School of Medicine

Year 3
Course Guide
2010/11

   NAME: .........................................................................................

Evelyn Rouse
(Years 3 and 5 Curriculum Assistant)
Faculty of Education Office (Medicine)
Imperial College London
Charing Cross Campus
Room 138, The Reynolds Building
St Dunstan’s Road
London W6 8RP

Tel: 020 7594 1616

Fax: 020 7594 9315

https://education.med.imperial.ac.uk
 Year 3
Course Guide 2010-11

Contents

Section Page

1 Getting the most out of your firm 2

2 Learning Outcomes 3

3 History and examination skills 13

4 Clinical skills and procedures 15

5 Communication skills 16

6 Patient Safety 20

7 Learning about patient care: Clinical Experience 21

8 Anaesthetics and critical care-learning outcomes 32

9 My E-portfolio 34

10 Formulary of drugs 37

11 Attainments in Pathology 50

1
 Section 1
GETTING THE MOST OUT OF YOUR
CLINICAL ATTACHMENTS
 During your clinical course you will be attached to firms and working on the wards.
This type of attachment is very different from any learning which you have
experienced in the past. You will be expected to plan much of your own learning,
including finding and seeing patients for yourself and taking histories from and
examining patients.
 Meet fellow students as a group once or twice a week to share experiences,
present cases to each other, look at X-rays and investigation results and learn from
each other.
 The more you do/participate the more you will gain from your clinical experience.
There is no substitute for participation!
 Set yourself objectives for each firm.
 Your firm leaders will also emphasise this: it is vital that you attend “takes”
when your firm is on call (construct a rota for yourselves if necessary). You should
all attend the post-take ward-round with the consultant early the next morning. This
provides a vast amount of experience in acute medicine and surgery
 Some suggestions to think about:

1. Talk to patients about what their experience in hospital has been like and how it
has affected them and their families.

2. Whenever possible go with patients who are having special investigations and ask
if you can watch. This is particularly important with patients you have clerked
yourself.

3. Ask if you can observe the physiotherapist, radiographer, cardiology technician,

dietician or occupational therapist on the ward or in their department when
they are caring for patients allocated to you. Where practicable, offer to help
(e.g. taking blood, doing ECGs). Offer to do a blood pressure or TPR round
with/for the nurses and do the charting. Ask if you can sit in on a nursing
report session.

4. Spend time on the ward after 5 pm when there are less people around and the
house officer might appreciate some help with routine tasks and will have
more time to talk about your patients.

2
 Section 2

YEAR 3 LEARNING OUTCOMES

 
 
  By the end of Year 3, you should be able to…
 
(italics = ability may be best demonstrated in discussions, mock situations or using
peers or professionals as simulated patients)
 
  
HISTORY, EXAMINATION AND PROCEDURES
 
       Take, record, and summarise a patient's medical history - talking to
relatives or other carers where appropriate – including:
 presenting complaint
 history of presenting complaint
 systems review
 dietary history
 past medical history
 family history
 personal and social history
 drug history (including allergies)
 establish ideas, concerns, expectations, and the patient’s own illness
representation.
 assess how their condition affects the life of the patient and their
relatives.

       Make accurate observations of clinical phenomena.

Perform, and recognise and summarise abnormal findings from, a full
physical examination including:
       General physical examination
       Cardiovascular system
       Respiratory system
       Alimentary system and abdomen
       Neurological system
       Locomotor system
Perform a basic mental-state examination, including mini-mental state
 
  Be able to describe, perform, measure and/or record a range of
diagnostic and therapeutic procedures, as listed in the Logbook on e-
portfolio.
 
 Apply the basic principles of communicable disease control and
infection prevention.

3
PATIENT-CENTRED PRACTICE AND COMMUNICATION SKILLS
 
 Communicate clearly, sensitively and effectively:
 with patients, relatives, carers, and colleagues.
 in various roles (e.g. patient advocate, teacher, manager).
 recognising non-verbal communication and incorporating it into your
practice.
 regardless of people’s age, social, cultural or ethnic backgrounds or
their disabilities, including when English is not the first language.
 with people who are angry, upset, vulnerable, or have a mental illness.
 when discussing sensitive issues, such as alcohol consumption,
smoking, sexual health or obesity.
 by spoken, telephone, written and electronic methods, and be aware of
other methods of communication used by patients.
 Record a history and examination.
 Write up and present case presentations.
 Maintain patients’ records concisely, accurately & legibly
 Make effective use of computers and other information systems,
including storing and retrieving information.
 Write a discharge letter.
 Write a clinic letter to a GP.

