Tutorial Approach
Bleeding
Module on Child Neglect
Edema
Hematochezia


 

Teaching Modules
Bleeding

STUDENT DIRECTED LEARNING: A CHANGE FROM FACULTY OBJECTIVES TO STUDENT GENERATED LEARNING GOALS

In the recent past, almost all of the modules in our curriculum were written with defined objectives set by the faculty. Unfortunately, this approach is felt to have has somewhat undermined the ability of the students to generate their own learning objectives and at worst limited their students interest in exploring the problem and defining their own learning needs. Defined objectives were therefore seen as “the curriculum” and perceived as the faculty’s expectation for student assessments. Consequently, students simply tried to answer and cover the breath of the objectives but not the depth in knowledge content, effecting therefore a subtle but gradual shift from “critical reasoning” to simply covering grounds with uncertain depth of knowledge.

Currently, there is a growing call for encouraging the students to identify their own learning goals while the faculty simply identifies key learning goals during tutorials or provide a brief overview. This approach is claimed to enhance critical reasoning while fostering self directed learning SDL among students.

The following module therefore is aimed towards this goal. Course objectives are not provided and the progress of students will depend on the students working as a group, defining their own learning objectives. Expectedly, a brief clinical trigger will be given, while further clinical information is only provided when the “need to know” is recognized by the students. Emphasis of the discussion is on the mechanism , principles and connecting links between known and new knowledge.

FOR TUTOR'S COPY

The columns of “reasoning and discussion” and “learning goals and learning issues” sample items are given to s serve as guide. Students' copy however will simply contain empty boxes . They must identify their own learning goals which has to be listed in the columns provided for. At the end of the session, the learning goals listed by the students will have to be submitted to the Evaluations Committee to serve as guidelines in the preparation of the students summative evaluations. Likewise, the students must agree to assign these learning goals among themselves and to share this in the next session.

INTRODUCTION

Traditionally, students in medicine have been taught in a structured approach. They are to gather complete clinical information and solve clinical problems in separate but sequential blocks. First, they are to get a complete history, then do a complete physical examination, then order routine laboratory tests. When these tasks are completed, they are asked to gather important clues from these three sources, then put them together to fit into a clinical diagnostic pattern.

This method is tedious and time consuming, although infrequently necessary for complicated or multi-systemic disorders. But this is not how it is done in real life practice by experienced clinician. Studies have shown that seasoned clinicians first form hypotheses immediately right from the given chief complaint of the patient, tracks a clue, forms a cluster, spots triad or tetrad of symptoms, considers a differential diagnosis, pursues only one subset of data, validate their hypothesis and subsequently focus on a very likely diagnosis. This approach is thought to lead into a focused physical examination while only appropriate laboratory test are requested.

Students, even early in their medical training, can be taught this approach. This type of learning is compatible to the principles of adult psychology where learning is undertaken in the way it will be applied in real life situation.

This case that follows this philosophy. It is presented to demonstrate the prime problem solving methods used by seasoned clinician. Including their Including their pattern of data collection and data analysis five separate decision point will be pursued.

1. Is the bleeding a local problem or generalized?
2. If diffuse, is the defect congenital or acquired?
3. If acquired, is the condition caused by a defect in the capillaries, platelets or coagulation factors?
4. If there is deficiency of platelets, is it due to production problem or excessive destruction?
5. If caused by excessive destruction, what are the various causes? e.g. TTP, DIC or AITP

MODULE FRAMEWORK AND STUDENT EVALUATION

The entire module on MUCOSAL and GUM BLEEDING, like the other modules in our institution, is organized around the three strands that makes up the total framework of the Problem Based Learning-Competency Based-Community Oriented Curriculum. These three strands are:

PROBLEM SOLVING SKILL STRAND
PROFESSIONAL SKILL STRAND
COMMUNITY SKILL STRAND

The module enclosed here will be for the Problem Solving Skill Stand, using a PBL strategy where the knowledge base on coagulation will be taken and the learning objectives generated by the students. The Professional skills strand on the on the other hand, includes a visit to the hospital where a bedside teaching covering the PE and History taking on a patient with gum bleeding will be undertaken. Students are to submit a case discussion of the patient assigned them following our standard format. Patients with other forms of bleeding disorders may be taken depending available patients in the ward. Included likewise is a session in the laboratory, viewing hematologic slides, CBC determination ( microscopic analysis of the peripheral blood smears), including Hemoglobin Reticulocyte counting, Mean Corpuscular Volume, and Hematocrit determination, identification of WBC differentials and PT and PTT determination. A section in the discussion of this module will cover for the Community Skill Strand where issues on population will be discussed. Behavioral Issues are likewise taken e.g. Religious beliefs on blood transfusion. The incidence of gingivitis as a cause for recurrent bleeding and poor dental hygiene among Filipinos will be emphasized. This can be taken in a debate session or simply an issue for discussion. The tutor will decide which course to take ( debate or disucssion)

Enclosed at the end of this module is a short assessment MCQ which should serve as a formative evaluation for students. It, unfortunately simply assess the Problem Based skill Strand of the students. However, the Case discussion to be submitted will serve partly for the student assessment on the Professional skill strand particularly in taking the history and doing the physical examination. These papers should be returned to the student with proper comments by the tutors and for the students to submit the final report with suggestions incorporated. The rest of the professional skills of the students will be assessed during the regular scheduled OSCE .

TIME LENGTH OF MODULE -This module can be taken in two or three days sessions. This will include the group discussion, hospital exposure, laboratory exposure and the debate to cover population perspective.

SUGGESTED SCHEDULE

Day 1 - Problem Based Learning Strand

Session 1 - Setting of agreed schedule for the module
Present the Clinical case
Initial group discussion

Session 2 - Sharing of new information regarding learning goals after SDL ( self directed learning)
Continue group discussion

Day 2 - Professional Skill Strand

Hospital Exposure -bed side
Laboratory Exposure

Day 3 - Community Skill Strand

Debate Issue or discussion issue
Religious belief in conflict with medical management involving blood transfusion products
Closure of private blood banking
Filipino views on Blood donation
Issues on Direct Blood transfusion for infants and neonates
Is it practical or risky?


CLINICAL PRESENTATION

23 year old woman comes to you for medical consultation complaining of bruises over her body and bleeding gums for the preceding two days.

Trigger Questions for Tutors

To open the discussion
How would like to proceed in discussing this case?

To help the students focus and define the presenting problem
What is the problem of this woman? Is there a problem?
What is abnormal about this complain? Can this be a normal occurrence?

If you like to elicit the mechanism of bleeding and definition of terms
What is the mechanism of bleeding? Bruisability? Gum bleeding?
What is the mechanism of blood clotting?
What is petechiae? Ecchymoses?
How does the body maintain a bleeding homeostasis?

After an initial discussion, the students may wish to request for more information. It can be provided accordingly by the tutor. Usually it is best to go through the usual stages like
Eliciting further history before proceeding to the P.E. findings and
subsequently the paraclinical studies results.

As the students ask for information : try to probe them further with the following question. It will surprise you what is in their mind.

Why do you wish to know that?
How will this information help us in the analysis of this case?
What is in your mind. Why to do want to know that?
Do you agree with his/her explanation?

If the students are unable to go further discussing over an issue, do not provide the answer. Have the issue listed in the board as a learning gap that must be pursued later. After listing, simply move on to discuss there other issues.

ENCOURAGE STUDENTS TO LIST AS MANY LEARNING ISSUES/GAPS AS THEY ENCOUNTER DURING THE DISCUSSION WHICH WILL PROPEL THEM TO RESEARCH FOR AND TO SHARE THE ANSWERS ON THE FOLLOW-UP
SESSION.

HISTORICAL INFORMATION

Note, not all information the students may ask will be available here. The tutor is given the liberty to ad-lib information to suite the situation. What is listed here are simply the relevant information that will help build the case.

No history of easy bruisability in the past
( epistaxis, gum bleeding, bleeding into the joints)
Menarche at 13 y.o., menses regular flow
Last Mense was 16 days before this consultation - normal regular flow
No history of fever recently, nor URTI
Had several dental extraction before, no untoward reaction. Site would ooze
for 2 hours then stops
No excessive bleeding on minor trauma
No history or surgery or pregnancy
No bleeding disorders in the family

At this point, challenge the students to make hypotheses even based on the limited information they have. These hypotheses will eventually guide them to ask for more specific and directed questions of focused PE information or laboratory studies.

