Step 4-professionalism - part II

1- Medicolegal cases in General Practice 2-8

2- Selection of medical investigations for 9-14
making a diagnosis

Personal Development plan 15-23

Sharing Departments

The board of professionalism Department

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 Medicolegal cases in General Practice

I. Definition of medicolegal cases (MLC)

Medicolegal cases (MLC) refer to a case of injury or illness that

indicates investigation by a law enforcement agency to establish a criminal
responsibility for the case.

In practice, doctors may encounter MLCs in the emergency

department or, less often in hospital wards.

When a doctor assumes that the medical cause under his care is a
MLC he should take the necessary steps to examine, report, and document
the case.

II. Categories of MLC

The spectrum of clinical presentations of MLCs is very wide and

variable. Some cases are clearly defined as MLCs and some are not. The
different categories of MLCs are illustrated in the following Table.

Table (1) Categories of Medicolegal Cases

1- Road traffic accidents ‫حوادث المرور على الطرق‬

2. Occupational injuries ‫اصابات العمل‬
3.Child abuse ‫اساءة معاملة االطفال‬
4. Accidental injury ‫االصابات العرضية‬
5.physical assault ‫االعتداء الجنسي‬
6.Crime cases ‫الجرائم‬
7. Poisoning ‫التسمم‬
8. Illegal drug abuse ‫تعاطي المخدرا ت‬
9. Disaster victims ‫اصابات الكوارث‬
10. Unexplained clinical cases ‫الحاالت المرضية الغير مبررة‬
11. Death ‫حاالت الموت الغير مبررة‬

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1. Road traffic accidents ( RTA)

Any victim of a road traffic accident is considered a MLC. The

resulting injury is inflicted by a blunt trauma. It ranges from a mild to a
grievous injury. Such injuries are considered mediclegal because of the legal
implications of road traffic accident in criminal law, civil law, and health
insurance.

2. Occupational injuries.

Injuries occurring in the work field are considered MLCs because they
usually implicate compensation from the work employer. They are either
physical injuries, disabilities, or chronic resulting from long term exposure
of disease causing factors at work.

3. Child Abuse. (Child maltreatment)

It may take the form of child neglect, physical maltreatment or

psychological maltreatment. Incase child abuse is documented; the parents
or the Child Guardians are hold legally responsible.

4. Accidental Injury

Any accidental injury may include a legal responsibility, such as .

Burns, electrical shock, fall from height, near drowning, suffocation,
Strangulation, and victims of animal ferocity (animal bite or injuries).

5. Physical assault

Victims of physical assault such as physical trauma & injuries, Sexual

assaults, rape and adultery, child sexual abuse.

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6. Crime conditions

Victims of firearm Injuries or torture victims. Also any illegal

(criminal) abortion.

7. Poisoning

Any case of confirmed, suspected, or alleged poisoning. Poisoning

may be due to medications, chemical or food. This category includes also
alcohol intoxication .

8. Illegal drug abuse (substance abuse)

Any case suspected or confirmed to take substances of Abuse ( illegal

drugs) considered a MLC.

9. Disaster victims

All cases coming to the hospital with injuries resulting from disaster
should be considered MLCs. Such as fire injuries, earthquakes, lightening,
blasts, and even victims of civil unrest.

10. Unexplained Clinical cases

Cases admitted with unexplained Coma or shock are considered

MLCs

11. Unexplained death cases

Cases brought dead to the hospital or who die on arrival to the

hospital. Also cases with sudden unexpected deaths including anesthesia &
surgical deaths.
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III. Responsibility of the hospital in MLCs

• Medico legal case examination & reporting is a legal

responsibility of all doctors working in hospitals.
• Doctors in hospitals cannot refuse examination and treatment of
medico legal cases.
• A good knowledge of the law and of the principles of forensic
medicine is accordingly mandatory.
• The responsibility to label any case as a medico legal case rests
solely on the attending doctor.
• Legal formalities should be suspended until the patient receives
due medical care.
• If a medico legal case needs to be kept under observation, it
should be hospitalized.
• A referred case already registered as an MLC in the referring
hospital, does not require a new medico legal report.
• If a MLC needs transfer to another hospital, it should be
accompanied with all necessary documents, including evidence
articles.
• If death is inevitable, the hospital administration should arrange
to obtain a dying declaration.
• Do not make unnecessary delays in issuing medico legal
reports.
• Inform promptly the authorities in case of admission, discharge,
discharge against medical advice, absence, or death.
• Do not issue a death certificate until a clearance is obtained
from the authorities.
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 • The hospital administration should provide adequate training
for the emergency department staff on writing medico legal
reports and forensic examination of injuries.

