Feedback 4 didn't pass 46%
Sun, Feb 19, 2023 7:53PM • 25:21
SUMMARY KEYWORDS
ambulance, patient, palpitation, case, examination, ecg, excellent, consultation, valsalva, question, comment, pulse, maneuver, medication, diagnosis, refer, explored, racing, red flag, important
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feedback of case number four, you started in a good way introducing yourself. greet me by name and ask how you can help me. And I asked for to do the ECG report and asked to see it. You see it for me. You said can you give me one second to view this is excellent. Just for for perfection, just to say one moment better than second because second counts a second, but moment can be seconds can be minute. After this, you could say that I will tell you what's in this report, but may ask a few questions. First, better to be better to be immediately right after seeing the report. So that it can be general consent to delay explaining the report until you ask the questions that you need to know before explaining to me, and then you encouraged me to talk more after I told you the details of the first minute. You said Okay, Miss. Okay, okay. Just be careful to call me by name in case you forgot, you can take a look at the paper. Okay, Mr. Nelson, just if you forget this fine, but just take a look at the table, it's right in front of you in the table. Or in the if you're practicing online, it's in the page of the doctor, just take a look and call me by name that would be much appropriate to then mentioning the ADM only without continuing and the next question was what things make it worse? As regards to heart racing? Perhaps it's better than to open question to be adult full question of yes or no first, a closed question like is there anything you noticed that make it better anything you've noticed that make it worse, or make it go away but in anything relieved? Because it could be the same pattern but it's just comes and goes? So the question of better or worse you can modify it to be anything make it go away? Anything bring it didn't notice anything that bring it anything make it go away? This is how to be much better and to be in a closed question way because there could be nothing in this particular trigger especially that the patient did not mention any possible trigger. And it just comes and it's difficult to bring it difficult to elicit it. Otherwise she she could have brought it when she was in the doctor examination room when she did the ECG resting This way they give her a halter because they cannot catch it. So in Edit Nia better to say rather than what makes it better, what makes it worse, it could say what brings it Do you notice anything that bring it anything that make it go away? Which you did after that you said anything that triggered the heart racing but it's better to be as part of the question of Make It Better make it worse. Then you ask if there is any chest pain, this was excellent and then you ask about shortness of breath. This is excellent also. But just what remarked that sometimes shortness of breath alone can be present. Also lightheadedness, mild lightheadedness, but not dizziness or or syncope is the one that is concerning but feeling a bit hard discomfort or or feeling that my heart is racing, I feel discomfort in my heart, you have to verify is it is being paid is that it flag. But if there is no pain that this is not a red flag, any palpitation can do this. And also shortness of breath, I can take my breath. Normally when I'm having this heart racing, it's also it's not a red flag but severe shortness of breath, I can take my breath. That it's it's that is it might severe shortness of breath that can indicate the reset flags. So I told you that my Blitz, I cannot take my breath normally, because the heart racing is too much. This is not considered as a red flag that weren't admission. And this was correct perception that you have received that you did not act that it is a red flag but more to be a part of the palpitations symptoms. Then you ask about this loss of consciousness. This is excellent. And you ask about past medical history of high blood pressure, hyperthyroidism, heart disease, this is all excellent. And family history of heart disease or sudden death. This was a perfect approach of the case that you did very well and very early. From the beginning of the case. This was very excellent. You asked after this about work and working as a car daSun in coffee shop should remind you of coffee. So you could ask it spontaneously of coffee, not to forget it. But you did ask However, later on. But my point is that sometimes the patient himself reminds us of things We could follow immediately, if we if we were able to. And also one more thing regarding work, work, bring stress most of the cases. So we could ask about stress immediately at work. So this, this might advise to immediately ask about things that the situation of the question brings it. So you could ask if there is any stress at work, that can be a very good trigger for palpitations, especially the PVCs. And svt, as well can be also brought. Then you ask about home and ask about husband, this is excellent. And when I told them, I'm divorced, you said this is challenging. Excellent. I really admire this reaction. Because we used to say that I'm very sorry, you should never say sorry, it says that judgmental or being a pre occupied that divorce is always a bad thing. So challenging, this is excellent. Reflection, this is considered as a deep reflection, actually, that it's not just an empathy, it's deep reflection, when I told you that I have divorce, you could have enforced it by giving more detailed sexuality to the care of your