Prepared by Dr. Mohammed AlAteeq Structured Oral Exam (SOE) Mock exam checklist malateeq@hotmail.com @drmalateeq You are the manager of a primary care center. You receive a letter from the principal of the neighborhood primary school to provide a health services inside the school. Daman Teed] Quedon ideal answer Waris | Tames Seore * Professional 1 / R&R of the Ministry in this regard | * Communicator ‘What issues you 2. My team: attitude, interest, experience need to conser | 3. My patents my practice: postive and negative betoresccentingor | eect refusing? 4. Myself: interest / experience / Time 20 Merton | 5. Schoo: aval reoures, experience, heath sats, et 6. Other tematie agencies or partners 7._Finaneial nd funding sues > Proesional | Whatarethe 1. More experince forme and my team | Heath advantagesot | 2 Settercommuntyivoherent Advocate acceptingthe | 3. Decrease load on my practice 20 request? | 4. Empowerment of stents and teachers Mentions 4 5._May have more money incentives : > Profesional | What are the 1 May sfect my practice & my patois * Health disadvantages of || 2. May face difficulties due to lack of experience | Advocate accepting the 3. May be rejected by my team: conflict 20 request” | &. ay lacksuppor fxm partners Mentions | 5 Mayatfct my practice pros > Manager 1 Meeting and dcussion wth my a communietor | Ifyouaccept how | 2. Communicate with my authority * Collaborator would you start the | 3. Visit the school / meeting with school staff miso? [4 Doasuveyandevaluaton fren stan | 20 Mortons |. Setanaction lan 6. Arrange for necessary tring | 7._Resoureemabiiation and alocstin ‘© Medical Expert '* Seasonal,e.g.: Mass vaccine / Health inspection / © Scholar Ifyou accept, what food & water sanitation / infection control / Pre- © Health heath service you admission checkup coo maumrewte? | cominuous.e¢. Shoo clini ER sence » + Preventive: edstional caries for public,students, parents / vaccines / infection conta Curative: One vi R sevice Tota 0Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeg@hotmail.com @drmalateeq Theme: Quality improvment Question Ideal Answer Marks | Trainee Score What is quality improvement? lis a method of continuously examining processes and making them more effective 20 The principles of Q) ‘* Astrong focus on customers — in our case, patients, '* Continuous improvement of all processes; ‘+ Involvement of the entire organization in the pursuit of quality; ‘* Use of data and team knowledge to improve decision making. 20 What are the preliminary stages of any QI project? © Finding key problems * Identifying potential changes ‘+ Prioritizing the opportunities for change 20 | What are the tools for finding key problems? ‘+ Ask your “customers.” Ask your patients, staff and colleagues for their ideas about how your practice might improve + Look for muda. , the uselessness and futility, the manifest in any activity that has no added value, ‘* Doan internal review / Auditing ‘© Consult external reviews / 3rd party ‘*_Find out what others have done well 20 What frame to use to start the change? FOCUS model ‘* Find a process to improve, ‘© Organize the team and its resources, ‘+ Clarify current knowledge about the process (analyze baseline data), ‘* Understand sources of variation and clarify steps in the process, ‘+ Select an improvement or intervention. Ther plan-do-study-act cycle: * Plan: Analyze the process, determine what changes would most improve the process, and establish a plan for making the. improvement; ‘+ Do: Put your change into motion on a small scale or trial basis; * Study: Check to see whether the change is working: ‘+ Act: Ifthe change is working, implement it on a larger scale. If the change is not working, refine itor reject it and begin the cycle again 20Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateea@hotmall.com @drmalateeq Self-Awareness Question Ideal Answer Marks | Trainee Score What is self-awareness? * An individual's tendency to pay attention to his or her own emotions, attitudes, and behavior in response to specific situations ‘* The various aspects of an individual's ability to direct attention inwardly (ie., to an insight or introspection into his or her own thoughts, attitudes, behavior, well-being, emotions, appearance, 20 Why we need self- awareness in medical practice? and competence) ‘Doctors’ emotional makeup's (e-., wellbeing, fears, attitudes, and self-assessed level of competence) may affect their patients’ care * Many factors in this regard affect patient care: conflict between the needs of patients and clinicians, strong emotions: the patient's and one’s own, technical errors, witnessing unbearable suffering, contradictory evidence, unanticipated serious illness, impermanence of knowledge, illusion of competence, lack of control, miscommunications and misunderstandings * Medical judgment is easily derailed by unexamined emotions, failure of curiosity, low-level heuristics, over-concreteness / rigidity, Inability to reframe the encounter ‘+ Physical or mental discomfort, whether transient (eg. fatigue, a recent conflict with another person) or chronic (e.g., alcoholism, depression, burnout), may impair clinical judgment and cause distraction and irritability ‘+ Fear of malpractice tigation may result in avoidance of high risk patients and procedures, or in a defensive ordering of diagnostic tests even when clinical judgment deems them to be unnecessary * Adoctor who expects patients to simply obey his or her orders ‘may become intolerant of those who want to be informed about their diseases and to participate in making clinical decisions How to improve self awareness? irect teaching intervention: * Focusing on doctor's feelings and emotional difficulties that arise in response to various clinical situations, '* Help them recognize how: - their feelings shape their behavior - this behavior affects patients and colleagues - doctors' values, needs, motives, and attitudes influence their practice of medicine. * Enhance doctor's private self-awareness, beliefs and attitudes , feelings and emotional responses to patient care . Educate about coping with challenging clinical situations (e.g.,‘medical errors, angry patients, patients with a terminal lines) * Educate about self-care (e.g, stress management, prevention of burnout). fect teaching interventions: Analysis of common patient complaints ‘Analysis of the variability in doctors counseling of different patients about their illnesses Training doctors to assess their own performanceStructured Oral Exam (SOE) Mock exam checklist Prepared by Dr. Mohammed AlAteeq, malateea@hotmail.com @drmalateeg Topic: patient safety Question [ Ideal Answer | What is patient safety? Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum, ‘What is the difference between patient safety and quality? ‘+ Patient safety is an important element of an effective, efficient health care system where quality prevails. * Safety has to do with lack of harm. Quality has to do with efficient, effective, purposeful care that gets the job done at the right time. ‘+ Safety focuses on avoiding bad events. Quality focuses on doing things well ‘+ Safety makes it less likely that mistakes happen. Quality raises the ceiling so the overall care experience is a better one. Interventions to Improve Safety and Examples of Potential Benefits to Patients, Staff, and Organizations * Safe patient handling: Patient lifting equipment; no-lft policies; specialized lift teams * Fall prevention: Patient assessment; safe-transfer technique; slipresistant flooring materials; absorbent floor mats ‘* Sharps injury prevention: Sharps with engineered sharps injury protections; blunt suture needles to prevent needle sticks, surgical injuries; minimize hand transfers of surgical instruments ‘+ Infection prevention: Health care worker immunization; hand hygiene; standard precautions; personal protective equipment ‘* Assault and violence prevention and management: Frontline staff and security staff training; track patients with history of disruptive behavior * Security in the neighborhood and facility: Lights, locks, video surveillance; training on threat recognition ‘+ Prevent exposure to hazardous drugs: Ventilated cabinets; closed system transfer devices; needleless systems; administrative controls; proper personal protective equipment * Active surveillance, analysis and feedback of adverse events, environmental hazards and risks Reporting “near misses"; safety walk-arounds; periodic health and safety inspections ‘+ Ergonomics and human factors engineering, work flow redesign: Adaptive clothing and scheduled toileting for residents; mechanical lift equipment; supply kits; toilet seat risers * Appropriate staffing levels, mix and workload assignments: Work-hour restrictions, evidencebased shift length, rotation, rest periods ‘+ Safer design of practices and built environment: Improved ventilation, surfaces, water systems, private rooms, room design, and equipment proximity; healing environments What are the factors that enhance patient safety? 1. Leadership and committed admin 2. Creating safety culture 3. Employees involvement 4. Analysis of worksite hazards 5. Prevention and control of workplace hazards 6. Safety and heath training 7._Accident and incidents investigationStructured Oral Exam (SOE) Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeq@hotmailcom @drmalateeq Norah, one of your patients, brings her only son, Mohammed. He is 7-years-old and still bed wets during the night. That affects the relationship between her and her husband as he is blaming her for not being a careful mother. How would you manage this case? Question | Ideal Answer =e] What do you think about this consultation? © Itis difficult situation which affects child and family / very sensitive burden & stigma so need time for full management * we may need to evaluate both separately | [need to consider my feelings and experience in dealing with such case How would you | ‘manage the child? * Full history: is it Primary or Secondary? * Examination: e.g. Growth chart, congenital disease / * Assess for possible psychological complication on the kid: depression / isolation / decreased school performance ...etc. * Investigation: e.g. U/A / Blood Sugar * Assess mother knowledge and previous intervention done so far * Treatment options: © Pharmacotherapy, e.g. minirin tab / TCA © Alarm system / caring for his room...etc © Education & advice * Caring for the psychological wellbeing: not blaming, encouraging, explaining * Confidentiality + Set FU to check: improvement, treatment effect, SE, .etc What about managing other aspects of this case? Caring for the mother: ~ Assess level of stress and marital disharmony / family life disruption / is she over caring? / look for other possible clues of wife abuse by husband - Assess for pathological reaction to stress, e.g. Depression: Review symptoms © Past history © Self-measures for alleviation - Find out her expectation for herself and her son: © Support? From her husband© Family therapy? © Cure of bedwetting? © Explanation & reassurance? Manage: © Support / counseling / Advice © Refer to psychotherapist if indicated © Talking to the husband indirectly, next visit to attend with the kid o FUStructured Oral Exam (SOE) Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeq@hotmail.com @drmalateeg During your duty in the clinic, a mother presented to you because her 3 years old boy is complaining, of acute pain in right wrist. The mother contributes the pain to recent trauma of the hand while the ‘boy was playing. During physical examination, you noticed multiple bruises in upper and lower limbs of different stages. [Question