MEQs for family physicians

Press the number of the question to get the answer

CONTENTS MEQ1. EXAMPLE OF BAD ANSWER MEQ2. Mrs. Sabreen is 40 years old, married and has no children. For the last 15 years she has been trying to be pregnant, but all her trials ended by failure. This time she succeeds and she became pregnant. She came to you for her first antenatal visit at 10 weeks gestation. How are you going to conduct this consultation?

MEQ3. Two days later Mrs. Sabreen came to you complaining of vaginal bleeding. Discuss your management of this situation.

MEQ4. Mr. Waseem is 28 years old, married, with 5 children. He works as a receptionist in a very luxurious hotel. He noticed white spots spreading in his hands and trunk which was diagnosed by a competent dermatologist as vitiligo, but Mr. Waseem did not accept the diagnosis and he came to you asking for referral to another dermatologist. 1. What are the etiological factors for Mr. Waseem’s behavior? 2. How are you going to end this consultation?

MEQ5. You are assigned as doctor in-charge of a health center, you decided to start mini-clinics for DM. What are the issues raised by this decision?

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MEQ1. EXAMPLE OF BAD ANSWER 

I will establish good patient – doctor relationship o o o o

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I I I I

will will will will

say hello, how are you? shake hand with the patient. look to his eyes (eye contact). ask open - ended questions e.g. what can I do for you?

I will find out the real reasons for his attendance & the effect of the problem o o o o o o

His idea His concern His expectation I will take full history I will do general examination I will look for the differential diagnosis  Is it physical?  Is it social?  Is it psychological?

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I will look for risk factors like smoking, obesity, hyperlipidemia, DM – hypertension, asthma, drug, abuse, sedentary life …

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I will reach shared understanding of the problems.

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I will choose with the patient the appropriate action for each problem.

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I will involve patient in the management.

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I will use time & resources affectivity.

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Management option: o o o o o o

Reassure the patient Advice the patient Prescribe medications Refer to hospital to social worker Investigation the patient Observe and give follow up appointment

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ANSWER MEQ2:

Mrs. Sabreen is 40 years old, married and has no children. For the last 15 years she has been trying to get pregnant, but all her trials ended by failure. This time she succeeded and she became pregnant. She came to you for her first antenatal visit at 10 weeks gestation. How are you going to conduct this consultation? 

Establish Doctor – Patient Relationship   



Physical assessment :  

LMP and calculate EDD. Physiological changes of pregnancy e.g. Tiredness, Nausea, Breast engorgement.  Any complication of pregnancy: Vaginal bleeding. Dysurea. Severe headache.  Past medical history – chronic diseases e.g. DM / Hypertension / Asthma  Past OB history: Abortion. / Ectopic pregnancy / Gynecological operation / Drugs increase ovarian activity

History:

Physical Examination: General inspection: Vital sign: General examination: OB examination: 

Congratulate her for her pregnancy. Ask God to save it for her. Showing her extra care & empathy e.g. by treating her very gently, give her enough time, put her at ease and invite her to ask any question.

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Pallor / Odema Pulse / BP Chest & CVS / Breast /Abdominal examination Vaginal examination if needed

Psychological Assessment: Patient ideas

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Patient concerns:

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Patient Expectations:

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She may think she needs traditional healer to save her pregnancy.  She might think that this is afalse pregnancy or tumor or ascitis, it is not a real pregnancy!  She may be thinking it is a twin pregnancy because of ovarian stimulant medications. Possibility of congenital anomalies. Possibility of complications e.g. toxemia or death of the fetus  Possibility of complicated delivery e.g. bleeding or fetal death.  Worry about future e.g. is she young enough to take good care of her baby?! She needs reassurance that every thing is normal. She may need more information about pregnancy at age of 40 years and possible complications.  She may ask for referral to a special care center to take maximum care of her pregnancy. 3

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Psychological symptoms:

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Social support:

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Degree of anxiety about her pregnancy. Her mood & interest

Relationship with her husband & his attitude towards this pregnancy.  The condition at work (if she is working) and if there is any risk needing to be avoided e.g. heavy work. Management options :

Reassurance:

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Advice:

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Prescribing: Referral:

Patient needs explanation & reassurance that she is in good hands and if any problem raised it will be diagnosed early and she will got the maximum treatment available.