Preferably, an algorithm can be drawn in the board on the mechanism of blood clotting with a listed possible causes of bleeding resulting from a faulty clotting mechanism. This algorithm should be "student directed". This student led algorithm can serve as the knowledge scaffolding by which subsequent medical information can be stored and organized for better retention, and recall.

Although the tutors are given a framework and additional "tutor notes", this is meant mainly for the tutors to have a handle on the case… especially for those tutors who may not be hematologist.

PHYSICAL EXAMINATION DATA

Well developed with no pallor or jaundice
Vital signs normal
Opthalmologic examination - normal
+ oozing in the gingivae
+ several hemorrhages bullae in the buccal mucosa
+ bleeding in the antecubital area- post venipuncture.
Several ecchymoses and multiple petechiae both Lower Extremities
No splenomegally or lympadenopathies
Rest of PE findings were normal

LABORATORY TESTS

Pro-thrombin time -( PT) 13.2 secs/ 12.0 secs control
Partial hromboplastin time ( PTT) - 31.0 secs /32 secs control
Hematocrit - 38%
Hbg 12.5
WBC -6.700/mm3
Differential - Normal
Platelet - 8,000/mm3
Peripheral smear - low platelet count
Large megathrombocytes
RBC and WBC normal morphology

Bone Marrow Aspiration : Normal cellularity, increased megakaryocytes with
normal morphology, normal myeloid, and erythrocyte maturation. No abnormal cells.

SMA -20 normal.
ANA and LE test - not significant

FOR TUTOR'S GUIDE

TUTORS ROLE
Session 1

PRESENT THE CASE
A 23 year old woman comes to you for medical consultation complaining of bruises over her body and bleeding gums for the last two days.

TRIGGER DISCUSSION
To open the discussion
How would like to proceed in discussing this case?

To help the students focus and define the presenting problem
What is the problem of this woman? Is there really a problem? Can this be a normal occurrence? What is abnormal about this complain?

If you like to elicit the mechanism of bleeding and definition of terms
What is the mechanism of bleeding? Bruisability? Gum bleeding?
What is the mechanism of blood clotting?
What is petechiae? Ecchymoses?
How does the body maintain a bleeding homeostasis ?

If you want to stimulate critical thinking when they request for additional information from the Hx or PE
Why do you wish to know that?
How will this information help us in the analysis of this case?
What is in your mind. Why to do want to know that?
Do you agree with his/her explanation?

NEVER SAY:
Are you sure about that?- this statement threatens the students and inhibits free and relaxed critical thinking. The must see you as a co-learner and not an authority.

NEVER GIVE A LECTURE
STIMULATE QUIET STUDENTS-
but do not threatened them. Sometimes students are quiet because they are thinking. What they need to learn is to think aloud.

KEEP YOUR MOUTH SHUT. Give student the time to arrive at what you know. Don't rush them to what you know. They will discover it.

STUDENT ROLES
REASONING AND DISCUSSION

Recognize Cues
Hints or clues in the history or PE that are significant cues

Formulate Problem
The students must be able to focus on the main problem despite the discussion on several issues.

Discuss Points
Discussion of core knowledge, basic science, mechanism, principles,


Formulate Hypotheses
Generation of several differential diagnosis. These must be organized either through mechanism or organ system causes.
Simply listing them will not have good retentive "hooks" unless they are organized into a system of scaffoldings.


Validate Hypotheses
Important clues in the history and PE can serve to validate or rule out the differential diagnosis


Reformulate Problem
After eliciting several information the problem of the patient should become more focused. Finally after the validation, the problem should be come more obvious and the diagnosis imminently clear.


Formulate Final Hypothesis
This is the diagnosis as the result of the repeated validation


Confirm Hypothesis
This includes the results of the laboratory confirmation to validate the hypothesis.


ESTABLISH FINAL DIAGNOSIS-
This includes the final diagnosis of the case, and the rationale

LEARNING GOALS

To be filled up by the students and submitted to the Evaluations Committee. Failure to do so, gives the committee the liberty to formulate the test blue prints based on standard perspective.

 

TUTOR ROLE

CLINICAL PRESENTATION

A 23 year old woman comes to you for medical consultation complaining of bruises over her body and bleeding gums for the last two days.