Ideal Answer =e How would you |* Full history: manage the injury? ‘© being nonjudgmental, non-prejudice © consider logical explanations given by mother © Consider biomechanics of injury Examination considering other signs of abuse, e.g. poor growth Possible investigation: e.g, skeletal survey Immediate treatment, e.g. pain killer, bandage, immobilization. ete Consider referral and admission for medical or social reasons How would you be dealing with suspected physical abuse or neglect, Being aware of suspected abuse and how to manage Full social and psychological history of family / caregivers Consider consent for proceeding as a case of abuse Identifying the perpetrator / other victims in the family Consider other family violence and dysfunction Safety of mother and kids at home. Documentation: reporting, photographing. etc Multidisciplinary approach: Involvement of other healthcare team: social workers / pediatrics...etc Availability of Rules/ Regulation for management of suspected abuse | Can you see any ethical aspect in this case? Confidentiality vs safety: mother may ask not to disclose the case but this may hinder safety Autonomy: respect the autonomy versus child benefit| For you asa treating physician, can this case affect you in nay way? Acknowledge difficulty of case Dealing with uncertainty Need to consult seniors / experts Control of emotions Housekeeping Consider legal implication on you, e.g. testifying in the courtStructured Oral Exam (SOE) Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeq@hotmail.com @drmalateeq Topic: outbreak investigation Question - Ideal Answer [ score | What is disease outbreak? ‘* Adisease outbreaks the occurrence of cases of disease in excess of what ‘would normally be expected in a defined community, geographical area or season ‘Whats the difference between | Endemic: a disease that exists permanently in a particular region or epidemic, endemic and population. Malaria is a constant worry in parts of Africa. e.g, | pandemic diseases ‘© Epidemic: An outbreak of disease that attacks many peoples at about the same time and may spread through one or several communities. Pandemic: When an epidemic spread throughout the world What are the steps in investigating an outbreak of disease? 1. Prepare for field work 2._ Establish the existence of an outbreak 3. Verify the diagnosis 4. Construct a working case definition 5. Find cases systematically and record information 6. Perform descriptive epidemiology 7. Develop hypotheses 8, Evaluate hypotheses epidemiologically 9. As necessary, reconsider, refine, and re-evaluate hypotheses, 10. Compare and reconcile with laboratory and/or environmental studies 11. Implement control and prevention measures 42. Initiate or maintain surveillance 13. Communicate findings What are the reasons for |» by identifying and eliminating the source of infection, we can prevent Investigating an outbreak? additional cases * the investigation may lead to recommendations or strategies for Preventing similar future outbreaks ‘+ describe new diseases and learn more about known diseases evaluate existing prevention strategies, e.g,, vaccines teach (and learn) epidemiology address public concern about the outbreakStructured Oral Exam (SOE) Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateea@hatmailcom @drmatateeg You have been requested by your manager in a Family Medicine Clinic to do a peer review of medical Charts for one of your colleagues. In reviewing the charts, you found that a mammogram was requested for a 48 years old lady and the result reported 4 months ago to be positive for breast mass and biopsy was advised. No documented visit for that patient since that time. Question - Ideal Answer =a) How would = Why pt did not show up? you manage ‘© Seen but no documentation? this patient? © Could not reach the doctor after missing appointment? (© Not educated about importance of FU © Fear of result? © Following in other hospital Manage her condition: (© Urgent recall © reassessment © urgent referral, e.g.to General Surgery - Break bad news = Support & counseling = _Orient about her right in suing the doctor or practice | What possible = communicate with the physician: issues related to © One to one? official? the treating (© Effect on professional and personal relation doctor? © Anticipate different reaction: anger, denial, burnout .te = Why doctor missed the case? (© Busy practice so revises scheduling of patients © Poor knowledge and skills in managing such condition, so need CPD, training © Poor documentation so train for proper documentation | (© Lack of reporting system so implement one © Lack of recall system so implement one = Orient him about possible medico legal consequences = _ Offer support / lawyer What possible = Se guidelines for Breast disease management issues relatedto | - Set effective recall system practice = Set effective reporting system of results = Set registry for high risk conditions ~ Educate and train doctors in management of breast disease + Manage busy practice: (© Booking system © Triage system _ -__Manage possible effect of the problem on practice reputation ‘What possible = Set a campaign about breast disease issues related to | - Set a campaign about importance of continuity of care & FU community? | |Structured Oral Exam (SOE) Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeq@hotmailcom @drmalateeq Topic: patients gifts ‘+ _ Inthe other hand, refusing it may cause embarrassment that could unnecessarily harm the relationship between a doctor and a patient. * _Soiit may hard to me to deal with such situation Question ideal Answer woe Why patients give [To show genuine gratitude gifts to their ‘+ Toredress the balance in terms of power sharing doctors? © Outof affection ‘+ Toattract attention + To manipulate the practitioner to carry out preferential treatment or some other treatment they would not normally give + _Toexpiate guilt for burdening the practitioner - what factors tobe | the reasons why a patient is giving a gift considered incase | the cost ofthe gift in proportion to the patient's means of patient’ gifts? |e the appropriateness of the gift | ‘+ whether there are particular circumstances +The timing of the gift _ What difficulties |» There are clear ethical obligations that prevent me from accepting gifts form patients youcan see inthis | There isa risk that accepting a gift could alter the way in which a patient is treated or situation ? ‘encouraging favoritism or preferential treatment. | What is the proper You must not encourage patients to give, lend or bequeath money or gifts that will response? directly or indirectly benefit you '* Incase patient gives a gift, you should discuss the issue with him/her ‘+ refuse the gift ina polite way ‘+ explain why you refuse the gift L + offer other ways (donation for the hospital or the clinic..etc) eee AAD AD 8 Aad LS UT Sa A 8 35g a al Gy pL Sw eS pe ed ol (9) (12) Balas Gah yl glad! iy Ale yall» 5a ll hal oh a el YN see Adal gy J CI AANA. gf Cal SY gl Gla pd paca Laas eal ig) Ge plea (gacall yx all SLIDE!) GS hy Syne le OS day eld jens 85 E I Gee Oe GSU: gs] ADE Yl ES Ag gly lala jae Be) CS Sys yl Lay Ua 5 jp le Sy 392 y 3) PBS Ba pally Lana 5 ge Ge | used pg LS (gle Gull Sc! Lea Mintle Glagll Sm pte eal pats Lah 5 py Lae Hg Uk gay ull Daal yall CS DNAs S sla tee Ga dedi gle tsStructured Oral Exam (SOE) Mock exam checklist Prepared by Dr. Mohammed AlAteeq, malateea@hotmail.com @drmalateeq Topic: medical malpractice Question Ideal Answer score What is meant by medical malpractice? Medical malpractice occurs when a patient is harmed by a doctor (or other medical professional) who fails to competently perform his or her medical duties. Give examples of medical malpractice Failure to diagnose or misdiagnosis Misreading or ignoring laboratory results Unnecessary surgery Surgical errors or wrong site surgery Improper medication or dosage Poor follow-up or aftercare Premature discharge Disregarding or not taking appropriate patient history Failure to order proper testing Failure to recognize symptoms ‘+ Conducting experiments or scientifically unestablished research on patients * Failure to consult anyone the consultation of whom is necessitated by the condition of (| a patient What are the basic requirements for a claim in case of medical malpractice? To prove that medical malpractice occurred, you must be able to show all these things: ‘© Adoctor-patient relationship existed. * The doctor was negligent * The doctor's negligence caused the injury (physical or mental harm / additional health cost / loss of work or earning capacity) What are challenges in dealing with medical malpractice? Under reporting by patient/ institution Lack of legislations Lack of proper documentation and prove of malpractice Finding a Qualified Medical Malpractice Lawyer Insurance Company Pressure Complicated Medical EvidenceStructured Oral Exam (SOE) Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeg@hotmailcom @drmalateeq Topic: Saudi Health Reform Aaa] Giga Athy plalh paca) GUnALl Lael! il gly Cuil gl aacagy GI il CAML y ApS cy lly ginal halls BLA) aa atsh Al pay sqgrsall LA Ge AB ly Atal Aaa 5a ay Uys ge gay Gevcall Gi I dg] pre] Asai b danall yy ale $2030 45) case pe oad Gy ule ae Gaal I BENT Ga Gut gall Gu 1 Gately pal) ye tbil Gi Lass le Hye Ce gll) Ais ph Ayal an all al Spot co Sl DS Hal B98) Lal asa ctl all pay Ca | jou Gepall Qgll Guade Ge Alaa ual Lal Lascal g gine 555 asi 3S41 Hall Lpasel LasS egy cht Sula Al QB sl igh ie jy WR analy cal Mia pa cl phy pally Gleaner gle Fag laced 5159 Cgasl jl le #2030 all lel Gas WY Gea Ge GL FA ga sl Maal Resell Clash) yi Ag by ght) Lat Spe 50 ae Lita hall Falah cag gall 5 pales Jali pale SHG Raat Be) Gedy Lad Gulia Blea pad Gh. 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Baal 5 al gal le Gy a hy Ql ey yall} HDB Ge Min ge Oty pally Cleaned yagi Al al pales gy oN a BS us Speed SL AY) AA jy Ged oS Kadi Apa hl go 85) ch 2030 cet avn tee all 1008) 3 32Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateea@hotmail.com @drmalateeg Theme: Conflict of interest ‘Question Ideal Answer ‘Marks | Trainee | Score Definition: A conflict of interest involves a conflict between the public Tellme how would | duty and the private interest of a public official, in which the official's 20 ‘you define conflict of | private-capacity interest could improperly influence the performance of interest? their official duties and responsibilities 1, [Gea Ihe relevant facts are clear 2. [Rpparent The relevant facts are not certain, Need further What are the types investigation 20 Peconic of 3. [PotentialJNo. atthe present moment, Oficial X has interests which ‘are not job-relevant, but itis reasonably foreseeable that in the future, X's personal interests could become relevant interests What conflict of 1. Dishonesty (e.g fraud, misrepresentation) 222i y= 4a> interest canleadto? | 2. Breach of the law or regulations 43 Gn0 Law so 3. Misuse of funds or resources Ber vere) 18 4, Abuse of position (e.g. to demand payment or impose a penalty unlawfully) 5. Failure to perform official duty adequately or correctly 1. Divestment (removal, sale, etc.) of the official's ownership or control of the private interest (asset, etc). another person may be given Wthere isa clear complete and independent control of the officials interest/asset. aruation of Confit Such a “blind teust” assignment/delegation of responsibility s fegone? 