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DEPARTMENT OF MEDICINE STUDY GUIDELINES

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INTRODUCTION TO MEDICAL PRACTICE (IMP)

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JUNIOR MEDICINE CLERKSHIP

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SENIOR MEDICINE CLERKSHIP

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DEPARTMENT OF MEDICINE OBJECTIVES OF THE INTRODUCTION TO MEDICAL PRACTICE PROGRAMME YEAR 1, SEMESTER 1
1. To introduce the students to the structured format of history-taking and the system used to garner/gather information from the patients so as to understand the medical problems, diagnoses of the patients and thus to offer medical therapeutics, be they pharmaceutical or non-pharmaceutical. To recognise and understand that this standard structured organisation of information obtained from the patient is used and recognised worldwide. To recognise that problems/situations. the format changes to accommodate different clinical

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To be introduced to and to be taught clinical history-taking from the paediatric patient. To be introduced to and to be taught clinical history-taking from the psychiatric patient. To be introduced to and to be taught clinical history-taking from the medical patient.

YEAR 2, SEMESTER 3
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- HISTORY TAKING

To develop the art of taking a clinical history and the art of writing case histories. To gain proficiency in the clinical skills of history-taking. This will be a continuation of Semester 1 in the series of “live contacts” with real patients during which interviews with a patient will be conducted; information retrieved will be summarized and presented using the formal language of the medical profession. The aims will be to diagnose and understand the nature of the problem and the patient‟s perception of the problem. A diagnosis will be made and a treatment plan designed. In addition, the skill of oral presentation of a case which is an essential skill used in communicating clinical problems to other physicians and surgeons will be taught. To practice the various skills utilized in taking an accurate history from a patient. Practice how to develop a partnership between patient and physician. How to develop trust between patient and physician, and thus (a) increase patient satisfaction

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(b) facilitate better patient compliance and (c) facilitate the revelation of sensitive yet important information from the patient.

Communication skills to practice will include: 7. 8. 9. Being empathetic Being attentive to the patient‟s need Being articulate and able to communicate without the use of jargon (being guided by the patient‟s educational state). Being a good non-verbal communicator. Being Friendly. Being interested and enthusiastic

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These will be done regardless of the patient‟s 1. 2. 3. educational level cultural background ethnic background

YEAR 2, SEMESTER 3

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CLINICAL EXAMINATION

To master the techniques of doing a thorough physical examination in a systemic manner, gently and thoroughly with a view to obtaining information that is both complete and relevant to the particular patient. The student should have: 1. 2. 3. 4. Understood and learnt the style and sequence of the physical examination. Understand what is a normal physical examination. Be able to identify abnormalities of the various systems of the physical examination. Be able to summarise relevant aspects of the physical examination which are present or absent. Be able to present a preliminary diagnosis after examining the patient.

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Text Books 1. Hutchinson’s Clinical Methods 21st edition. Edited by Michael Swash Chapter 1, and Chapters 4, 5 (60-68); 6 (84-91); 7 (128-148, 150-151); 11(221-278); 12 (289-299) Pages 10-20 2. Macleod’s Clinical Examination 10th edition. Edited by John F. Munro and Ian W Campbell Chapter 2 Pages 24-64; Chapters: 3 (81-100); 4(125-140); 5 (159-170); 6 (192-240, 174-176); 7 (243-257); 8 (274-276) 3. A Clinical Guide to the cardiovascular examination – Denbow 4. Example of Case Notes (Refer to previous handout – pages 18-21)

Format 1. 2. Didactic lectures of 1 hour given to the entire class. Class will then be divided into two, one set to go to Department of Medicine from 16/1/06 to 20/2/06 (n=6 weeks) and the other to the Department of Surgery then the groups to switch around after six weeks 6/3/06 to 10/4/06 (n= 6 weeks). In the Department of Medicine, the group will be divided further into 6 subgroups (Group A – Group F). Each subgroup will be seen by an instructor (Consultant or Senior Resident) who will instruct in the examination of the system which as timetabled. They will then each have a chance of examining in front of the instructor an aspect of the examination being done at that time.

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Grading None Quality assurance A record of attendance will be kept. Those who are absent will be asked to submit a valid excuse for their absence.