 Provide explanation, advice, reassurance and support to patients

(and their carers).
 Explain test results
 Explain procedures, including
       Endoscopy
       Chest x-ray
       Contrast enema/meal
       IVU
       CT
       USS abdomen/pelvis
       Echocardiography
       Doppler
       MRI 
       Isotope scan (bone, lung, thyroid)
 Explain treatment regimes.
 Understand the principles of breaking bad news or sharing difficult
news
 
 Place patients’ needs and safety at the centre of the care process.
Adopt the principles of patient-centred care and deal with patients’
healthcare needs in consultation with them and, where appropriate,
their relatives or carers.
 Assess how their condition affects the life of the patient and their
relatives.
 Elicit the patient’s understanding of their condition and treatment
options.
 Elicit and respond to the patient’s concerns.
 Elicit and respond to patient’s expectations of the clinical encounter.
 Determine the extent to which the patient wants to be involved in
decision-making about their care.
 Obtain informed consent, where appropriate.
4
  Formulate a plan for investigation, treatment and management in
partnership with the patient and their carers as appropriate.
 Respect the rights of patients to reach decisions with their doctor about their
care and to refuse or limit treatment.
 Demonstrate awareness of the WHO ICF (International Classification of
Functioning, Disability and Health) model.
 Describe the standardised assessments of cognition, capacity and function.
 Demonstrate an understanding of the impact of impairments, activity
limitations and participation restrictions on the individual.
 Analyse the impact on carers of someone with impairments, activity
limitations and participation restrictions.

 DIAGNOSIS

 Synthesise a full assessment of the patient's problems, appreciating the

importance of clinical, psychological, social, religious, and cultural factors.
 Interpret findings from the history, physical and basic mental state
examination, and investigations.
 For any one patient, outline a list of differential diagnoses, particularly
focussing on common and important disorders.
 Appreciate the processes by which a differential diagnosis is made.
 

FORMULATING PLAN OF INVESTIGATION

 
  Appreciate the fundamental principles underlying investigative techniques.
 Formulate and justify a plan of investigation for common clinical cases.
 Have a basic understanding of cost/resource implications of investigations.
 
 
MANAGEMENT
 
 Make clinical judgements and decisions, based on the available evidence;
this may include situations of uncertainty.
 Apply strategies to reduce the effects of heuristics and cognitive
biases on clinical decision making.
 Formulate a treatment plan for common diseases according to scientific
principles, and be able to recognise their modes of action and their risks.
 Identify ways of preventing common diseases.
 Recognise how to support patients in caring for themselves and promote
self management programs.
 Recognise the principles underlying the care of patients and their families
at the end of life.
 

SAFE AND EFFECTIVE PRESCRIBING

5
 
 Establish an accurate drug history, covering both prescribed and other
therapies.
 Plan appropriate drug therapy for common indications, including pain and
distress, and recognise the potential for side effects.
 Provide a safe and legal prescription.
 Provide patients with appropriate information about their medicines.
 Appreciate that, and explain why, many patients use complementary and
alternative therapies.
 

ASSESSMENT AND MANAGEMENT OF EMERGENCIES

 
 Recognise the severity of a clinical presentation and the need for immediate
emergency care.
 Diagnose acute medical emergencies.
 Provide basic first aid.
 Provide immediate life support.
 Provide cardio-pulmonary resuscitation, working with other team members.
 
  
WORKING WITH THE MULTI-DISCIPLINARY TEAM AND OTHER
PROFESSIONALS; ADMISSION, DISCHARGE AND PLACE OF TREATMENT
 
 Appreciate the framework in which medicine is practised in the UK, including
the organisation and management of healthcare provision.
 Work with colleagues, including those in other professions, in ways that best
serve the interests of patients.
 Demonstrate an understanding and respect for other professionals and
the contribution that effective interdisciplinary team-working makes to
the delivery of safe and high-quality care.
 Communicate effectively with other professionals, including passing on
information, with the aim of improving the patient pathway.
 Formulate a plan for discharge.

6
APPLYING SCIENTIFIC METHOD, RESEARCH APPROACHES, EVIDENCE-BASED
MEDICINE AND STATISTICS.
 
 Appreciate the importance of evidence-based practice when deciding upon a
treatment plan.
 For the most common disorders, cite a major piece of evidence and/or
national guideline (e.g. NICE) that supports a treatment plan.
 Apply findings from the literature to answer questions raised by clinical
problems. 

ASSESSING PSYCHOLOGICAL FACTORS; PSYCHOLOGICAL AND

PSYCHOSOCIAL MANAGEMENT AND CHANGING BEHAVIOUR
 
 Identify psychological factors that may be contributing towards a patient’s
illness, the course of the disease, treatment adherence, and/or the success
of treatment.
 Appreciate the ways a patient may adapt to major life changes (inc. illness
and bereavement) and relevant illness-related, personal, physical and social
environmental factors and appraisals contributing to successful or
dysfunctional coping.
 Recognise that patients may present with physical symptoms, but whose
underlying causes are psychological rather than physical, such as in
psychosomatic disorders.
 Assess patient preferences for coping with treatment and adapt preparation
accordingly and utilise basic psychological strategies to reduce pain and
distress during medical procedures.

