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.

Stress and Anxiety

THE Dental PBL Case

Background:

It is extremely common for patients to experience dental anxiety. Dental phobia is less common with the 2009 Adult Dental Health Survey reporting that 12% of the UK adult population are dental phobic. Dentists encounter dentally anxious and phobic patients everyday, therefore, it is important that these patients are managed appropriately to ensure they receive high quality care in a way they feel comfortable with. 

Scenario:

Mrs Smith is a 48 year old female and is a new patient to the dental practice. She missed the previous dental appointment she was scheduled to have last week and arrives 15 minutes late to her appointment today. The dental nurse calls Mrs Smith through to the dental surgery and she immediately apologizes for her lateness and seems flustered. Dr Miller introduces himself and asks Mrs Miller to take a seat in the dental chair so he can start to take a patient history. Mrs Smith is quiet and seems reluctant to sit in the dental chair, but complies. Dr Miller begins the patient history and as he does he notices that Mrs Miller starts to fidget with her fingers, she starts to breathe faster, her eyes start to dart around the room and she seems distracted. Dr Miller asks if there is something on Mrs Millers mind and she blurts out “I’m scared of dentists and I haven’t been to the dentist for 20 years because of this”. 

  1. What is the difference between dental anxiety and dental phobia?
  2. What signs in the text indicate that Mrs Smith may be anxious?
  3. What other signs may anxious patients present with?
  4. What further questions would you like to ask Mrs Smith? 
  5. What could cause/trigger dental anxiety/phobia?
  6. What could be the consequences/impact of dental anxiety or phobia on a patient and their oral health?
  7. What consequences could patient dental anxiety or phobia have on dentists?
  8. How can dental anxiety or phobia be managed?
  9. Challenge: how does anxiety affect the pain sensation experienced by the patient during dental treatment?

The answers were covered during the Virtual Medical Society Meeting on 24th November 2020. 

 

THE Medic PBL Case

Rebecca is an 18-year-old woman who has recently started studying medicine in London. She has been very stressed lately due to upcoming exams, and she has not had much sleep in the last week, but she has decided to take the night off to see the fireworks with her friends.  

During the display’s finale, her friends heard her cry out and collapse, falling stiffly to the floor. They notice that, after half a minute of trying to rouse her, she starts twitching her limbs. A couple of minutes later, she stops and wakes up to find herself suddenly on the ground with her friends gathered around her, concerned. She is very confused and drowsy, and she has no memory of collapsing. 

Her friends called the ambulance, and Rebecca is taken to the local hospital, where the doctors carry out a full ABCDE investigation. As part of this, they test her blood glucose levels, do some blood tests, take her blood pressure, and do an ECG. These tests all come back normal. Since Rebecca is still a little confused, they take a collateral history from one of her friends who came with her. The doctors discharge Rebecca that same night, and she is referred to a ‘first fit’ clinic at the same hospital in a couple of weeks. There, she is told that she has had a generalised tonic-clonic seizure and is prescribed lamotrigine to try to prevent any more in future. 

Firstly: Look up any medical terms or investigations that you don’t know. 

  1. What are some of the different causes of collapse? What would you want to rule out?
  2. What is the difference between a seizure and epilepsy?
  3. What are the stages of a generalised tonic-clonic seizure?
  4. What are the risk factors and common triggers for this type of seizure?
  5. Are there any complications that can occur from seizures?
  6. What is an ABCDE assessment and what does it cover?
  7. What is the general structure of a medical history?
  8. Are there any specific questions that doctors would want to ask her or her friend to try to narrow down the diagnosis?
  9. Challenge: What are some potential risks with giving Rebecca anti-epilepsy drugs, like lamotrigine, and would you tell her about anything else at the hospital or have her make any changes to her daily life for the near future once you suspect a seizure?

The answers were covered during the Virtual Medical Society Meeting on 24th November 2020. 

THE Vet PBL Case

Case 1:

As lockdown measures eased over Summer, the small animal practice you work in received many calls from worried owners about their new puppies struggling at home when their owners went back to work. The phone calls were often diverted to you as the new graduate in the practice. 