children on your own. This was to be the most best reflection I've ever healed if you just add this extra comment. However, what you did was really brilliant. I liked it very much to say challenging. I proceed. Previous colleagues was so commented on the same thing. They said, I'm sorry, you should never say this because it saying sorry for a divorce is means that you always consider divorce as a bad news. Sometimes it's the best news. There's domestic violence, or this agreement. So you could just say challenging and comment about extra comment or enforce it by that you have you are responsible about them on your own. That would be great, complex reflection. Then you ask about smoking and alcohol. And while you're asking about smoking, I told you that I have this heart racing right now. This is excellent that you reacted with what I said it is just to say, Okay, we will get back to this point later, how many seconds per day, that would be a very negative thing against you in the exam, but you reacted you said, can you lie on couch, okay, I will do for you ECG right now, this is a very excellent reaction, but I recommend always EBC in the, in the clinic, start examination and then do ECG. Okay, it's okay to start examination, just I will check your pulse, even checking the pulse alone that would be at least at least showing that you are doing the the algorithmic approach to do an examination then ECG, if you if you did ECG, also in the concepts that this palpitation can go away, and you want to catch it before it goes away, it's still very good. But don't forget that you still need to do examination you need to do check the pulse with your hand. And also to check to do the solver maneuver, as well as checking if there is any structural abnormality that suggests there are red flags and this patient after this. You said do you want me to give you anything right now. It this is not a pain symptoms that you could give the option for the patient to endure the pain or take something for it. This is palpitation that could turn into serious palpitation. So you need to give something it's not a matter of taking opinion of the patient for it. You could say that I would like to give Do you mind just taking permission from the beach diver to give you some time for this. But rather than give you something that I would like to do a maneuver to abort it Do you would like me to try do you mind if I try this would be much better. You did valsalva maneuver by blowing over the cheeks. I prefer to use other other performance if you would like to do Valsalva like for example. And now I'm going to touch your neck area, I'm going to do gentle massage on your area, this cold carotid area and then try to do this with your neck with your hands. And I will stay do this for a while. Let me know if you feel better. Or tell the patient to lay down in bed and cough. But I prefer highly recommend to do the modified valsalva maneuver. And then you you need to say like for example I will bring a syringe and put it to your mouth. I want you to grow as much as you can explain the procedure. And then after this, I said I'm going to check your pulse again. Now can I do the ECG in case they brought to see it in the spine? If they didn't bring the syringe you can describe the procedure that you're going to do. If the examiner commented that there is no serums for example, at this point, you could say that I will do the Valsalva itself. However, from the feedback of our candidates who did the examination They did this modified Valsalva no comment about that it was not done appropriately. And they managed to get through the exam. So looks obviously that the this this way was accepted in the exam. After the maneuver, you said, Do you feel better now this is good. But also it's better to check the pulse verify by checking the pulse I asked you do you want to check my pulse now, you'd split Are you you need to ask to do it on your own. And now I will check your pulse. And you can also repeat the ECG as well. When you do the examination, you also do the examination you said I want to listen to your chest. And then you said I want to palpate your chest area. And I want to auscultate to not say palpate, or skin teeth. This is jargons it's better to say I want to touch your your, your heart, I want to listen to your heart, this is how to say it. And also don't forget to expose a warranty to uncover your thumb, your chest, then you can ask whatever you are going to do. Also, it's so important to thank the patient after doing the examination, apart from this examination was done. Well. One more thing I could not judge to you, which is the blood pressure because I gave you a finding of blood pressure area. So I'm not sure if but you didn't ask it. But if you forgot to ask it, you wouldn't have asked it. It's it's very important to ask about blood pressure because hypotension means that the patient has need urgent resuscitation right now with IV fluid that he is going through a shock. So it's very important to like could do it could need Edie DC shock right now. In order to restore the, the the circulation, then you said that I want to send you by ambulance, it's very negative to say intervention before mentioned diagnosis, you need to mention that was what is it? And then based upon this diagnosis, you will do whatever management you will do. So you said first in I will send you by ambulance after the examination. And this. This is not right, you should first say that diagnosis is VT and explain it and then say that since it's not exist, a refresher that said it's not going away with the maneuver I told you, I need to refer you to the ambulance to the hospital right now. So that