SOCIOLOGICAL PRINCIPLES, PROCESSES AND FACTORS; THE DISTRIBUTION

AND DETERMINANTS OF DISEASE
 
 Identify sociological and social factors that may be contributing towards a
patient’s illness, the course of the disease and/or the success of treatment −
including issues relating to:
 health inequalities
 the links between occupation and the environment and health
 the effects of poverty and affluence.
 Discuss the role of nutrition in health and take a nutritional assessment.

7
DISEASE PREVENTION, HEALTH PROMOTION, PATIENT SAFETY and CLINICAL
GOVERNANCE
 
 Discuss the basic principles of health improvement and disease
surveillance, using examples from your clinical experience.
 Discuss the principles and application of primary, secondary and tertiary
prevention of disease, using examples from your clinical experience.
 Discuss and apply the basic principles and methods of communicable
disease and infection control in hospital and community settings.
 Apply the principles of quality assurance, clinical governance and risk
management to medical practice. Promote, monitor and maintain health and
safety in the clinical setting:
 Discuss how errors can happen in practice
 Appreciate concepts in error theories
 Recognise own personal and professional limits and seek help from
colleagues and supervisors when necessary.
 Recognise conditions and situations that predispose to error and to take
measures to control them.
 Outline responsibilities and processes for raising concerns about safety
and quality, and apply where necessary.
 
 
APPLY TO MEDICAL PRACTICE BIOMEDICAL SCIENTIFIC PRINCIPLES, METHOD
AND KNOWLEDGE
 
 Apply knowledge of normal human structure and function to medical practice.
 Explain the scientific bases and causes for common disease presentations.
  

ETHICS, LAW and the GMC

 
 Adopt the clinical responsibilities and role of the doctor, including the
legal and ethical responsibilities involved in protecting and promoting
the health of individual patients, their dependants and the public −
including vulnerable groups.*
 Outline and adopt the GMC’s ethical guidance and standards including
Good Medical Practice.
 Demonstrate knowledge of laws relevant to medical practice, including
the ability to complete relevant certificates and legal documents and
liaise with the coroner or procurator fiscal where appropriate.
 Recognise the rights and the equal value of all people and how
opportunities for some people may be restricted by others’ perceptions.
 Identify the signs that suggest vulnerable people may be suffering from
abuse or neglect and know what action to take to safeguard their welfare.
 Keep to the requirements of confidentiality and data protection legislation
and codes of practice in all dealings with information.
 Assess a patient’s capacity to make a particular decision in accordance
with legal and GMC guidance.
8
  Accept the importance of appropriate consent.
 
 Be polite, considerate, trustworthy and honest, act with integrity,
respect patients’ dignity and privacy.
 Respect all patients, colleagues and others regardless of their age, colour,
culture, disability, ethnic or national origin, gender, lifestyle, marital or
parental status, race, religion or beliefs, sex, sexual orientation, or social or
economic status.

CONTINUING PROFESSIONAL DEVELOPMENT

 Establish the foundations for lifelong learning, including a professional

development portfolio containing reflections and achievements.
 Continually and systematically reflect on practice and, whenever necessary,
translate that reflection into action.
 Respond constructively to the outcomes of appraisals and assessments
 Manage time, prioritise tasks, and work autonomously when necessary and
appropriate.

9
 Some of the above outcomes relate to specific presentations. Below are some
common/important presentations with a guide to:
  which system they most commonly relate to (‘X’)
  which attachment you are more likely to see them in (Surgery, Medicine)
 
General CVS Resp GI Endo Haem Renal / Neurology Musc Emergencies
Urology
Weight loss X X
Fever X X X X
Night sweats X X X
Tiredness / fatigue X X X X
Lumps / nodes in neck/groin X X
Pallor X X
Rashes X
Cellulitis X
Alcohol abuse X X X X X X X
Collapse / Loss of consciousness X X X X
Chest pain X X X X
Shortness of breath (acute/chronic) X X X X
Palpitations X X
Oedema X X X
Claudication X X
Cardiac Arrest X X
Stroke X X X
Haemorrhage/shock X X
Cough X
Haemoptysis X
Wheeze X
Respiratory failure X X
Abdominal pain (acute/chronic) X X
Nausea & vomiting X X
Haematemesis X X
Diarrhoea X
Constipation X
GI obstruction X X
Melaena/ pr bleed X
Weight gain X
Polyuria / polydipsia X
Goitre X
Easy bruising/bleeding X X
Loin pain X X
Haematuria X
Uraemia X
Urinary retention X X
Urinary frequency X
Incontinence X
Scrotal swelling X
Headache (acute/chronic) X X
Seizures X X
Focal motor/sensory disturbance X X
Cognitive deficit (delirium/ chronic) X X
Joint pain X
Joint swelling X
Backache X
Anaphylaxis X
Severe sepsis X
Poisoning X
Trauma X
Burns X
 

10
 Some of the above outcomes relate to specific disorders/conditions.
Below are some common/important disorders, grouped according to system.
Many can present as acute emergencies.