3 | 2. Recusal withdrawal ~ thats, by having another oficial temporarily Perform the officia’s duties etc. that otherwise would be affected by the conflict. Aledo L betno cis Give examples of |. Bonds with drug companies ~ ~ possible conflict of | 2. Treating relatives a5 interest in the 3. Treating VIP patients Profession of 4, Experimental treatment of patients | medicine | ‘+ Simple questionnaire-style framework for identifying the specifically | How conflict of relevant features of conflic-of interest situations in detail (self-test) fgasreeel ‘* Checklist for Identifying “At-risk” Areas for Conflict of Interest fT omer ‘+ Ethics Code Provisions Relevant to Conflict of interest ‘+ Auditing the practice regularlyPrepared by Dr. Mohammed AlAteeq Structured Oral Exam (SOE) - Mock exam checklist Theme: Telephone consultation malateea@hotmail.com @drmalateeq ‘Question Ideal Answer ‘Marks _ _ Score ‘When to use phone * Practice initiated calls: consultation? ‘+ most of the time by clerical team for appointment issues, recall..cte | «* Patient initiated calls for triage: | ‘+ Can be handled by receptionist, nurses or even by physicians to guide 20 the patient for the appropriate action, mainly during emergencies ‘* Patient initiated calls for full consultation and management: * For acute or chronic conditions / preventive care How to ensure safety | © Ensure all staff undertaking telephone triage have received in phone consultation? | appropriate training ‘+ Provide standard checklists or protocols to protocols for managing 20 ‘common scenarios and to ensure a safe approach ‘+ Implement back up system by a nurse practitioner or physician difficult cases. «Dedicated time and persons for telephone contacts ‘* Keep registry and documentation of all phone consultation with patients contact for follow up, possible recall, auditing...ete ‘What about the issue of confidentiality? ‘* Ensure all staff follow best practice in protecting confidentiality when contacting patients by phone. In particular, itis important to confirm the identity of the person 20 answering the phone _ + to ascertain the patient's preference regarding leaving messages. What are the ‘* Speed, improved access advantages of phone | # Decrease patient load on the clinic consultation? * convenience to patients a * possible cost savings What are the ‘© State your name and role important tips for | « Active listening and detailed history taking answering phone ‘* Frequent clarifying and paraphrasing (to ensure that the messages have coneaeny been got across in both directions) ‘* Picking up cues (such as pace, pauses, change in voice intonation) 20 + Offering opportunities to ask questions + Offering patient education / advice ‘* Documentation (date /time/ patient name, sex, age, contacts numbers or MRN)Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq, malateeg@hotmail,com @drmalateeq Theme: Medication safety in outpatient setting Question Ideal Answer Marks | Trainee Score Which patients are | Patients on multiple medications most at risk of ‘* Patients with another condition, e.g. renal impairment, medication error? pregnancy ‘+ Patients who cannot communicate well es + Patients who have more than one doctor ‘+ Patients who do not take an active role in their own medication use + Children and babies (dose calculations required) Whats the difference | Side-effect: a known effect, other than that primarily intended, between side effect, relating to the pharmacological properties of a medication, e.g. | adverse drug reaction opiate analgesia often causes nausea 2s | and medication * Adverse reaction: unexpected harm arising from a justified | error? action where the correct process was followed for the context in which the event occurred, e.g. an unexpected allergic reaction in a patient taking a medication for the first time * Medication error: failure to carry out a planned action as intended or application of an incorrect plan - What are the In prescribing: ‘common causes of ‘© Inadequate knowledge about drug indications and medication error? contraindication ‘© Not considering individual patient factors, such as allergies, pregnancy, co-morbidities, other medications ‘* Wrong patient, wrong dose, wrong time, wrong drug, wrong route ‘* Inadequate communication (written, verbal) ‘+ Documentation - illegible, incomplete, ambiguous ‘+ Mathematical error when calculating dosage 28 Incorrect data entry when using computerized prescribing e.g, duplication, omission, wrong number In administering: ‘© Wrong patient, drug, dose, rout and time © Omission, failure to admit Inadequate documentation ‘+ In monitoring: * Lack of monitoring for side-effects ‘Drug not ceased if not working, or course completed© Drug ceased before course completed ‘* Drug levels not measured, or not followed up ‘* Communication failures In what situations are staff most likely to contribute toa medication error? Inexperience Rushing Doing two things at once Interruptions Fatigue, boredom, being on “automatic pilot” leading to failure to check and double-check Lack of checking and double-checking habits Poor teamwork and/or communication between colleagues Reluctance to use memory aids 25Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeg@hotmail.com @drmalateeg Theme: Ethical dilemma Question Ideal Answer Marks | Trainee Score What is medical ‘+ itis a system of moral principles that apply values to the practice of 5 ethics? uuidusa sap|su09 pjnoys '595e9 [enPINpUl 40} (14a) aBere| se}oanjeoysUOI_ 'saseo paye2yidwo> pue BuluasioM 40} 10 anisnj>uodUl AXD 4.19 “{saIe.RIYU ‘Aseuownd :3uipuy p2123dxa) paulergo aq pinoys Aes x S949 papuowiworai s| sinoy 8o-2 UYRIM dr-mojiog‘ssaum axaN9s ssa] yamM SIUaned 40} siseq aseD ~Ag- 9589 & uo pasapisuo9 aq 1yBIW juaWaBeueW! uaReding 'ssaN}sIp ‘Asoyedtds94 Ut a4e J0 s1e woos uo (9¢<6>) uoneimes (ZO) paseaspap aney Aaya s!Jeuidsoy aya 01 paniuupe aq pinoys squaned gsaseo payiodas 404 auop aq ues sey TaUn0 yal (508pU4e5 0 "Spd a4 Spinby"SeDINap) ‘sanpoud ‘Buiden 40 ‘anjase8}o-9 Buseys ss Jenuarod 19430 ‘sn aoueasqns jo poyray pasn (sjaaiaag unos aoueasans pasn (sjaouersqns © :Buluonsanb ayenud jewwew2pnt-uou ‘snayedwo Bulsn ‘Bumolio} ayy Burpueda, Asoxsiy payierap wjergo ‘Aunful Bun} suanied e yo ABojon ‘ajqissod e se painadsns s|asn yonpoud “Buiden so ‘ayase812-9 41 “swioydusts jeuonnynsuos ue ‘Jeunsaujossse8 ‘Auoyenidsos ynoge shep 06 358) 1 Uuyaim asn aonposd ‘Bulden 40 ‘anase810-2 yoda1 oum swaned je sy ugar asn janpoud ‘Buiden so ‘aiase +940 Aloysty e pue A8ojone Jeajsun Jo Aunful Bun} jo sase> uodoy sa1121819 930 saBuep \pjeay ay anoge saninoe jwU09 e1A 0 BuNIas [eotulyo 2 quaryed nok areanp3 eaishyd Ayusey e se OP NOA pynoys ey,Prepared by Dr. Mohammed AlAteeq Structured Oral Exam (SOE) - Mock exam checklist ‘Theme: Model of Care malateea@hotmail.com @drmalateeq ‘Question Ideal Answer Marks Trainee | Score Why we need anew model of care? Poorly integrated services / fragmented care Poor outcome / increasing comy suboptimal productivity of health care providers Increasing expenditures Poor satisfaction of customers and providers Inequity of care Poor patient involvement / empowerment Poor virtual services Nonunified system/level of care What are the principles of MoC? ‘Empowering people and their families to take control of their health. Providing knowledge to people as part of their treatment and enabling them to be well-informed and in control of their health. Fully integrating the health system from the people's perspective. Keeping people healthy and focusing on the whole population through a preventive approach rather than a solely curative approach to health provision, Providing treatment in a patient-friendly and outcome-focused way, without over treating or under treating patients. From hospital to home From activity to outcome; What are the Mot From treatment to prevention themes? From institution to patient From physical building to virtual service; and From passive recipients to active participants Keep me well 6 initiatives (interventions) ees Planned care: 6 initiatives (interventions) i Maternity care: 7 initiatives (interventions) systems of care in Urgent care: 4 initiatives (interventions) ‘the Moc? Chronic care: 4 initiatives (interventions) End of life: 4 initiatives (interventions) ‘What are the service layers in the MoC? ‘Activated person Health community Virtual care Primary care General hospital care Specialized hospital care What are the cross- ‘cutting interventions in the MoC? PPE N Slee relpyeeNepwaeNe ‘School education programs Virtual Education and Navigation Tools Public awareness Campaigns Health Hotline services Enhanced Home care services Enhanced Primary Care Services7. National Referral Networks Integrated Personal Health Records 9. Systematic data collection 10. Outcomes monitoring 11, Resource optimization 12. Health research programs I Phyto whatever shee | > ersten 3. Soclnest 1 Workforce 2 neath wiatarethetay | 3. Prat sector pariatin enablersotMoct | 4. Aopropte pamnentmeransm 5. Governance and Casters &_Roguaton ; Franca bene r"Tanbe sched eitherby reducing patent dean, rbynresing product What woudberse | Cpeced et song of AR 105m by 2021 Patient Outcomes: ~ MOC could help life expectancy in the Kingdom reach 80 years by the year 2030Visualising the Model of Care ‘The ystem wl apport people to stay a1e9 ppuueyg Payment Mechanisms Private Sector Participation 2The new Model of Care will deliver 43 interventions ‘Over 300 cians came topsther inthe design phase and agreed on 31 SoC spat interventions, nd 12 interventions tha ut serossthe SoCs Keep Well} Planned Procedure sete sith CtronieCondtion | ast Pose bee = 5 Selt-care oe sce Control eo ic Disease beretlay One| was ssc’ [ENGST | eoxcouminn | psa, coo Salen (CPs |Oua Ysere es or a Wen Crees Lents onsen, | (6D) emt oet | aeatscae | “BB vt se.ce Nel cacry ‘ep Byres S)rc wn od Our Ouse @2e~- Oran cat (lear ayes, Ze Ose Aa GE Oem Gar Interventions That Cut across all systems of careNew Primary Health Care in MoC: | trust that my primary care providers are qualified, professional, and extremely reliable to support me with many of my needs | prefer to go to primary care provider because... Although primary care services are very close to home, | can get everything | need there My practitioner knows my history and my preferences My practitioner knows my family and my family history, so they can diagnose me faster { wait a lot less there than in any secondary+ service including EDs Primary care services are capable of supporting all my health needs across systems and specialties. | [trust that if | leave secondary+ care, my primary care provider will be the | easiest way to navigate the system, and go back to secondary+ care if | need it.‘hq — ede 2m 398 pur — om ‘heys 01 ajdoad yoddns jy warshs a4, 34k JO [APO] 243 BursijensiAThe new Model of Care will deliver 43 interventions ‘Over 300 clinicians came together in the design phase and agreed on 31 SoC specific interventions, and 12 interventions that cut across the SoCs. Keep Well Planned Procedure Safe Birth Dr Chronic Condition Last Phase Health Coach : e Premarital 2) Resource controt Chronic Disease Patient and Program Screening ‘ger Center Screening Family Support Community-Based : Preconception é yuse ant Care nat National ‘Wellness Case Coordination Q Programs @D Care Services Fee ‘Clinics Guidelines Workplace ne tery care | 6 national conten care zy cattle Wellness 3 Guidelines | Workforce Programs apy Se {Ld Development ¢ 5S Wellness ¢ ‘) re ee e:: ational Birth inal Popclation-baved Tis) vival seticare | () virtual secre Programs Sa J vaste Registry DE centers Ln YES vst roos | 6 Ofer nd postnatal care Promotion a ce Services Health ea, © Edutainment \e See Q- Baby Clinics Programs ideli Neonatal Genetic Counselling £5 school Education (a) Pubic Awareness Enhanced Home Or National Referral =o ae Data anes: ay Programs PWD care services ‘Optimisation Virtual Education Integrated Health Hotline Enhanced Primary 7 Tm Outcomes G Health Research = ee Services Ax re Services ey at Health BE) srontonng Programs Interventions That Cut across all systems of careStructured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq, malateeg@hotmail.com @drmalateeq Theme: Burnout - Question Ideal Answer Marks What is burnout? Professional burnout is the loss of emotional, mental, and physical energy caused by continued job-related stress. It results from ongoing, unrelenting work stress without adequate time away from professional work duties for rest and recreation. 