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By B. Achmed. Troy State University.

In addition generic 4.5 mg exelon mastercard symptoms pulmonary embolism, most people Example of a key feature question involved consider them to be a suitable approach buy exelon 6 mg with visa medicine song, which makes them more acceptable. Yesterday you made a house call on Mr However, the key feature approach is rather new and Downing. From your history taking and physical examination you therefore less well known than the other approaches. You gave an intramuscular injection of construction of the questions is time consuming; inexperienced 100 mg diclofenac, and you left him some diclofenac suppositories. Nevertheless, these questions are respond well to the diclofenac, but since 5 am he has also had a continuous pain in his right side and a fever (38. Students should understand that an option may be Example of an extended matching question correct for more than one vignette, and some options may not (a) Campylobacter jejuni, (b) Candida albicans, (c) Giardia lamblia, apply to any of the vignettes. The idea is to minimise the (d) Rotavirus, (e) Salmonella typhi, (f) Yersinia enterocolitica, recognition effect that occurs in standard multiple choice (g) Pseudomonas aeruginosa, (h) Escherichia coli, (i) Helicobacter pylori, (j) Clostridium perfringens, (k) Mycobacterium tuberculosis, (l) Shigella questions because of the many possible combinations between flexneri, (m) Vibrio cholerae, (n) Clostridium difficile, (o) Proteus mirabilis, vignettes and options. Also, by using cases instead of facts, the (p) Tropheryma whippelii items can be used to test application of knowledge or problem For each of the following cases, select (from the list above) the solving ability. They are easier to construct than key feature micro-organism most likely to be responsible: questions, as many cases can be derived from one set of options. On physical examination there is answers is easy and could be done with a computer. Abdominal radiography shows free air under the unknown, so teachers need training and practice before they diaphragm x A 45 year old woman is treated with antibiotics for recurring can write these questions. She develops a severe abdominal pain under-representation of certain themes simply because they do with haemorrhagic diarrhoea. Extended matching questions are best used pseudomembranous colitis is seen when large numbers of similar sorts of decisions (for example, relating to diagnosis or ordering of laboratory tests) need testing for different situations. Conclusion Choosing the best question type for a particular examination is Using only one type of question not simple. Extended-matching items: a practical alternative to free response questions. Further developments in assessing clinical competence;proceedings of the second Ottawa conference. Assessment of clinical competence: written and computer-based simulations. A comparison of free-response and multiple-choice forms of verbal aptitude tests. An approach to the assessment of medical problem solving:computerised case-based testing. Assessment of clinical skills has formed a key part of medical education for hundreds of years. However, the basic requirements for reliability and validity have not always been achieved in traditional “long case” and “short case” assessments. Skill based assessments have to contend with case specificity, which is the variance in performance that occurs over different cases or problems. In other words, case specificity means that performance with one patient related problem does not reliably predict performance with subsequent problems. For a reliable measure of clinical skills, performance has to be sampled across a range of patient problems. This is the basic principle underlying the development of objective structured clinical examinations (OSCEs). Several other structured clinical examinations have been developed in recent years, including Written tests can assess knowledge acquisition and reasoning ability, but they modified OSCEs—such as the Royal College of Physicians’ cannot so easily measure skills Practical Assessment of Clinical Examination Skills (PACES) and the objective structured long case (OSLER). This article focuses mainly on OSCEs to illustrate the principles of skill based assessment. OSCEs The objective structured clinical examination (OSCE) was introduced over 30 years ago as a reliable approach to assessing basic clinical skills. It is a flexible test format based on a circuit of patient based “stations.