IV.Management of MLCs

When a case transferred to the hospital emergency department is

suspected or notified to be a MLC. The attending physician should obtain
initial information about the case and accordingly identify it as a MLC. Once
identified, the following steps are undertaken:

• Registration of the case as a MLC in a special medicolegal register in

the hospital
• Notification of the local Police office and documentation of receipt of
notification by the police office. The notification report should include
the information (Table 2.)

Table (2) Information in the notification report

1. Complete name
2.Age
3.Sex
4.complete address
5.Date and time of reporting
6.Name of the person who brought the case
7.Identification marks if present
8.Finger impressions

• The doctor should provide any urgent resuscitation and treatments and
should not delay such interventions

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 • The doctor should obtain a medical consent from the case who should
accept physical examination & understand that the examination is for
medicolegal purposes and would culminate in the preparation of a
medicolegal report.
• Perform appropriate physical examination, which should include :
➢ Comment on breath odour
➢ Details of the level of consciousness and awareness
➢ Detailed description of all injuries
➢ Examination of body openings.
• Collection and preservation of any body fluids, blood, tissue collected
from the patient. Such material should be preserved and sealed in a
container labelled with the patient name & number.
• Writing a medicolegal report.

The medicolegal report should be well written, accurate, detailed and

Complete. It should be in duplicate Kept copy. One of which is in the

hospital records, the other is handed over to the authorities.

• Treatment

Finally the case should receive the appropriate treatment. The case
may be admitted to hospital or referred to a more specialized hospital.

The police authority should be notified about any action done with the
case, either discharge, admission, or transfer.

In conclusion, cases of medicolegal importance are very Common in daily

hospital practice . Hospital administrations have the responsibility to record ,
document, and manage these cases according to standardized procedures.

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Doctors working in the emergency departments should be alert and aware
about medicolegal Cases, and should have the expertise and skills to deal
and manage such cases.

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Selection of medical investigations for making a
diagnosis
I. What are medical investigations?
Medical investigations are the medical tests which the doctor requests to be
performed, outside the bedside clinical setting, in order to help him to make
the proper diagnosis of his patient's illness.
Medical investigations are numerous and very diversative. They belong to
several branches of medicine; mainly clinical pathology (laboratory
medicine), pathology, microbiology, radiology, nuclear medicine, and
internal medicine.
Most of the medical tests used for medical investigations are technology-
based and thus are subject to continuous development and innovations.
For simplification, we can view medical investigations within major
categories as follows:
Categories of medical tests
1. Laboratory analysis:
▪ Blood chemistry.
▪ Biological tests (hormonal assay-tumor markers).
▪ Serology/ Immunology.

2. Medical microscopy:
▪ Hematology (complete blood picture).
▪ Examination of body fluids (urine, stool, sputum, cerebrospinal
fluid, seminal fluid, pericardial or pleural effusion, ascites fluid).

3. Histopathology: Histopathological examination of biopsy tissue either

gross or microscopic pathology. A biopsy tissue may be obtained by skin
or mucous membrane snap or through endoscopy or intraoperative.

4. Microbiology:
▪ Direct smear examination.

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 ▪ Immunofluorescences smear examination.
▪ Culture and antibiotic sensitivity testing.

5. Imaging:
▪ Plain radiography.
▪ Contrast radiology.
▪ Ultrasonography.
▪ Cardiac ultrasonography.
▪ Computed tomography (CT).
▪ Magnetic resonance imaging (MRI).
▪ CT/MRI angiography.
▪ Positron emission tomography (PET).
▪ Radio nuclear imaging.
▪ Special imaging techniques (Breast mammography- retinal
fluoroscopy).

6. Endoscopy:
▪ Intravascular catheterization.
▪ Cardiac catheterization.
▪ Respiratory endoscopy (bronchial- laryngeal- sinuscopy).
▪ Gastrointestinal endoscopy (upper- lower).
▪ Urinary endoscopy.
▪ Fetal endoscopy.