Case 2:

The fireworks season is a stressful time for many pets who have noise-phobias. This year with official firework displays being cancelled due to COVID there were reports of many more shop-bought fireworks being purchased for back-garden displays. As a result of this, there are lots more clients wanting help to calm their dog down during these anxious evenings.  

Case 3:

An owner, Ms Elliot wishes to trial Pexion tablets for her 14kg 3yo, MN Border Collie Rusty who is petrified of fireworks, as soon as he hears any bangs he will bark and pace the house all night long. You wish to trial him on Pexion 400mg tablets for 7 days. The starting dose for pexion tablets is 30mg/kg twice daily

Case 4:

Finally, you have a young JRT, Ralphie who is only 2 years old but is extremely anxious about coming to the vets. At every visit he is incredibly difficult to get into the practice and hates to be examined. His owners are worried that he will never get over his fear of the vets and that this will be at great detriment to his clinical health and future veterinary care. 

Case 1:

  • Discuss what is meant by ‘separation anxiety’ in dogs?
  • What are 3 clinical signs of separation anxiety in dogs?
  • Name 3 tips for owners to try in order to reduce separation anxiety in their pets. 

Case 2:

  • What are some non-pharmaceutical options for calming dogs down during fireworks?
  • If these fail to work, there are some licensed pharmaceutical treatments for treating noise-phobias in dogs; Sileo Oralmucosal Gel and Pexion tablets
    • Research two facts each about these licensed medications

Case 3:

  • Work out what dose of pexion Rusty needs and how many tablets need to be dispensed from the pharmacy. 

Case 4:

  • You propose starting desensitisation techniques with Ralphie.
  • What is meant by desensitisation?
  • Give 3 examples of how you could desensitise Ralphie in this situation. 

The answers were covered during the Virtual Medical Society Meeting on 24th November 2020. 

Answers

Separation anxiety is  is triggered when dogs become upset because of separation from their guardians, the people they’re attached to.

Clinical signs of separation anxiety:

  • Urinating and Defecating
  • Barking and Howling
  • Chewing, Digging and Destruction
  • Escaping
  • Pacing
  • Coprophagia

Treatments:

  • Counterconditioning, so conditioning a dog that being alone isn’t a bad thing, instead you make it a good thing by leaving them with delicious food or new toys or puzzles etc
  • Desensitisation so training dogs that ques which normally mean you are leaving actually don’t mean that at all, this desensitises them to reacting to stimuli
  • Lots of exercise so they are tired and have more of a routine
  • Dog sitter/doggy day care
  • Crate training
  • Hide treats around the house
  • Leave the radio on, get a neighbour to pop in daily 

Calming dogs down (non-pharmaceutical)

  • Turn the radio/TV up
  • When its not firework season, play fireworks/bangs to desensitise them from a young age that fireworks are not to be feared
  • Thunder shirt
  • Create a cozy place for them to seek shelter in 
  • Pheromone plug-ins, calming sprays (pet remedy)

Sileo Oralmucosal Gel

  • Licensed treatment for noise-phobia
  • Contains dexmedetomidine in it, this is a sedative so makes the animal dopey
  • Given as soon as a bang etc is given off (bad for animals that are set off from first bang)
  • Can’t be given to dogs with heart issues
  • Oral formulation, apply to gums, easier than tablet?
  • Can re-dose after 2 hours
  • Lasts for about 2-3 hours in total

Pexion

  • Imepitoin
  • Licensed for seizure control as well as noise phobia
  • Tablet formulation
  • Have to give it for 2 whole days before fireworks start, so more tablets needed
  • Usually might need to buy an entire tub so more expensive?

Pexion calculation

  • 14kg x 30 (30mg/kg) = 420mg
  • So x1 400mg tablet given TWICE DAILY, therefore for 7 days it needs 14 tablets

Desensitisation techniques

  • This is training a dog to no longer associate a badness with a certain experience usually by performing the experience and it ending up with a good outcome
  • The dog then learns that it is no longer a bad outcome produced
  • For vet visits, you would take the dog in the car to the vet then get out and have lots of treats, lots of praise, and a nice walk but NO VET VISIT
  • Then next time maybe the dog would go into the practice but just to be weighed/have a fuss/get treats rather than actually have a clinical exam performed