HISTORY
( -) easy bruisability in the past
(epistaxis, gum bleeding, bleeding into the joints)
Menarche at 13 y.o., menses regular flow
Last Mense was 16 days before this consultation - normal regular flow
(-) history of fever recently, nor URTI
Had several dental extraction before, no untoward reaction. Site would ooze
for 2 hours then stops
(-) excessive bleeding on minor trauma
(-) history of surgery or pregnancy
(-) bleeding disorders in the family

PHYSICAL EXAMINATION
Well developed with no pallor or jaundice
vital signs normal
Opthalmologic examination - normal
(+) oozing in the gingivae
(+)several hemorrhages bullae in the buccal mucosa
(+)bleeding in the antecubital area- post venipuncture.
Several ecchymoses and multiple petechiae both Lower Extremities
(-) splenomegally or lympadenopathies
Rest of PE findings were normal

LABORATORY
PT - 13..2 secs/ 12.0 secs control
PTT- 31.0 secs /32 secs control
Hematocrit - 38%
Hbg 12.5
WBC -6.700/mm3
Differential - Normal
Platelet - 8,000/mm3
PS -low platelet count, Large megathrombocytes RBC and WBC normal morphology

Bone Marrow Aspiration : Normal cellularity, increased megakaryocytes with normal morphology, normal myeloid, and erythrocyte maturation. No abnormal cells.

SMA -20 normal.
ANA and LE test - not significant

STUDENT ROLE
· GROUP DISCUSSION
· GATHER RELEVANT INFORMATION
· SUMMARIZE ISSUES ON BOARD
· RECOGNIZE CUES
· GENERATE LEARNING GOALS
· FORMULATE PROBLEM
· GENERATE HYPOTHESIS
· VALIDATE HYPOTHESES
· REFORMULATE PROBLEM
· SUMMARIZE-SYNTHESIZE ISSUES

 

TUTORS GUIDES -TO STUDENT DISCUSSION

CUE RECOGNITION
History
Young lady, (-) recent URTI
Symptoms recent-acute onset
(-) past history of bleeding
Menses normal-recent
Generalized bleeding v s local
(-) sexual promiscuity
Physical examination
VS normal
(-) organomegally / lymphadenopathy
Optha-normal
Hemorrhagic bullae-bucal mucosa
Laboratory
Thrombocytopenia
Normal PT, PTT
BMA- Increased Megakaryocytes
Negative LE cells,
ANA-insigniticant

PROBLEM FORMULATION
A 23 y.o. with recent-acute generalized bleeding

HYPOTHESES FORMULATION
Causes of bleeding

DISCUSSION POINTS-
Basic Science- core knowledge and mechanism
Mechanism of blood clotting?
How does the body maintain a bleeding homeostasis ?

Validation of Hypotheses
Is the bleeding problem local or diffuse?
If diffuse, is the defect congenital or acquired?
If acquired, is the condition caused by a defect in the capillaries, platelets or coagulation factors?
If there is deficiency of platelets, is it due to inadequate production or excessive destruction?
If caused by excessive destruction, what are the various causes? e.g. TTP, DIC or AITP

FINAL HYPOTHESIS
Bleeding secondary to thrombocytopenia
R/o platelet destruction versus decreased

POSSIBLE LEARNING
GOALS

Mechanism of bleeding? Bruisability? Gum bleeding?

Mechanism of blood clotting?

What is petechiae? Ecchymoses?
Hemorraghic bullae?

How does the body maintain a bleeding homeostasis ?

Mechanism of bleeding in DHF ,liver disease, leukemia, aplastic anemia, diseases of newborn, etc?

Causes of prolonged bleeding

Basis for PT & PTT test

Precursors of platelets

von Willibrand factors?

Reticulocyte Index?

Causes of thrombocytopenia?

Hypersplenism?

Role /function of spleen?

Bone marrow activity?

 

FOR STUDENTS

Session 1

PRESENT THE CASE
A 23 year old woman comes to you for medical consultation complaining of bruises over her body and bleeding gums for the last two days.

STUDENT ROLES
REASONING AND DISCUSSION

1. Recognize Cues


2. Formulate Problem

3. Discuss Points


4. Formulate Hypotheses


5. Validate Hypotheses

6. Reformulate Problem


7. Formulate Final Hypothesis

8. Confirm Hypothesis

9. ESTABLISH FINAL DIAGNOSIS

LEARNING GOALS

 

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Ateneo de Zamboanga University
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