10 ‘What are the aspects that usually measured in assessing burnout? Three aspects of professional burnout syndrome: emotional exhaustion, depersonalization, and lack of personal accomplishment. 15 What are the risk factors for physician burnout? Being a primary care or emergency medicine physician. Middle career physicians Number of hours worked per week Experience of recent work or home conflict, and how that conflict was addressed or resolved Highly driven, “workaholic,” perfectionistic personality Poor coping skills for stress (smoking, alcohol abuse, drug use , avoidance, confrontational) 25 What are the common causes of physician burnout? Continued unabated work stress Poor relationships with colleagues Difficulty resolving home and work relationship conflicts Lack of time for self-care Feeling there is not enough time in the day to complete work tasks Regret of specialty choice | Lack of control over clinic schedule or office processes Increasing bureaucratization of health care Complex and challenging patient panels 25 What are the possible ‘effects of physician burnout? Negatively affects quality of patient care: © disruptive to continuity of patient care ©. costly to health care organizations © increased suboptimal patient care © increase medical errors Depression, suicidal ideation and at risk for substance abuse Increases absenteeism Increased physician turnover Decreases job satisfaction 25Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeg@hotmail.com @drmalateeg ‘Theme: Chronic care model Question Ideal Answer Marks | Trainee Score How would you define a chronic disease? Chronic diseases are a “diseases of long duration and generally slow progression” (WHO) “conditions that are not cured once acquired and must have been present 3 months or longer” (CDC). ‘Mention common risk factors for chronic disease Common modifiable risk factors: © Unhealthy diet © Physical inactivity © Tobacco use Unmodifiable risk factors: © Age © Hereditary Socioeconomic, cultural, political and environmental determinants © Globalization © Urbanization Population aging What are the Six elements of Chronic Care Management (ccm), (Wagner, Austin & Von, 1996) Health system or a health organization Clinical information systems (Cis) Decision support Delivery system design Self-management support Community including organizations and resources for patients Why to find a model for chronic disease? Chronic diseases are by far the leading cause of mortality in the world, representing 60% of all deaths Out of the 35 million people who died from chronic disease in 2005, half were under 70 and half were women. Significantly more likely to see their General Practitioner ( 80% of GP consultations), Significantly more likely to be admitted as inpatients more likely to use more inpatient bed days than those without such conditions. ‘More likely to be admitted as medical emergencies (2/3 of ER admissions) Almost half of all people with chronic illness have multiple conditionsStructured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq, malateeg@hotmail.com @drmalateeg ‘Theme: Emergency services in PHC You are the manager of class A PHC. You received a letter form the ER department in the nearest hospital asking you to help in providing emergency services at your center due to the overload of patients in the hospital ER. How to respond? Question Ideal Answer Marks | Score What are the percentage and | « In literatures: 55% ofthe attendances at emergency departments | nature of ER cases attending | (ED) re made for non-urgent complaints that can be managed in ‘to PHC? And Vis Vera primary care or urgent care centers. Establish Urgent Care Center: Extended hours in your center, to provide out-of- hours urgent care services with full of partial ‘What options due you have in | operation. responding tothe request? | + Operating extra clinics inthe OPD hospital + Atelephone consultation or advice from one of your doctors +A home visit from an advanced nurse practitioner or doctor = The American Academy of Urgent Care Medicine (AAUCM) defin urgent care service as “the provision of immediate medical service offering outpatient care for the treatment of acute and chronic illness. and injury * Urgent care centers are delivery centers that provide ambulatory How would you define Urgent | __urgent care services, generally on an unscheduled basis, for injuries Care Medicine? or illnesses that require immediate attention but are not severe enough to require hospital-based or free-standing emergency care by an emergency medicine specialist. Urgent care services are generally provided by family medicine specialists with support from physician extenders such as nurse practitioners and physician assistants. * [tis similar to PHC/FM as first contact / similar scope * [tis actually run in most ofthe countries by family physicians * The conditions can be managed by PHCP / FP with no need to specialist How is the Urgent Care service is related to PHC or rw? + The setting and requirements are almost same as for PHC/FM clinics + _Itis used sometimes to solve the shortage of PHC centers/physicians + Identified scope of service: + urgent primary care needs, which cannot wait until the next If you agree to open your available in-hours visit center for extended ours to + agreement with ER for coordination and shared care coverhelp ER(Urgent Care| + Timingand scheduling: Center), how to establish this * Could be out-of-hours or 24/7 service? + Determine capacity in term of patient's slots/daily visits + Registry: | Patient registry+ Well defined catchment area + EMR + Manpower + Trained staff, doctors / nurses / receptionists / technicians .ete + Certified / well trained staffin providing urgent care | + Equipment’: | + ECG / AED ete + V/S Monitoring facilities + Crash Cart + ‘Treatment room equipment’s + Imaging: plain x rays / mobile U.S / may be CT + Ambulance + Casting materials + Sterilization Center (CSS) + Essential quick lab testing + Pharmacy: + Formulary of acute conditions treatment + Guidelines: + Acute disease management guidelines + Regulations: + Triaging system: in / out (home) / out (main ER) + Categorizing system according to case severity / urgency + Job description ofall staff + Communications system: | + With ER for urgent referrals + With admin for urgent issues ‘+ With the PCP / MRP for continuity of care ‘What values or standards that ensure high quality of out-of-hours services? ‘The aim is to provide a high-quality service and using TAKES CARE as key iples: + Timely - itis provided at the right time for the patient needs + Accessible — it is easy to obtain advice and assessment in a way which is reasonable for patients. The patient should be at the heart of the + Knowledgeable - staffed by Clinicians and non-clinical staff, who are appropriately skilled and participate in on-going CPD and appraisals + Effective — it does what we intend it to do ~ ie. improve the outcomes for the patients and their carers and integrates with other unscheduled care providers across health and social care ‘Safe — it does not cause harm; there are mechanisms in place to reduce risk. + Consistent - there is minimum variation from day to day and each organizations will have contingency plans for dealing with predictable variation (e.g. winter plans), unexpected and outbreaks. + Acceptable ~ (Equitable) -it is available to all who need it, offering variety of communication modes to best meet patient need. * Relevant - itis planned to meet the needs of your patients and population + Bificient —it makes good use of resources without waste and is sustainableStructured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq, malateeg@hotmail.com @drmalateeq Theme: Uncertainty in Family Practice ‘Question Ideal Answer Marks | ‘What is meant by uncer Family Practice? inability to formulate a clear diagnosis for the patient presentation ‘What are most common causes of Uncertainty in Family Practice? Faulty knowledge ‘Insufficient knowledge of the condition ‘0 Insufficient skills ‘Inability to generate hypotheses + Faulty data gathering © Poor history taking ©. Failure to perform indicated screening procedures ‘o. Excessive/insufficient data gathering ‘« Faulty information processing ‘© Inability to generate early hypotheses ‘o_ Erroneous interpretation of clues © Missing noticeable symptoms and signs © Faulty verification ‘Failure to consider other possibilities ‘© Confirmation bias and coveremphasis on positive o. findings co Premature closure 35, ‘What could be the effects of Uncertainty in Family Practice? Physician burnout Physician under tress Missed cases Patient satisfaction More disease complication Wats of resources 25 How to deal with uncertainty in family practice? eI is important to accept that uncertainty is anormal part of general practice 1 Agood doctor-patient relationship is vital (giving time with good communication skills and creating trust) Involve the patient in the decision-making process = Discuss probabilities including the degree of uncertainty involved if relevant «Consider each patient as an individual and take their background into consideration — support, social network, education e _ Use external evidence (evidence-based medicine particularly risk calculation, guidelines) and respect the internal (doctor’s and patient's) evidence © Consider the use of a chec! for diagnosis 35‘Maintain good clinical records | Be aware of your feelings and acknowledge them - be able to forgive yourself and others when managing the unexpected Apply reflective practice Peer group discussions on problematic cases can be very helpfulStructured Oral Exam (SOE) - Mock exam. checklist Prepared by Dr. Mohammed AlAteed, malateeg@hotmail,com @drmalateeq Theme: Falls ‘Question. Ideal Answer [Marks | How much you think falls are prevalent among elderlies? > Each year, approximately 30% of persons older than age 65 years fall at least once, and the incidence increases with age. © Upto 10% of falls result in serious injury. + falls are the leading cause of injury-related deaths in people older than 65 years + By 2050, itis estimated that the worldwide number of hip fractures will rise to 6.26 million | What are the risk factors for fall? “The multiple risk factors for falling can be categorized as: «Intrinsic risk factors include age related physiologic changes and diseases that affect the risk of falling. © Age-related changes in vision, hearing, or proprioception © Decreased blood pressure response to postural changes © Delayed compensatory muscle response to postural changes ‘Age older than 80 years Cognitive impairment Depression Functional impairment History of falls Visual impairment Gait or balance impairment Use of assistive device Arthritis / Leg weakness «Extrinsic risk factors include medications and environmental obstacles. 