Clinical Summary and Reasoning Format: Cognition Levels and Proposal of a Grading System.

The Clinical Summary and Reasoning Format (CSRF) was designed by the Faculties of Paediatrics of the National Postgraduate Medical College of Nigeria and the West African College of Physicians. The form is recommended for routine use in clinical practice as well as for training and examination purposes. The form has sections for documenting information derived from interacting with an index patient and sections for documenting sequential deductions on the way to various levels of diagnosis. The levels of cognition required to complete different sections of the Clinical Summary and Reasoning Format (CSRF) vary in complexity. The CSRF is potentially useful for assessing the quality of a clinician's clinical reasoning process. Such assessment will be enhanced by having a grading system for completed CSRF forms. In turn, grading contents of the form should reflect complexity of the levels of cognition required for the various sections. The present paper evaluated the sections of the CSRF with reference to the modified Bloom's Taxonomy of cognition and also proposed a grading scheme for assessing CSRF forms completed by trainees.

Le format de résumé clinique et de raisonnement (CSRF) était conçu par les Facultés de Pédiatrie du National Collège médical de troisième cycle du Nigeria et de l'Afrique de l'Ouest Collège des médecins. Le formulaire est recommandé pour la routine utilisation dans la pratique clinique ainsi que pour la formationet l'examen Fins. Le formulaire comporte des sections pour documenter les informations dérivé de l'interaction avec un patient index et des sections pour documenter les déductionsséquentiel les sur le chemin de diverses niveaux de diagnostic. Les niveaux de cognition requis pour compléter différentes sections du résumé clinique et du raisonnement Le format (CSRF) varie en complexité. Le CSRF est potentiellement utile pour évaluer la qualité d'un processus de raisonnement clinique du clinicien. Cette évaluation sera amélioré par la mise en placed'un système de classement pour le CSRF complété Formes. À son tour, le contenu de classement du formulaire doit refléter complexité des niveaux de cognition requis pour les différents sections.Le présent document a évalué les sections du CSRF avec référence à la taxonomie modifiée de bloom de la cognition et a également proposé un système de notation pour l'évaluation des formulaires CSRF complété par des stagiaires. Mots-clés: Cognition, Raisonnement clinique, Évaluation, Notation.

Clinical Summary and Reasoning Format: A Tool for Clinical Practice and Medical Training.

Patients' records are often bulky and unwieldy, necessitating the creation of summaries. A structured summary format adds the advantage of improved organization and easier retrieval of information. However, typical clinical summary formats do not document intermediate deductions linking symptomatology to diagnosis and to that extent fall short of tracking the cognition process of the clinician. The Clinical Summary and Reasoning Format of the Faculties of Paediatrics of the National Postgraduate Medical College of Nigeria and the West African College of Physicians was designed to track the clinical thought and reasoning processes of clinicians. It consists of two major sections. The first section is for documenting data from history, physical examination and early laboratory reports while the second section is for recording hierarchical deductions on the way to reaching various levels of diagnosis. Definitions and descriptions of the various components of the format are herein presented. The usefulness of the format for clinical practice, clinical training and assessment of trainees is discussed.

Les dossiers des patients sont souvent volumineux et peu maniables, ce qui nécessite la création de résumés. Un format de résumé structuré offre l'avantage d'une meilleure organisation et d'une récupération plus facile de l'information. Cependant, les formats de résumé clinique typiques ne documentent pas les déductions intermédiaires reliant la symptomatologie au diagnostic et, dans cette mesure, ne permettent pas de suivre le processus cognitif du clinicien. Le format de résumé clinique et de raisonnement des facultés de pédiatrie du National Postgraduate Medical College of Nigeria et du West African College of Physicians a été conçu pour suivre la pensée clinique et les processus de raisonnement des cliniciens. Il se compose de deux sections principales. La première section sert à documenter les données provenant de l'histoire, de l'examen physique et des premiers rapports de laboratoire, tandis que la seconde section sert à enregistrer les déductions hiérarchiques permettant d'atteindre les différents niveaux de diagnostic. Les définitions et les descriptions des différents composants du format sont présentées ici. L'utilité du format pour la pratique clinique, la formation clinique et l'évaluation des stagiaires est discutée. Mots clés: Cognition, Résumé clinique, Raisonnement clinique, Format, Diagnostic. Mots clés: Cognition, Résumé clinique, Raisonnement clinique, Format, Diagnostic.