CVS Respiratory GI Endocrine

MI Asthma Peptic ulcer disease Diabetes mellitus (inc.
Angina COPD (inc. perforation) complications eg.
Heart failure Pneumonias Gastro-oesophageal ketoacidosis, non-
(acute/chronic) reflux Hiatus hernia ketotic hyperosmolar
Tuberculosis
Inflammatory bowel coma)
Arrhythmias (inc atrial Bronchial
fibrillation, heart block) disease Metabolic syndrome
carcinoma
Valve disease Inguinal / femoral Hypo /
Pneumothorax
hernias hyperthyroidism
/ endocarditis Fibrosing lung
Hepatitis Osteoporosis
Hypertension disease
(acute/chronic) Osteomalacia
Aortic aneurysm Bronchiectasis
Cirrhosis / portal Diabetes insipidus
Stroke
hypertension Hypopituitarism /
Lower limb vascular
Cholecystitis / pituitary tumours
disease
gallstones Acromegaly
Deep vein thrombosis
Appendicitis Cushing’s syndrome
Pulmonary embolism
Peritonitis Adrenal insufficiency
Varicose veins
Pancreatitis Hyperparathyroidism
Cardiac arrest
GI Infections Hypo /
Arterial Occlusion
Haemorrhoids hypercalcaemia
Anal fissures / Hypo /
fistulas hypernatraemia
Diverticular disease
GI Carcinoma
Liver failure

Renal / Urology Rheumatology* Haematology* Neurology*

Renal failure Osteoarthritis Anaemia Migraine
(acute/chronic) Rheumatoid Leukaemia (acute/ Stroke – ischaemic /
Glomerulonephritis arthritis chronic) haemorrhagic
UTI Systemic lupus Lymphoma Transient ischaemic
Renal / ureteric Sarcoid Myeloma episodes
stones Polymyalgia Clotting disorder Meningitis
Prostatic hypertrophy rheumatica Sickle cell disease Peripheral neuropathy
Carcinoma (prostate, Acute arthropathy Malaria Subarachnoid
kidney, bladder) haemorrhage
Congenital Parkinson’s disease
abnormalities of renal Epilepsy
tract Dementia
Head injury
Multiple Sclerosis
Myasthenia Gravis
Motor Neuron
Disease
Brain tumours

* These systems will also be specifically encountered in specialist attachments and

courses later in the curriculum.

11
Anaesthetics

 Apply your understanding of basic physiology to the cardiovascular, respiratory

and metabolic events, normal and abnormal, occurring during anaesthesia
 List the common medical conditions likely to increase perioperative risk and the
principles of their management
 Recognise critical events perioperatively
 Identify the critically ill patient, in particular sepsis and the systemic inflammatory
response syndrome following major surgery
 Describe the principles of management of critically ill patients, with particular
emphasis on oxygen therapy and fluid balance
 Outline approaches to the management of acute pain, particularly post-operatively,
and of chronic pain, emphasising the multidisciplinary nature of the pain team

12
 Section 3

HISTORY AND EXAMINATION SKILLS

A good history is the most powerful investigative tool we have in getting to
understand the patient’s clinical problem. It is a skill which is difficult to acquire
and you can only become good at it if you take every opportunity to practise
history-taking again, again and again.

In taking a history you should:

1. Introduce yourself to the patient and obtain his/her agreement to undertake a

clinical assessment. The great majority will be happy to speak to you but some will
not and you have to accept that. Try to establish a good rapport and listen
sympathetically to the patient.

2. The next and crucial stage of history-taking is a detailed and careful questioning of
the patient. Establish the patient’s main complaint or complaints (i.e. the
presenting complaint) – in the patient’s own words.

3. Obtain a clear picture of all the important symptoms (the history of the presenting
complaint); in particular clarify the chronology and characteristics of each major
symptom (this is often best done by having a list of questions ready). Try to avoid
medical terms and do not accept ‘diagnostic terms’ from the patient. Instead, get a
detailed description of the actual symptoms – in the patient’s own words. Try not to
lead the patient, but allow them to communicate their problem in their own way.

4. Having elucidated the clinical problem, go on to the rest of the history:

 systems review - you should have a set of standard questions to ask about
every system but you have to use your judgment about leaving some out if
appropriate;
 past medical history
 family history – parents, siblings, other close relatives, children
 personal and social history - including accommodation, work, with whom they
are living (tactfully!), smoking and drinking habits (likewise)
 drug history, including any allergies – and also including non-prescribed drugs
such as food supplements and herbal preparations, and recreational drugs
other than alcohol and nicotine.
See the Communication Skills section for a more detailed description.

