SMALL GROUP SESSION 8 October 21st or October 23 rd. Narratives Discussion/ OSCE Practice

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1 SMALL GROUP SESSION 8 October 21st or October 23 rd Narratives Discussion/ OSCE Practice Readings: Review your upper extremity, blood pressure and chest/lung OSCEs; Read Rita Charon s Narrative Medicine: A Model for Empathy, Reflection, Profession and Trust, available at: Prepare by: Attending this week s lecture. It will be very difficult to join the discussion if you don t. Bringing your hospital interview write-up Bringing your stethoscope and blood pressure cuff Brief outline: Section 1. Section 2. Section 3. Section 4. Touch base Narratives discussion OSCE practice Midterm feedback Preparation for next week: Readings: Mosby s Physical Examination, 4 th ed, pages and or 5 th ed, pages Ahronheim, Moreno and Zuckerman. Ethics in Clinical Practice. Don t tell mother. Copy is in your appendix. Prepare by: Wearing two-piece clothing so that you can examine each other s abdomens. Bring your stethoscope. Next week your videotaped standardized patient interviews will begin. You should already have a schedule. 1

2 Part 1. Touch base (30 minutes) Small Group Session 8 What did you learn by writing up your hospital interviews? Part 2. Narratives Discussion (60 minutes) Objectives: to better understand patients experience of illness to consider how to improve our own care for very ill patients The film Wit that you saw this week is a patient s narrative: her account of the personal meaning of her life, her illness and her encounters with medical providers. This discussion is largely borrowed from the Wit film project. The questions that follow are to help guide your discussion of the film. Part one: the patient 1. Describe Vivian Bearing. 2. How does her personality affect the care she received? 3. How does she experience her illness? 4. How does she grow or change in the course of her illness? 5. What alleviates her suffering in the course of the film? Part two: the medical providers 1. Are Dr. Posner and Dr. Kelekian like actual physicians, or do they seem stereotyped to you? 2. In what ways did Dr. Posner and Dr. Kelekian provide admirable care? 3. In what ways was Dr. Posner s and Dr. Kelekian s care ultimately inadequate for Vivian Bearing? 4. When did you realize that there was a problem in the care Vivian Bearing was receiving? 5. How did the care provided by Susie Monahan differ from that of Dr. Posner and Kelekian? 6. Why is Susie Monahan more comfortable than Dr. Jason Posner in discussing the meaning of life garbage? 7. Describe how Susie Monahan exhibited empathy and compassion. Part three: overview: 1. How has this film helped you understand how patients experience severe illness and dying? 2. How might it affect how you interact with patients in the future? 2

3 Part 3. OSCE Practice (45 minutes) Objectives: To practice the upper extremity, blood pressure and chest/lung OSCEs. Have your mentor demonstrate any part of the OSCEs that you are unsure of (all is fine). Then divide into pairs and examine each other s upper extremities, blood pressure and chest/lungs. The OSCE sheets are included at the end of this session. Part 4. Midterm feedback (45 minutes) Your mentors will meet with each of you individually to offer midterm feedback. This will include: 1. Group participation: how are you contributing to the group? Are you too quiet, too talkative or just right? Are your contributions thoughtful and helpful? 2. Preparation: Do you come prepared to each group? Have you done the readings and thought about them? 3. Teaching: Are your presentations to the group designed to help your fellow students learn? How could they be more helpful? 4. Interest: Do you seem interested in learning and involved with the group? 5. Interactions: Are your responses to others in the group helpful? Are you a good listener and a constructive questioner? 6. Skills: How are you doing in your interviews? How could you improve your technique? 7. Analysis/Insight: How well do you analyze factual material? Finally: This is an opportunity for student feedback to mentors. How could the group be run better? What changes would help you to learn? To feel more comfortable? 3