Clinical Summary and Reasoning Format: A Tool for Clinical Practice and Medical Training.

Patients' records are often bulky and unwieldy, necessitating the creation of summaries. A structured summary format adds the advantage of improved organization and easier retrieval of information. However, typical clinical summary formats do not document intermediate deductions linking symptomatology to diagnosis and to that extent fall short of tracking the cognition process of the clinician. The Clinical Summary and Reasoning Format of the Faculties of Paediatrics of the National Postgraduate Medical College of Nigeria and the West African College of Physicians was designed to track the clinical thought and reasoning processes of clinicians. It consists of two major sections. The first section is for documenting data from history, physical examination and early laboratory reports while the second section is for recording hierarchical deductions on the way to reaching various levels of diagnosis. Definitions and descriptions of the various components of the format are herein presented. The usefulness of the format for clinical practice, clinical training and assessment of trainees is discussed.

Les dossiers des patients sont souvent volumineux et peu maniables, ce qui nécessite la création de résumés. Un format de résumé structuré offre l'avantage d'une meilleure organisation et d'une récupération plus facile de l'information. Cependant, les formats de résumé clinique typiques ne documentent pas les déductions intermédiaires reliant la symptomatologie au diagnostic et, dans cette mesure, ne permettent pas de suivre le processus cognitif du clinicien. Le format de résumé clinique et de raisonnement des facultés de pédiatrie du National Postgraduate Medical College of Nigeria et du West African College of Physicians a été conçu pour suivre la pensée clinique et les processus de raisonnement des cliniciens. Il se compose de deux sections principales. La première section sert à documenter les données provenant de l'histoire, de l'examen physique et des premiers rapports de laboratoire, tandis que la seconde section sert à enregistrer les déductions hiérarchiques permettant d'atteindre les différents niveaux de diagnostic. Les définitions et les descriptions des différents composants du format sont présentées ici. L'utilité du format pour la pratique clinique, la formation clinique et l'évaluation des stagiaires est discutée. Mots clés: Cognition, Résumé clinique, Raisonnement clinique, Format, Diagnostic.

Doctors' Knowledge, Comprehension, Attitude to and Application of Ethical Principles in Child Healthcare in a Nigerian Teaching Hospital.

BACKGROUND AND OBJECTIVES: Due to the prevailing socio-cultural and religious affiliations, Paediatricians in sub-Saharan Africa face unique ethical dilemmas. An understanding and application of the ethical principles can help prevent and resolve these dilemmas, and improve child health indices. The objective is to determine the knowledge, attitude and practical applications of non-maleficence and beneficence by child-care doctors at a Teaching Hospital. METHODS: This is a questionnaire-based study. Socio-demographics, knowledge and attitude towards the ethical principles, and its utilisation by doctors in childcare was sought. Data were analyzed using descriptive statistics. RESULTS: 294 doctors participated. The mean percentage knowledge score of nonmaleficence and beneficence was 31.00±21.14, significantly higher among doctors in Paediatrics (39.35±23.44, p=0.0001). For every decrease in professional rank, knowledge score decreased by 3.8224 (95% CI -5.824 - -1.819; p=0.0001). The doctors had a high mean percentage score on attitude towards ethics of 74.79±16.34, and for every increase in years of practice, attitude towards ethics score would increase by 2.922 (95% CI 1.133 to 4.711, p=0.001). There was a low practice score of 34.27±20.07. Majority (69%) encountered less than one dilemma a month. More than 90% of doctors had encountered dilemmas involving the principle of non-maleficence [184 (90.6%)], while 154 (75.9%) involved beneficence. CONCLUSION: Most respondents have a low level of knowledge and practice of the principles of nonmaleficence and beneficence. Their excellent attitude implies their willingness at improving their knowledge and practice.

