Essential Features of Essential Features of the Clinical Presentation the Clinical Presentation

Curriculum Curriculum Payman Hemmati, MDPayman Hemmati, MD

Hemmatipayman@yahoo.comHemmatipayman@yahoo.comTel: (+98)(912)(526 2005)Tel: (+98)(912)(526 2005)

Iranian Center for Diseases ControlIranian Center for Diseases ControlMinistry of Health & Medical EducationMinistry of Health & Medical Education

OutlineOutline

• Current difficulties• Clinical presentations• Hypothetical deductive reasoning• Scheme induction• Pattern recognition• WHO project in Medical Education• Summary

OutlineOutline

• Current difficultiesCurrent difficulties• Clinical presentations • Hypothetical deductive reasoning• Scheme induction• Pattern recognition• WHO project• Summary

The proposed educational strategy

The traditional educational strategy Manifestations

⇓ Diseases

⇓

Comparison between Modern & DOME strategies

Designer: Payman Hemmati, MD

Chief Complaint eg. Palpitation

Cardiac Arrhythmias

Pheochromocytoma

Toxic Multinodular

Goiter & Adenoma

Ovarian Teratoma ( Struma Ovarii )

Well-differentiated Follicular

Carcinoma

Grave’s Disease

Increased TSH-Receptor

responsiveness

β) HCG Stimulation

Factitious Thyrotoxicosis

Pheochromocytoma

Grave’s Disease

Hypertension

Dizziness

Headache

Palpitation ( Chief Complaint)

Heat Intolerance

Fatigue

Increased Appetite

Weight loss

Nervousness

Real Direction Unreal

Direction

Disease 1Disease 2

Disease 3

Disease 5

Disease 4

Disease

2000

Disease

2600

Disease 6

Disease

2500

Disease 2800

Disease 3262

Disease

2900

SHOOT

Physician

OutlineOutline

• Current difficulties• Clinical presentationsClinical presentations• Hypothetical deductive reasoning• Scheme induction• Pattern recognition• WHO project• Summary

Dif ferent Clinical Present at ions

JaundiceChest painDysuriaPalpitation

3262 Diseases or More

Cough

Disease 1Disease 2

Disease 3

Disease 5

Disease 4 Disease 6

Physician

OutlineOutline

• Current difficulties• Clinical presentations• Hypothetical deductive reasoningHypothetical deductive reasoning• Scheme induction• Pattern recognition• WHO project• Summary

Patient Information

Perception

Analysis

Problem SynthesisMultiple

Hypothesis Generated and Regenerated

Inquiry Strategy Designed and Redesigned

Clinical Skills, Questions & Examinations

Hypothetical Deductive ReasoningHypothetical Deductive ReasoningBarrows & Tamblyn (1991)

One hypothesis (disease) tested in cycle

05/24/2005 Drs. Payman Hemmati & Peter H. Harasym 9

Disease 1Disease 2

Disease 3

Disease 5

Disease 4 Disease 6

?

The proposed educat ional

st rategyWhat is t hat magic t ool box?

+

OutlineOutline

• Current difficulties• Clinical presentations • Hypothetical deductive reasoning• Scheme inductionScheme induction• Pattern recognition• WHO project• Summary

Scheme for Palpitation & weight loss for patient referred to an Endocrinologist

Palpitation & weight

loss

Primary Thyrotoxicosis

Central Thyrotoxicosis

HyperthyroidismSubacute

ThyroiditisExtra-Thyroid

CausesDrugs

- Viral- Silent

- Teratoma- Well-diff Carcinoma

- Factitous Ty -Tox- Amiodarone- Radio contrast

AutonomousNon-

Autonomous

- ↑ B-HCG

- Hyperemesis Gravidarum

- Hydatiform Mole

- Choriocarcinoma

- TSH Hyp.Responsiveness

- Graves disease- Toxic MNG

- Toxic Adenoma

- Hashi Toxicosis

7

8

8

7

6

5

4

3

2

1

6

5

4

3

2

1

4

3

1

2

D3= FT3

The descriptions & footnotes

The data which should be extracted by clinical consulting & lab procedures

The predictor (D) value

The possible or definite diagnosis

Palpations with weight

loss

D1= FT4 D2= TSH

1) Ty.Tox = Thyrotoxicosis 5) Eu.Ty = Euthyroid 2) NL= Normal 6) Sug.v)= Suggestive of 3) ↑ = Increased 7) Hyp.Ty= Hyperthyroidism 4) ↓ = Decreased 8) N.Ty= Non-thyroid