5. At the end of this process you should have a good idea what the problem is and
you should summarise the history, before going on to the clinical examination of
the patient (which is dealt with further on in your log book).

6. The final stage of the history and examination is to construct a differential

diagnosis. This is a list of possible pathologies which could explain the features
13
 shown by the patient. Try to do this when you write your notes, putting the most
likely causes first. You may form a reasonably clear picture of the problem quite
early in this process and this will increasingly influence the rest of what you say
and do as you gain experience.

The main aim of Year 3 is to develop and practise the basic clinical skills of
history-taking and examination in medicine and surgery.

Attaining Competence

It is suggested that you work with a colleague to provide mutual feedback on your
development of clinical competencies. When you feel that you have attained
competence in a particular skill, ask a member of your firm, (a consultant, registrar or
SHO) a senior nurse or GP, to observe you performing this skill, and if they are satisfied
with the standard of your performance. Your firm leaders will want to see you do this as
part of their assessment of your overall clinical competence.

14
 Section 4
CLINICAL SKILLS AND PROCEDURES

Clinical skills and procedures may be taught in GP practices, the Clinical Skills
Laboratory or on the ward. Your level of confidence and skill will increase only through
practice with patients or in the lab.

Whilst on all your introductory firms you need to acquire some basic skills; some you will
witness, others perform. Because it is important that you obtain regular practice, you
should record each time you practice or witness a procedure within E-portfolio. We do
not feel that being signed off is particularly helpful for either students or teachers but
remember that if you do not do or see these procedures only you will lose out.

Levels Criteria for Clinical Skills

You will find a list of skills which should be described or performed during your Year 3
clinical course within E portfolio.

The minimum skills level you should attain is shown and the levels have the following
meaning:

Level 1 – Student can describe

Level 2 – Student can perform on a model

Level 3 – Student can perform (on patient) with supervision

Level 4 – Student can perform without supervision, or can explain or interpret

Depending on the learning opportunities available students may have the chance to
outperform the minimum levels.

15
 Section 5
COMMUNICATION SKILLS
You will have many opportunities to develop your communication skills. As well as
being able to practice and reflect on how you take a history (gather information) you will
also be able to observe and practice both the sharing of information with patients and
written communication.

To help you in the development of the appropriate skills we have included the lists of the
skills associated with effective gathering and sharing of information with patients which
you will be familiar with from Years 1 and 2.

When practising these skills remember that it is not the practice in itself that is useful but
the opportunity to reflect on what you did and to receive feedback. It is the three-tiered
approach of practice, reflection and feedback that enables identification of areas of both
strength and those that need further work.

Skills associated with patient-centred interviews

Stage 1: Commencing the interview
A Preparation
 Attend to self-comfort
 Minimise distraction
 Focus attention on next consultation
B Start to establish a relationship
 Greet the patient
 Introduce yourself (full name)
 Clarify your role in health care team
 Clarify patient’s name
 Attend to patient’s comfort
 State purpose of interview
 Mention note taking
 Clarify time available
 Assess patient’s ability to communicate
 Demonstrate interest and respect

Stage 2: Gathering information

 Use open questions initially

 Allow patient to complete initial sentence
 Ask patient if s/he has any questions
 Demonstrate Active listening
 Verbal
 non-verbal
 Facilitative responses
 Pick up verbal and non-verbal cues
16
 Wait time
 Survey for problems
 Set agenda
 Clarify patient's use of terms
 Avoid unexplained jargon
 Summarise
 Use signposting/transition statements
 Use silence appropriately
 Use open-to-closed ended cone
 Avoid leading questions
 Avoid multiple questions
 Probes sensitively
 Show warmth
 Make empathic statements
 Identify patient's feelings
 Acknowledge feeling

Stage 3: Closing the interview

 Provide an end summary
 Discuss action plan
 Carry out a final check
 further information
 questions
 worries and concerns
 Thank patient and say goodbye

Content (PC = Presenting Complaint)

Students should be able to obtain information on the following:

1 Patient's major concerns
2 Patients' understanding of the cause of the presenting complaint
3 The effect of the PC on the patient's life
4 History of the PC
5 Previous episodes of the PC
6 Patient's knowledge of treatment to date
7 Patient's knowledge of investigations to date
8 Past medical history
 previous illnesses
 at least 5 from list for screening
 previous hospitalisations/operations
 medication (PC)
 medication (other)
 allergies
9 Family history
 Parents’ health
 siblings’ health
17
  other family members (e.g. children/partner)
10 Social History
 age
 who lives in household
 work (nature and satisfaction)
 housing
11 Lifestyle
 smoking
 alcohol
 recreational drugs
 diet
 exercise
 sleep
12 Function enquiry (systems to be covered)
 General
 Cardio-respiratory
 Gut
 Genito-urinary
 Neurological
 Musculo-skeletal
 Thyroid

Skills associated with giving information

 Explain purpose of interview
 Check what patient already knows
 Determine amount of information patient wants
 Use short words and phrases
 Avoid use of jargon
 Use explicit categorisation
 Summarise
 Use specific advice statements
 Check understanding
 Clarify if patient has any questions
 Clarify if patient has any concerns
 Use active listening techniques

Remember that patients recall best what they are told first and last.