Simple Vision Screening in Lower Primary School Children in Port Harcourt City

Background: Vision disorders are significant causes of morbidity worldwide and in children; can lead to life long visual impairment or blindness. Thus; the impact on a child's education and life if not detected and ameliorated on time; can constitute a huge socio-economic burden to the child; family and community. Aim: To determine the prevalence of reduced vision in lower primary school children in Port Harcourt city. Methods: A multi-staged sampling technique was used to select 1;234 lower primary school pupils from 12 schools in Port Harcourt for visual screening. Visual acuity (VA) measurements using Snelling's charts; and a basic eye examination using a pen torch was carried out in all the pupils. Vision was regarded as reduced if VA is 6/18; in which case a pinhole was presented to the affected eye and VA repeated; to check for presence of refractive error. Results: A total of 1;234 school children were screened; 73 pupils had reduced vision in one or both eyes giving a prevalence of 5.9. Refractive errors accounted for 72.6of cases of reduced vision. Gross external eye abnormalities accounted for 9.6of cases of reduced vision; with corneal opacity and nystagmus being the most commonly seen. Conclusion: Reduced vision is an important cause of visual disability in primary school pupils in Port Harcourt city; mostly due to correctable refractive errors. There is therefore a need for routine vision screening of all pupils; especially on commencement of school for early detection and treatment; to prevent life long visual disability

Screening for congenital color vision deficiency in primary children in Port Harcourt City; teachers' knowledge and performance.

BACKGROUND: One hundred and thirty teachers were studied to evaluate their knowledge of congenital Color Vision Deficiency (CVD), and their ability to perform the Ishihara color vision test, so as to determine if they can provide color vision screening services for their pupils. METHODS: The teachers were randomly selected from 13 schools in Port Harcourt City (PHC) and given a six hours training workshop on vision disorders in children and congenital color vision screening. They were given a self administered pre and post test questionnaires before and after training respectively. Subsequently, they screened 1,300 of their school pupils for congenital vision deficiency using the Ishihara color vision chart; and their results compared to that of the research team. RESULTS: Female teachers constituted 84.6% and males 15.4% of the study population. Seventy three teachers (53.8%) were from public schools while 46.2% were from private schools. Prior to the training workshop, only 6.2% of teachers had heard of the Ishihara color vision chart and none of the teachers could identify or knew how to use the chart. However with training there was significant improvement in knowledge of CVD. Comparison of the teachers' performance of color vision screening using the Ishihara chart to that of the research team showed a sensitivity of 67.6% with a specificity of 99.1%. The prevalence of congenital color vision deficiency in the 1,300 primary school screened was 2.6%, with males having a significantly higher prevalence than females. CONCLUSION: The study thus concludes that congenital color vision deficiency is prevalent amongst primary school children in Port Harcourt City, and with training, teachers can effectively perform color vision screening, and as such modify their teaching methods to accommodate the child with color vision deficiency.

Development and validation of standardized clinical summary format.

BACKGROUND: The use of a structured guideline in medical education to reach a diagnosis provides accurate information which is relatively free from bias. The purpose of this paper is to assess the performance of medical students using unstructured and structured format in case summary. METHODS: One hundred and sixty- nine medical students in Part III MB; BS Programme in the University of Port Harcourt were studied. There were 83 students in Paediatics [SP] and 86 students in Obstetrics and Gynaecology [SOG] postings. The students had video recorded presentation of three clinical cases comprising of two paediatrics [PC1&PC2] and one surgical case [SC3]. The summary for the first case [PC1] was done using an unstructured format, while the second case [PC2] was done with both unstructured PC2a and structured PC2b format. The Surgical case [SC3] was done using only the structured format. The discrete pieces of important information in each case were quantified and scored by trained assessors. PC1and SC3 had a total of 16 points each while PC2 had a total of 24 points. RESULT: The pre-exposed SOG students scored significantly higher than none-exposed SPG students in PC1 and SC3; P<0.05. In PC2 75.1% students scored above 12 points using structured summary format compared to 38.5% students with unstructured format , P<0.05. The students had significantly higher score using structured format in SC3 than PC1. CONCLUSION: The use of structured summary format enabled better case summary than unstructured format, and it's transferable across different departments.