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Note that answers to direct questions about the system principally involved (in this case gastrointestinal) are included under HPC (History Of Presenting Complaint). It should be realized that this is not a list of all the possible questions which could be asked. The number of questions in this example is a reasonable minimum. The object should be to record all abnormal physical signs plus important normal ones. Once again experience will show what is necessary and the details given (for example under ROS) represent this minimum required. 5 . one learns how to question patients closely in order to elicit symptoms which they do not mention spontaneously. The history illustrates the way in which the patient‟s symptoms may be recorded in chronological order so that the pattern of illness can be readily appreciated by others.DEPARTMENT OF MEDICINE HISTORY TAKING AND PHYSICAL EXAMINATION The imaginary case history which follows is meant as a guide for students learning clinical method. With experience. Under ROS (Review of Other Symptoms) answers to some important questions about the symptoms in the other systems are recorded. It would be possible to record under the Physical Examination many more normal facts about the patient than are given here.

was “sticking” in character. tended to come on before meals and would sometimes wake her at night. she felt “dizzy” on getting out of bed. Abdominal pains 5/7 Vomiting blood 1/7 H.P. Presenting Complaints Or C/C : 1. she had a recurrence of the same pain. Eighteen months ago. She could not recall any aggravating factors. Well until 3 years ago when she began to notice occasional epigastric pain. 2. She found that it was relieved by food.Esmerelda COBRINS Age: 54 years Domestic Helper Address: 7 Rise Road. Two days ago. The dizziness was relieved by lying flat in bed. 1990 as an emergency. 6 . usually severe and of gradual onset. the epigastric pain returned.C. but she did not faint. It troubled her for three weeks and then disappeared spontaneously. The pain. did not radiate. milk and “white medicine” which she bought at a pharmacy. After six weeks. during which the pain was experienced daily. she became symptom free. often lasting up to 3 hours. Five days ago. it was more severe than before and occurred 3 to 4 times each day. Kingston 10 Religion: Pentecostal Admitted from Casualty to Ward 7 on January 7. She then noticed that she had passed black tarry stools on two occasions.

She had no other episodes of vomiting and no jaundice. Father: died 35 years ago (age 57) after falling off a ladder.Three hours before admission she suddenly vomited about 2 cups of bright red blood.H. She has never noticed black stools until 2 days ago. age 24. 31 years 1 daughter. No history of - Diabetes Hypertension Sickle Cell Disease 7 . Her bowels were normal in colour with no blood or slime. P. she had no dysphagia and her weight was steady.H. 29. 7 years ago: Operation on right foot for vallux valgus (UHWI) No other operations. : No tuberculosis. well for her age but partially blind from cataracts.H. She felt „sweaty” and faint. Her appetite was normal. Rheumatic Fever. age 26 years The eldest son had a lung operation 2 months ago. Until 5 days ago her health had been generally good. and was brought to hospital by her son. : Mother: age 85 years. No drug allergies. All others are alive and well. Diabetes or Hypertension. : White medicine for epigastric pain (most likely Magnesium trisilicate mixture) No other medications Never takes aspirin or other analgesics F. Siblings: 2 brothers] 1 sister ] All alive and well Children: 3 sons. hospital admission or serious illness D.

ROS or S/E CVS : No dyspnoea on exertion No orthopnoea or proxysmal nocturnal dyspnoea No palpitations or chest pain No ankle swelling RS : No cough or sputum No haemoptysis G. G.C.S.I. No ganja. : See H.H. Second son – unmarried – lives at home. Does not drink alcohol.U. works in a small factory rethreading truck tyres. Smokes 10 cigarettes daily for about 15 years. : Married: Works as a part-time domestic helper Husband – age 57 years. Has never been abroad. stones or haematuria No incontinence No loin pain No polyuria or polydipsia Micturition D/N = 4/0 No urgency or hesitancy Good urinary stream CNS : No headaches. fits or loss of consciousness No numbness or tingling in limbs No tinnitus 8 . : No dysuria.P.

Nails normal but pale. Tongue: normal. several loose and carietic. Temperature 37. hair going gray. : Chest shape normal : no kyposcoliosis Trachea central Expansion normal Tactile vocal fremitus normal Percussion note resonant Vocal resonance : normal Breath sounds vesicular: no crepitations or wheezes.2o C. no added sounds CVS : Pulse 100/minute. Mucus membranes pale: no cyanosis or jaundice. All other pulses palpable JVP is not visible No left parasternal heave or thrills or P2 palpated 9 . No lymphadenopathy. R. regular. No peripheral oedema. symmetrical No radiofemoral delay Dorsalis pedis pulses not palpable. lying flat in bed in no cardiopulmonary distress. small volume. eyesight normal Climbs steps normally and combs hair without difficulty GYNAE : LMP 5 years ago No post-menopausal bleeding No PV discharge O/E : Ill looking. middle aged woman. Skin normal and sweaty.S. thyroid not palpable. papillae preserved. feet cool.No diplopia. Breasts normal. Teeth: poor condition.

