Clean vs Cleanse; Cleaned vs Cleansed

PBLI: clean vs cleanse; cleaned vs cleansed

Last August 14, 2012, I jot down an item in my problem-based learning issue (PBLI) list when I was seeing patients in my clinic.

The PBLI is what is the right word to use, wound is “cleaned” or wound is “cleansed.”  I asked myself this question as I was jotting down notes on a patient’s chart after I did a cleaning procedure.

If I make an order on the chart or if I advise a patient, using either word in the active voice, I usually say “clean wound once a day” or “clean wound twice a day.”  I don’t usually say “cleanse wound once a day” or “cleanse wound twice a day.”

How about using either word in the passive voice?  Do we say the “wound cleaned?” Or do we say “wound cleansed?”

Grammarist (http://grammarist.com/usage/clean-cleanse/) says these:

“Both clean and cleanse can be used to mean to remove dirt or filth from. But clean is more often used literally, and cleanse is more often figurative. So cleansing is often spiritual or psychological, while cleaning is usually sanitary or cosmetic.”

My take from Grammarist:

Resolution: From now on, I will use the phrase: “wound cleaned” or “wound is cleaned.”  I will not say or write: “wound cleansed” or “wound is cleansed.”

Is there a place for “cleanse” in the medical language?  I asked further.

Yes, there is.

According to Grammarist, “cleanse”rather than “clean” is also used to mean to rid one’s body or a part of one’s body of toxins and other impurities. This definition is a literalization of the spiritual sense of “cleanse.”  “Cleanse the body of toxins and impurities” or the body is “cleansed of toxins and impurities,” one would say.  Not “clean the body of toxins and impurities.”

Classifying Primary Skin Lesions for Easier Diagnosis

There are so many types of skin lesions.  It is a challenge for everybody on how to diagnose them.  I will try to develop a system of practical classification for easier diagnosis (hopefully).

Primary Skin Lesions

(For development – ROJ)

	Tumorous Lesions	Non-tumorous Lesions
Malignant	Squamous cell carcinoma Basal cell carcinoma Melanoma	Lymphoma of the skin
Non-malignant	Non-malignant tumorous lesions: Keratoacanthoma Keratosis ???	Non-inflammatory / infectious lesions: Eczematous dermatoses Non-eczematous dermatoses Reactions patterns
	Inflammatory / infectious lesions: Abscess	Inflammatory / infectious lesions: Cellulitis Fungal infections

Skin Tumor – Keratoacanthoma on the Neck

July 2012, I had this 70-year-old female patient with a skin lesion on the neck.  I gave a primary clinical diagnosis of granuloma pyogenicum.  My secondary clinical diagnosis is keratoacanthoma.  After excision, the histopath result shows keratoacanthoma.

I read and learned from this experience.

Keratoacanthoma (KA) is classified as a skin tumor, which may be benign or malignant depending on who is talking.  It is akin to squamous cell carcinoma, albeit a low-grade one.  This is the reason for the conflicting views.

The defining characteristic of KA is that it is dome-shaped, symmetrical, surrounded by a smooth wall of inflamed skin, and capped with keratin scales and debris.  This should be used in the clinical diagnostic process using pattern recognition.

(I will remember this and I will not forget this as I reviewed the pictures I took of the skin lesion of my patient. See below.  I also looked at two pictures of published KA in the Net.   This is new learning for me.  I don’t think I will easily forget this because of my problem-based learning process and I spent quite some time researching and writing about it.)

From my patient.

From my patient, close-up.

From the Net.

From the Net.

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The best way to become acquainted with a subject is to write a book about it.

Benjamin Disraeli

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Dermatofibrosarcoma Protuberance, Back, and Rhomboid Flap Reconstruction

OP, 40s-year-old female domestic helper working in HongKong, came to me on August 3, 2012, upon a referral from Dr. Lawrence Oliver from Cauayan, Isabela.

OP had a soft tissue tumor on her back which was biopsied in HongKong and which showed “Dermatofibrosarcoma Protuberans.”

The mass was movable so that there was no concern on the wide excision.  My challenge was on how to close the defect resulting from the wide excision without having to use skin graft.   This was my problem-based learning issue.

I searched the Internet for a review of the flaps that I have done or been exposed to.  I decided that a rhomboid flap be used.  I reviewed the details of the rhomboid flap and then execute the procedures on the day of the operation.  These steps are illustrated below.  The pictures show some drawings on incision planning, tentative and final.

Post-script:

1. This write-up illustrates a problem-based learning in action during an actual management of a patient at the clinic and before the operation.

2. This latest experience reinforces and adds to my stock knowledge on flap reconstruction, particularly, on rhomboid flap, and using flap on the back.

 

 

 

Alternatives 1 and 2.

Planning on “where to connect” the flap after transposition.  Examples: “C” to “C – A”; “E” to “B – E”; and “F” to “C-F.”

Initial steps in flap reconstruction.

Initial steps in flap reconstruction.

 

After complete coverage of the defect with the flap.  Refinements on the wound repair still have to be done.

The specimen.

The cut-section of the specimen.  The gross appearance of dermatofibrosarcoma protuberance on cut-section.