they can give you medicine to abort it. Because if we let it like this, it could turn into serious form of arrhythmia. Your justification for the management of the ambulance was incorrect because you said that I have a chest pain. This is not right. I don't have chest pain. And you inquire asked me about chest pain. I told you I don't have it. After this, I told you that after that would have just been I said that it comes very often during the past month, it comes after an hour they go. You just said can we proceed now to the consultation you should response my query that what exactly I would like to tell you behind this that I don't need an ambulance. This was comment about the ambulance. So you have to say that I know that it can goes into on its own, but sometimes it doesn't. And sometimes it may turn into a serious type of heart racing that can compromise your life. This is how to justify why you need an ambulance. And then if the patient agrees, you can see that while waiting for the ambulance Can we proceed now in our consultation? That would be very good to say that while waiting to the ambulance, we do have time to talk more about you to other things. After this, you said do you do consume alcohol or coffee? It's better not to separate both of them especially that they are not connected to each other. So better to ask each one separately especially that you said Do you consume alcohol and or drink coffee? I would say yes. Or I would say no. Yes to both or no to both or one to one of them. Yes to one of them or no to one of them. So better to be separate questions and it could be just a quick questions like in a phrase like for example in one in one question, but in separated or for example, do you consume alcohol? No. What about coffee? So you did not repeat the question again. So that it can be less time consuming but at the same time appropriate and separated. After this you rearrange yourself and you ask about driving this was excellent and you give a summary a very excellent summary and you you forgot to to ask about idea and concern expectations. Expectations already voluntary mentioned But idea, concern and impact, you forget about them. And the summary did not remind you that you forget about them. You said that you came today because you have a report and you want me to tell you what's in the report. Okay. And you are worried for your kids and smoker, smoking for six years. This was the only summary that you mentioned. It's good, but he did not, it did not remind you that you did not ask about the concert, you didn't ask about the idea. What's causing this problem? So it would be appropriate at this point to explore the idea and, and, and concert. And even if you already mentioned a diagnosis, when you mentioned the ambulance, you could say What were you thinking that possibly you have? Even even sometimes in our daily clinic, even if you mentioned that diagnosis to the patient, sometimes he still have doubts about this diagnosis, because he has hidden false belief that you need to clarify you need to correct it. So you could say What were you thinking? What what are you worried about this condition, you can address it spontaneously. And immediately, you did very well explanation and you explain that diagnosis as well as explanation. And you said, I want you to change your lifestyle started by smoking and you advise me to stop smoking explored whether I want to stop or not, this is excellent. And you you said that it's a risk factor and is better to quit your advice leaflet to read about it and appointment for smoking cessation, this is also this is great. And you also give me advice to reduce the amount of caffeine and the don't drive if this attack occurred while driving. But during those advices you are too fast, you are not pausing, you are not stopping. Except when you said that don't drive you you give advice multiple advice together and we just separated by okay then move on then select for example, you fail to have smoking cessation clinic, okay. And also better to decrease amount of coffee use that use Okay, and while you're driving. So this not stopping can be a more Doctor centered approach. So be careful about it. I know that didn't mean that you were thinking that it's time is running, you want to finish quickly. But please pause a little bit stop the patient should receive you should receive input from the patient. As I said, it's enough for nonverbal cues or to say it yes, okay, or whatever. When you told me earlier about the ambulance, I told you that it comes and goes on its own. Then you moved on to the rest of the consultation. And here, you came back to me and you said I will give you medication, medication. To take it whenever you have attack. This means you will let this patient go home. This is very wrong to leave this patient go home if she still have the attacks. So I'm not sure what were you intending to do when you give this medication. But if you're sending a patient to the hospital, you should never give medication except for acute reliever of pain for example. Or if nitroglycerin for example to for the chance to do dilatation of blood vessels or reduce blood pressure, any urgent intervention medication. But to take it whenever you have attack, this means discharge home. This means home the shot and you weren't able to correct yourself before the case finished and this is a negative thing that you let this patient go home which is a negative thing to do in an emergency case that you did not address the patient safety and you let this patient go home. And when I asked her about the medication he said propranolol propranolol is BT beta one and two blocker it's it's not selective, better