so BP not taken in this position Abdomen : Soft. Prostate: normal. supine (phase V) Felt faint on sitting up. black. No rectal shelf felt.Disc: Well defined. Shifting dullness not present.Apex beat in 5th left intercostal space. No masses felt. Liver soft on deep palpitation Spleen not palpable Kidneys not palpable No palpable masses. No haemorrhages No Exudates 10 . Physiological cup normal No A-V nipping No silver wiring or copper wiring. no visible peristalsis. Cranial nerves : 1: Smell normal 11: Fundi . Fluid thrill not present Bowel sounds normal PR: No skin tags. heart sounds 3 & 4 not present. mid-clavicular line Cardiac impulse normal Heart sounds 1 & 2 normal. Anal tone normal. No anal fissures. foul smelling CNS : Alert and oriented in time. Neck supple. smooth mucosa edge just palpable non-tender span 11 cm Stools – tarry. no murmurs or added sounds B/P 100/60 mmHg right arm. place and person Higher mental function normal Speech normal Kernig‟s negative. Colour normal.

size 3mm. react briskly to light direct consensual normal accommodation Eye movements full No diplopia or nystagmus V: Corneal reflexes present.VI: Pupils - equal. Motor : No muscle wasting. X: Gag reflex normal. IV. Palate moves centrally XI: XII: Sternomastoids and trapezius normal Tongue protrudes centrally. no motor and sensory deficits VII: VIII: No facial asymmetry No deafness Air conduction better than bone conduction No lateralisation IX.III. no wasting or fasciculations. bulk normal No fasciculations or abnormal movements Tone normal Power : Reflexes: Grade V in all limbs SJ BJ TJ Abdomen KJ AJ Babinski ++ ++ ++ __ ++ ++ -ve ++ ++ ++ __ ++ ++ -ve 11 .

Haematemesis and melaena with . Hb and blood film 2. No crepitations. PROBLEMS : 1. Smoking tachycardia cold extremities INVESTIGATIONS : 1. pain normal Vibration and position senses normal in feet.hypotension 2. Operation scar on right foot over position of absent distal end of first metatarsal. Blood group and cross match 6 units 6. Urine : No protein No sugar Microscopy not done SUMMARY : 54 year old woman with a 3 year history of epigastric pain and recent onset of melaena and haematemesis. Exclude gastric neoplasm: unlikely in view of duration of symptoms. LFT‟S 5. Platelets 3. U+E‟S 4. Endoscopy when condition stable 12 . Romberg‟s negative Gait normal Coordination normal Musculo-skeletal : Joint full range of movements. DIAGNOSIS : Peptic ulcer disease : Probably duodenal. normal appetite and weight.Sensory : Light touch normal. PT. Smokes cigarettes. PTT.

Complete bed rest. 8/1/90: PROBLEM: GI BLEEDING S: (Symptoms): No further haematemesis or melena No epigastric pain Feels much better Not faint now O: (Observation): Pulse 32/minute BP 115/75 lying 110/80 sitting CVP = + 6 cms Chest : NAD.V. I. 2 hourly observations of blood pressure and pulse. Nil by mouth 5. When acute problems are over. Transfuse with normal saline until whole blood available 3. CVS: NAD Abdomen: NAD Investigations: Initial HB = 7.2 g/dl PT = 12/12 secs Platelets normal on film Has had 3 units of blood A: (Assessment): Bleeding probably stopped No indication for emergency surgery 13 . discuss dangers of smoking and peptic ulcer disease. 6.Management : 1. Inform Surgical team 4. Line with CVP 2.

If confirmed. Repeat Hb. Check Liver function tests.” Pulse 76/minute BP 120/80 supine and sitting Investigations: Chest) CVS) NAD Abd.2 g/dl A. Book BARIUM MEAL and then surgical consultation. O. Bleeding site probably duodenal ulcer.) Hb after 4 units blood = 11. will need to give Ranitidine. „Not bad. Urea and electrolytes Chest x-ray ECG 14 . Mag. Endoscopy. Trisilicate 15 mls 2 hourly Can begin light diet at breakfast time Seen by Consultant 9/1/90: PROBLEM. GI BLEEDING S. if this is not possible : then P. doc. then change to normal saline Drip open. Mist.P: (Plan): 1 more unit blood.

Asymptomatic. Abd. Eating well. Discharge home on Ranitidine 300 mg nocte for 6 weeks To be seen in Gastroenterology Clinic in 1/12. . Stable. Chest.15/1/90: PROBLEM GI BLEEDING S. P. CVS. BP 120/80 supine and erect. 15 . Duodenal ulcer: Confirmed on barium meal. Patient advised to stop smoking.NAD Investigations: Liver function normal A.

JUNIOR MEDICINE CLERKSHIP Department of Medicine Revised 2006 16 .