4 Physical Examination Objective Structured Clinical Examination (OSCE) Upper Extremity Exam A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt Procedure A B C Comments 1. SHOULDER Inspection: Assesses symmetry, deformity and discoloration. (Ex states what they are inspecting for) 2. SHOULDER Range of motion: Ex asks patient to flex, extend, abduct (full arc), internally rotate (elbow flexed, thumb at opposite scapula) and externally rotate (elbow flexed, hands out at sides or behind head) both shoulders. 3. SHOULDER Palpation: Ex. palpates scapular spine, acromion process, acromioclavicular joint and bicipital groove (one side OK). 4. SHOULDER Strength: Ex resists patient while patient shrugs shoulders, flexes shoulder forward and abducts shoulder. 5. ELBOW Inspection: Assesses symmetry, deformity and discoloration. (Ex states what they are inspecting for) 6. ELBOW Range of motion: Ex asks Pt to flex, extend, pronate, (elbow at 90, palm up) and supinate (elbow at 90, palm down) both elbows. 7. ELBOW Palpation: Ex. palpates lateral epicondyle, medial epicondyle and olecranon process (one side OK). 8. ELBOW Strength: Ex. resists patient while patient flexes and extends elbow. 9. WRIST and HAND Inspection: Assesses symmetry, deformity and discoloration. Assesses thenar and hypothenar eminence. (Ex states what they are inspecting for) 10. WRIST and HAND Range of motion: Ex asks Pt to flex and extend wrist, move hand to ulnar and radial sides, flex and extend fingers at MCP joint with fingers straight, and make fist. 11. WRIST and HAND Palpation: Ex. palpates wrist, CMC, MCP and PIP joints. 12. WRIST and HAND Strength: Ex. resists patient while patient flexes and extends wrist, assesses grip strength, resists finger abduction, and resists opposition of thumb and small finger. 4

5 Physical Examination Objective Structured Clinical Examination (OSCE) Blood Pressure A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt Procedure A B C Comments 1. Ex slightly flexes patients arm and supports arm (table, hold arm, etc). 2. Ex checks size of cuff, locates brachial artery by palpation, and places cuff snugly about upper arm, centering the bladder over the brachial artery arm should be free of clothing. 3. Ex palpates radial pulse, and pumps up blood pressure cuff until radial pulse is no longer palpable, and then rapidly deflates the cuff, and waits 30 seconds before proceeding Ex places stethoscope (bell preferred, diaphragm acceptable) over brachial artery, pumps up cuff 20 to 30 mm Hg above palpable systolic pressure, and then releases cuff slowly, at rate of 2 3 mm Hg per second, listening for Korotkoff sounds. Ex records blood pressure. 5

6 Physical Examination Objective Structured Clinical Examination (OSCE) Chest and Lung Examination Checklist A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt Procedure A B C Comments 1. INSPECTION OF CHEST: Ex visually inspects Pt s chest while sitting for shape and symmetry, symmetry of respiratory excursion, pulsations, heaving and respiratory effort. (Ex states what they are inspecting for) 2. THORACIC EXPANSION: While standing behind Pt, Ex places thumbs parallel and several inches lateral to pt s mid to lower spine. Ex then asks Pt to inhale deeply while Ex feels the range and symmetry of Pt s respirations. 3. TACTILE FREMITUS: While standing behind Pt, Ex places his/her palmar surface of both hands on Pt s upper, middle, and lower back. Ex asks Pt to recite a few words or numbers (ex. 99 ) while Ex palpates with a firm, light touch both sides simultaneously. 4. PERCUSSION: Ex percusses over posterior and anterior chest. Ex moves from one side across to the other and down. 4a. PERCUSSION TECHNIQUE: Ex places middle finger, which is hyperextended, against pt s skin, lifting the rest of stationary hand up. Using the middle finger of the dominant hand, ex bounces it off the stationary one. 5. DIAPHRAGMATIC EXCURSION: Ex asks Pt to take a deep breath and hold it while Ex percusses down the scapular line. Ex then asks Pt to exhale and hold it as much as possible while he/she percusses the back. Both inhale and exhale percussion procedures should be done on both sides of the Pt s back. 6. POSTERIOR BREATH SOUNDS: Ex asks Pt to breathe deeply through mouth while Ex listens to AT LEAST ONE FULL BREATH AT EACH POSITION on the back. Ex moves from one side of the back across to the other and down. 7. ANTERIOR BREATH SOUNDS: Ex uses stethoscope to listen to both sides of the front of Pt s chest. Ex progresses from side to side moving downward using the same sequence while listening to one full respiration on each location. 8. AUSCULTATION TECHNIQUE: Ex listens to the Pt s chest using the diaphragm of the stethoscope, which should be pressed firmly onto chest. 9. VOCAL RESONANCE: While auscultating with the stethoscope over the back, the examiner asks the patient to say E. Ex moves the stethoscope from one side to the other, moving downward, while listening to patient say E at each location. 6

SMALL GROUP SESSION 18A January 17th or January 19th. Groups 1-12: VS and Chest Exam and Harvey Stethophone Session

SMALL GROUP SESSION 18A January 17th or January 19th Groups 1-12: VS and Chest Exam and Harvey Stethophone Session Readings: Complete the cardiac examination web module. Mosby s Physical Examination, 4