18
Information a patient may wish to know about any given procedure
 When the procedure will take place
 Where
 What preparation is necessary
 How long it will last
 How painful it will be
 Who else will be present
 What are possible side/after effects
 When the result will be available
 Who will give the result
 Offer to inform relatives

There is no single correct approach. Requirement is for flexibility, sensitivity to individual

needs and ability to take the initiative to empathise and communicate with the individual.
Good practice is rooted in values, primarily the value of the person – adult or child and
respect for both the individual and their family or close friends/carer.

19
 Section 6

PATIENT SAFETY IN THE 3rd YEAR CURRICULUM

Background

In order to enhance patient safety a number of strategies and interventions are

necessary but it is critical that learning about patient safety and human error should start
at an early stage in order to inculcate a culture of safety amongst tomorrow’s doctors.
This program represents the formal integration of Patient Safety into the undergraduate
curriculum and builds on similar efforts already undertaken within Imperial.

The learning objectives of this teaching programme are:

 To gain an understanding of human error.
 To appreciate concepts in error theories.
 To acknowledge that all of us have limitations of knowledge and skill and might
need to seek help sometimes.
 To be able to recognize conditions and situations that predispose to error and to
take measures to control them.

Teaching format

There will be one lecture given to all third year students that will cover all the learning
objectives described above. This will be supplemented by two e-learning modules that
highlight errors that have occurred in real practice and use these to illustrate key
concepts in patient safety theory. All third year students will be expected to access and
complete these two modules.

Assessment

Patient safety principles will be integrated into two OSCE stations during the third year
OSCEs and students will be assessed for observed behaviours that reflect safe practice.

20
 Section 7
Learning about Patient Care
CLINICAL EXPERIENCE

Introduction 21

Where you will learn 22

Learning Outcomes 22

Learning Methods 23

Inter-professional Learning 24

Checklists
 Clinical Presentations 25

 Syndromes and diseases 28

Anaesthetics, Critical Care and Emergencies are covered in Section 8

Introduction
At qualification all doctors, whatever their eventual career path, should have a common
core of clinical knowledge and experience. As you move through this year you will
proceed from learning basic clinical examination and history taking skills to more
complex clinical investigation and management. By the end of the year you will be well
on your way towards acquiring the general clinical knowledge and experience necessary
to satisfy the medical school and the GMC. In Year 5 you will build on this clinical basis
to study some subjects in more depth for example neurology and rheumatology.
Remember though that this is a life-long process and, as a very eminent physician once
said: “You never know enough”!
This section is a companion to your logbook of clinical skills and should be used in a
similar way.

21
Where you will learn

As you know from this course guide the year includes 4 clinical attachments; one of 3
weeks (completed during Year 2) and the next three of 10 weeks each. It is intended
that the first two attachments will be at the same site and that you spend at least one-
third of the year at one of central sites (Charing Cross, Chelsea and Westminster or St
Mary’s).
During the year you will be expected to see emergencies on the ward and in the
A and E department and being on emergency take with your firm is a vital part of
clinical experience. You will also gain other clinical experience on the wards, in
outpatients and in the last 3 attachments in general practice, where you will spend half a
day a week for 18 weeks with a general practitioner whose teaching will focus on clinical
skills. As you move through the firms you should therefore have the opportunity to meet
patients with the common symptoms, syndromes and diseases and you should try to
meet patients with less common conditions on the list. Your experience will be paralleled
by the Systems and Topics e-Lecture course which will be delivered predominantly as
online learning via Blackboard and via up to 10 live lectures during the clinical
attachments, and of course you must supplement this with private study using, books,
journals and the Internet. PBL will very largely be based on actual patients rather than
paper scenarios.
Clinical teaching takes place at a large number of hospital sites and it follows that your
experience will differ at each location. Teaching will be organised differently to fit in with
the clinical service needs of each hospital and with the local availability of particular
expertise. The learning objectives however are the same everywhere and the learning
programmes will be based on that principle. At or before the beginning of each of your
10-week attachments you will be given a detailed scheme of the learning opportunities
for the whole of your stay which will almost always include teaching outside your own
firm.

Learning outcomes

Clinical examination
 By the end of the year you should know how to examine the normal cardiovascular
system, respiratory system etc and be able to recognise common abnormalities of
each system.

Interviewing patients
 You should be able to take a history relevant to the symptoms, syndromes and
diseases on the list

Clinical Knowledge
 By the end of Year 3 you should know the common causes of the list of general
and specific symptoms.
 You should be able to describe and understand the basic features (presentation,
pathophysiology and aspects of pathology), investigations and the principles of
clinical management for the common syndromes.