17 . 6) To learn professional conduct considered to be consistent with the clinical practice of medicine. In addition. At this point in the course. the student would have already been taught professional conduct and history taking and would have had a series of lectures and clinical teachings on physical examination. 3) To perform a full and complete physical examination and to accurately interpret these findings.INTRODUCTION The Junior Medicine Clerkship is a 8-week course during semester III of the medical course. it is expected to build on the students knowledge of internal medicine. AIMS AND OBJECTIVES The aim of this clerkship is to reinforce history taking and physical examination. 5) Competence in coming to an appropriate differential diagnosis and to be able to outline appropriate investigation and treatment. At the end of the 8-week period the following objectives should have been achieved: 1) The ability to take a thorough and complete medical history. 2) The ability to communicate appropriately with patients. their families and members of the healthcare team. It provides an opportunity for an „apprenticeship‟ with the healthcare team. 7) To learn the art of self-training 8) To understand the application of evidence-based Medicine 9) To understand the role of alternative medicine in the life of the patient 10) Prevention of disease to be integrated in teachings. 4) To be able to perform a specified list of practical procedures and to have knowledge of other medical procedures commonly requested or performed in the management of medical patients. This clerkship represents the first time the student is fully assigned to medicine and is used to reinforce the previous teachings and to enhance the students‟ basic clinical knowledge.

the collection and interpretation of results. assist with their day to day management including procedures.25% .5% Failure Failure of the Clerkship.STRUCTURE OF THE CLERKSHIP The 8-week clerkship period is divided into two 4-week periods where students spend 4 weeks at KPH and 4 weeks at the University Hospital of the West Indies. If the Grade is less than D. the student will keep records on the patients. SAQ (2) Clinical examination OSCE (3) Consultant assessment of the ward work (4) One case presentation . the students will have (1) A written examination = MCQ. if the Grade is above D will require remedial work and repeat of the examination. During these rounds students may be asked to present cases they had seen and clerked the day before. For each assigned patient. the clerkship will have to be repeated. Students will attend ward rounds directed by the consultants and residents assigned to the service. Outpatient Service All services have a specialty clinic at least once weekly.40% . Students attend the clinics associated to their assigned service but are encouraged to attend other clinics if time allows. Students will see and evaluate the consultations when they are being assessed by the residents. Assessment At the end of the clerkship. They then return the following day for post call ward rounds which usually occur between 6:30am and 8:30am.30% . During these periods students are assigned to patients admitted to the services and would be expected to be directly responsible for up to 16 patients. During these clinics students are allowed clerk patients in groups and then to discuss the cases with consultants. EMQ. During rounds students will participate in the discussion of management of cases and will be asked to present cases to which they are assigned. students do emergency on-call duty once every 4 days. On Call Duties Students are rostered to take calls with other members of the duty team. or to see patients with consultants and residents. On average. A repeat student cannot get a grade higher than a C 18 . Consult Service Each specialty provides a consultation service to the entire hospital on a daily basis. During these periods the students spend time with the duty team until 10pm.

STUDY GUIDE SENIOR MEDICINE CLERKSHIP Department of Medicine Revised 2006 19 .

You have already done your Junior Medicine Rotation and been exposed to history taking and physical examination of the various systems. (5) Competence to perform various practical procedures. and completed your rotation in Pathology & Microbiology.INTRODUCTION Welcome to your Senior Clerkship in Medicine. (6) Competence to properly investigate and manage a patient. At the end of the Senior Clerkship the following objectives should have been achieved: (1) The ability to take a thorough and complete medical history. you are now more equipped to understand disease processes seen on the medical wards. and report this information in a concise and systematic manner so that the patient‟s problems can be clearly understood. AIMS AND OBJECTIVES The aim of the Senior Medical Clerkship is for the student to develop competent clinical skills and competence in investigating and managing patients. (7) Competence in accessing medical literature. (4) Construction of differential diagnosis. Note that these are to be performed and not observed. (See Practical Procedures List). (9) Knowledge on how to complete a death certificate 20 . This Senior Clerkship can be viewed as (1) your last formal training in medicine before the final examination and (2) the last opportunity to acquire the clinical competence to function as a good intern. Armed with this additional knowledge. In addition you have had formal lectures in Medicine. Two weeks are spent in General medicine at Kingston Public Hospital and the other eight weeks at the University Hospital of the West Indies. (8) List and classify reportable diseases. (3) Perform a competent physical examination of the various organ systems. and offer patient education. and accurately interpret physical signs. The Senior Clerkship in Medicine is done in the fifth year and spans ten weeks. both to retrieve information from the patient. (2) Competence in communication skills.