D1=NL2

D2=NL

D1= ↑3

D2= NL/ ↑

D1= ↑

D2= ↓4

D1= NL D2= ↓

Eu.Ty5

Sug.v)6

Central Ty.Tox

Primary Ty.Tox

Sug.v)6

Primary Ty.Tox

D3= FT3

D3= NL/ ↓

D3= ↑ Central Ty.Tox

Reduction of T

4 → T

3

Transformation

Sug.v) Subclinical

Hyp.Ty7

T3

Ty.Tox

D3= ↑

D3= NL

Repeat TFT after 6-12

weeks

D1= NL D2= ↓

Subclinical Hyp.Ty

Consider: 1-Drugs

2-N-Ty8 illness

3-Genetic Disorders of the Thyroid

5

5

4

3 2 1

9

8

7

6

5

4

3

2

1

4

3 2 1

Primary Ty.Tox

D9 = Opht.p1

D10 = RAIU2

D11 = TGB3

D12 = Anti-TGB4

D9 = +

D9 = −

D10 = NL ⁄ ↑

D10=↓

D11 <10 or undetectable

D12 = −

D11 >100

D12= ±

10 < D11 <100

D12 = ±

Sug.v) Factitious

Ty.Tox

Ty.T

D13 = WB.6

Scintigraphy

D13 = −

D13 = +

Extra Ty. Causes

Sug.v) 1-Grave’s

2-Hashi.Tox

Hyp.Ty

Figure 5

1-Opht.p = Ophthalmopathy 5- PMH =Past Medical History 2-RAIU = Radioiodine Uptake 6- WB = Whole Body 3-TGB = Thyroglobulin 4- Anti-TGB = Anti-thyroglobulin Antibody

D14=Fecal Ty. Hormone

D15= PMH5

Factitious Ty.Tox

Oropharyngeal Esophageal

Dysphagia

Neurologic MechanicalMetabolic Muscular Mechanical Neuromuscular

DysmotilityDiseases

HypomotilityDiseases

Extra-luminal

Intra-luminal

Extra-luminal

Intra-luminal

Disease 1

Disease 2

Disease 3 Disease 5Disease 4 Disease 6

The proposed educat ional

st rat egy

+Disease 2

Disease 1

Disease 4

Disease 3 Disease 6Disease 5

Boom !Boom !

Schemes

Induction

Categories and subcategories

+Disease 2Disease 1 Disease 4

Disease 3 Disease 6

Disease 5

OpenThe new

educationalstrategy

Visual heuristics

Schemes

Induction

Categories and subcategories

+Disease 2Disease 1 Disease 4

Disease 3 Disease 6

Disease 5

OpenThe new

educationalStrategy

Visual heuristics

SummarySummaryInformation overload

Encourages HDRClinical presentation

Scheme inductionPattern recognition

Physician

Schemes

Induction

Categories and subcategories

OutlineOutline

• Current difficulties• Hypothetical deductive reasoning• Clinical presentations• Scheme induction• Pattern recognitionPattern recognition• WHO project• Summary

Symptoms

Laboratory Signs (Paraclinical) Signs

Clinical Pattern

Or

Information Structure

Or

Syndrome Signs are the

data extracted by physical examination The

laboratory signs are the

data extracted by paraclinical procedures such as CT

Scan, Complete

Blood Count (CBC), &...

