Problem Based Learning

Problem based learning (PBL) is a popular method of learning, currently used by most health professional courses in the UK.

The aim of PBL is for you to read through a complex and broad series of information, to identify areas of interest and areas you would like to explore further, in order to further your knowledge of specific topics, through self-directed learning.

 The questions our mentors have provided offer ideas of topics to explore and are written in three streams for aspiring medics, dentists and veterinarians; focus on all three or simply what interests you!

  • Remeber you can leave a comment if you have any questions and we will be sure to answer them.
  • We will  be discussing and answering the PBL cases in the VMS meeting at 7pm – 8pm on 24th November 2020.

Overindulgence during Festivities

THE Dental PBL Case

Background: 

Over the Christmas and new year period people’s diets and drinking habits tend to change. In general, people tend to eat more unhealthy food (e.g. chocolate, crisps etc.) and tend to drink more alcohol and carbonated drinks. These tend to be short term changes, however, if these habits are continued for a prolonged time (e.g. months) these can have negative impacts on the oral environment. 

 

Scenario:

Mrs Wilson, a 50 year old female patient presents for her annual check-up at the start of January. As Mrs Wilson is called into the dental surgery she mentions to her dentist Dr Miller how much fun she had over Christmas and New Year drinking with her family and friends in pubs and at parties. Dr Miller takes a history:

  • Dental history: 
  • She has noticed increased sensitivity to cold food on her front teeth over the past few months. 
  • She has had a few fillings in the past. 
  • She brushes her teeth in the morning but often forgets to brush her teeth in an evening. 
  • Medical history: fit and well. 
  • Social History:  
  • Occupation: 6 months ago she became a banker in London. 
  • On average she drinks 12 glasses of white wine (175ml) a week; mainly on the weekend, but on special occasions she often drinks more than this. 
  • Diet: due to her busy work schedule she has a smoothie for breakfast on the way to work and sips on energy drinks or coffee throughout the day instead of having lunch. She gets home late in the evening so she eats a shop-bought ready meal for Dinner. 

Upon examination, Dr Miller identifies that Mrs Wilson has dental caries on four of her molars and erosive toothwear on her front teeth. 

Alcohol:

  1. What are the recommended weekly alcohol limits?
  2. How many units of alcohol is Mrs Wilson roughly having a week?
  3. What are the effects of excess alcohol on general and oral health?
  4. What further questions would you as the patient?
  5. What advice would you give to this patient?

Dental caries:

  1. What is dental caries?
  2. How does dental caries present itself in the mouth?
  3. What causes dental caries?
  4. How can dental caries be prevented?
  5. How is dental caries treated?
  6. What further questions would you like to ask the patient?

Toothwear: 

  1. What is toothwear?
  2. What are the specific different types of toothwear? 
  3. How does toothwear present in the mouth?
  4. What are the causes of each type of toothwear
  5. How can toothwear be prevented? 
  6. What further questions would you like to ask the patient?

Challenge: What could be the cause of Mrs Wilson’s increased sensitivity?

The answers were covered during the Virtual Medical Society Meeting December 2020.

THE Medic PBL Case

 John is a 60-year-old man who is living at home with his family on Christmas Eve. He is a type 2 diabetic and manages this with gliclazide. During the festivities, his family starts drinking a couple of bottles of wine together, and John joins in, although he knows that he is not supposed to mix alcohol with his diabetic medication. He hasn’t eaten much recently, as he is leaving room for his Christmas meal tomorrow. 

Two hours later, John starts to feel lightheaded and drowsy, and he goes to the kitchen for a glass of water. His family hear a loud crash, and they hurry in to find John unconscious on the hard kitchen floor. They call an ambulance, and John is admitted to hospital. 

The doctors there working over Christmas do an ABCDE assessment and some blood tests. After taking a collateral history from his wife, who came with him, they also test for insulin. This is found to be raised in his blood, and his glucose levels are very low. They also note that his left leg is shortened and externally rotated. John is treated with an IV infusion of glucose, is given an x-ray and rushed straight to theatre with the orthopaedic surgeons. They end up replacing his left hip. 

Thankfully, John makes a full recovery from the operation, but he unfortunately has to stay in hospital over Christmas. 