7. Functional tests:
▪ Electrocardiography (several modalities).
▪ Electroencephalography (several modalities).
▪ Pulmonary function tests.
▪ Uro dynamic tests.
▪ Gastrointestinal dynamics tests.
Accordingly, medical investigations are performed in specially equipped
laboratories by specially trained personnel.

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The personnel involved in performing medical investigations are either
technicians or specialty physicians; all are being supervised by consultant
physicians specialized in their fields.
On the other hand, owing to technology advancements, some medical tests
can be performed at the bedside of the patient by the treating doctor himself.
Examples of such bedside medical tests are:
- Random blood Glucose test.
- Strip method urinalysis.
- Transcurancous pulse oximetry measurement.
- Fetal ultrasonography.
- Vascular Doppler ultrasonography.
Medical tests are not only useful for making a diagnosis, but also they serve
many purposes in clinical practice.
Table 1. Purpose of medical investigations
• Detect occult disease
• Affirm the suspected diagnosis
• Assess disease complications
• Determine stage of activity of a disease
• Evaluate severity of disease
• Monitor course of disease
• Select drugs and adjust therapy

II. Medical diagnosis:

In clinical practice, medical diagnosis is a systematic methodological
pathway. It starts by the collection of the patient's data through obtaining the
medical history and doing a skillfull physical examination. The next step is to
define the specific medical problem (medical Condition) based on analysis &
interpretation of the collected patient's data.

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According to the medical problem specified, the doctor formulates a list of the
diagnostic possibilities in his patient. He then makes an analysis of each
diagnostic possibility in the light of the given patient's data, where he
evaluates the data which are in favor & those which are not in favor of each
diagnostic possibility.

This process, called the differential diagnosis, guides the doctor to consider
the most likely diagnosis (Also termed the presumptive or provisional
diagnosis) and to list the other diagnostic possibilities by order of their
probability (see table 2).

The most likely diagnosis (provisional diagnosis) is the diagnostic possibility

with most data in favor, and fewer data not in favor of the proposed diagnosis.

Nevertheless, the identification of the provisional diagnosis should also be

guided by the Golden Medical Rule; "Common things are Common".
Accordingly the doctor should know what are the commonest diseases in the
region where he makes his clinical practice.

Table 2. Data in favor Data not in favor

Possibility A 1- 1-
2- 2-
3-
Possibility B 1- 1-
2- 2-
3-
Possibility C 1- 1-
2- 2-
3-
4-
Possibility D 1- 1-
2-
3-

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 III. Selection of the medical Investigations
After the process of differential diagnosis, and after listing the diagnostic
possibilities by order of their probability, the doctor should select the
appropriate medical investigations that will help him decide which of the
diagnostic possibilities in the presout diagnosis of his patient.
The rules and guidelines to make an appropriate selection of medical tests:
It is clear that the doctor should not select a panel of medical tests blindly
regardless of the presumptive diagnosis of the patient. His selection should be
appropriate to the presumphive diagnosis.

The rules and guidelines to make an appropriate selection of medical tests are
the following:
1. To select the medical tests which are useful to document the most likely
(presumptive) diagnosis. Usually these tests should be specific to the proposed
diagnos.
2. To select the medical tests which are useful to exclude the other diagnostic
possibilities in the list of differential diagnosis. Usually these tests should be
sensitive to the proposed diagnosis.
3. The selected medical Tests should provide the needed and expected
information in relation to the case.
4. Select tests which are easy to be performed, practical, accessible, and safe.
5. Put into consideration the cost of the medical test. If less expensive tests
can provide the required information, they should be prefered to more
expensive tests.
6. Set the pretest probability which means what is the percent chance that the
selected test is positive in view of the proposed diagnosis.

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The request form:
Any medical test should be requested on a standard form which should contain
the following information:
a) Patient name & patient ID number
b) Patient age
c) Relevant clinical data
d) Medication history
e) Provisional diagnosis
f) Type of test and additional technical details
g) Aim of requesting the test (expected findings)
h) Date of request
i) Doctor name and signature
j) Details of the sample & sampling

Interpret the test result

1. Appraise the quality of the report and the quality of the tracing/images.
2. Check for external factors which may affect the test results.
3. Revise the reference interval of the test.
4. Revise the significance of the abnormal finding of the test in context of
physiological differences (age - gender).
5. Interpret the test result in context of the proposed diagnosis and of results
of other tests.
6. Define the probability of disease depending on the test result [post test
probability].
Avoid making a diagnosis based on a test result.