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Clinical experience

You will see a rather formidable list of clinical presentations and even more of
syndromes and conditions. Some of these are relatively uncommon and you may see
only one or two examples during the year, or even none. But we believe that it is
important for you to be aware of the basic facts about even these disorders-we have not
included anything really rare or “small print”. Equally, if you are on take and someone
with a truly unusual syndrome comes in, do not feel that you should overlook it just
because it is not on the list. All clinical experience is valuable.
It is also essential to remember at all times, as no doubt you have in the first two years,
that:

1. All meetings and interactions with patients are dependent on their consent.
Whatever the setting this cannot be taken for granted.
2. Within the limits of what you can and should do you should always take
opportunities to be actively helpful in the care of patients, not only as observers.
3. In several of the situations listed here you will appreciate that the patient can take
the role of teacher.

Learning methods

As already mentioned, these will comprise:

 Lectures
 Intranet / Blackboard material
 Tutorials
 Ward rounds
 Bedside teaching
 PBL (mainly patient based)
 Textbooks
 Internet sites
 Journals

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Interprofessional learning

As a doctor you will be part of a team looking after patients. It is therefore important for
you to know how other members of the team approach their patients and what skills
they bring which will complement your own.
Most of your time is spent learning from doctors, but during your attachments in Year 3,
to help you with understanding the approach of other team members you will be having
some sessions with students of other health care professions.
The form that these sessions will take will vary according to the resources of the
particular trust: you may be learning alongside other students or from other
professionals or both, most often in the context of a Multidisciplinary Team.
You will be learning about them but just as importantly they will be learning about your
approach as doctors and the impression that you make on them may affect their future
attitudes towards doctors.
In the OSCE you will be assessed on

1. Promoting effective and appropriate communication between health

professionals with the aim of improving the patient pathway.

2. Demonstrating an understanding and respect for the role of others by

participating in interprofessional working practices.

3. Demonstrating sound clinical judgement across a range of differing

professional and care delivery contexts.

Please note that there is an opportunity to detail case studies, where you have observed
multi-disciplinary teamworking, in the Portfolio of Clinical Experience.

Questions to consider:
1. When taking a history, what questions do other professionals ask that might be
useful to you?
2. How do they approach their patient? Is the patient relaxed?
How do patients react to their approach of other professionals?
3. How is the information that they gather useful to you?
4. How is it shared with you and others?
5. Do you understand the notes made by other professionals?
6. When would you normally meet other professionals to discuss a patient?

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Clinical presentations

For convenience these are listed under systems headings. As you already realise this
may not necessarily fit into predictable categories: for instance, chest pain sometimes
has gastro-oesophageal origins. Medical and surgical diagnoses are not separated. It is
expected that at the end of the year students will have knowledge of the common
differential diagnoses for these symptoms and presentations and a basic scheme of
investigation.
Since the 3rd and 4th attachments occupy an almost unbroken period of 20 weeks it
might be helpful to have some landmarks, bearing in mind that half of you will be doing
your medical attachment first and half the surgical. In this section therefore we have
marked each presentation or condition as M which is medical or S as surgical. In some
circumstances this is rather artificial, but the main purpose is to help you in pacing your
learning. You will see that medical conditions predominate and this does reflect clinical
practice on an everyday basis. Therefore we suggest:
 That you familiarise yourself with all items marked S during your surgical
attachment, whether you do that first or second.
That the items marked M will mainly form part of your medical attachment but that
you can take opportunities for learning about them during the surgical firm if it does
not interfere with your main learning objectives during that period

General
Weight loss–also endocrine M
Fever M
Night sweats M
Tiredness - also endocrine, haematology etc M
Lumps in neck and groin – also haematology S
Rashes – as markers of systemic disease M
Cellulitis M
Alcohol abuse (may be gastrointestinal, neurological, psychiatric) M
Collapse +/- loss of consciousness
(may be cardiovascular, neurological) M

Cardiovascular
Chest pain M
Shortness of breath (acute and chronic) – also respiratory M
Palpitations M
Oedema-also GI, renal M
Claudication – also neurological S
Stroke –also neurological M

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Respiratory all M
As above
Cough
Haemoptysis
Wheeze

Gastrointestinal all S
Acute abdominal pain
Chronic abdominal pain
Nausea and vomiting – also infections, cardiovascular, neurology, etc.
Haematemesis
Diarrhoea
Constipation
Melaena and rectal bleeding

Endocrine all M
Weight loss
Weight gain
Polyuria and polydipsia
Goitre

Haematology all M
Lymph node enlargement
Pallor
Fatigue
Easy bruising/bleeding

Renal/urology
Loin pain S
Haematuria S
Oedema M

Uraemia M
Urinary retention S

Urinary frequency S
Incontinence S
Scrotal swelling S

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Neurology (Year 5 attachment but important general medical presentations)