General advice: Avoidance of medications Diet – high quality vitamin and iron Rest – enough sleep Hygiene and care for breast Specific advice: Signs of complication e.g. abdominal pain, vaginal bleeding, severe headache.  May she need amniocentesis at 18 weeks because of her age.  She may need referral to a radiologist for detailed U/S for early diagnosis of any fetal abnormality.  Iron and Folic acid  May be calcium if her dietary intake is not enough.  

Investigations:

To OB specialist because she is high risk pregnancy. May be a genetic counselor if there is any indication e.g. hereditary disease.  She may need tertiary care center if she develops any complications.  CBC  RBS  Urine culture & sensitivity  Urine dip stick  U/S

Observation:

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To be seen after the result of her investigation are ready or after 2 - 4 weeks Self awareness

My feelings:

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I may feel anxious in dealing with high risk pregnancy lady like this patient.  How can I help her if she lost this pregnancy, she might become depressed and angry from me.  I will feel very sad if she lost her pregnancy

Possible ways to deal with my feelings:  Express my feeling by showing to her extra care and empathy.  I may discuss her problem with her OB specialist, this may give me some satisfaction.

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ANSWER MEQ3: Two days later Mrs. Sabreen came to you complaining of vaginal bleeding. Discuss your management of this situation. 

Maintaining Doctor – Patient Relationship :  

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Treat her energetically to show how much I care? Show empathy (I understand how much it is important to you to save this pregnancy).  Help her to lay down on the examination couch if this is more comfortable for her.  Assess vital signs immediately while taking history, because she might need resuscitation (hypovolemic shock because of bleeding). Physical assessment :

History :

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Examination :

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Differential diagnosis:

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Nature of the bleeding: Heavy or just drops or full fetus with clot Onset & duration of the vaginal bleeding. Any associated symptoms: Abdominal pain /Fever / Severe headache Possible causes for abortion: Infectious disease /Trauma / Congenital disease General appearance: Pallor / Exhaustion Vital signs: Pulse / BP / Temperature Abdominal examination: Tenderness in the lower abdomin or Mass Vaginal examination: Amount of bleeding Fetal parts Cervix: closed or open

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If drop of blood & no abdominal pain, it is most probably threatened abortion.  If heavy bleeding & the cervix is open, may be it is incomplete abortion.  If heavy bleeding but the cervix is closed, it might be complete abortion.

Psychosocial assessment:

Patient ideas :

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concerns :

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It is only local problem and nothing to do with her pregnancy (denial).  She may think she lost her baby and this is her last chance of pregnancy. About her future trial of pregnancy (is it worthwhile). About her husband, he may look for another wife. About her future life, she will be lonely lady with no children and no husband.  About her health deterioration because of this bleeding.  About her mother in law will stigmatize her for being a hopeless infertile lady. 5

Expectations :

Social resources :

Risk assessment :

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Treatment to stop this bleeding and save her pregnancy. D & C because she might think she already lost the baby. Referral to a special center to do anything to save her pregnancy.  Sick leave to give her a chance for complete bed rest.  Family support by her husband or mother or sisters or friends.  Support at work because she is physically & psychologically fragile.  

Symptoms of depression e.g. her mood and interest in life. Symptoms of pathological anxiety e.g. palpitation and dyspnea.  Bereavement (state of shock & denial). Immediate Managements :

Management options: Reassurance :

Investigations :

Specific Treatment : threatened abortion :

incomplete abortion complete abortion : Referral & Observation :

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Explanation of the findings and reaching shared understanding of the situation: If it is threatened, complete or incomplete abortion.