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 Personal Development plan
I- Life domains:
Life domains are the different aspects and experiences that we should
consider in our life to have a good quality of life. Every individual should give
time and importance to each life domain and should balance and integrate all
domains in his life.
The important life domains are:
1 - Family
The family is the domain where we share beliefs, values, and ethics with other
family members. We should fulfill our roles and responsibilities within our
families, each one according to his position in the family.
2.Friends
We need friends to share with us our good and difficult moments in life. We
need their support and encouragement during life stress. Accordingly, we
should give time and effort to support our friends and maintain good relations
with them.
3. Community
The community provides the person with a sense of belonging, of safety, and
of security. When a person is working towards a shared community goal, he
acquires a sense of achievement and fulfillment, which important for a
psychological balance.
4. Vocation (work)
Work plays a fundamental part in the life of adults; it provides a chance to
learn, develop, and accomplish goals. It satisfies an essential need in life, to
be part of the society.
It is thus important that we invest well: the time spent at work, and that we
make work a source of enjoyment and satisfaction.

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5. Avocation (hobby)
An avocation is an activity that someone engages outside their main
occupation (work). Such activities may be the true passion in one's life.
Spending time in a hobby activity helps the person to perform better in his
occupation and helps to reduce the stresses imposed on the individual.
6- physical (sports)
It is essential to adopt a healthy lifestyle and promote healthy living.
Understanding how to exercise and eat healthy food helps to promote
emotional& mental health and wellbeing.
7- Intellectual
Everyone should care for the intellectual aspect in his life. This means giving
sometime for reading and acquiring knowledge, improving the spectrum of
new information and enlighten, cultivating himself about life matters.
8- Spiritual
This area of life should be prioritized. Spirituality enables a purpose in life
and allows simply for a good life. It includes the individual's relation with
God, practice of religions, and meditation.
9- Personal
After all, everyone should care for himself. We should allow sometimes for
relaxation, for self-reflection, and for doing the small things in life that
provide us with self-satisfaction.
Strategies to balance life domain
Balancing life domains is not easy but is important. Life domains should be
regularly assessed and evaluated then adjusted by setting goals. The following
are strategies that can be used to balance life domain:
a- Compensation:
Is a technique where you increase the positive life domains to counteract the
negative life domains. Increasing the good aspects of life reduces the unhappy
influence from the not- so- good parts of life on overall life satisfaction.

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b- Acceptance:
One Should acknowledge and accept that not everything can be done in every
domain all the time. There will be always limitations to getting everything
done in perfection. The ability to accept these facts is important in maintaining
our overall wellbeing.
c- Time management
A good planning & time allow to organize life activities and perform as
required in every domain. So, everyone should learn the important skills of
time management.
II- The personal development plan (P. D. P)
To achieve success and happiness in your education, career, and personal life,
you should continuously improve your knowledge, skills, and experiences.
This is known as personal development which is continuous lifelong process.
Personal development is beneficial for you as an individual and also for
society as whole. Continuous learning improves your mental wellbeing, as it
gives you a sense of purpose and boosts your confidence.
An effective way of personal development is by completing a personal
development plan (P.D.P.). Such a plan helps the individual to focus and
achieve his/her intended goals.
“If you fail to plan, you are planning to fail” Benjamin Franklin
A P.D. P. is thus an action plan that you can formulate for achieving success
in your professional as well as personal life.
In order to formulate a P.D.P. you need to identify the following Important
aspects:
1- Your values in life
What are the moral and ethical values that you acquired in your life and which
guide your decisions and actions?
2. Your vision in life
what you want to be in the near future? where you want to be? what you want
to achieve to get there?

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3. Your strengths & weaknesses
You should perform a self-reflect to evaluate the points of strength and the
points of weakness in your personality, qualities, or attitudes.