Symptoms are the data extracted by history taking

(medical interview)

The General out line of informat ion st ruct ures in

Medicine

Pattern recognition

Physician

Pattern

1

Pattern

2

Pattern

6

Pattern

3 Pattern

7

Pattern 5

Pattern

4

Pattern X

The Pat t ern recognit ion for diagnosis t he “ Pat t ern X”

OutlineOutline

• Current difficulties• Hypothetical deductive reasoning• Clinical presentations• Scheme induction• Pattern recognition• WHO projectWHO project• Summary

سسسسس • س س س سسس س سس س سسسسسسسسس س سسسس س سس سسسس

سسس سسس س سسسسس سسسسسسس سسسسسس س سسسسس سسسسس س سسسس

(سسسس) سسس

سسسس • سسسسس س سسسس : س سسسسسسسسسسسسس = سس سسس سسسس سسسسسس

سسسسس • : سسس سس سسس سس سسس س س سسسسسس س سسس سسسسس س سسسسس س س

سسسسس سس سسس س (سسسسس CPCسسس سسسسسس سس سسسسسسس سسس )

سسس سسس سسسس سس سسسسسس سسس سس •سس سسسسسس س سسسسسس س س س سسسسس سسسسسسسس سسسس سسسسس

سسس سسسسسسسس سسسسسس سسسس سسسسسس سسس سس سسسسسسس) (سسسسس

سسسسس سس سسسسس

سسس سسسس سسسس سسسسسس سس سسس •سسس سسسسس سس سسسسس سسسسسسسس

سسس سسسس سسس سسسسس سسسس

WHO projectWHO project

Workshops CP modules

WHO projectBiennium 2004-5

• Those seminars were highly accepted• Faculty believed “CPC is desirable and feasible

in Iranian medical education system”

WHO projectWHO project

Workshops CP modules

WHO project 2006-8

• WHO & the MOHME funded the development of 10 CP modules

1. Infertility

2. Vaginal discharge

3. vaginal bleeding

4. Sore throat

5. Nasal obstruction

6. Chronic cough

7. Hypercalcemia

8. Hyperglycemia

9. Dysphagia

10.Anemia

WHO project 2006-8

• The best qualified clinical & basic faculty members have been selected nationwide to develop the modules

1. Infertility 2. Vaginal discharge3. vaginal bleeding4. Sore throat5. Nasal obstruction6. Chronic cough7. Hypercalcemia8. Hyperglycemia9. Dysphagia10. Anemia

WHO project 2006-8

• Each module will contain:

1. Logical development of a scheme

2. Scheme3. Matrix4. Terminal objectives5. Basic science Content

list6. Enabling objectives7. Learning materials

(e.g., reading materials and assignments)

8. Teaching materials (PowerPoint slides)

9. Problem-based cases (used with scheme induction)

10.Process worksheets for tutors to guide small group PBL scheme-inductive sessions

11.Schedule12. Formative (mainly basic

sciences) and 13. Summative evaluations

(mainly clinical vignettes and OSCEs)

14.Remedial intervention

• •

•)Terminal Objectives( Enabling Objectives•action(

a

Loss of Conscious

Ness/ Syncope

Presyncope

‌ ‌ ‌

b سسسسس سسس

c سسسسسس سسسسس

dسسسسسس

سسس سسسس

e

سسسسس سسسسسس

سسسسسس س(

سسسسس سسسس

fسسسسس سسسسسس

سسسس

g

سسسسسسسسس

سسسس سسسس

h

سسسسسسسسس

سسسس سسسسس

0 1 2 3 4 5 6

Syncope(Exclude Seizure)

OtherCerebrovascular(15%)

Cardiovascular(75%)

ElectricalMechanicalReflex / Under

fill(35%)