  1. How does the body regulate blood sugar?
  2. What is the cause and progression of type 2 diabetes?
  3. How is this different to type 1 diabetes?
  4. What is the problem with having too much glucose in the blood for a long period of time?
  5. What are the effects of alcohol on the body? 
  6. How does gliclazide work? 
  7. Why do you think John has collapsed?
  8. What do you think the x-ray showed?
  9. Challenge: Consider the blood supply to the femur. Why is the type of fracture that John        likely sustained much more dangerous than a fracture lower down the bone? 
  10. Challenge: Is there anything else you would investigate for John in hospital after he has come in for a collapse and why? 

The answers were covered during the Virtual Medical Society Meeting December 2020.

THE Vet PBL Case

Case 1:

Over the Christmas period, pets tend to get very spoilt with copious amounts of treats as well as human food from the table. Sometimes owners are not aware of what is fine for their pets and what is actually very toxic. 

Imagine you are a vet, unlucky enough to be on call on Christmas Day. You get a phone call from a distraught owner saying their dog has gotten into the family-sized tin of Celebrations 30 minutes ago. 

Case 2:

Christmas is a great time for giving and receiving gifts. Unfortunately, many pets are given as gifts at Christmas without the owners being fully aware of the life-long commitment that animals require. An owner asks for your veterinary advice regarding getting their 8-year-old daughter a Labrador puppy for Christmas. They have never had a dog before and their Dad in the house is very allergic to cats. 

Case 3:

Imagine you are a large animal vet and you are called out to see Rudolph the reindeer. Rudolph’s herd live beside a cow herd who have recently had a positive test for bovine tuberculosis. 

Case 1:

  • What is more concerning in this scenario; chocolate toxicity or plastic packaging ingestion?
  • What is the toxic component of chocolate? And is it found in all types of chocolate?
  • How would you best treat this case in the clinic?
  • Name 3 other Christmas Day toxins that you should be aware of as a small animal vet. 

Case 2:

  • What specific breed requirements do Labradors have in comparison to other dogs?
  • What would be your recommendation for gifting a puppy at Christmas time?
  • If they were to gift their daughter a puppy, list 3 things the owner should look out for when purchasing a puppy from a breeder. 

Case 3:

  • What is bovine tuberculosis?
  • Should we be worried about Rudolph contracting bovine tuberculosis?

The answers were covered during the Virtual Medical Society Meeting December 2020.

https://youtu.be/nGO4CH6qB0c 

Answers

Chocolate toxicity is more concerning as the plastic packaging in a celebrations wrapper is very small and will likely pass all the way through the gut.
Toxic component of chocolate is THEOBROMINE. It is found with increasing cocoa content (white chocolate has hardly any, milk chocolate has more, dark chocolate has high values, cooking chocolate has very high values)
Best treatment option is to induce ‘emesis’ meaning making the animal sick with an injection of apomorphine. Then you would want to soak up as much as possible in the gut with feeding activated charcoal.
Examples of other Christmas Day toxins would be:
– Christmas pudding (raisins toxicity)
– Christmas decorations (tinsel, baubles, toys)
– High fat content foods (beef trimmings, stuffing, gravy) can cause pancreatitis
– Alcohol
– Poinsettia plants
– Batteries from toys
5. Labradors are large breed dogs, they require a lot of walking and exercise, they are intellectual breeds so need mental stimulation, they are prone to joint problems (elbow and hip dysplasia) as well as osteoarthritis so they need joint support, chocolate labs are also high risk for obesity
6. Gifting a puppy would not be recommended as a gift, especially for an 8-year old. They should be well planned and owners well informed. Possibly getting a lower maintenance pet such as a fish or small rodent may be better so that the owners can get used to this. If an owner has a known allergy to pet dander then getting a dog is not recommended either.
7. Potential owners should always be encouraged to come and visit a puppy when it is with its mother and litter mates. You should be able to see its living environment and see a normal interaction between the mother dog and pup (grooming, suckling, sleeping etc). The puppy should come with a microchip, wormer, flea treatment and be vaccinated. Any previous health screens on the mother dog should be known about. The breeder should also be very interested in where their puppy is going to.
8. Bovine tuberculosis is a mycobacterium (M. bovis) which is a notifiable disease in the UK. Cows don’t usually show signs of TB in the early stages but in the late stages, disease can be noted with pneumonia or loss of condition and is confirmed at post-mortem.
9. Reindeers can get bovine TB! Usually as a spill-over from a cattle population and the disease doesn’t usually spread unless there are high density populations of reindeer housed together. TB in deer is a chronic disease which rarely shows acute clinical signs until the very late stages.

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