Currently Wards 4 and 8 admit male patients. & 8.Provides inpatient and outpatient care. Students are encouraged to visit the Haemodialysis Unit to see how renal patients on dialysis are managed.e. There are 7 subspecialty services with acute admissions to Wards 3. GASTROENTEROLOGY & PULMONARY patients are admitted to primarily to Wards 3 and 4. Wards 3and 7 admit female patients. NEPHROLOGY & ENDOCRINE patients are admitted to Wards 3 and 4. Medical Out Patient Clinics are held daily according to the following schedule: 21 . These patients are subsequently managed by the appropriate Specialty Service. GENERAL MEDICINE i. A Consultation Service is offered throughout the hospital. patients with on going multisystem involvement. Haemodialyis Unit. NEUROLOGY & CARDIOLOGY patients are admitted to Wards 7 and 8.STRUCTURE OF THE CLERKSHIP The medical service operates on a subspecialty basis. 4. 7. The peritoneal dialysis service is on Ward 4.

OUT PATIENT CLINICS Monday AM Neurology Hypertension General Medicine Special Neurology –TSP. MG. 22 . They are encouraged to attend other specialty clinics. if they can. Polymyositis etc Diabetes. Parkinsons. Monday PM Tuesday AM Screening Renal Dermatology PM Wednesday AM Endocrine Pulmonary Wednesday PM HIV / CHARES Thursday AM PM Screening Rheumatology GI Friday AM PM Cardiology Dermatology Students are obliged to attend the clinic of the service to which they are assigned.

including the weekly Pulmonary sessions at the National Chest Hospital.DUTIES OF THE STUDENT During the rotation each student is expected to: (a) Report to the Consultant in charge of the unit to which he/she has been assigned. theory and clinical. (i) Attend all departmental seminars and conferences e. In the final MBBS examination the Allenbury Prize is presented for the most outstanding performance in the Medicine Clinicals. (e) Prepare and submit records of one patient clerked and condition researched. (g) Attend all floor wide / balcony teaching sessions. CPC. Grand Round. (b) Function as assistants to the interns and fully participate in the day to day management of the patients. (h) Attend selected out – patient clinics as necessary.g. (c) Clerk and present new admissions to the Consultant on service and the Residents. (d) Be able to discuss continuation of management and progress of existing patients. 23 . (f) Perform emergency duty as assigned on a prepared rota and attend the post admission ward round. There is also an Owen Morgan Prize for the best Mona student in Medicine i.e.

Repeat of CLERKSHIP is MANDATORY. a signed list of Practical Procedures done or observed during the Senior Clerkship is mandatory. An overall final assessment is also given a grade A – E. This assessment will take place throughout the clerkship and will be done by the consultants on each rotation to which the student has been assigned. Additionally a sheet signed by the duty consultants indicating the students presence on call duty and at the post admission ward round is mandatory. Any specific comment on the student‟s performance may be made by the consultant. On this form the student will be graded on: (a) (b) (c) (d) (e) (f) (g) (h) Attendance Factual Knowledge Approach to Clinical Problems Participation in Discussions Performance of Ward Duties Record Keeping Conduct.ASSESSMENT (A) WARD PERFORMANCE – 25% weighting. deportment Examination Each item is graded either: A B C D E - Excellent Good Satisfactory Borderline – remedial action. This will allow the student time for correction of any deficiencies identified. Of note. PRACTICAL PROCEDURES 24 . no repeat. Each student will receive “feed back” on ward performance approximately midway through the clerkship. in the Performance of Ward Duties. Failure to submit the above mentioned documents may result in the need to repeat the clerkship. A student assessment form will be completed by the consultant at the end of each rotation.

supervised by a Consultant or Resident in Medicine. 4. (D) CASE REPORT . Completing a death certificate. Perform an arterial puncture for arterial blood gas and analyze the blood gas results. 10. SENIOR CLERKSHIP TEACHING SCHEDULE. 9.5% Each student will be expected to produce at least one detailed case report on a patient seen during the clerkship. It is administered usually in the tenth week of the clerkship. 11. 8. 12. Perform a lumbar puncture. 1. 13. 5. 25 . extended matching and short answer questions and will be done during the tenth week of the clerkship. Plan and appropriately administer insulin and a heparin infusion. Observe and assist in insertion of central lines and acute peritoneal dialysis catheters. Report on a Chest X-Ray Write up Medication Kardex for patients being managed Observe and assist in thoracocentesis and paracentesis. (C) CLINICAL EXAMINATION – 40% This is in the form of an Objective Structured Clinical Examination – (OSCE).30% This is usually in the form of multiple choice. 7. A review of the examination paper will be carried out before the end of the clerkship. 3. (B) WRITTEN EXAMINATION . Completing a discharge summary for Medical Records. Perform urine microscopy. 6. This report will include research on some aspect of the patient‟s management. Pass a nasogastric tube. Complete a disease notification form from Public Health. Plan and write up a fluid balance chart. 2.The following practical procedures are required to be done during the Senior Clerkship.