PsychiatricMetabolic

•Aortic Stenosis•HCM•Myxoma

•Bradycardia•Tachycardia

•Vasovagal (20%)•Orthostatic (10%)•Situational•Carotid Sinus Sundrome

•Hypoxia•Hypoglycemia•Drugs/Alcohol

•Panic disorder•Hyperventilation•Hysteria

•Carotid Artery dis/ TIA•Vertebro-basilar•Intracranial pressure up

a

Loss of Conscious

Ness/ Syncope

Presyncope

‌ ‌

b سسسسس سسس

c

d--

eسسسسسس

سسسسس•HCM•Myxoma

0 1 2 3 4 5 6

a

Loss of Conscious

Ness/ Syncope

Presyncope

‌ ‌

eسسسسسس

سسسسس

• Chest pain•Exercise intolerance•Fam. Hx of sudden cardiac death• palpitation

•LV heave•Atrial pulse•S4•Ejection systolic murmur

•HCM•Myxoma•Pulmonary stenosis

•Echo• Cardiac catheterization????????????????????????

•Diastolic heart failure•Systolic heart failure•Arrhythmia•Sudden death

•Afterload reduction (medical Tx)• Surgical replacement of valve (valvuloplasty)•Serious Tx of streptococcal Angina

0 1 2 3 4 5 6

CP module

•b-1 :(

seizure

.

:•••

Audience

Behavior

content

Condition 1

Condition 2 Degree

CP module

•C-1 :(

•

• :••chest pain•

Audience

Behavior content

Condition 1Condition 2 Degree

Terminal Objective

• b2: The graduate student should be able to identify an Adrenal Mass with a size of

at least 6 cm with abdominal palpation in a non-obese patient.

Terminal Objective

• b2: The graduate student should be able to identify an Adrenal Mass with a size of

at least 6 cm with abdominal palpation in a non-obese patient.

Terminal Objective

• b2: The graduate student should be able to identify an Adrenal Mass with a size of

at least 6 cm with abdominal palpation in a non-obese patient.

Terminal Objective

• b2: The graduate student should be able to identify an Adrenal Mass with a size of

at least 6 cm with abdominal palpation in a non-obese patient.

Terminal Objective

• b2: The graduate student should be able to identify an Adrenal Mass with a size of

at least 6 cm with abdominal palpation in a non-obese patient.

•23

•23

CP module

•

•

Audience

Behavior content

Condition 1

Condition 2 Degree

Condition 1

OutlineOutline

• Current difficulties• Hypothetical deductive reasoning• Clinical presentations• Scheme induction• Pattern recognition• WHO project• SummarySummary

Further Study1. Aflatoonian A, Baghianimoghadam B, Hemmati P,et al. Developing an educational scheme for

undergraduate medical Curriculum: the unit of "INFERTILITY" as a sample. Journal of Medicine and Life 2012; 5(1): pp.16 20.‐

2. A. Aflatoonian, B. Baghianimoghadam, P. Hemmati, et al. A new classification for female infertility. Clin Exp Obstet Gynecol. 2011;38(4):379-81. (1091 reads - on Research Gate Spotlight)

3.3. Haeri A, Hemmati P, Yaman H, Haeri A, Hemmati P, Yaman H, What Kind of Curriculum Can Better Address Community What Kind of Curriculum Can Better Address Community Needs? Problems Arisen by Hypothetical-Deductive Reasoning. Needs? Problems Arisen by Hypothetical-Deductive Reasoning. Journal of Medical Systems;2007(31):173–7. DOI 10.1007/s10916-007-9052-5

4. Coderre S, Mandin H, Harasym PH, Fick GH. Diagnostic reasoning strategies and diagnostic success. Med. Educ. 2003; 37(8):695–703.

5. Shahabeddin Safi, P. Hemmati, SHS Beheshtiha, et al. Developing a clinical presentation curriculum in veterinary education: a cognitive perspective. Comp Clin Pathol (2012) 21:1521–1526.

6. Barrows HS, Pickell GC. Developing clinical problem-solving skills: a guide to more effective diagnosis and treatment, 1st ed.W. W. Norton & Co., London (1991): pp 9–15

QUESTIONS?QUESTIONS?