000000000 25 ‘What is the best screening test to identify potential fallers. ® Atpresent, no one screening test can be recommended to «identify potential fallers. © The two best predictors of falls are a history of falls anda reported abnormality in gait or balance, 10 | How would you initially evaluate a senior for risk factor? * History Circumstances of fall Presence of risk factors ‘0 Medical conditions © Medication review Functional abilities «Physical examination Postural blood pressure ‘o CV examination focusing on rhythm and murmurs Visual acuity © Neurological examination: strength, proprioception, cognition © Musculoskeletal examination: ROM, joint abnormalities © Gait and balance assessmentMinimize medications Provide individually tailored exercise program Treat vision impairment ‘Manage postural hypotension ‘Manage heart rate and rhythm abnormalities Manage foot and footwear problems Modify the home environment Provide education and information 30FAMILY MEDICINE - SAUDI BOARD STATION No. (4) Structured Oral Exam (SOE) — Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateeq@hotmailicom — @drmalateeq Theme: Precision Medicine Question Ideal Answer Trainee | Score ‘What is meant by precision medicine? ‘And why itis important? ‘The National institutes of Health defines precision medicine as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person”. Precision medicine has evolved to encompass using genetic testing to tailor care and to integrate multiple streams of information, including behaviors, physical characteristics, and multiple genetic and nongenetic biomarkers, as well as patient preferences, to optimize care. Application of precision medicine will minimize the risk from avoidable, ineffective, or hazardous treatments and from over- or underscreening for chronic conditions. What is the difference between “precision | medicine” and. "personalized care"? ‘The two terms are used sometimes interchangeably ‘The term personalized medicine or care, which was used earlier, emphasizes consideration of the individual patient in the full context of her or his life rather than the episodic care of a presenting complaint. In precision medicine, the focus is on identifying which approaches will be effective for which patients based on genetic, environmental, and lifestyle factors. Why we need precision medicine? Because diagnosis is so imprecise it follows that treatment will be haphazard ‘There is big variation in how individuals respond to drugs and yet that variation is not usually recorded. Drugs are approved on their average performance. The future is not therapeutics and diagnostics but “theragnostics,” combining. the two: how patients respond to treatments will be one of the main ways of classifying their disease Give examples of disease treated by precision medicine ‘Most of the current examples of precision medicine are in cancer and involve ‘expensive drugs. For instance: breast cancer, malignant melanoma, ovarian cancer... etc Most current examples are a combination of a single drug and test, but rapidly ‘we will move to multiple tests and multiple treatments What are the barriers to precision medicine? ‘Economic: many tests and drugs in precision medicine now is expensive and nonaffordable by institutions or patients. Developing regulatory processes: Regulators are also struggling with how to approve combinations of drugs and diagnostic tests. And what sort of evidence should be needed? Ideally there should be randomized trials showing, reduced mortality and morbidity with one trial to show the benefit of the test and another the benefit of the drug, but this double randomization is “an unaffordable luxury,” Health Systems: The health systems are clearly not ready for such a world ‘when most healthcare workers have never heard of stratified medicine and are trained for a world of diseases that will be rendered redundant and ways of treating that will be subdivided TotalFAMILY MEDICINE - SAUDI BOARD. STATION No. (5) Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateea@hotmail.com @drmalateeg ‘Theme: Recertification / Revalidation ‘Question ideal Answer | marks | Tainee Score What is meant by Maintenance of certification (MOC) / Recertification / Revalidation different terminology? All mean: the process by which doctors show that they are up to date and fit to practice medicine. 10 '* Different forms of mandatory / voluntary revalidation exist in US, UK, 7 Canada, Australia, New Zealand, Germany, and the Netherlands. _ | ‘What component Formative assessment of medical knowledge, clinical competence, would be included in ‘communication skills the process of © Elements of CPD/ CME recertification/revalidat | « Participation in an annual appraisal 23 ion? ‘+ Multisource feedback from multiple health practitioners © Practice audit I _ Completion of a practice improvement program - _| Whatisthe rationale | The current system, based on CME alone for renewal of registration, behind recertification without some kind of test, cannot possibly assure competence. /revalidation? © There is.a need to address several highly publicized concerns about the quality of healthcare a ‘+ There is a need to identify poorly performing physicians and early Identification of physicians at risk of poor performance, ‘+ There is some evidence that recertification is associated with higher L standards of care, What would bethe | The system has been criticized as being drawbacks? © Cumbersome © Labor intensive ‘¢ The “one size fits all” process didn’t appear to achieve anything 2 positive for those already performing well © Very costly. The costs of cumbersome system will be passed on to 7 consumers. _| What other alternatives | Proactive screening for underperforming doctors: to recertification? '* Random selection members each year to undergo a “peer assessment” program. ‘+ Target high risk doctors: physicians who have been in independent practice / over the age of 60 / remote areas / small practices/outliers (on billing and prescribing data/ those subject to complaints/ those 2 performing only office-based work with no hospital appointment ete ‘= This assessment consists of a review of medical records, formal interview, discussion of the record review, multisource feedback .etc ‘This can be done by governmental designated body or at the level of each institution. TotalFAMILY MEDICINE - SAUDI BOARD STATION (6) Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq, malateeq@hotmail.com @drmalateeq Theme: Telemedicine and Telehealth Question Ideal Answer Marks | Score ‘What is Telemedicine and Telehealth? ‘Some consider them as synonyms and use the terms interchangeably ‘+ Telemedicine: is the practice of medicine using technology to deliver care at a distance. It occurs using a telecommunications infrastructure between a patient (at an originating or spoke site) and a physician or other practitioner (at 2 distant or hub site). Telehealth: refers to a broad collection of electronic and telecommunications technologies that support health care delivery and services from distant locations, Telehealth technologies support virtual medical, health, and education services. ‘© Telecare: refers to technology that allows consumers to stay safe and independent in their own homes. For example, telecare may include consumer-oriented health and fitness apps, sensors and tools that connect consumers with family members or other caregivers, exercise tracking tools, digital medication reminder systems or early warning and detection technologies. 20 What are the benefits of telehealth / telemedicine? (full mark: mention 5 points) T. Increases access to healthcare: Remote patients can more easily ‘obtain clinical services / Remote hospitals can provide emergency and intensive care services. 2. Improves treatment outcomes and reduced mortality: Patients diagnosed and treated earlier often have improved outcomes / Telehealth supported ICU’s have substantially reduced mortality rates, reduced complications, and reduced hospital stays 3. Reduces healthcare costs: Home monitoring programs can reduce high cost hospital visits / High cost patient transfers for stroke and other emergencies are reduced 4, Assists in addressing shortages and misdistribution of healthcare providers: Specialists can serve more patients using Telehealth technologies/ staff shortages can be addressed using Telehealth technologies. 5, Supports clinical education programs: Rural clinicians can more easily ‘obtain continuing education / Rural clinicians can more easily consult with specialists 6. Improves support for patients and families: Patients can stay in their local communities and, when hospitalized away from home, can keep in contact with family and friends 7. Improves organizational productivity: Reducing extended travel to obtain necessary care/ employees can avoid absences from work when telehealth services are available on site 30 What different types of application of telemedicine / telehealth? ~ Networked programs link tertiary care hospitals and clinics with outlying clinics and community health centers in rural or suburban areas through either hub-and-spoke or integrated networked systems,FAMILY MEDICINE - SAUDI BOARD. STATION (6) | (full mark: mention 3 points) Point-to-point connections: private networks are used by hospitals and clinics that deliver services directly or contract out (out sourced) specialty services to independent medical service providers at ambulatory care sites. Health provider to the home connections involves connecting primary care providers, specialists and home health nurses with patients over single line phone-video systems for interactive clinical consultations. Such services can also be extended to a residential care center such as nursing homes or assisted living facility. Direct patient to monitoring center links are used for pacemaker, cardiac, pulmonary or fetal monitoring and related services and provide patients the ability to maintain independent lifestyles, Web-based e-health patient service sites provide direct consumer ‘outreach and services over the Internet. 25 What issue may arise with the growing use Of telemedicine / telehealth? (full mark: mention § points) Safety Confidentiality ‘Accuracy of information gathering and diagnosis Inequality: not every patient and every health institute can afford the services due to high cost Impairment of therapeutic relationship between patient and health care provider Limit the human interaction which is vital for healing process overuse by some health professionals for conditions or health needs not met through telemedicine 25 Total 100Structured Oral Exam (SOE) - Mock exam checklist Prepared by Dr. Mohammed AlAteeq malateea@hotmail.com @drmalateeg Theme: Autonomy ‘Question Ideal Answer | Marks What is autonomy? the right of competent adults to make informed decisions about their | 5 ‘own medical care | What are the important ‘Adult age conditions for autonomy capacity to make the relevant decision: relevant internal capacities for self-government (mentally competent) 20 does so voluntarily: free from external constraints has sufficient information to make the decision 7 | ‘What are the Age fully competent :18 years for both males and females. considerations relevant to The age of discrimination: the age of 7 is considered jul! ow after ‘medical practic which a child can make some decisions | At puberty, a person becomes mukallaf (4353! fully responsible for fulfilling all religious obligations. Proxy consent and + The proxy or substitute is usually a member of the family. substitute decision + If family members are not available, other proxies may be found. maker + Insome cases, the patient might have designated one of them as decision maker, which makes the process very easy. * agreement among family members about who should decide, the | 30 matter is again easy to