to be called to selective beta one blocker which is bisoprolol or Carvedilol. But this is not you are not the one to prescribe this. You could prescribe it confidently and competently it will never be wrong. If the attack is abolished. Attack is abolished and you refer to cardiologist and give syphilitic if ever come back again to go to your you could give this medicine tentatively it won't help make sure that there is no contraindication first however, as a family physician, I prefer not to give it this should be assisted by the cardiologist. First. However, you You did this was the ending of the case that you prescribe this medication you ended by prescribing this medication to be taken daily and if it's not returned to come back to you. So this means that you discharge the patient as long as this was ended. In the consultation even if you said umbrellas earlier in during the consultation with this statement it means that you have changed your mind especially that I was arguing with you and you did not end the consultation from your site or in this topic or in this particular subject from your site by insisting on ambulance. I told you, but it comes to me, and it's going comms going on its own, then you move to the rest of the consultation without responding to my objection. So this means as a few already accepted my my objection, which is not appropriate to be done in this case. So overall score of this case is as follows As regards consultation and counseling skills, the empathy, it was very brief at the beginning, but you did not ask about the impact did not give an empathy after the impact because it was not inquired about so done, but incomplete, fulfilling few of it. You didn't ask about the idea. You didn't ask about expectation. So the expectation is already mentioned. You didn't ask about the concern. I mean, as well as the impact. The sequence was a bit disturbed, not because you examined me earlier, but because you decided to send me to the ambulance without explanation. You have to explain something, even if the diagnose is unsure at this point, you have to justify first before referring to the ambulance that like I can see that this heartbreaking is not going and I'm concerned about it that it could be something serious, I will refer to ambulance right now. Do your mind. You have to justify what you say before saying the ambulance word. You did very good summary. I have no comment about it you but you weren't able to end the consultation or take the patient. You did excellent reflection. However, you use jargon terms when he said palpitation auscultation. So overall, a consultation across the skills 55% unsuccessful. And as regards data gathering skills, everything was done very well as regards the family history, personal history, main complaint, it didn't ask whether I'm taking any drugs or regular basis. And as regards the psychosocial it was very well explored. But apart from stress at work, he did not discover so done but incomplete fulfilling most of it and asking about differential diagnosis was explored. But you did not ask about last menstrual period. She's female, she could be pregnant. So you need to ask about and you ask about two questions that are one like when you said Do you drink alcohol or coffee, this was not accepted. So overall data gathering borderline past 74%. And as regards examination, it was done very well apart from exam asked for exposure for the part to be examined. Apart from this, everything was done well. So 84%, clear pass, I just I said before that I suggest to be modified Valsalva rather than Valsalva. And you should say it I will do a maneuver called modified Valsalva just to give the impression about what exactly you are doing. And SEC regarding management investigation skills. You did very well explanation, diagnose and explanation. And you get pharmacological advice that is very good and complete. And you give advice for driving for smoking, but he didn't give advice about stress in this case, because he didn't identify it. Also addressing the idea. That is hyperthyroidism. He didn't ask me. So it didn't know whether I think it's or not. And also the concern you didn't address my concern. And you did very well explanation, investigate investigation and explain the investigation. The problem is that you did not refer to the hospital right now, this was very negative point in the case that literally will not make you pass this case, whatever you did in the case, whatever good you were, you will not pass the case if he did not refer to the hospital and insist till the last moment to refer to the hospital. Finally justification of management was done. Well, I just apart from just one remark that you did not justify the ambulance at the beginning you said that you said the ambulance without justification. Why you want the ambulance you said first you should say the diagnosis first, so done but incomplete fulfilling most of it. So in management investigation, just because you didn't refer to the hospital 3% 3% Image of diversification unsuccessful in the management diversification and it's not enough to say it, you have to stick to it until the end of the case. If you change your mind or accepted the patient refusal, then it will not be counted to you. So overall score 46% unsuccessful less overall this case, I'm sure if you if we assume that you did refer this patient to the hospital, you would have done I'm better at least you could marginal postures case, but it's very important to admit a patient of emergency. And also the other remarks at Everest. I'm sure if you pay attention to it, you will get an easy clear pulse inshallah. If you encountered this case ever again, good luck