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CBC to assess the degree of chronic bleeding Urgent US to establish the diagnosis of abortion  HCGT if low it may indicate abortion 

Bed rest may help but there is no Evidence Based Medicine supporting this advice (EBM).  Hormonal treatment may help, but there is no Evidence Based Medicine supporting this treatment.  Grate proportion of patient with threatened abortion can complete there pregnancy to the end. 

She will need Dilatation & Curettage

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Reassurance & bed rest

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Mrs. Sabreen need urgent referral to hospital for evaluation and may be for admission or D&C  According to degree of bleeding and my preliminary assessment, she may need referral by ambulance after IV line insertion & supply of oxygen  A nurse or paramedic or even a doctor may need to accompany her in the ambulance if the bleeding is severe 

Long Term Managements :

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Anticipatory Care :

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If Mrs. Sabreen lost her pregnancy, she will need close observation during bereavement for early diagnosis of abnormal bereavement reaction & appropriate intervention, e.g. Referral to psychiatry  If the diagnosis is threatened abortion, she need social support & reassurance from her husband and /or relatives to complete her pregnancy

Self awareness:

My feelings :

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Dealing with my feeling:

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I may feel anxious in dealing with life threatening situation (bleeding)  I may feel depressed if Mrs. Sabreen lost her pregnancy  I may feel helpless if the diagnosis is threatened abortion and there is no effective (EBM) treatment which I can offer I will try to act promptly and be very cautions in my decision e.g. I may accompany Mrs. Sabreen in the ambulance if needed  I may talk to her obstetrician to discuss the situation , this may give some relieve

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ANSWER MEQ 4:

Mr. Waseem is 28 years old, married, with 5 children. He works as a receptionist in a very luxurious hotel. He noticed white spots spreading in his hands and trunk which was diagnosed by a competent dermatologist as vitiligo, but Mr. Waseem did not accept the diagnosis and he came to you asking for referral to another dermatologist.

1.

What are the etiological factors for Mr. Waseem’s behavior? 

Patient factors:

Patient Ideas:

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Patient Concerns:

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Patient Expectations:

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Family factor :

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Dermatologist :

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Doctor factor :

Vitiligo is an infectious disease & it may affect his family.  It is an acute illness and he will find radical treatment for it by an expert dermatologist.  It is a very serious illness & may progress to skin cancer. He may loss his wife because of this disease and also his friends.  Losing his job in that luxurious hotel.  He cannot find another job because no body likes his appearance.  The treatment is expensive and he can not afford its cost.  The disease may be hereditary & it will affect his children.  His daughters will be stigmatized and no body will come to marry them. He needs more explanation about vitiligo. He wants more investigation to confirm diagnosis.

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the

His wife is pushing hem to ask for a second opinion. 

His appointment system makes it difficult to see him.  May be he did not convince Mr. Waseem about the diagnosis.  May be he advised him to see another dermatologist. May be Mr. Waseem had difficulty in communicating with him and needs to see another dermatologist. 

The PHC physician may not have enough time to discuss his worries with him.  Lack of trust between the patient and his PHC physician.  Dependent Dr – Pt relationship makes the patient think he can ask for anything any time.

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The health care system :  

Flexibility of the referral system allows multiple referral. Different hospitals have different resources so the patient is asking for a better hospital with more resources e.g. not every hospital has laser treatment.

2.

How are you going to end this consultation? 

Maintaining Doctor–Patient relationship: 

Express my empathy: (I can understand how you feel and how this problem is affecting you).  Being flexible and negotiating all possible management options with the patient.  Respecting his autonomy and let him make the final decision after appropriate discussion of all options. 

Physical assessment: History: Family history: Precipitating factors:

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Painless depigmentation of the skin. Hair changes in the affected area (becoming white).  Similar disease in the family 

Risk assessment:

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Physical examination:

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Psychological assessment: ICE: Effect of the problem:

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Psychological stress at work or at home Possible associated autonomous disease e.g. Thyroid disease, Pernicious anemia, DM, Alopecia arietta in the patient and / or his family.