Growth pattern of exclusively breastfed infants in the first six months of life: a study of babies delivered at the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria.

BACKGROUND: Some authors demonstrate that exclusively breastfed infants have growth patterns comparable with the NCHS standards while others conclude that exclusively breastfed infants grow slower. These conflicting results informed the need for this study to aid the paediatricians and health workers to justify or condemn the recommendation of exclusive breastfeeding for six months. This was a prospective longitudinal study carried out to determine the growth pattern of exclusively breastfed infants in the first 6 months of life and compare them with the International, National Centre for Health Statistics (NCHS/WHO) reference and the Local, Janes' Elite Standards. METHOD: Using weight, length and occipito-frontal circumference as indices, 530 infants were recruited consecutively by convenience sampling over 17 months. Measurements were taken at birth, 2 weeks, 6 weeks, 2 months and subsequently monthly until the end of the 6th month. RESULTS: The exclusively breastfed infants doubled their birth weights at 3 months. The mean weight, OFC and length gains were maximal at 2 months, 2 weeks and 2 months respectively The growth of exclusively breastfed infants compared favourably with the NCHS/WHO reference group and also compared favourably with the Janes' 'Elite' reference group. CONCLUSION: It is concluded that the growth in weight, length and OFC of exclusively breastfed infants appears adequate for the first 6 months of life.

Growth pattern of exclusively breastfed infants in the first six months of life: a study of babies delivered at the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria

BACKGROUND: Some authors demonstrate that exclusively breastfed infants have growth patterns comparable with the NCHS standards while others conclude that exclusively breastfed infants grow slower. These conflicting results informed the need for this study to aid the paediatricians and health workers to justify or condemn the recommendation of exclusive breastfeeding for six months. This was a prospective longitudinal study carried out to determine the growth pattern of exclusively breastfed infants in the first 6 months of life and compare them with the International, National Centre for Health Statistics (NCHS/WHO) reference and the Local, Janes' Elite Standards. METHODS:Using weight, length and occipito-frontal circumference as indices, 530 infants were recruited consecutively by convenience sampling over 17 months. Measurements were taken at birth, 2 weeks, 6 weeks, 2 months and subsequently monthly until the end of the 6th month.RESULTS: The exclusively breastfed infants doubled their birth weights at 3 months. The mean weight, OFC and length gains were maximal at 2 months, 2 weeks and 2 months respectively. The growth of exclusively breastfed infants compared favourably with the NCHS/WHO reference group and also compared favourably with the Janes' 'Elite' reference group. CONCLUSION:It is concluded that the growth in weight, length and OFC of exclusively breastfed infants appears adequate for the first 6 months of life

Screening for Congenital Color Vision Deficiency in Primary Children in Port Harcourt City; Teachers' knowledge and performance

Background: One hundred and thirty teachers were studied to evaluate their knowledge of congenital Color Vision Deficiency (CVD); and their ability to perform the Ishihara color vision test; so as to determine if they can provide color vision screening services for their pupils. Methods: The teachers were randomly selected from 13 schools in Port Harcourt City (PHC) and given a six hours training workshop on vision disorders in children and congenital color vision screening. They were given a self administered pre and post test questionnaires before and after training respectively. Subsequently; they screened 1;300 of their school pupils for congenital vision deficiency using the Ishihara color vision chart; and their results compared to that of the research team. Results: Female teachers constituted 84.6and males 15.4of the study population. Seventy three teachers (53.8) were from public schools while 46. 2were from private schools. Prior to the training workshop; only 6.2of teachers had heard of the Ishihara color vision chart and none of the teachers could identify or knew how to use the chart. However with training there was significant improvement in knowledge of CVD. Comparison of the teachers' performance of color vision screening using the Ishihara chart to that of the research team showed a sensitivity of 67.6with a specificity of 99.1. The prevalence of congenital color vision deficiency in the 1;300 primary school screened was 2.6; with males having a significantly higher prevalence than females. Conclusion: The study thus concludes that congenital color vision deficiency is prevalent amongst primary school children in Port Harcourt City; and with training; teachers can effectively perform color vision screening; and as such modify their teaching methods to accommodate the child with color vision deficiency