handle | + Ifthe patient does not nominate anyone, according to Saudi customs the father has the right to decide. + _In some cases, the father acts as the decision maker Consent for children | + Parents have the overall right to decide for children below the age of majority, which is 18 years in Saudi Arabia. + If both parents refuse, the physician can go ahead and give ‘emergency life-saving treatment with no consent in the interests of saving life. 9s + Ifthe two parents disagree, the physician can go ahead and give life-saving treatment based on the consent of one parent. ‘+ Refusal by one or both parents of non-urgent treatment that the physician considers necessary for saving life can be resolved by reference to the law courts.FM mock exam checklist for OSCE Prepared by Dr. Mohammed AlAteeq @drmalateeg malteea@hotmail.com ‘Dx: post bariatric surgery care ‘Asma, 32 years old married woman, came to visit your FM clinic one month after sleeve surgery. Domain Te Se Information gathering Check for active symptoms: © Nausea & vomiting / Food intolerances © Dumping Sx (the post-prandial occurrence of symptoms elicited by the rapid transit of calorie- dense food to the small): headache / fatigue / sweating / nausea / weakness / sleepiness / Dyspnea / desire to sit down / palpation / restlessness / syncope or fainting) Malabsorptive pathology Sx: diarrhea and Steatorthea () Weight change Cold intolerance, hairloss, and fatigue © Local pain at surgical site Dietary Hx Physical activity Systemic inquiry Psychological $x Social Hx: effect on home / work ooo | Physical exam General / VS ‘Signs of anxiety or depression Skin: ? redundant skin Management plan Diet: ‘+ Gradually and progressively change the food consistency, moving from clear liquids to soft or creamy foods and then to solid to avoid or minimize regurgitation and vomiting, Eat three structured meals and one or two high-protein snacks per day. Each meal should begin with protein to ensure adequate intake of 80 to 90 g per day to minimize the loss of lean body mass ‘+ Aminimal protein intake of 60 g/day and up to 1.5 g/kg ideal body weight per day should be targeted. ‘The use of liquid protein supplements (30 g/day) can facilitate adequate protein intake ‘+ Toavoid dumping syndrome: eating small but frequent meals, avoiding ingestion of liquids within 30 min ofa solid-food meal, avoiding simple sugars, increasing intake of fiber and complex carbohydrates and increasing protein intake ‘* Hypoglycemia may be prevented by drinking half a glass of orange juice (or taking the equivalent small sugar supplement) about 1 h after eating Pharmacotherapy: * Iron supplementation: 60 mg elemental iron / day B12: 350-500 g/day (alternatively: 1 mg/month IM or 3 mg every 6 months IM) | Calcium: 1,200-2,000 mg/day of elemental calcium Vita D: 400-800 / day Other multivitamin and minerals (vitamin A, E, K, Zinc, Copper, Selenium, Magnesium). One-tab BID PPI: in a regular basis or prn according to the condition Oral or parenteral thiamine (50-100 mg/day) may be considered for persistent vomiting Physical activity: ‘© Moderate aerobic physical activity to include a minimum of 150 min/week and goal of 300 ‘min/week, including strength training 2-3 times per week[ Referral to dietian: ‘+ Should receive periodic counselling by a dietician about long-term dietary modifications in order tomaximize the results of the bariatric procedure | General advice & education: ‘In case of persistent vomiting or regurgitation (>6 months) and/or frequent vomiting, a physical cause should be suspected and a surgical diagnostic work-up considered «Observe weight regain factors: nutritional non-adherence, mental health issues and physical inactivi {© _ Advice to sustain healthy lifestyle to prevent weight regain, Management of comorbidities: + DM: for most cases, tapering of DM medications start immediately after surgery. lose observation of hypoglycemia, Gradual dose decreases and probable D/C of some or al Rx. Long-term FU with HgAlc. Standard diabetes guidelines should be followed + DSL: Lipid-lowering medications should not be stopped after surgery unless clearly indicated. Patients with dyslipidemia and on lipid modifying medications should be have lipid profiles and cardiovascular risk status reassessed periodically. ‘© HTN: Continued surveillance of blood pressure is needed after surgery, because of the high risk of recurrence over time. Treatment of hypertension inthe long-term should adhere to current ‘general guidelines, possibly avoiding anti-hypertensive medications with a known unfavorable effect on body weight. n the patients in whom hypertension have resolved, continued surveillance should be guided by recommended screening guidelines for the specific age group. Use of other medications: '* - Ifpossible, liquid oral dosage forms should be used instead of solid dosage forms for atleast two months after surgery ‘+ _ NSAIDs, salicylates, bisphosphonates, corticosteroids and other drugs that may cause gastric damage should be avoided + Oral contraceptives should be replaced by non-oral contraceptives due to reduced efficacy after gastric bypass and bilio-pancreatic diversion = Replace extended release formulations with immediate release formulations ‘¢ Use diuretics with caution due to the increased risk of hypokalemia Pregnancy: ‘© Pregnancy is not recommended in the first 12-18 months following bariatric surgery. Follow up and lab testing: every 3-6 months in the frst year and then every 12 months thereafter: CBC, electrolytes, iron, ferritin, vitamin B12, folate, vitamin D, PTH, LFT, zinc, copper, + safety netting (0. Symptoms of continuous vomiting, dysphagia, intestinal obstruction (gastric bypass) or severe abdominal pain require emergency evaluationFM mock exam checklist for OSCE Prepared by Dr. Mohammed AlAteeq @drmalateeg malteea@hotmail.cor Dx: Hypertensive emergency Sceni hmed is 55 years old male, known case of HTN on medication, came for regular follow up. he checked his BP today at home and found to be 185 / 95, repeated at home also and was 190 / 92. How would you manage? [Dom Gok [Soe Information gathering ‘Symptoms: ~ Acute target organ injury symptoms (Hypertensive Emergency): neurologic (headache, vision ‘changes, seizure, neurologic deficits), cardiovascular (chest pain, shortness of breath, myocardial infarction, syncope, history of palpitations or arrhythmias), renal (oliguria, anuria), peripheral arteries (claudication, cold extremities, weak distal pulses), pulmonary (sleep apnea, chronic lung disease) ~ Other symptoms due to high BP but not related to target organ injury (Severe asymptomatic hypertension or Hypertensive urgency): headache, lightheadedness, nausea, shortness of breath, Palpitations, epistaxis, or anxiety, depending on the acuity and severity of blood pressure elevation. Treatmer © Compliance © Side effects © Concurrent medication/drug use: nonsteroidal anti-inflammatory drugs, antidepressants, oral contraceptives, cold medications, sympathomimetics (amphetamines, cocaine, phencyclidine), corticosteroids, herbal remedies ~ Previous hypertension (duration and levels) ~ Any similar episodes before ~ Past Medical Hx: Personal history: coronary artery disease, congestive heart failure, cerebrovascular disease, chronic kidney disease, peripheral vascular disease, diabetes mellitus, sleep apnea ~ Revisit the diagnosis: i it secondary HTN? family history of kidney disease, personal history of renal disease, medications and ilicit drug use, clinical features of metabolic disorders (e.g,, thyroid disease, pheochromocytoma, hyperaldosteronism) ~_Any acute psychosocial event Physical exam ~ 30-minute rest period is recommended when the initial blood pressure reading is severely elevated. (in > 30% of cases, BP will lower to an acceptable level without intervention) Look for signs of target organ injury: > Neurologic (motor or sensory deficits), © Ophthalmologic (arteriolar narrowing, hemorrhage, papilledema), © Cardiovascular (arrhythmia, displaced point of maximal impulse, murmur, third heart sound gallop), Pulmonary (rales, hypoxia, tachypnea) © Vascular (diminished or absent peripheral pulses, abdominal bruits, unequal pulses or blood pressure, jugular venous distension) investigations 1050) Sire Gene rem aaa ~ No recommend laboratory testing for patients with severe asymptomatic hypertension ~ _ Patients with symptoms or clinical findings suggesting acute target organ injury require appropriate diagnostic testing and evaluation for possible hypertensive emergency like: CXY / ECG / CT brain. .etc Ee i zt Formulate diagnosis Hypertensive Urgency? Hypertensive Emergency? Management plan~ Aggressive lowering of blood pressure can be harmful and should be avoided in patients with severe asymptomatic hypertension. Gradual reduction over several days to weeks is recommended short-acting antihypertensives. Patients with symptoms such as headache, lightheadedness, shortness of breath, epistaxis, or anxiety are more likely to benefit from these agents. Inthe absence of acute target organ injury, blood pressure should be lowered gradually ~ _ toless than 160/100 mm Hg, but not acutely by more than 20% to 25% of the mean arterial blood pressure ‘over several days to weeks.» Every two to four weeks, antihypertensive intensification is recommended to achieve target blood pressure goals. ~ _ Patients who have not been compliant often can safely resume ther outpatient medications, Dosing ‘adjustments and additions are recommended for those already on antihypertensive therapy. No specific medication clases are recommended for the initial management of severe asymptomatic hypertension. ~ Hospitalization is rarely required for patients with severe asymptomatic hypertension. However, those with escalating blood pressure measurements, progressive symptoms of target organ injury, or evolving clinical evidence of acute target organ injury should be hospitalized. ~ Pharmacologic + Short acting Anti HTN medications: Prazosin / Labetalol/ Clonidine / Captopril ~ When blood pressure improves, long-acting antihypertensive therapy should be initiated, restarted, or adjusted ~ Parenteral medication is not indicated and should be reserved for the management of hypertensive emergencies, ~ _ Inpatient treatment of acute hypertension is often aggressive, and intravenous antihypertensives are ___ commonly used Education / Safety netting FU in one 2-3 weeksManagement of Severe Asymptomatic Hypertension Paen preseres with sey Hora blood presse (180 men Hig or more ssid o 10 mm fig or mare castle)* { “Signs oF symptoms of Soute target organ injury? Yes to Oh tay coal peal pice a No ' sept Peron smn Mild symptorra§ ‘Previous typertension? Maat art ae * an tensive veatment mantosing with ambulatory os ote | ee = . eee | te ——— ee to assess for target organ inlry nicht | Acute target ongan injury? Yes NoOSCE exam checklist Prepared by Dr. Mohammed ALAteeq, malateeq@hotmail.com @drmalateeq case scenario :A mother of 18 months years old boy came to you with her child for consultation. Grade | Score Start Introducing self / role / Smiling / Establishing rapport Explore why here? Identify reason for attendance Collect information: nature / frequency/provoking factors/ associated symptoms/ parent's reaction * Consider DDx: congenital heart disease/ Epilepsy: last longer, no provoking factor/may happen at sleep, jerky body movement, loss of sphincter control, remaining confused for longer time systemic inquiry Impact on parents Physical exam: + Growth parameters / wellbeing / General + _CVS/Chest/ CNC [Management + Explain what breath-holding spells is: * Nature: stop of breathing for less than one