4. Areas you need to improve

Define the areas which you think are deficient and where you need to improve
yourself in your profession.
Benefits of a P. D.P.
1. It provides you with clear goals
2- It improves your performance
3- It increases your motivation
4- It helps you to track and assess your progress
5- It enhances your mental wellbeing and improves your sense of purpose
Steps of writing a P.D.P.
1- Define your learning needs
Think about the fields or topics you want to learn or complete in your
education. Make a table of your learning needs and give a score for your actual
competency in each learning area. This will help you decide your needs and
prioritize (Table 1)
Table (1): Example Table of learning needs:
Area of Practice Present competency Learning goal

1. Dermatology Weak Study types of rashes

2.Examination of the eye Weak Perform steps of examination

3. The 1.Q. Testing Weak Learn How to do test
4. Child development Fair Understand the subjects

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 5. Interpretation of ECG Fair Read an ECG

6. Types of diabetes Fair Know types of diabetes

7. Basic life support Fair skills of BLS

8. I.T. skills Fair study basic IT

9. Time management still Good Review skills
10. Medical ethics Good Understand well ethics

2- Define your learning goals

After deciding about the areas or fields where you want to improve learning,
make a priority list i.e. the areas where your competency is weak will be a
priority as a learning need. Then define for each area a specific learning goal.
For each area you may define several goals depending on your deficiencies
and the extent to which you want to improve learning
3-Design an action plan for each learning goal
• What are the specific tasks required to achieve each objective?
• How I intend to complete the tasks?
• What is my time frame?
• How I will evaluate my learning?
• How I will document my learning?
• Who is/are my supervisor (s)?
4- Select the educational activities
For your learning objectives. There are different varieties of education and
activities that you may use for your PDP. Decides for each objective what
activities can be used, and form a table of the activities & objectives (Table
2)
Table Different Educational activities for personal development
(2): Educational activity Learning Learning Learning
area 1 area 2 area 3
1 Reading literature/journals
2 Internet searches/distant learning
3 Studying guidelines/protocols
4 Practice in clinics

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5 Team meetings within practice
6 Feedback from seniors/colleagues
7 Reflective diary
8 Recording PUN/DEN
9 Problem case analysis
10 Significant event analysis
11 External review of clinical data (patient medical
records)
12 Research
13 Writing review articles
14 Attending lectures/ seminars/ courses/ conferences
15 External examination (e.g. MRCP)
16 Self-assessment against external standards (e.g.
MCQ)
5- Making a PDP Template
Write down a resume of your PDP design according to the following template
(Table 3)
Table (3): Personal development Plan Template
Name:
Date:
• My own strengths in my job are:

• My own weaknesses in my job are:

• My previous PDP (if applicable) has resulted in the following learning outcomes:

• Over the past year I have been particularly helped by:

• Over the past year I have been particularly hindered by:

• My learning needs for the next year are:

• My specific learning objectives are:

• I will use the following learning activities:

• I will evaluate my learning by:

• My learning would benefit my practice by:

• In the longer term my plan is to:

6- Recording and documentation of the learning activities of the PDP

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You can document the different learning activities in several forms of
documentation. The following are the commonest forms of recording &
documentation of learning activities in medical education:
a- Case reporting

• Personal data
• Past acute illness (if relevant)
• Chronic disease (patient known to have……)
• Past interventions
• Specific medications
• Past medical tests (if relevant)
• Chronic or hereditary disease in the family
• Pertinent (relevant) data by physical examination
• Pertinent (relevant) results of medical tests
• Final diagnosis
• Treatment given and outcome of treatment
• Lessons learned

B- Significant event analysis

Date Event description

1- What happened?
2- How did it affect the patient?
3- How did it affect you?
4- How did it affect the practice?
5- Why did it happen?
6- Learning needs revealed by the events
7- Action to be taken to avoid similar events

C- Formal teaching
Lectures, seminars, classes, clinical rounds

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 1- Date and time of the event
2- Name of the event
3- Subject(s) covered
4- Name of tutor/instructor
5- What I learned from this session

D- Log book
The logbook is used for registration of your training experience, either by
observation or by performance by yourself. You register the manual or
cognitive skills which you learn, and the name of your supervisor.
Date Event Supervisor/tutor

Formation of the academic Portfolio

A portfolio is a portable collection of materials that describe your work such
as documents that describe your qualifications, training, skills & learning
achievements. It also includes your reflection and self-evaluation and life
experience. It contains your updated C.V. as well. The portfolio is revised and
amended once every year.
What does your portfolio contain?
• Personal Portfolio of (Your Name)- Use this on the cover and the first
page inside
• Page of Contents
• Statement of Originality and Confidentiality
• Personal Profile
• Resume or CV
• Reference
• Job Posting
• Education
• Transcript of Marks
• Goals

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• Letters of Recommendation or Reference
• Awards
• Memberships
• Special Training
• Work samples
• Volunteer Work e.g. Letter or article explaining your involvement in
the community
• Academic Plan
• Computer Disc

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