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
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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?
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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.
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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.
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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.
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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
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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.
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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
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LEARNING GOALS
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