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Note the processes that I went through in problem-based learning.

 

ROJoson’s Problem-based Learning in Medicine (Surgery) – Logo

From this day onward, August 4, 2012, below will be the logo that will accompany all  online posts on my problem-based learning issues in medicine and surgery activities.

Mass on the Right Hand – Problem in Diagnosis – June, 2012

A 50-plus-year-old male with a 6-month duration of a lesion on the thenar area of his right hand.

Squamous cell carcinoma or chronic inflammation/infection?

Initially, treated by a dermatologist, who did cauterization.

Underwent needle biopsy of the developing mass on the same area, suspicious of squamous cell carcinoma.

When I saw him in April, 2012.  I gave him co-amoxyclav.

There was a palpable 2 cm node in the right axilla.

Underwent section biopsy of the mass, cannot rule out squamous carcinoma.

On June 1, 2012, a wide excision and axillary dissection done.  During the operation,  the differential diagnoses was still between malignancy and chronic infection.

With pus, on and off.   I did not proceed to skin grafting because of this and during excision, there were pus in several ares in the thenar muscles.

After a conservation wide excision.  If this turns out to be chronic infection with multiple abscesses (ala carbuncle), then this operation is “saucerization.”

The specimen, from the surface.

Cut-section: fibrosis, necrosis, pus.

The axillary node on cut-section.

Will await the histopath report.

Postop, overall, the balance is tilted towards chronic infection with multiple abscesses and sinuses (ala carbuncle).

Trigger, Resolution and Utility of Problem-based Learning Issues in Medicine (Surgery)

Trigger, Resolution and Utility of Problem-based Learning in Medicine (Surgery)

Processes

Concept of Problem-based Learning in Medicine (in Surgery) – [Re-post #2 – May 12, 2012]

Posted on May 18, 2011 by rojoson

This was derived from a module which I wrote in 1997 with the title: Problem-based Learning in Medicine, An Off-campus Study.

I will be using these concepts when I write my blog on “Problem-based Learning in Surgery.”  [and when I facilitate the PBL Program for Surgical Residents and Interns in Manila Doctors Hospital, Ospital ng Maynila Medical Center and Philippine General Hospital – May 12, 2012]

ROJoson – May 18, 2011

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What is Problem-based Learning (PBL) in Medicine (in Surgery)?

PBL is the learning that occurs in the process of solving a problem.  Experience has shown that this is mainly how human beings learn to live life and it is undeniably the best way of learning especially in terms of retention and recall of knowledge and skills.

The   founders of PBL in medicine recalled their sad experiences with the conventional memory-based medical curriculum – hard to recall facts “learned” in the first 2 years and difficulty in integrating the basic and clinical sciences.   They theorized that retention and recall of medical knowledge and skills would be enhanced when learned in a context which closely approximates real life, i.e. clinical problems.

Thus, PBL in medicine has been proposed and it is essentially learning the science and art of medicine in the clinical or functional context.

In the practice of medicine, the following events actually or should take place:

1. A physician meets a patient without prior knowledge of what the patient’s problem is.

2. During the encounter, the physician establishes rapport, diagnoses, treats, and gives advices with the goal of resolution of the health problem of the patient.

3. In the process of understanding and resolving the patient’s problem, the physician invariably encounters some insecurities, questions, and gaps in competencies.

4. The physician fills in the gaps in competencies through various means, such as self-study and learning from other people like consultations, referrals, and enrolling in a formal course.

5. The new competencies acquired are used by the physician on the patient on hand and on future patients.

If PBL in medicine is learning the science and art of medicine in the functional context, then the educational activities should consist of the following:

1. The student is presented with a health problem which can be simulated or actual, without the student having prior study on the problem.  This means there is no prior teacher’s lecture nor prior assignment to study on the problem.

2. The student tries to understand and to solve the problem.

3. In the process of trying to understand and to solve the problem, the student will invariably encounter questions, uncertainties, and gaps in competencies, which constitute the so-called “learning issues”.

4. The student then decides how to go about settling the “learning issues”.

5. The student implements his plan of study.

6. The student applies what he learned to the problem on hand as well as to future problems or patients.

Illness – by Susan Sontag [Life Notes]

Illness – by Susan Sontag [Life Notes]

“Illness is the night side of life, a more onerous citizenship.

Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick.

Although we all prefer to use the good passport, sooner or later each of use is obliged, at least for a spell, to identify ourselves as citizens of that other place.”

― Susan Sontag

 

This is a fact of life.  Be prepared to accept and respond to illness as best as you can.

ROJoson’s Teaching Contribution to the Department of Surgery of Manila Doctors Hospital and PBL in Surgery

ROJoson’s Teaching Contribution to the Department of Surgery of Manila Doctors Hospital and PBL in Surgery

May 12, 2012

I started active practice in MDH in 1985 soon after I came back from my Mammadi Soudavar Cancer Fellowship abroad.

I became a training officer in the Department of Surgery of Manila Doctors Hospital under the Chairmanship of Dr. Romeo Gutierrez between 1987 to 1989 (have to recheck this) before I was appointed Assistant Medical Director of MDH in 1989.