These are usually held at 12. Annals of Internal Medicine. This is usually in the form of an interactive tutorial that deals with the presentation of a case. Whittle/M. discussion of management issues and the disease condition. Williams D. Elliott/M. Gilbert R. etc. Barton/T. Maloney Students should report any missed tutorial directly to the Department office so that the Facilitator can be contacted.Hosang E. Hurlock/V. New England Journal Medicine. Macleod‟s Clinical Examination – 10th Edition Hutchinson‟s Clinical Methods – 21st Edition Reference Text: Harrison‟s Principles of Internal Medicine Journals: West Indian Medical Journal. Murphy/A. (Please see topic guidelines). Lee/T.00 noon or at a time specified by the Consultant. DAY Monday Tuesday TIME 12 pm – 1 pm 3 pm – 4 pm 12 pm – 1 pm 2pm – 4 pm Wednesday Thursday Friday 12 pm – 2 pm 2 pm – 3 pm 1:30 pm – 2:30 pm 12 pm – 1 pm TUTORIAL/FACILITATOR National Chest Hospital D. RECOMMENDED READING: A Clinical Guide to the Cardiovascular Examination – Charles E. Clarke M. 26 . Scott/ K.During the Senior Clerkship there are scheduled teaching sessions which you must attend.. Aquart W. Denbow.N. Gayle L. Soyibo/ F. Mills/M.LawrenceWright/M. Postgraduate Doctor. Wright-Pascoe/P. Arthurs/ A. Principles & Practice Of Medicine by Davidson.

GUIDELINES FOR TUTORIALS RENAL Tests of kidney function – Blood tests. Indications for renal biopsy 27 .hour urine collection for creatinine clearance. urine protein. urine protein/ creatinine ratio. spot Na.Ultrasound . Renal nuclear scan Diagnosis & Management of acute renal failure Management of acute glomerulonephritis: Poststreptococcal and lupus nephritis Diagnosis & management of nephrotic syndrome Management of haematuria Diagnosis & management of chronic renal failure Slowing progression to endstage renal failure Management of urinary tract infections Urolithiasis Diet modification in renal failure Hereditary renal diseases Renal neoplasms Renal replacement therapy peritoneal dialysis haemodialysis renal transplantation. 24. urine microscopy Imaging Studies . IVP.

ENDOCRINE Diabetes Mellitus – diagnosis. classification. and prolactinoma Hyponatremia – Diabetes insipidus. Diagnosis & treatment of thyrotoxicosis Diagnosis & treatment of hypothyroidism Hypercalcaemia & hyperparathyroidism Panhypopituitarism Pituitary tumours . and treatment Management of diabetic ketoacidosis Management of diabetic hyperosmolar coma Endocrine causes of hypertension Cushing‟s syndrome Adrenocortical insufficiency.acromegaly. SIADH Genetic abnormalities 28 .

PCP Interstitial lung diseases Principles of Fiberoptic Bronchoscopy Interpretation of chest X-Rays Interpretation of arterial blood gas 29 .PULMONARY Classification of lung diseases . Lung abscess Bronchiectasis Presentation Mantoux testing Latent tuberculosis infection Pulmonary Infections Pulmonary Tuberculosis Causes of haemoptysis Causes of pleural effusion Opportunistic lung infections e. PEFR Obstructive Lung Diseases . classification. & Management Emphysema & chronic bronchitis Diagnosis & management Sarcoidosis. Idiopathic pulmonary fibrosis Collagen vascular diseases & the lung Obstructive Lung Disease - Restrictive Lung Diseases - Occupational Lung Disease Diagnosis & Management of Acute Pulmonary Embolism Lung Cancer Classification Staging Treatment Community acquired pneumonia Nosocomial pneumonia.g.Obstructive vs Restrictive Pulmonary Function Tests – Spirometry.Asthma Diagnosis . FEV 1.

CARDIOLOGY Hypertension - Diagnosis & management Congestive Cardiac Failure - Symptoms & signs Aetiology Diagnosis Management Rheumatic fever Rheumatic heart disease Diagnosis & Management of Valvular Heart Disease Cardiomyopathies Arrhythmias Diagnosis & Management of infective endocarditis Myocarditis Ischaemic Heart Disease Chronic stable angina Acute coronary syndromes Unstable angina Non ST Myocardial infarction Acute MI – diagnosis & management Definition & management Atherosclerosis - Risk factors Management of Hypercholesterolemia Drug Therapy in Cardiac Diseases Cardiac imaging Basic ECG Interpretation Invasive modes vs Non-invasive 30 .

and other viruses Brain abscess Causes & management Diagnosis & management Differential diagnosis Investigation & Management Vitamin B12 deficiency Cervical Spondylosis HAM /TSP (see above) Guillain . haemorrhagic Transient Ischaemic Attacks Dementia Epilepsy Headache definition & management diagnosis & classification classification & treatment definition of migraine other types of headache Diagnosis & management Diagnosis & treatment Benign Intracranial Hypertension Parkinson‟s Disease Multiple Sclerosis Optic Neuritis – Causes Trigeminal Neuralgia HTLV-1 syndromes: TSP.NEUROLOGY Definition & classification of Strokes .ischaemic.Herpes Simplex. embolic. Polymyositis CNS Infections Optic Neuritis Transverse Myelitis Myelopathies Meningitis Encephalitis .Barre Syndrome Sciatica Neurological complications due to Vitamin B 12 deficiency 31 .

