1 - Presenting Complaint of Mrs DV, a 29 year old lady:

Racing of heart, for the past 3 days

2 - History of Presenting Complaint:   
-   
-    The palpitations started from Friday, which was intermittent in duration. She was sleeping when it starts. The palpitations progressed until Monday when it became worse and continuous throughout the day. She had difficulty of breathing too. e She then referred herself to A&E
-    She denied of any ankle swelling, orthopnoea, dyspnoea on exertion, paroxysmal nocturnal dyspnoea or crushing chest pain.
-    She loss 22kg for the past 2 years, she attributed it to being a vegetarian.
-    However she described that she was being hungry all the time, although she didn’t eat much since she becomes increasingly picky with her food.
-    Her bowel habit is regular for the past 2 years except that she had loose stools for the past 3 days, not watery, and there was no blood or mucus.
-    For the past 2 years, she got anxiety attacks over flying and driving. She could not drive now. She would scream hysterically or being agitated although there is no danger. She never experience that before.
-    For the past 2 years, her menstrual cycle was regular but a bit light. She is on contraceptive pill.
-    She preferred to be in warm room but she can wear a light coat over the winter. She can tolerate the cold weather well.
-    She was feeling weak when getting out from the bed and getting into shower.
-    Last week she noticed that her neck was so big.

This is perhaps the most interesting case in my first 6 weeks rotation in Beaumont hospital. A classic presentation of hyperthyroidism, all the facts that I learned from my pathology course becomes so handy especially in history taking from this ever so pleasant lady. It is like a long read story unfolds itself upon my own eyes. I felt an indescribable feeling of fulfillment by making the right diagnoses, just from history and physical exam. I presented the case to Dr. Smith during the ward round, my first case presenting with a consultant. I was so nervous at first, all the feedbacks from my previous presentation flashed back in, but suddenly a sudden urge to just being confident taking over me. It was really a phenomenal experience, just me to inform him on everything and he relied on it. I feel like a real doctor working with him. I did a thorough thyroid physical exam and he was satisfied with all the findings I presented. All in all he was very satisfied with my presentation and I got a good feedback from him. For the first time, I feel so motivated. I learned a really big point today, that I can do it; I can present a case successfully, if I just want to do it. ☺

For the past 6 weeks, all rcsi’s third med students are attached to
clinical teams in Beaumont or Connoly Hospital.. i’ve attached to
infectious disease team, surgical team, and endocrinology team, and
i’ve met with so many senior doctors and patients.. the main essence in
this clinical attachment is to take history from the patients and then
to present it to the senior doctors.. the history taking part is quite
enjoyable for me, as i’m the person who’s like to chit chat
anyway….;) and all the patients are so sweet and nice.. the real
difficult part is too present the case history, ouch that’s so
mysteriously pain in the ass! seriously , i just couldnt understand
why, because in a logical induction, it should be easy since we just
need to report what’s the story.. but in the real world, that nice easy
logic doesnt happen at all..(well maybe sometimes on good days) . i’ve
received numerous comments from multiple senior doctors, hehe.. which
i’m happy to receive too, because i really need to build up my
presenting skills asap, before this coming osce in june.. well dr
shazly said i have the attitude but i’m a big gigly, huhu, and dr david
wants me to be more confident, and dr zubin said dont ask questions
while presenting the case.. i feel so stupid some times, as i think its
unusual to not acquiring the skill in overnight time.. but now i
realize that , it comes with practice and practice..to infinity,
nothing more..i’m improving now,thank god,and a few consultants even
gave me honest grade recently..phew…and then as i google to search
for few good websites for this case presentation, i stumbled upon this
journal, which kinda solved all my 6 weeks mystery.. hehe –> oh
really i’m gigly! is that a bad thing?? really!

Journal of General Internal Medicine

Learning Oral Presentation Skills

A Rhetorical Analysis with Pedagogical and Professional Implications

OBJECTIVE:

Oral
presentation skills are central to physician-physician communication;
however, little is known about how these skills are learned. Rhetoric
is a social science which studies communication in terms of context and
explores the action of language on knowledge, attitudes, and values. It
has not previously been applied to medical discourse. We used
rhetorical principles to qualitatively study how students learn oral
presentation skills and what professional values are communicated in
this process.

DESIGN:

Descriptive study.

SETTING:

Inpatient general medicine service in a university-affiliated public hospital.

PARTICIPANTS:

Twelve third-year medical students during their internal medicine clerkship and 14 teachers.

MEASUREMENTS:

One-hundred
sixty hours of ethnographic observation. including 73 oral
presentations on rounds. Discoursed-based interviews of 8 students and
10 teachers. Data were qualitatively analyzed to uncover recurrent
patterns of communication.

MAIN RESULTS:

Students and teachers
had different perceptions of the purpose of oral presentation, and this
was reflected in performance. Students described and conducted the
presentation as a rule-based, data-storage activity governed by "order"
and "structure." Teachers approached the presentation as a flexible
means of "communication" and a method for "constructing" the details of
a case into a diagnostic or therapeutic plan. Although most teachers
viewed oral presentations rhetorically (sensitive to context), most
feedback that students received was implicit and acontextual, with
little guidance provided for determining relevant content. This led to
dysfunctional generalizations by students, sometimes resulting in worse
communication skills (e.g., comment "be brief" resulted in reading
faster rather than editing) and unintended value acquisition (e.g.,
request for less social history interpreted as social history never
relevant).