Most of these disorders present in infancy or early childhood with hypotonia discount 1.5 mg exelon with mastercard symptoms quotes, muscle weakness 1.5mg exelon amex symptoms your period is coming, and delayed achievement of motor milestones. DIAGNOSIS AND CLINICAL FEATURES The congenital myopathies have a number of common features: early-onset general- ized weakness, hypotonia and hyporeflexia, and a characteristic body habitus with thin elongated facies, high arched palate, slender build, poor muscle bulk, scoliosis, and pectus carinatum. Each is defined by a single distinguishing, but not specific, morphologic abnormality in muscle fibers. Clinical clues to the specific diagnosis may include the pattern of inheritance and associated features such as ophthalmople- gia and cardiomyopathy (Table 1). Certain congenital myopathies are well defined clinically, morphologically, and genetically (Table 2). A number of other conditions with specific structural abnorm- alities remain that have not, as yet, been associated with a demonstrable genetic abnormality. Other myopathies seen in childhood include infantile and juvenile- onset acid maltase deficiency, the inflammatory and metabolic myopathies. THERAPEUTIC CONCERNS There are no curative therapies for the congenital myopathies. A multidisciplinary approach to the treatment of individual patients will, however, greatly improve their quality of life and may influence survival. Management of individuals with a conge- nital myopathy should include the following considerations: prevention; monitoring; risk management; and symptomatic therapy and rehabilitation. PREVENTION Genetic counseling for families with congenital myopathies can be challenging, even for those disorders in which disease genes have been identified and molecular genetic testing is available. Causative mutations are identified in only a minority of cases, and in many cases genetic heterogeneity and clinical variability limit the extent to which definitive genetic counseling is possible. Clinical evaluation (and even muscle biopsy) of other family members may identify very mildly affected relatives. Table 2 Congenital Myopathies with Identified Gene Loci Chromosome Disorder Protein and gene (symbol) Inheritance localization Nemaline myopathy Nebulin (NEB) AR 2q 21. Congenital Myopathies 187 MONITORING AND PROSPECTIVE DETECTION OF MEDICAL COMPLICATIONS The mainstay of therapy for patients with congenital myopathy is early detection of disease manifestations and complications. Particularly important to management of these children are regular monitoring of pulmonary function and sleep, early identi- fication of cardiac involvement, nutritional care, maintenance of mobility, and screening for scoliosis (Table 3). RISK MANAGEMENT Surgical Procedures and Anesthetic Risks Malignant hyperthermia (MH) is characterized by uncontrolled hyperthermia in response to certain anesthetic agents and depolarizing muscle relaxants. Central core disease and multiminicore disease are the only congenital myopathies clearly asso- ciated with an increased risk of malignant hyperthermia. Because the diagnosis is unknown in most patients undergoing muscle biopsy, however, MH precautions should be taken in all cases prior to definitive diagnosis. The first exposure to trigger- ing substances elicits an event in only 50% of MH susceptible patients, so previous tolerance to halothane, succinylcholine, or other depolarizing neuromuscular block- ade medications does not guarantee safe future use of these agents. In general, patients with congenital myopathy tolerate surgical procedures and general anesthetics well, but it should be recognized that they have an enhanced risk for respiratory decompensation postoperatively. Preoperative assessment of respira- tory status is important in determining the timing of surgical intervention. Prolonged postoperative immobility may exacerbate or worsen muscle weakness. Patients should be mobilized as soon as possible after a surgical procedure. SYMPTOMATIC THERAPY AND REHABILITATION Respiratory Care Respiratory muscle weakness is common to many of the congenital myopathies and is the primary cause of death from these disorders at all ages. It important to be aware that the degree of skeletal muscle weakness does not necessarily reflect that of respiratory muscle involvement. Respiratory compromise occurs secondary to involvement of the intercostal muscles and diaphragm and may be exacerbated by scoliosis. Bulbar weakness increases the risk of aspiration, and poor nutritional sta- tus may increase susceptibility to respiratory infection. Respiratory failure can occur at any age and may be of very sudden onset. Most patients, even those with no symp- toms of pulmonary disease, will show restriction of their respiratory capacity on for- mal testing. Patients with congenital myopathy also run a great risk of insidious nocturnal hypoventilation, symptoms of which include sleep disturbance, night- mares, morning headache, daytime fatigue, and weight loss. Nocturnal hypoventila- tion may occur even in the absence of diurnal symptoms.

One of the difficulties students might have under such circumstances is the contrast between what you do in practice and what you expect of the students generic exelon 3mg without prescription medicine 3604. The important thing is for the students to see you in action exelon 3mg cheap medicine abuse, particularly in regard to the way you relate to the patients while at the same time achieve the medical aims of the encounter. Even in busy clinical situations it is important to demonstrate a concern for the patient’s feelings. Involve the student: the need for active participation is the recurrent theme throughout this book and nowhere is it more important than in the clinical teaching situation. This may range from talking to a patient, checking physical signs, presenting the case history, answering questions and looking up clinical information for presentation at the 74 next teaching session. In general try and make sure all the tasks are directly related to the patients the student has seen. Observe the student: as mentioned earlier, a consistent finding in studies of clinical teaching has been a lack of direct observation of student interactions with patients. All too often the clinical teacher starts with the case presentation and many never check to see whether the features described are actually present or were elicited personally by the student. Serious deficiencies in clinical skills are consistently found in interns and residents which must be an indictment of the undergraduate clinical teaching. Only a commitment to the somewhat boring task of observing the student take the history, perform the physical examination and explain things to the patient will allow you to identify and correct any deficiencies. This type of activity is particularly essential with junior students and must be conducted in a sympathetic and supportive way. Provide a good teaching environment: the more senior and prestigious you are, the more intimidating you are likely to appear to the students. It is vital that you adopt a friendly and helpful manner and reduce the natural and inevitable apprehension felt by your students. Not only may they be apprehensive about you, but they will also be apprehen- sive about their impending contact with patients. You can assist this by preparing the patients and by showing to the students you understand their fears. IMPROVING THE CLINICAL TUTORIAL Clinical tutorials are all too oftendidactic with the emphasis being on a disease rather than on the solving of patient problems. We firmly believe the clinical teacher should concentrate on the latter. The students will inevitably have many other opportunities to acquire factual information but relatively little time to grapple with the more difficulttask of learning to apply their knowledge to patient problems. It is sad, but true, that in traditional medical schools the students are often as much to blame as their teachers by encouraging didactic presentations, particularly when examinations are imminent. Surprisingly, clinical teaching 75 in problem-based schools often exhibits the same char- acteristics. Plan the teaching: once again it is important to establish the aims of the sessions you have been allocated. In either case you must be sure in your own mind what you intend to achieve in each session. Involve the student: make it clear from the beginning that you expect most of the talking to be done by the students and that all of them are to participate, not just the vocal minority. At the first session, explain what tasks you expect them to perform in preparation for each tutorial. You may, for example, expect them to prepare cases for discussion or to read up aspects of the literature on a particular subject. Provide a good teaching environment: the way in which you set up the session is vital for its success, particularly when you wish to encourage active participation. Your role as a facilitator, not the fount of all knowledge, must be emphasised and you must resist the temptation to intervene with extra information all the time. This is very hard to avoid but if it happens too frequently you will soon find all conversation is channelled in your direction and there will be no interaction between the students. As the clinical tutorial is another form of small group teaching you should read Chapter 4 for further advice. Concentrate on clinical problem solving: in the last thirty years there has been a substantial research effort into how doctors and students go about solving clinical problems.