Syringomyelia Peripheral Neuropathies - Diagnosis Aetiology Management Neurological Causes of Syncope Proximal Myopathies e.g. Polymyositis Myasthenia Gravis Brain Imaging modalities CT Scan MRI Angiography OTHER COMMON AREAS: Sickle Cell Disease and CNS Collagen Vascular Diseases .neurological effects 32 .neurological effects HIV Infection .

Acute Pancreatitis. Inflammatory bowel disease. Dysphagia. Motility disorders. ERCP 33 . electrolyte. Diverticula disease. Neoplasms of the stomach. Irritable Bowel Syndrome. and nutrient absorption. Gallstones Pancreas: Physiology of pancreatic secretion. Neoplasms of the colon. Malabsorption. Oesophageal varices Stomach: Physiology of gastric secretion. Gastroesophageal reflux disease. Gastric ulcer disease. Helicobacter pylori infection. Small Intestine : Duodenal ulcer disease. Pancreatic neoplasms. Chronic pancreatitis. Gut hormones. Physiology of water. Oesophageal neoplasms.GI TOPICS Oesophagus: Physiology of swallowing. Colon: Lower gastrointestinal bleeding. Inflammatory bowel disease Liver: Physiology of bilirubin metabolism Viral Hepatitis Leptospirosis Cirrhosis and its causes and complications – other causes of cirrhosis: Haemochromatosis Wilson‟s Disease Αlpha Antitrypsin Deficiency Non-Alcoholic Fatty Liver Disease Autoimmune Hepatitis Vaso-Occlusive Disease GI imaging: Endoscopy. Causes of acute and chronic diarrhoea. Biliary Tree: Physiology of biliary secretion. Radiographic imaging. Dyspepsia and upper gastrointestinal bleeding.

Respiratory  Asthma  Lower respiratory tract infection  COPD  Sinusitis  TB  Drug induced e. ACE Endocrine  Hypothyroidism  Diabetes mellitus Anaemia Chronic disease  Collagen vascular (see above)  Chronic infection *This is not meant to be exhaustive Chest pain Cough Fatigue 34 .g. Cardiac  Chronic stable angina  Acute coronary syndrome Respiratory  Lower respiratory tract infection  Pleuritis Musculoskeletal  Costochondritis Cardiac  Congestive cardiac failure.CLINICAL PROBLEMS GUIDELINES* Clinical Problems Anaemia Key Diagnosis Haematological  Sickle cell disease  Leukamia  Lymphoma  Bleeding disorders Renal  Chronic renal failure GI  GI bleed  GI malignancies Chronic disease  Collagen vascular disease  Malignancies.

HIV Inflammatory  Collagen vascular diseases Malignancy Cardiac  Cardiac failure Respiratory  Lung cancer  TB / Bronchiectasis  Lung abscess Haematuria Headache Hypertension Jaundice Joint pain Renal  Glomerulonephritis  Polycystic kidney disease  Renal cell carcinoma  Bladder lesions. UTI  Chronic – TB. Drugs. Secondary  Renal disease  Endocrine Hematological  Sickle cell disease GI  Hepatic failure  Biliary obstruction.Fever Haemoptysis Infections  Acute – pneumonia.  Urolithiasis Vascular  Migraine  Subarachnoid haemorrhage Raised ICP  Tumour  Intracranial haemorrhage  BIH Infection  Meningitis /encephalitis  Brain abscess Tension headache Primary / Essential. Infections  Viral hepatitides Infection Inflammatory 35 .

Cardiovascular Respiratory Haematological Syncope Cardiovascular 36 .Muscle weakness Numbness & tingling Palpitations Paraparesis Polydypsia Pruritus Dyspnoea  Collagen vascular Neurological  Polymyositis  Myopathies  Neuropathies Drugs  Steroids Endocrine  Thryotoxicosis  Diabetes Paraneoplastic Neurological  Peripheral neuropathy Endocrine  Diabetes Cardiovascular  Arrhythmias Drugs Anxiety Endocrine  Thyrotoxicosis  Phaeochromocytoma Infection  HTLV 1  HIV  Tabes dorsalis Nutritional  Vit B 12 deficiency Spinal cord compression Endocrine  Hypercalcaemia Psychogenic. Endocrine  Diabetes mellitus GI  Obstructive jaundice Renal  Chronic renal failure Allergic reaction.

