:

 Express my empathy: (I can understand how you feel and how
this problem is affecting you).
 Being flexible and negotiating all possible management options
with the patient.
 Respecting his autonomy and let him make the final decision after
appropriate discussion of all options.

 Physical assessment:
History:
Family history:
Precipitating factors:
Risk assessment:
 Painless depigmentation of the skin.
 Hair changes in the affected area (becoming
white).
 Similar disease in the family
 Psychological stress at work or at home
 Possible associated autonomous disease e.g.
Thyroid disease, Pernicious anemia, DM,
Alopecia arietta in the patient and / or his
family.

Physical examination:  Well-defined oval or irregular depigmented

area.
 Common sites – axilla, groins, genitalia
dorsum of the hands and face.
 Psychological assessment:
ICE: (Refer to answer 1)

Effect of the problem:  Social isolation.

 Depression symptoms: mood & interest
 Anxiety symptoms :palpitation, nervousness
 Any financial problem or marital problem or
problem at work.

 Dealing with the demanding patient :

Clarification:  Why does he want referral to another
dermatologist?
 (His ideas, concerns & expectations)

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 Explanation & reassurance:  The disease is not uncommon, it is not
infectious.
 The disease is autoimmune, usually has no
complications, there are different treatments for
this disease, but no radical treatment e.g.
 Potent topical steroids, PUVA, sunscreens,
Disagree with Mr. Waseem : cosmetic camouflage.
 (No need for referral at all), but this option
may affect Dr. – Pt. relationship and also it may
Agree with Mr. Waseem : deny from him the benefit of another expert
opinion.
 (refer him directly to another dermatologist).
 By this option I may express my sympathy &
support and maintain Dr. – Pt. relationship.
 But it may make patient dependent, it might
be a waste of resources (unnecessary referral).
 The dermatologist may become angry from
my behavior.

 Negotiation of alternative solutions:

 (Negotiation & reaching with the patient a
compromising solution), e.g.
 No need for referral now, but if Mr. Waseem did not
benefit from the current treatment I will look for the most
expert dermatologist in this disease to refer this patient to
him.
 Order some investigation to rule out possible associated
disease e.g. Thyroid or pernicious anemia.
 Mr. Waseem may be depressed and need treatment for
his depression.
 He may have financial problem or marital problems and
need counseling, or referral to social worker or psychiatrist.

 Self awareness:
My feelings:
 Mr. Waseem might make me feel sad &
depressed because of the effect of vitiligo in his life.
 He may make me feel angry because of his
demanding behavior.
 I may feel helpless because there is no radical
treatment for his disease.

Dealing with my feeling:  During the consultation, express my empathy (I

can understand how much it is important to you to
have nice appearance).
 Ventilate my feelings by talking to a friend or
colleague.
 CME about recent management modalities for
vitiligo.

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ANSWER MEQ 5:
You are assigned as doctor in-charge of a health center, you decided to start mini-clinics for DM.

What are the issues raised by this decision?

 Assessment of needs :
 What are the prevalence of DM and what are the
priorities in this health center
 What are the needs of the population in the
catchment area of this center ? e.g. if they are
mainly young, they may need mini-clinic for
asthma more than DM or we may need to improve
vaccination clinic before starting a new mini clinic.

 Assessment of Resources :
Man Power :  Trained and interested nurse.
 Trained and interested doctors.
 May be social workers and / or dietitian.
 Lab technicians.
 Trained receptionist.
 If they are not trained, they need special training
before the center can start the clinic.

Materials & equipment  Drug needed for patient. With DM

:  Lab & equipment for basic investigations
 Free access to central lab for other important
investigations
 Registers & special files

Space & Time :  Suitable room for the clinic

 Suitable waiting area for the clinic
 Suitable appointment system & enough
consultation time

 Protocol of the clinic:

 The local Ministry of health Protocol
 Or Royal College of General Practitioner in UK Protocol
 Or any other agreed protocol

 Community Participation :
 The opinion of the community should be taken in to
consideration
 The role of the community may be discussed : e.g.
their role in offering some help to get the necessarily
equipment, and their role in compliance

 Plan for Implementation :

 Advertisement for the clinic
 Identification of target population , e.g. from the High
Risk Register or From

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  Arrangement of routine referral to hospital
 Time : how many sessions per week ? what sort of
appointment system
 Space : in the dr. consultation room or special room
for the clinic
 Staff : special staff for the clinic or every doctor take
care of his diabetic patient

 Evaluation of the Clinic :

 Comparative study between the present situation and
after 6-12 months of implementation of the clinic. E.g.
Evaluation of level of blood sugar control or evaluation
of patient knowledge & attitudes towards their illness
(DM)

 Advantages of the Clinic

 This clinic may improve patient care
 It may improve community participation
 It improve team work
 It is a good chance for Personal growth & Continuing
Medical Education
 It is may be of political benefit especially if the issue is
important for the higher authority

 Disadvantages of the Clinic
 Such clinic need a lot of time , effort , resources &
commitment
 It may affect other activity in the health center by
shifting of limited resources

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