My training for surgical residents and interns of Manila Doctors Hospital was very active (I hope to chronicle my past teaching activities) before I became more and more involved in hospital administration.  However, I would still continue to do my share of teaching to surgical residents and interns even when I am already part of the administration of MDH (starting 1989 up to present – 2012).

With lesser opportunities for contacts with the surgical residents and interns in MDH for training purposes, with my wish to continue to reach out to them, in 2005 (I have to recheck this), I decided to institute an online interaction with them (through emails) for training purposes.

In 2010, I created a program which I dubbed as ROJoson’s Problem-based Learning for MDH Surgery Residents and Interns (See General Procedures for ROJoson’s Problem-based Learning for Surgical Residents and Interns of Manila Doctors Hospital below).

In May 21, 2011, I created rojoson_mdhsurgery_pbl@yahoogroups.com in Yahoo Groups. I had this description for the group:

This is an online collaborative and interactive learning (OCIL)in general surgery created by Dr. Reynaldo O. Joson in May 21, 2011 to facilitate problem-based learning in general surgery among the surgery residents and interns of Manila Doctors Hospital.

ROJoson’s Problem-based Learning in the Department of Surgery of Manila Doctors Hospital

Basically, the ROJoson’s Problem-based Learning (PBL) in Surgery consist of the following concept and historical background:

 

Concept of Problem-based Learning and Problem-based Learning Issues (PBLI) in Surgery

Every time I have an operation, whenever I discuss my patient with residents and interns who are assisting me and whenever I do introspection on the patient on hand, I always discover I have gaps in knowledge.  These gaps are what I call problem-based learning issues (PBLI).

In the same way, every time the surgical residents and interns assist in the management of patients, mine as well as other surgeons, there will always be gaps in knowledge. This is evidenced by their difficulty in answering the questions being posed by the surgeons they are assisting.  The surgical residents and interns should be made to realize the existence of these gaps and be ready to admit them and use them as stimuli for learning.  These gaps are what I call problem-based learning issues (PBLI).  The “problem” here is the management of the patient.  While managing a patient, the surgical residents, interns, and even consultants will most likely discover gaps in knowledge. The gaps are the PBLI.

 

What Do I Do with the PBLI?  What should the Surgical Trainees Do with the PBLI?

I try to look for the answers usually through the Internet, at times, by asking people whom I think have the answers and also reading books that are available.  Whatever answers I get, I process and transform them into knowledge which I store in my brain for future use, particularly, for purpose of refining my management of current as well as subsequent patients presenting with the same or almost similar kind of medical or surgical problems.

These are also what all surgical residents and interns should be doing with their PBLI.

 

Problem-based Learning – the Way to Continually Learn Medicine and Surgery

This is how I continually learn medicine and surgery.  This is how I continually improve my competency in managing patients.  This is how I continually improve myself as a physician and a surgeon.

This type of learning that starts with self-identification of gaps of knowledge (PBLI) and then proceeding to actively looking for the answers for purposes of self-improvement is what is called self-directed learning.  This is the kind of learning that all medical educators are advocating as the best way for physicians to learn medicine and surgery initially in schools and eventually, after leaving schools.

 

History of ROJoson’s Advocacy for Problem-based Learning in Medicine

I have been advocating problem-based learning in medicine as seen in my personal practice described above and in the problem-based learning medical curriculum that I formulated in 1994 that is being used by Ateneo de Zamboanga Medical School (formerly, Zambaonga Medical School Foundation) and other schools in Luzon and in the Visayas.   I have also been advocating problem-based learning in the Department of Surgery of Ospital ng Maynila Medical Center since 2001 and in my preceptorial sessions in the University of the Philippine College of Medicine, Department of Surgery, and Manila Doctors Hospital.

 

General Procedures for ROJoson’s Problem-based Learning for Surgical Residents and Interns of Manila Doctors Hospital

Sources of problem-based learning issues – when assisting Dr. Reynaldo O. Joson in his operations in the MDH Operating Room (primarily) and when making rounds with Dr. Reynaldo O. Joson in his patients in the MDH floors (secondarily).

The problem-based learning issues (PBLI) are formulated and agreed upon by the surgical residents / interns and Dr. Reynaldo Joson in the operating room and in the floor.

The surgical residents / interns are given usually two (2) weeks to settle the PBLI and post the answers in the rojoson_mdhsurgery_pbl@yahoogroups.com

The surgical residents / interns are encouraged to open their emails at least once a week and interact for learning purposes, with each other and Dr. Reynaldo Joson, as the facilitator and moderator.

 

The PBL Yahoo Groups as a Resource and Archive for Learning of MDH Surgery Residents and Interns and ROJoson’s Legacy

The rojoson_mdhsurgery_pbl@yahoogroups.com together with its website, http://groups.yahoo.com/group/rojoson_mdhsurgery_pbl serve as the repository of resources for learning of MDH Surgery Residents and Interns starting May 21, 2011, the day they were created.  The surgical residents and interns who graduated from MDH can still access the archive as they will not be delisted as long as Dr. Reynaldo Joson is alive and is the moderator.  This is a legacy of Dr. Joson for MDH’s surgical residents and interns.