For exam- ple discount exelon 6 mg with visa 5 medications post mi, software could locate particular words or phrases; make lists of words and put them into alphabetical order; insert key words or comments; count occurrences of words or phrases or attach numeric codes order 6 mg exelon amex symptoms nausea headache fatigue. Some software will retrieve text, some will analyse text and some will help to build theory. Although a computer can undertake these mechanical processes, it cannot think about, judge or inter- pret qualitative data (see Table 10). QUANTITATIVE DATA ANALYSIS If you have decided that a large survey is the most appro- priate method to use for your research, by now you should have thought about how you’re going to analyse your data. You will have checked that your questionnaire is properly constructed and worded, you will have made sure that there are no variations in the way the forms are administered and you will have checked over and over again that there is no missing or ambiguous information. If you have a well-designed and well-executed survey, you will minimise problems during the analysis. Computing software If you have computing software available for you to use you should find this the easiest and quickest way to ana- lyse your data. The most common package used by social scientists at this present time is SPSS for windows, which 122 / PRACTICAL RESEARCH METHODS TABLE 10: USING COMPUTERS FOR QUALITATIVE DATA ANALYSIS: ADVANTAGES AND DISADVANTAGES ADVANTAGES DISADVANTAGES Using computers helps to In focus groups the group moves alleviate time-consuming and through a different sequence of monotonous tasks of cutting, events which is important in the pasting and retrieval of field analysis but which cannot be notes and/or interview recognised by a computer. Computers are a useful aid to Programs cannot understand those who have to work to tight the meaning of text. Programs can cope with both Software can only support the multiple codes and over-lapping intellectual processes of the codes which would be very researcher – they cannot be a difficult for the researcher to substitute for these processes. Some software can conduct Participants can change their multiple searches in which more opinions and contradict than one code is searched much themselves during an interview. Programs can combine codes in The software might be beyond complex searches. Programs can pick out instances User-error can lead to of pre-defined categories which undetected mistakes or have been missed by the misleading results. Computers can be used to help Using computers can lead to an the researcher overcome over-emphasis on mechanical ‘analysis block’. HOW TO ANALYSE YOUR DATA/ 123 has become increasingly user-friendly over the last few years. However, data input can be a long and laborious process, especially for those who are slow on the key- board, and, if any data is entered incorrectly, it will influ- ence your results. Large scale surveys conducted by research companies tend to use questionnaires which can be scanned, saving much time and money, but this op- tion might not be open to you. If you are a student, how- ever, spend some time getting to know what equipment is available for your use as you could save yourself a lot of time and energy by adopting this approach. Also, many software packages at the push of a key produce profes- sional graphs, tables and pie charts which can be used in your final report, again saving a lot of time and effort. Most colleges and universities provide some sort of statis- tics course and data analysis course. Or the computing de- partment will provide information leaflets and training sessions on data analysis software. If you have chosen this route, try to get onto one of these courses, especially those which have a ‘hands-on’ approach as you might be able to analyse your data as part of your course work. This will enable you to acquire new skills and complete your re- search at the same time. Statisticl techniques For those who do not have access to data analysis soft- ware, a basic knowledge of statistical techniques is needed to analyse your data. If your goal is to describe what you have found, all you need to do is count your responses and reproduce them. This type of frequency count is usually the first step in any analysis of a large scale survey, and forms the base for many other statistical techniques that you might decide to conduct on your data (see Example 12). For example, someone might be unwilling to let a researcher know their age, or someone else could have accidentally missed out a question. If there are any missing answers, a separate ‘no answer’ category needs to be included in any frequency count table. In the final re- port, some researchers overcome this problem by convert- ing frequency counts to percentages which are calculated after excluding missing data. However, percentages can be misleading if the total number of respondents is fewer than 40. HOW TO ANALYSE YOUR DATA/ 125 EXAMPLE 12: TOM Tom works part-time for a charity which provides infor- mation and services for blind and partially sighted peo- ple in the town. He was asked to find out how many people use the service and provide a few details about who these people are and what they do in life.