min. with brief jerky movement of stiffness, may lead to LOC. Skin may be pale, sweaty or cyanotic _ + Age: at age 6m-6y, more 1-3 y. + Types: cyanotic with anger and palled with slow heart rate, + Cause: Reflex/ involuntary Precipitating factors: Anger / frustration / pain / IDA __Prognosis: benign condition / no complication / go as child grows up Investigation ‘+ Frequency; very variable, may occur daily of rarel CBC / Iron / Ferritin Reassurance / Education: ‘+ Advice on how to deal with it at home: be calm / do not shake him/ lay child down on floor to keep him safe/ call 937 if not wake up quickly or breath again / take him to ER + _After the spell: do not blame child (involuntary) or feel angry on him / reassure him + Rx: no specific Rx + Follow up: When to see again: open / if has more frequent or new symptoms Opportunistic care + Wellbeing / Immunization [+ Nutrition advice + Advice for safety General ‘Ask open questions / Listens attentively / Facilitante réponse verbale & non-verbale Use easily understood question and comments / Encourages expression of emotion ‘Address concems, ideas, expectations, background ‘Show empathy: acknowledge parent's frustration Provide the correct amount and type of information Time management TotalOSCE exam checklist Prepared by Dr. Mohammed ALAteeq malateeq@hotmail.com @drmatateeq case scenario :A mother of 18 months years old boy came to you with her child for consultation. Grade Score Start Introducing self / role / Smiling / Establishing rapport Explore why here? Identify reason for attendance Collect information: nature / frequency/provoking factors/ associated symptoms/ parent's reaction * Consider DDx: congenital heart disease/ Epilepsy: last longer, no provoking factor/may happen at sleep, jerky body movement, loss of sphincter control, remaining confused for longer time «systemic inquiry Impact on parents Physical exam: «Growth parameters / wellbeing / General * CVS / Chest / CNC Management «Explain what breath-holding spells is: * Nature: stop of breathing for less than one min. with brief jerky movement of stiffness, may lead to LOC. Skin may be pale, sweaty or cyanotic * Age: at age 6m-6y, more 1-3 y. “Types: cyanotic with anger and palled with slow heart rate, «Cause: Reflex/ involuntary Precipitating factors: Anger / frustration / pain /IDA «Prognosis: benign condition / no complication / go as child grows up «Frequency; very variable, may occur daily of rarely |. Investigation * CBC / Iron / Ferritin Reassurance / Education: ‘+ Advice on how to deal with it at home: be calm / do not shake him lay child down on floor to keep him safe/ call 937 if not wake up quickly or breath again / take him to ER * After the spell: do not blame child (involuntary) or feel angry on him / reassure him «Rx: no specific Rx Follow up: When to see again: open / if has more frequent or new symptoms Opportunistic care * Wellbeing / Immunization Nutrition advice + Advice for safety General ‘Ask open questions / Listens attentively / Facilitante réponse verbale & non-verbale Use easily understood question and comments / Encourages expression of emotion Address concems, ideas, expectations, background ‘Show empathy: acknowledge parent's frustration Provide the correct amount and type of information. [e “Time management [TotalPrepared by Dr. Mohammed AlAteeq @armalateeg malateeq@hotmail.co\ FM - Consultation Checklist Evaluation of palpitation ‘CANDIDATE SHOULD COVER THE FOLLOWING A History i Si Palpitation History: # Patient age: younger patient tends to have congenital heart or psychiatric cause of palpitation more Onset, frequency ‘Duration: palpitations lasting les than five minutes make a cardiac ethology les likely Character: regular, rapid, pounding sensation in the neck (suggestive cardiac causes) Activity during palpitation: © Atrest: even cardiac cause can occur at rest (e.g. PCs) (©. With exertion (more worrying some, e.g, mitral valve prolapses) © During sleep (more worrying some, could be cardiac / metabolic) ‘© Position: if triggered by standing up after bending over or when lying in bed (suggestive cardiac, e.g. SVT / VPC) © Snoopy of pre-soupy; (suggests of cardiac cause, e.g. Ventricular tachycardia, or structural heart disease) ‘© Evaluate for: an ischemic cardiac cause, ASCVD risk estimation / for structural cardiac causes (valvular disease/ congenital heart disease) ® Screen for non-cardiac organic causes: anemia / thyroid disorder / pheochromocytoma ‘* Screen for psychiatric causes: GAD / specific anxiety / panic attack / panic disorder / somatization ® Medication / Substance / dietary supplement Use: e.g. B agonists / decongestants / antihistamines / anabolic steroids / caffeine / nicotine ¢ _FHX: focused on early cardiac death / inherited cardiac conditions yhysical examination ‘© General: on distress / overworked / irritable...etc. © Vital signs: BP / Weight / RR © Pulse: rate type / character / irregularity: irregular pulse with no repeating pattern suggests atrial fibrillation) ‘* Other CVS Jugular venous pulse: if cannon wave noted, could be ventricular tachycardia © Murmurs: holosystolic murmur or a midsystolic click (suggestive of mitral valve prolapse / other valvular stenosis) / harsh murmur (suggestive of cardiomyopathy / congenital defects) ‘© Lower limb exam: look for edema ©. Tilt- table testing: ‘or pt. with palpation and syncope or pre-syncope © Chest: look for crepts or rales © Abdomen + Psychiatric exam: signs of anxiety / hypochondria-type behavior, Investigation: + Blood works; o CBC o TSH / Free T4 © Renal function © ECG; for all cases: co Normal resting ECG findings do not eliminate a cardiac etiologyPrepared by Dr. Mohammed AlAteeq @armalateeq smalateeq@hotmail.com ‘© Nonspecific ST-segment and T-wave changes in symptomatic patients should not be considered normal and should prompt further evaluation | + Ambulatory ECG monitoring: If the index of suspicion for a cardiac cause remains high even with normal resting ECG Echo: for suspected structural or ischemic cardiac disease / known cardiac disease / more |__complex signs and symptoms Standard exercise stress testing: for patients with exertional Sx Management: aa © Treat undelying metabloci or psychiatric disease. If resolved ok / if not, re-evaluate for structural or ischemic cardiac cause. « Evaluated for structural or ischemic cardiac causes, and found normal for ECG, Echo or holter: reassurance. If abnormal, ref to cardiology. + If complicated or alarming Sx (e.g. syncopy or prescyncopy, exertional, sleep or rest. palpation.) Sx or unclear cause or indefinite results of investigations: consult cardiology 3. Doctor/patient Interaction / Effective Use of Consultation: i Understanding the patient's perspective: Ideas, Concerns and Expectations ‘Non-verbal behaviour: eye contact, posture and position, movement and expression ‘= Demonstrates interest, concer, respect for the patient a8 a person (Haroughout the interview) ‘© Encourages patient to talk ‘¢ Uses open-ended questions and closed questions as appropriate "© Listening: listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think ‘*__Pacliation: facilitates patient's responses verbally and non-verbally eg. use of encouragement, silence ete Tnternal summary: periodically summarizes to verify own understanding of what the patient has said; invites ppatient to correct interpretation or provide further information ‘Uses concise, easily understood questions and comments, avoids or adequately explains jargon [5 Promote informed decision making ‘© Attends to timing ‘Source: https:/www.aafp.org/afp/2017/1215ip784.htmlFM mock exam checklist for OSCE Prepared by Dr. Mohammed AlAteeq @drmalateeq malteeq@hotmail.com ‘Dx: acute management of panic attack Domain Gade | Se Information gathering ‘Active Sx : Palpitations / Sweating/Trembling or shaking/Sense of shortness of breath or smothering/Feeling of choking/Chest pain or discomfort/Nausea or abdominal distress/Feeling dizzy, unsteady, lightheaded, or faint/Derealization or depersonalization (feeling detached from ‘oneself)/Fear of losing control or going crazy/fear of dying/Numbness or tingling, sensations/Chills or hot flashes Assess precipitating events: e.g,, major life events, phobias, agoraphobia, obsessive- compulsive behavior Check triggers: injury/ illness/interpersonal conflict Medications and substance abuse: alcohol, nicotine, ilicit drugs and medications (e.g., caffeine, theophylline, sympathomimetics, anticholinergics), OTC agents / stimulants / SSRI discontinuation Past Hx: Previous similar attacks Medical conditions: DM / CHD / HTN ...ete Psychiatric Dx: anxiety / OCD / depression / other disorders Physi exam Sign of an increased sympathetic state: hypertension, tachycardia, mild tachypnea, mild tremors, and cool, clammy skin. Mental stat exam: State: extreme anxiety, fear, and a sense of impending death or doom ‘0 Speech: may reflect anxiety or urgency, or it may sound normal 9 Mood: may be described as like "anxious," with congruent affect. incongruent affect should raise suspicion of other diagnostic possibilities. © Thought processes: should be logical, linear, and goal directed, © Thought content: ensure that a patient has no suicidal or homicidal thoughts Keep observing panic attack normally lasts 20-30 minutes from onset Formulate diagnosis, Dx of exclusion. Attention focused on the exclusion of other disorders Urgent management Place patient on oxygen and in a supine or Fowler position. Avoid rebreathing into a paper bag Diaphragmatic breathing slows the respiratory rate, gives patients a distracting maneuver to perform when attacks occur, and provides patients with a sense of self-control during episodes of hyperventilation Monitor the patients with pulse oximetry, electrocardiography (ECG), and frequent determination of vital signs (including one set of orthostatic vital signs, when possible) ‘Amajor component of therapy involves educating the patient that their symptoms are neither from a serious medical condition nor from a psychotic disorder, but rather from a chemical imbalance in the fight-or-flight response requent reassurance and explanation.