The Trigger

htinaung

“ to teach is to learn” htinaung

Tell me and I’ll forgetShow me and I may rememberInvolve me and I’ll understand

Chinese proverb

Vision and Mission(of a Medical School)

Produce practitioners who are•analytical•demonstrate critical thinking •possess problem -solving

skills

in the clinical setting

DEFINITION 1

• A trigger is the starting point of problem-based learning

• Usually in the form of 5 – 6 text lines that provide key information about the main character

• Includes 3 to 4 presenting problems

• A lot of programs include a visual trigger

DEFINITION 2

Description of a phenomenon

Prepared by a team of teachers

Directs learning activities

TYPES of Triggers

• Visual trigger

• Single image

• Series of images

• Video clip

• Patient’s investigation results

• Or …. even a cartoon

The Video Trigger

Objectives of a trigger

• Introduces problem

• Enhances observation skills

• Stimulates to ask questions

• Allows to develop an enquiry plan

• Provides new information to add to the cues obtained from trigger text

• Allows learners to manage complexities and behave like real practitioners.

Functions of a trigger

• Raises issues for new learning

• Stimulates group discussions

• Provides opportunities to be actively involved

• Demands appropriate feed back from teachers

• Demands corrective assistance from teachers

GUIDELINES• Problem revolves around something that

will pose a problem to a practitioner. • As realistic as possible, the kinds of

problems that students would encounter in real life

• Problem format is sequential• Emphasize aspects of basic and clinical

science• Contains a tutor/facilitator guide

MOTIVATIONAL PROBLEM

CRITERIA Introductory Advanced

1 Educational goals clearly stated independence

2 Background info one source many sources

3 Setting details stated omitted

4 Problem summarize not stated

5 Content focus/detail general

6 Resource self-contained key concepts

7 Presentation tight/specific vocabulary

fluid

Throughout the sequence the problems need to support the shift to this last phase where the problems are more complex and relate strongly to interrelations between basic concepts in the field of study

My head is Like a ton of bricks!

Part 1

A 35 year old man was brought to the hospital by family members in a drowsy state. According to the brother, the patient was having severe headache, vomiting and fever for one week, and which had progressively worsened.

Hypotheses / problem/ differential diagnoses1. 2.3

Students’ copy

Let’s see if this trigger conforms to the guidelines:

pose a problem to a practitioner. realistic to real life format sequential emphasis on aspects of basic

and clinical science

My head is like a ton of bricks!

Part 1A 35 year old man was brought to the hospital by family members in a drowsy state. According to the brother, the patient was having severe headache, vomiting and fever for one week, and which had progressively worsened.

Hypotheses/ problems/ differential diagnoses Severe headache and vomiting caused by

1. infections (abscess, encephalitis, meningitis, subdural empyema)2. brain tumour (SOL)3. intracranial haemorrhage4.cerebral oedema

N.B. Other causes presenting with vomiting and headache but which would not fit the picture of fever and drowsiness are severe hypertension/giant cell arteritis; tension headache or migraine; hydrocephalus.

Part 2He has a history of chronic sinusitis.

On examination, he was drowsy.

Urgent investigations: The total white cell count was 20,000/ uL Differential count of 85 % neutrophilsSerum C reactive protein was raised.

Emergency CT scan of the brain shows low-signal intensity centrally, suggestive of the presence of fluid, surrounded by an enhancement ring, beyond which extends an area of low-signal that indicates oedema.

The diagnosis was further confirmed by MRI.

Empirical antimicrobial therapy was initiated and further management options were discussed with his family members.

Refine the hypothesis

Neutrophilic leucocytosis indicates acute intracranial infection The intracranial infection might have been transmitted from chronic sinusitis and the alcoholism might have caused lack of immunity/ hyponutrition/lack of attention or medical care at the early infective stages.

What is the final hypothesis?

A space-occupying lesion, fluid in nature; probably a brain abscess.

Concept

A brain abscess due to an extension of a previous sinus infection or dental infection can present as a space-occupying lesion (SOL) with increased intracranial pressure and must be managed as a medical emergency. [ However, raised ICP can also be a surgical emergency as in cases of head injury or hydrocephalus]

Learning Objectives

Basic Sciences1. Recapitulate the causes of vomiting and headache.2. Describe the anatomical structures associated with transmission of infection from the paranasal sinuses to the cranial cavity. 3. Explain the mechanisms which maintain the intracranial pressure within a narrow range4. Explain why an increase in brain volume or intraventricular spaces cause a rise in ICP.5. Outline the formation, circulation and absorption of cerebrospinal fluid. 6. Outline the causes of SOL / increased intracranial pressure.7. Explain the basis of the clinical presentations of raised intracranial pressure.8. Outline the management of a case of raised intracranial pressure. 9. Discuss the aetiology, pathogenesis, clinical presentation, and complications of

brain abscess.

Community Medicine1. Outline the epidemiology and prevention of brain abscess.

Ethics1.Recapitulate the clinical testing for level of consciousness2. Resuscitation. Patient’s will [issues of DNR] 3. Definition of brain death 4. Discuss the ethical issues regarding invasive procedures

Behavioural science1. Communiucation skills 2. Breaking bad news

Evidence-based medicine (EBM)Choice of drugs in brain abscess

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