Top 30: Murtagh, a zebra and the elephant sat in your consultation room…

donkey-156767_960_720 ‘It would be so nice if something made sense for a change’- thought the doctor.


 

Just when you thought the start of the day couldn’t get any weirder, a ships captain arrived with a red flag, followed quickly by Sherlock Holmes, and Zorro. ‘Sorry we’re late’ they exclaim, ‘we’re ready to help you take on the day.’

Then Murtagh spoke up and suggested- ask yourself these 5 questions for the presenting problems today:

  1. What is the probability diagnosis?
  2. What serious disorder/s must not be missed?
  3. What conditions can be missed in this situation?
  4. Could the patient have one of the ‘masquerades’ commonly encountered?
  5. Is the patient trying to tell me something?

http://www.amsj.org/wp-content/uploads/files/articles/amsj_v2_i1/AMSJ_v2_i1_pg46-47.pdf

Before you point out Murtagh is sitting next to a zebra, you remember Dr Cox quoting Dr Theodore Woodward at JD:

And you remember that the top 30 reasons for encounter in General Practice make up 58.7% of presentations. Suddenly the apprehension and uncertainty facing you that day, seems a little more manageable.

Intro 30 most common reasons for encounter in General Practice.pdf

‘Ok team,’ you say. ‘What can you help me with?’

The ships captain explains the red flag is a warning sign. A good history should include at least these 6 general questions:

  1. Tell me about your general health? Tiredness, fatigue or weakness.
  2. Do you have a fever or night sweats?
  3. Have you lost any (unplanned) weight?
  4. Have you noticed any unusual lumps?
  5. Do you have persistent pain anywhere?
  6. Have you noticed any unusual bleeding?

Sherlock Holmes pulls out his magnifying glass and reminds you to be thorough and search for clues for conditions that are commonly missed in this situation. Think cancer, think AMI in adults, and think meningitis in children.

The epidemiology of malpractice claims in primary care: a systematic review

Zorro warns to be en garde for masquerades. The most common are:

  1. Depression
  2. Diabetes
  3. Drugs- iatrogenic, over-the-counter, or self-abuse
  4. Anaemia
  5. Thyroid and other endocrine disorders- especially Addison’s disease
  6. Spinal dysfunction- pain syndromes
  7. Urinary tract infection

Finally, someone named the elephant in the room. Nelly discussed that patients might come with ‘yellow flags,’ or something they are trying to tell you but can’t do it outright.

During the series we hope to introduce you to a collection of tools you can use in your daily practice, as well as resources to be aware of. Murtagh’s diagnostic strategy, presented above is the first.

In the spirit of FOAM (Free Open Access Medical Education) we hope you will share any approaches or resources that you find helpful in your practice too.

Acknowledgement: This is the first of a series of posts that will address the 30 most common reasons for encounter in General Practice, based on a series of A4 handouts created by Tropical Medical Training.

Intro 30 most common reasons for encounter in General Practice.pdf


Are you exam ready?

File:Dr. Thomas Dwight lecturing students.jpegMultiple Choice Questions: (Example of questions to come every week)

Three registrars were sitting around in a group preparing for their upcoming RACGP exams and ACRRM MCQ’s. One was blonde, one was a brunette, and the final one was a red head.

Which one of these registrars is more likely to pass?

  • A – The registrar who spent 6 – 9 months preparing for their exams spending 2-3 hrs a day on study, sacrificed some of their social time, and had a good study plan.
  • B – The registrar who was told ‘you just have to be sober to pass’ and therefore didn’t do any study
  • C – The registrar who studied for 1-2 months because they knew they knew everything and Einstein was their cousin
  • D – The registrar who spent 12 months studying but only did a bit here and there because they knew their wedding was coming up
  • E – The red head

The KFP Case: (Examples to come)

Jack is a registrar who is preparing for his exams. He has never had a study plan before for any exams as usually ‘wings’ it. You would like to assist him in creating one for the upcoming exams.

Name 5 features that a good study plan requires:

OSCE/StAMPS tips: 

Have an approach to the cases so that if you get stuck you can approach the scenario systematically. I had an A4 piece of paper at each station which took me <10 seconds to scribble the following on as a prompt for me to organise myself:

OSCEStAMPS Structure

Work out what works best for you. Practice using it whilst you are studying and working. Remove what doesn’t help you and add things you need reminding of.

 

 

The answers are below this line


Answers:

AKT – A

KFP – (all of the following answers would earn 1 mark – If more than one answer on any one line then marks will be deducted from the entire paper)

  • A list of topics to be covered
  • A weekly schedule of times to study
  • Organising a study group
  • Allocate times for recreation and relaxation
  • Collect resources for studying
  • Discuss the plan with supervisor or medical educator
  • Documented on paper

 

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