Swollen feet Tremor Wheezing Weight loss Vaso vagal Neurological Cardiovascular Renal Hepatic GI Endocrine Neurological Drugs Respiratory Cardiac Endocrine  Diabetes Infection  TB  HIV Malignancy 37 .

A 45 . Pneumonia G.52 litres (Predicted 3. Presents with worsening dyspnoea. His DLCO was Normal. Pulmonary Embolism B.PRACTICE THEME: DYSPNOEA Extended Matching Questions (EMQ’s) A.year old male with oral candidiasis and a history of weight loss of some fifteen pounds associated with fever and haemoptysis. His CXRay is abnormal.8 litres.year old male. 4. 5. anti RNP positive for about 5 years. Tuberculosis. Asthma E. a previous smoker presents with SOB and wheezing. The predicted was 4. SaO2 on room air was 88%. Each option may be used once. presents with SOB. His actual FVC was 3. A 50 .year old female with SOB known to be ANA positive. 38 . coarse bibasal crackles are heard.0 litres. 3. Pneumothorax I. PCP C.4 litres). For each options above.year old female one week post chemotherapy in hospital presents with a high fever.year old male with a history of amputation a year ago for osteosarcoma. Pulmonary Fibrosis D. COPD F. A 25 . more than once or not at all. Examination shows a deviated trachea. Pleural effusion H. A 15 . cough and respiratory distress. On auscultation. 2. 1. choose the most likely option for the problems below. A 45 . PFT‟s FEV1.0 of 2.

No radiation. pCO2 of 25 mmHg. 4. 3. Localized to a band just below the sternal angle. 39 . Pains are severe on lying flat and worse after a heavy meal. Physical examination unremarkable. A 60 . 5. Significant findings on examination .year old male with a low grade fever. and taking a few drinks with his friends. Costochondritis I.PRACTICE EMQ’S THEME: CHEST PAIN A. Pulmonary embolism G. HCO3 of 22mols/l. A 24 . Herpes Zoster C. A 55 . 12 lead ECG is low voltage with diffuse ST elevation. Oesophagitis F.peripheral cyanosis. complains of chest pains one week after moving to her new house. Fibrocystic disease. A 46 .year old female with a history of chest pain associated with SOB worse when lying flat. 1. CXRay shows a globular heart. other than tenderness along the sternal edge on palpation. Pericarditis E. Angina Pectoris B. Pneumonia D.year old housewife with no history of any chronic illnesses. 2. A 50 .47. PaO2 of 80% on room air.year old diabetic businessman with severe retrosternal chest pain at nights. pH of 7. and “band like” chest pain quite severe and burning in nature. ABG shows a pO2 of 50 mmHg.year old male brought to A&E found collapsed in his office. Aortic dissection H.

All the following may be used to treat atrial fibrillation except: (a) (b) (c) (d) (e) Digoxin Amiodarone Lignocaine Beta blockers Calcium channel blockers. 40 . All the following may be associated with aortic incompetence except: (a) (b) (c) (d) (e) Displaced apex beat Corrigan‟s pulse Opening snap Austin Flint murmur Duroziez‟s sign.PRACTICE MCQ’s All the following are major criteria to diagnose acute Rheumatic fever except: (a) (b) (c) (d) (e) Migratory polyarthritis Sydenham‟s chorea Erythema nodosum Carditis Subcutaneous nodules.

candidates must select one answer only. 1) Prophylaxis against opportunistic infections is advised when the CD4 count falls below: a) b) c) d) e) Answer: d 500 cells / mm3 300 cells / mm3 250 cells / mm3 200 cells / mm3 100 cells / mm3 2) The most useful initial test for SLE is: a) b) c) d) e) anti-ds DNA antibody anti-nuclear antibody anti-cardiolipin antibody C3 and C4 levels anti-extractable nuclear antigen (ENA) antibody Answer: b 3) The most common cause of painless frank haematuria in male patients over 50 years is: a) b) c) d) e) bladder squamous cell carcinoma carcinoma of the prostrate hypernephroma transitional cell carcinoma of the kidney transitional cell bladder carcinoma Answer: e 41 .MULTIPLE CHOICE QUESTIONS In these questions.

An ABG is done and comes back with the following results: pO2 = 48 mmHg. HCO3 = 34 mols/l. pCO2 = 120 mmHg.SHORT ANSWER QUESTIONS A forty year old obese truck driver is admitted to the medical wards. he is noted to be very drowsy and difficult to rouse.31 What is your diagnosis based on this ABG? List three (3) possible causes of this problem? What other complications may you expect in this patient? List 4 investigations you would carry out: 42 . On post admission ward round. He weighs about 140Kg. pH = 7.