‘+ Must listen effectively and remain empathic and nonargumentative, Statements made by healthcare staff, such as, "It's nothing serious" and "It's related to stress" are frequently misinterpreted by the patient as implying a lack of understanding and concern. ‘© Oral benzodiazepine for a brief duration (approximately 1wk) may be appropriate for some patients, * Intravenous (IV) medication (e.g., lorazepam at 0.5 mg lV q20min): for patient with poor impulse control, pose a risk to themselves or to those around them Other measures Social service intervention: may provide supportive discussions and explore resources for outpatient care = Referral to a CB therapist ~ Near follow up to consider long term management (pharmacotherapy and non- pharmacotherapy) ~ Educate how to treat panic attacks at home: religious practices, cognitive restructuring, relaxation techniques, breathing exercises, hypnotic suggestion, interoceptive exposure, mindfulness, Self-help videotapes or books ...ete = _Ensure and stress on compliance if patient already on Rx for anxietyFM mock exam checklist for OSCE Prepared by Dr. Mohammed AlAteeq @drmalateeg malteeq@hotmail.com 32 years old male, teacher, came to the clinic with left foot pain after twisting his ankle j downstairs. No Hx of chronic disease and not on any Rx. Not Allergy to Rx. How would you manage? it while going Domain Gade [Se information gathering Mechanism of trauma: why, when, where, and how it occurred (usually inversion-type twist) Main Sx. ~ pain / swelling / skin discoloration (sudden, intense pain and rapid onset of swelling and bruising suggest a ruptured ligament) ~ weight bearing / exclude fracture (able to walk) coldness & paresthesia (exclude neurovascular compromise) / = past ankle injuries ~ level and intensity of their sports and activity medical history: presence of any complicating conditions, such as arthritis, connective tissue disease, diabetes, neuropathy, or trauma Physical exam General: V/S, pain grading Gait Local exam: ~ Look for: swelling / hotness / skin discoloration & ecchymosis / boney deformity ~ Boney tenderness: over the medial malleolus, lateral malleolus, base of the fifth metatarsal, or midfoot bones (if any present, # most likely) ~ Soft tissue tenderness: over the anterior talofibular ligament and/or calcaneofibular ligament areas ~ Ankle joint movement: ROM / pain & tenderness ~ Special test: Drawer, Talar tilt tests: to assess ankle instability ~ Squeeze tests: for tibiofibular ligaments injuries Neurovascular: pulses and sensation Formulate diagnosis Grading the sprain: G1: little swelling is present, with litle or no functional loss and no joint instability G2: moderate-to-severe swelling, ecchymosis, moderate functional loss, mild-to-moderate joint instability and usually have difficulty bearing weight. G3: immediate and severe swelling, ecchymosis, an inability to bear weight without experiencing severe pain, and moderate-to-severe instability of the joint. Investigation ~ Plain x ray if: bone tenderness at the base of the fifth metatarsal or at the navicular bone, and/or Inability to bear weight immediately after the injury and in the clinic ‘Management plan = __ Education & advice = Analgesia(PRICES): = protection (air splints or plastic and Velero braces) for 1-2 weeks relative rest. = ice & compression = elevation = _ support / ankle taping PT ‘Surgery for: third-degree sprain that causes widening of the ankle mortise / deltoid sprain with the deltoid ligament caught intra-articularly and with widening of the medial ankle mortise = _ Return to usual activity gradually according to pain tolerance and absence of tenderness Follow Up.FM Mock exam cheektist Prepared by Dr. Mohammed AlAteeq @adrmalatceq —__malatcoq@hotmail.eom Ahmed Salem is 38 years old, teacher. Asymptomatic, with no chronic disease, not in any chronic medication and no Hx of allergy. Planning to travel abroad for tourism. Coming today asking for travel health advice. Grade | Score Data Gathering (@) Trip data: + Countries and regions to be visited; urban versus Farad Dates and length of travel Purpose of travel (cx, business, vacation, visiting friends and relatives) Planned and possible activities + Mode(s) of travel & local transportation ‘Types of accommodations Medical Hix: + Vaccination history, including prior adverse events + Chronic illness: Asthma / COPD / Cardiac disease / Hyper coagulopathy / impaired cognition / psychiatric disease) + Immunity status (no live vaccine for immunodeficient pts) ‘+ Medication & Allergy ‘Vaccination and reaction history ‘+ Vaccination status: routine and others + Contraindications and reactions: Egg allergy 7 psoriasis on biological Rx 7 Seizures (possible contraindication to yellow fever and malaria vaccine) _ Personal characteristics ‘+Health belief model ‘+ Experience as traveller + _ Risk tolerance = _ High-risk behaviours (may merit additional counselling Management (%) Tnsect-borne disease: * Insect repellents with 30% DEET oF 20% picaridin / Wear proper clothing ‘+ Consider permethrin impregnated bednets when traveling to high-risk areas ‘+ Minimize outdoor exposure during times of peak vector activity in high-risk areas ‘+ _Chemoprophylaxis is effective for preventing malatia Food born disease: + Cook all food thoroughly; avoid foods that cannot be boiled or peeled + Consider self-directed therapy for traveler's diarthea (first-line treatment: ciprofloxacin (Cipro), 500 mg twice daily for one to three days; azithromycin (Zithromax), 500 mg daly for one to three days in southeast Asia; rifaximin [Xifaxan], 200 mg three times daily for three days is an alternative) ‘+ Antimotiity agents such as loperamide (Imodium) may be used in the absence of fever or bloody diarshea + Although discouraged for most travelers, chemoprophylaxis for traveler’ diarthea can be considered for select travelers with brief itineraries (c.g., bismuth subsalicylate [Pepto-Bismol], 524 mg four times daily; ciprofloxacin, 500 mg daily; sfaximin, 200 mg twice daly) Waterborne disease: ‘+ Drink only bottled, boiled, iodinated, microfiltered, or carbonated beverages + Avoid ice in beverages, and do not brush teeth with tap water * Avoid swimming in unchlotinated freshwaterSolar injury: Wear proper clothing (including broad-brimmed hat) Use sunscreen (SPF of a least 30) Avoid sun during peak hours, especially at higher altitudes and lower latitudes ‘Altitude sickness: Ascend slowly Rapid descent is advisable if significant illness develops Consider prophylactic acetazolamide; 125 to 250 mg twice daily) “Transportation injury: Staying hydrated, moving around the cabin, and wearing compression stockings may decrease sisk of DVT during air travel Scopolamine (1.5-mg patch every three days) or dimenhydeinate (Dramamine; 50 mg every six hours) diminishes motion sickness Pseudoephedrine (60 mg every six hours) may decrease risk of barotrauma Staying hydrated and avoiding caffeine during air travel may decrease jet ag; consuming caffeinated beverages in the mornings after arrival may ai in alertness, and melatonia may promote sleep; exposure to bright light during the day and dim lights during the evenings may speed acclimatization Political hazards: Avoid large crowds and demonstrations ‘Travel in pairs or small groups Be familiar with local laws Be aware that persons with dual citizenship may be subject to local requirements, including. conscription Selection, administration, and documentation of recommended vaccinations General guidance on Symptoms (eg, fever, gastiointestinal oF dermatologic symptoms) that may require medical attention during or after travel General guidance on Preparing a travel health kit General guidance on accessing medical care abroad Patient = Doctor relation (4) Understanding the patient's perspective: _Ideas, Concerns and Expectations ‘Demonstrates interest, concer, respect for the patient as a person (throughout the iacerview) Listening: listens encourages patient to talk Facilitation: facilitates patient's responses verbally and non-verbally eg, use of encouragement, silence ete Uses concise, easily understood questions and comments, avoids or adequately explains jargon Promote informed decision making General (%) Attends to timing Total 100FAMILY MEDICINE - SAUDI BOARD MOCK 1 - STATION No. (3) Performance Evaluation: Station (3) ian Sa [Soe Information gathering ~ Cardiac symptoms / Symptoms suggestive of post MI complications | - Daily function / activity - Social issues = Smoking - Job 20 Screen for depression / anxiety = Assess understanding of the discharge plan = _ Awareness about cardiology FU /appointments/ difficulties in access = __ Review of other comorbidities: DM / HTN...etc - Medication review Physical exam —_ General: wellbeing, signs of depression or anxiety ~_Vis - Cardiac 10 ~ Chest = Lower limbs { Management plan ion review: ] = ASA: 75 to 162 mg per day upon discharge and continued indefinitely for prevention of recurrent MI, Clopidogrel is alternative if allergic to ASA ~ Dual antiplatelet therapy (ASA plus Clopidogrel) continue for a minimum of 12 months in patients receiving drug-eluting stents and for up to 12 months in those receiving bare metal stents: ~ Beta blockers: In patients with a left ventricular ejection fraction (LVEF) of 40% or less, beta~ blocker therapy should be titrated gradually and continued indefinitely 25 = Angiotensin-converting enzyme (ACE) inhibitors are strongly recommended after an MI in patients with hypertension, diabetes mellitus, an LVEF of 40% or less, or chronic kidney disease. ARB is alternative if cannot tolerate ACE - Statin: initiate and continue indefinitely - PPI: for pts receiving dual therapy if have risk factors for gastrointestinal bleeding -_Nitroglycerin: $/L or spray for management of acute cardiac symptoms ‘Smoking cessation: The "5 A's": Ask, Advise, Assess, Assist, and Arrange. 5 ~ Diet: Mediterranean diet / Referral to dietian 3S: - May begin walking soon after discharge. encouraged to return to physical activity as tolerated, ideally with guidance after an exercise stress test ~ Drive within three weeks after symptom resolution, although recovery times will vary depending on individual circumstances. 20 Air travel should be avoided for two weeks unless the patient is symptom free, possesses nitroglycerin, has a traveling partner, and avoids situations requiring increased physical demands - Resume sexual activity in as early as one week Education: : 15FAMILY MEDICINE - SAUDI BOARD MOCK 1 - STATION No. (3) = To recognize cardiac symptoms, initiate the emergency response system, and use prescribed nitroglycerin ~ Identify and resolve barriers to understanding. ~ About problem-solving strategies, including contacting the primary care physi = _About the diagnosis and plan of care during hospitalization Follow Up: ~ Ensure Pt has FU with cardiology = _ Give FU with FM clinic in 1/12 Candidate Number: ‘Comments Examiner Name:FAMILY MEDICINE - SAUDI BOARD MOCK 1 - STATION No. (1) MS Mark History 25 Chief complain: Breast enlargement Detail © When and how noticed/ progression ‘* Associated symptoms: pain / nipple discharge / constitutional symptoms / emotional or physical distress © Other body mass: testicular mass Consider different cause of gynecomasti © Thyroid disorder: both hypothyroidsm and hyperthyroidism: weight change / fatigue/ cold or hot intolerance / low mood / overactivity / palpation / excessive sweating ...etc * Primary hypogonadism: genital system Sx (c.g., hypospadias, micropenis, and eryptorchidism) / | slow beard growth, impaired libido and sexual function, affected muscle strength, and lack of | energy | Hx of substance or supplement use lavender, tea tree oil, dong quai, tribulus terrestris / Soy more than 300 mg per day / Anabolic steroid / marijuana, heroin, or amphetamines ‘© Medication use: e.g. antipsychotics, antiretrovirals, spironolactone, exogenous testosterone © Genetic conditions: e.g. Klinefelter syndrome ‘© Related medical conditions: chronic liver or renal disease / Inflammatory Bowel disease Sx ‘© Repetitive mechanical stress (unilateral symptoms) ‘© _ Testicular injury from illnesses (¢.g., mumps orchitis, tuberculosis, hemochromatosis) or trauma ICE: Idea: what pt knows already. © Concern: breast pain, embarrassment, or fear of breast cancer / parents concern + Expectation: reassurance / surgery / cosmesis or analgesia Physical examination25 20. ‘© General: is he on distress / over worried / irritable...etc ‘* Vital signs: BP / Weight / syndromatic features © Local exam: © Breast: size, skin change / nipple discharge /, nipple retraction / tenderness / symmetry and consistency © True gynecomastia: Palpable, firm glandular tissue in a concentric mass around the nipple areolar complex © Pseudogynecomastia (a proliferation of adipose rather than glandular tissue): Increases in subareolar fat © Tumour: hard & immobile masses © System exam: (© Sings of genetic disorder / syndromatic diseases Genitals, liver, lymph nodes, and thyroid. __ © Investigation 20 ‘© Stepwise approach guided by history and physical examination * Diagnosis of physiologic gynecomastia should not be made until underlying etiologies are excluded | + Blood works: _