Impaired acidification of urine in children aged two months to two years with acute gastroenteritis complicated by acidosis.

BACKGROUND: In some children with acute gastroenteritis and acidosis, the urine pH may be abnormally high thus simulating distal Renal Tubular Acidosis (dRTA). This inability to acidify urine properly in the presence of metabolic acidosis has been shown to be due to poor delivery of sodium to the distal nephron which prevents full excretion of a hydrogen ion load, instead of an intrinsic defect in the ability of the distal tubule to acidify urine. The aim of this study is to determine the prevalence of transient urinary acidification defect in children aged two months to two years with acute gastroenteritis, dehydration and acidosis, and the relationship between urine pH and urine sodium concentration. METHOD: A prospective study of children aged two months to two years admitted for the treatment of acute gastroenteritis and dehydration at the Children's Emergency Ward (CHEW) of the University of Port Harcourt Teaching Hospital, Rivers State. RESULTS: Of the 196 children (140 males and 56 females) studied with spontaneous acidosis which developed as a result of acute gastroenteritis, seventy-three of them had impaired acidification of urine, giving a prevalence of 37.2%. There was no significant difference in the age, duration of symptoms, degree of acidosis, degree of dehydration and serum potassium concentration between the children with impaired and those with proper urine acidification. Those with impaired acidification of urine however had a significantly lower serum sodium and urine sodium concentrations and a significantly higher urine potassium concentration and urine anion gap than those children with proper urine acidification. All urine samples with sodium concentration less than or equal to 25 mmol/L (52) had urine pH greater than 5.5. CONCLUSION: Mere presence of acidosis and high urine pH should not lead to a diagnosis of Distal Renal Tubular Acidosis (dRTA). The urine anion gap (UAG) should be calculated using the formula: urine [Na+] + [K+] [Cl], and if negative, it suggests a high ammonium excretion, which makes the diagnosis of dRTA unlikely.

Growth pattern of exclusively breastfed infants in the first six months of life: a study of babies delivered at the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria.

BACKGROUND: Some authors demonstrate that exclusively breastfed infants have growth patterns comparable with the NCHS standards while others conclude that exclusively breastfed infants grow slower. These conflicting results informed the need for this study to aid the paediatricians and health workers to justify or condemn the recommendation of exclusive breastfeeding for six months. This was a prospective longitudinal study carried out to determine the growth pattern of exclusively breastfed infants in the first 6 months of life and compare them with the International, National Centre for Health Statistics (NCHS/WHO) reference and the Local, Janes' Elite Standards. METHODS: Using weight, length and occipito-frontal circumference as indices, 530 infants were recruited consecutively by convenience sampling over 17 months. Measurements were taken at birth, 2 weeks, 6 weeks, 2 months and subsequently monthly until the end of the 6th month. RESULTS: The exclusively breastfed infants doubled their birth weights at 3 months. The mean weight, OFC and length gains were maximal at 2 months, 2 weeks and 2 months respectively. The growth of exclusively breastfed infants compared favourably with the NCHS/WHO reference group and also compared favourably with the Janes' 'Elite' reference group. CONCLUSION: It is concluded that the growth in weight, length and OFC of exclusively breastfed infants appears adequate for the first 6 months of life.

Survey of knowledge of HIV infection among senior secondary school 3 (SSS3) students in Port Harcourt.