CONCLUSIONS:

Students learn oral
presentation by trial and error rather than through teaching of an
explicit rhetorical model. This may delay development of effective
communication skills and result in acquisition of unintended
professional values. Teaching and learning of oral presentation skills
may be improved by emphasizing that context determines content and by
making explicit the tacit rules of presentation

a perfect conclusion!!!

Mind Map: a recommended study technique.. me and my friends use this and we find out that it’s pretty helpful and addictive too! do try!

Tony Buzan suggests using the following foundation structures for Mind Mapping:

1. Start in the centre with an image of the topic, using at least 3 colours.
2. Use images, symbols, codes and dimensions throughout your Mind Map.
3. Select key words and print using upper or lower case letters.
4. Each word/image must be alone and sitting on its own line.
5. The lines must be connected, starting from the central image. The central lines are thicker, organic and flowing, becoming thinner as they radiate out from the centre.
6. Make the lines the same length as the word/image.
7. Use colours – your own code – throughout the Mind Map.
8. Develop your own personal style of Mind Mapping.
9. Use emphasis and show associations in your Mind Map.
10. Keep the Mind Map clear by using radial hierarchy, numerical order or outlines to embrace your branches ^[1].

An idea map is similar to a mind map but does not adhere to the
above guidelines. Rules are constantly broken based on the purpose and
application of the map.

My childhood evolved around fantasy story books, one of the best series is :

The Magic Faraway Tree series is a popular series of children’s books written by Enid Blyton.
The stories revolve around an enchanted wood where a gigantic magic
tree grows, which is discovered by three children living nearby. Every
now-and-then, at the top of the tree, a new magic land appears, which
the children can visit; but they have to leave before the land "moves
on", or they could be stuck in that land when it is replaced by a new
land at the top of the tree.

The Faraway Tree is inhabited by people who include Moonface and The Tinks, the fairy Silky, The Saucepan Man]], Dame Washalot,
Mr. Whatsisname and the Angry Pixie. The lands at the top were
sometimes extremely unpleasant (the Land of Dame Slap) or sometimes
fantastically enjoyable (the Land of Birthdays, the Land of
Take-What-You-Want).

The titles in the series are:

1. The Enchanted Wood (1939)
2. The Magic Faraway Tree (1943)
3. The Folk of the Faraway Tree (1946)
4. Up the Faraway Tree (1951)

This is my second week in a surgical team and already I learn a lot. First from my team, I learn how to have a good bedside manner with the patients, which is basically simple humanism. And then I got the opportunity to be in OT and scrubbed in for Mrs IM’s anterior resection, which was very fulfilling since I had taken history from her before. I learn few surgery techniques such as laparatomy and laparoscopy. And then I follow up Mrs IM post operatively, accompanying her to gastrograffin enema and such, chit chatting with her all the way. I guess the most learning I got is from Mrs IM herself, the patient. She is very brave indeed, enduring this new rocky pathway of life with such patience and acceptance. From her I learned the secret art of healing, of the patients themselves and of us too, the medical personnels. By being aware of our own vulnerability, the crucial part of our humanity is being opened to flawness and only then we are opened to pain and subsequently healing. It is a reciprocal and reflexive process between the wounded and the healer, if we just listen, patient will guide us to heal them.

I got feedbacks from my interns, and sho, which are very motivating. They said I’m very good at history taking and clinical acumen but I need to be more confident in presenting the case and doing physical exams. Thus I hope by paving my way through this intensive clinical attachment, I can get enough practice to build my confidence on a solid ground.

A few bits from my recent case report..

Mrs VC a pleasant 54 years old female electively referred by OPD with altered bowel habit, abdominal pain and progressive faecal incontinence for the past 18 months and significant past surgical history of gastrointestinal system. She had very poor quality of life and also psychologically disturbed which she described as the feeling of being ‘dirty’. Thorough investigations did not yield any definite diagnosis. She had a loop colonostomy done successfully and she is doing well now and had been discharged home. This case shows an excellent example of how surgical intervention improves a person’s life dramatically.

“I will follow that system of regimen, which according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever deleterious and mischievous” says the old Hippocratic oath 425BC, which I just cannot agree more.

This is my first week in the surgical team and I really learned a lot of new things. Besides the theoretical knowledge, I am exposed to a new culture of the ‘surgical values’, which comprises of competency, competency and competency. There is just no place for error in surgery. However there are no clear-cut case and the best way to treat the patients are through integrating knowledge, synergy between team doctors and also learning via time and experiences.

    I interacted with lots of patients and most of them were very pleasant and cooperative. And every patient differs and the art of taking the history is to tailor it accordingly. I hope with the help of the supportive interns, Dr David Mak and Dr Michelle, my skill will improve especially in presenting the case in a more confident way.

cheerios full day in operating theater tomorrow..