Well-defined oval or irregular depigmented area.  Common sites – axilla, groins, genitalia dorsum of the hands and face. (Refer to answer 1)    

Social isolation. Depression symptoms: mood & interest Anxiety symptoms :palpitation, nervousness Any financial problem or marital problem or problem at work.

Dealing with the demanding patient : Clarification:

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Why does he want referral to another dermatologist?  (His ideas, concerns & expectations)

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Explanation & reassurance:

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The disease is not uncommon, it is not infectious.  The disease is autoimmune, usually has no complications, there are different treatments for this disease, but no radical treatment e.g.  Potent topical steroids, PUVA, sunscreens, cosmetic camouflage.  (No need for referral at all), but this option may affect Dr. – Pt. relationship and also it may deny from him the benefit of another expert opinion.  (refer him directly to another dermatologist).  By this option I may express my sympathy & support and maintain Dr. – Pt. relationship.  But it may make patient dependent, it might be a waste of resources (unnecessary referral).  The dermatologist may become angry from my behavior.

Disagree with Mr. Waseem : Agree with Mr. Waseem :

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Negotiation of alternative solutions: 

(Negotiation & reaching with the patient a compromising solution), e.g.  No need for referral now, but if Mr. Waseem did not benefit from the current treatment I will look for the most expert dermatologist in this disease to refer this patient to him.  Order some investigation to rule out possible associated disease e.g. Thyroid or pernicious anemia.  Mr. Waseem may be depressed and need treatment for his depression.  He may have financial problem or marital problems and need counseling, or referral to social worker or psychiatrist. Self awareness: My feelings: 

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Mr. Waseem might make me feel sad & depressed because of the effect of vitiligo in his life.  He may make me feel angry because of his demanding behavior.  I may feel helpless because there is no radical treatment for his disease. Dealing with my feeling:

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During the consultation, express my empathy (I can understand how much it is important to you to have nice appearance).  Ventilate my feelings by talking to a friend or colleague.  CME about recent management modalities for vitiligo.

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ANSWER MEQ 5: You are assigned as doctor in-charge of a health center, you decided to start mini-clinics for DM. What are the issues raised by this decision? 

Assessment of needs :  

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What are the prevalence of DM and what are the priorities in this health center What are the needs of the population in the catchment area of this center ? e.g. if they are mainly young, they may need mini-clinic for asthma more than DM or we may need to improve vaccination clinic before starting a new mini clinic.

Assessment of Resources :

Man Power :

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Trained and interested nurse. Trained and interested doctors. May be social workers and / or dietitian. Lab technicians. Trained receptionist. If they are not trained, they need special training before the center can start the clinic.

Materials & equipment :

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Drug needed for patient. With DM Lab & equipment for basic investigations Free access to central lab for other important investigations Registers & special files

 Space & Time :

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enough

The local Ministry of health Protocol Or Royal College of General Practitioner in UK Protocol Or any other agreed protocol

Community Participation :  

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&

Protocol of the clinic:   

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Suitable room for the clinic Suitable waiting area for the clinic Suitable appointment system consultation time

The opinion of the community should be taken in to consideration The role of the community may be discussed : e.g. their role in offering some help to get the necessarily equipment, and their role in compliance

Plan for Implementation :  

Advertisement for the clinic Identification of target population , e.g. from the High Risk Register or From 11

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Evaluation of the Clinic : 

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Comparative study between the present situation and after 6-12 months of implementation of the clinic. E.g. Evaluation of level of blood sugar control or evaluation of patient knowledge & attitudes towards their illness (DM)

Advantages of the Clinic     

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Arrangement of routine referral to hospital Time : how many sessions per week ? what sort of appointment system Space : in the dr. consultation room or special room for the clinic Staff : special staff for the clinic or every doctor take care of his diabetic patient

This clinic may improve patient care It may improve community participation It improve team work It is a good chance for Personal growth & Continuing Medical Education It is may be of political benefit especially if the issue is important for the higher authority

 Disadvantages of the Clinic  

Such clinic need a lot of time , effort , resources & commitment It may affect other activity in the health center by shifting of limited resources

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