BACKGROUND: The objective of this paper is to study the knowledge of the students on Human Immunodeficiency Virus and Acquired Immunodeficiency Deficiency Disease (HIV/AIDS) among third year senior secondary school (SSS3) students in Port Harcourt metropolis. METHOD: This was a cross-sectional survey involving 1800 SSS3 students from thirteen secondary schools in Port Harcourt metropolis, selected by a two-stage stratified sampling technique, using a self administered structured questionnaire. RESULTS: Thirty one percent, 14.4%, 9.1% and 8% of the students studied identified sexual intercourse, blood transfusion, mother to child (vertical) transmission and intravenous drug use, respectively, as modes of transmission of HIV infection. Only 7.1% identified all the listed four modes of transmission of HIV whilst 0.7% of the students identified all the listed preventive methods. The level of knowledge of the students on HIV did not significantly increase with age (p = 0.745). Students from Federal school demonstrated more knowledge than students from state and private schools. Similarly, students from all-male school had more knowledge than students from all-female and co-educational schools. Students from high social class demonstrated more knowledge than those from middle and low social class. CONCLUSION: It is concluded that the knowledge of the students on the transmission and prevention of HIV/AIDS is poor. There is need to intensify HIV/AIDS education programmes among adolescents.

Malaria parasite density and splenic status by ultrasonography in stable sickle-cell anaemia (HbSS) children.

BACKGROUND: To determine the relationship, if any, between malaria parasitaemia, parasite density and presence/size of the spleen, using abdominal ultrasonography in stable sickle cell anaemia subjects aged 6 to 15 years. METHODS: A prospective study of one hundred consecutive sickle cell anaemia (SCA) and 100 matched healthy HbAA controls aged 6 to 15 years was undertaken. The presence of malaria parasite, and parasite density were determined using thick blood film. Splenic status was determined by using abdominal ultrasound. None of the children was symptomatic for malaria. RESULTS: The prevalence of autosplenectomy and splenomegaly were 20% and 27% respectively in SCA subjects compared to 0% and 4% respectively in HbAA controls. Thirty percent and 34% of the SCA and controls respectively had malaria parasitaemia. In SCA subjects, the parasite density ranged from 33 to 4000 per microl with a mean of 1071.10 +/- 895.5 per microl. In HbAA controls, the parasite density ranged from 180 to 5150 per microl with a mean of 1759 +/- 1382.87 per microl. The difference in parasite density between SCA subjects and HbAA was significant p<0.05. The parasite densities were relatively higher among SCA with splenomegaly and normal spleen sizes compared to SCA subjects with autosplenectomy. CONCLUSIONS: The prevalence of malaria parasitaemia is lower in healthy SCA subjects than in HBAA controls. Sickle cell anaemia subjects have lower malaria parasite density. Autosplenectomy may be a positive adaptation in SCA subjects with effective innate immunity to malaria.

Medical journals of Nigeria, quo vadis?

The Nigerian health sector is beset with an underdeveloped Continuing Medical Education (CME) programme, a scarcity of reading materials and the lack of a reading culture. Recent issues of available journals were obtained and read to identify data such as: the ownership and base, presence of mission statement, print quality, administrative and editorial matters, abstract format, CME value of articles, advertisements, subscription information and communication channels and practice. The availability of the journals in the libraries of the three 'first generation' teaching hospitals and accessibility through the Medline were ascertained. Twenty-eight current journals were obtained. Lagos has the highest number of editorial bases. Fifteen journals belong to national medical associations, 2 to regions and 11 to institutions. The journal title was considered appropriate in 13, cover design was good in 15, paper quality was good in 20 and legibility was good in 11 journals. Poor editing was manifested by bad grammar, spelling and punctuation. Six journals contained review articles of good CME value. Eight journals had a full compliment of communication facilities. The existence of a functional independent administrative office or staff was indicated in 7 journals. No journal indicated the dates of submission and acceptance of articles. Twenty-one journals were on the shelf of the library of ABUTH, Zaria. Two journals are accessible through the Medline and another is on-line. Adequate funding and improved management will effectively address most of the problems identified.