As under cardiovascular, also: all M

Acute headache, including meningism
Chronic recurrent headache
Collapse
Seizures
Focal weakness
Focal sensory disturbance
Cognitive deficit/decline
Acute confusion/delirium

Rheumatology
(also a Year 5 attachment but important general medical presentations)
Joint pain all M
Joint swelling
Backache

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Clinical situations, syndromes and diseases

Our intention is that you will become acquainted with main presentations, and the
principles of investigation and management of these conditions. You should make every
effort to gain first-hand clinical experience of as many as possible. For some rare
conditions this may be difficult or impossible but form the majority it should be possible
during one of the four attachments in the year, even if, as already mentioned, students
have to go outside their own firm. Again, the subdivision is largely by systems, but
remember the note in the previous section.

Cardiovascular all M unless indicated

Myocardial infarction
Other acute coronary syndromes
Stable angina
Acute heart failure
Chronic heart failure
Atrial fibrillation (see also emergencies)
Valve disease including endocarditis
Hypertension
Aortic aneurysm
Cerebrovascular accident (stroke)
Lower limb vascular disease S
Deep vein thrombosis
Pulmonary embolism
Varicose veins S

Respiratory all M
Asthma
Chronic obstructive pulmonary disease
Pneumonias
Tuberculosis
Carcinoma of the bronchus
Pneumothorax
Fibrosing lung disease (especially occupational)
Bronchiectasis

Gastrointestinal
Peptic ulcer disease (see also emergencies, acute abdomen) M

Gastro-oesophageal reflux and hiatus hernia M

Inflammatory bowel disease M
Inguinal and femoral hernias S
Hepatitis (acute and chronic) M
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 Cirrhosis and portal hypertension M
Cholecystitis and gall stones S
Appendicitis S
Peritonitis S
Pancreatitis M
Diarrhoea due to infection or infestation M
Haemorrhoids S
Anal fissures and fistulas S
Diverticular disease S
Carcinoma of the large bowel S
Carcinoma of the pancreas S
Carcinoma of the stomach S
Carcinoma of the oesophagus S

Endocrine and metabolic all M

Diabetes mellitus
“Metabolic syndrome”
Hypothyroidism
Hyperthyroidism
Osteoporosis
Osteomalacia
Diabetes insipidus
Hypopituitarism and pituitary tumours
Acromegaly
Cushing’s syndrome
Adrenal insufficiency
Hypercalcaemia (including hyperparathyroidism)
Hypocalcaemia

Haematology all M
Anaemias (iron/folate/B12 deficiencies)

Leukaemias (acute/chronic) these will be covered in detail

Lymphomas in the Year 5 Pathology Course
Myeloma but may present in general medicine

Clotting disorders (genetic/acquired)

Sickle cell disease

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Renal/urology M/S respectively
Acute renal failure (see also emergencies)
Chronic renal failure and its complications
Glomerulonephritis
Use of dialysis (haemo- and peritoneal)
Urinary tract infections
Renal/ureteric stones

Prostatic hypertrophy
Carcinoma of the prostate
Carcinoma of the kidney
Carcinoma of the bladder
Congenital abnormalities of renal tract

Neurology (predominantly Year 5, but may present in general medical setting)

Migraine all M
Transient ischaemic episodes
Meningitis
Peripheral neuropathy
Paraparesis / Paraplegia
Subarachnoid haemorrhage
Parkinson’s disease
Epilepsy
Dementias

Rheumatology (predominantly Year 5, comment as for neurology)

Recognition of osteoarthritis and rheumatoid arthritis all M
Recognition of multisystem diseases (systemic lupus, sarcoid)
Polymyalgia rheumatica
Acute arthropathy

Oncology mixed M and S unless indicated

Malignancies already mentioned under specific systems
Concepts of screening
Carcinoma of the breast (and non-malignant breast lumps) S
Principles of radiotherapy and chemotherapy
Palliative care including pain management

Medicine for the elderly all M

Although most of the conditions affecting the elderly have already been listed (with the
very important exception of dementia), students need to be aware of the principles of:
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 Differential epidemiology of disease
Variation in disease presentation in the elderly
Modifications in management in the elderly

Clinical Pharmacology and Therapeutics all M

Most of the formal teaching of therapeutics takes place in the final year but the following
are part of learning for Year 3:
Principles of pharmacokinetics and drug metabolism
Types of adverse drug reaction
Adverse drug interactions
Special considerations in prescribing for the elderly, children and in pregnancy and
lactation (these are particularly relevant for Year 5)
Principles of new drug development
Students should also be aware of the main types of drugs used in the above conditions
and their main uses and problems but detailed descriptions of management will not be
expected at this point, except for the emergencies listed in the next section.

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 Section 8
ANAESTHETICS AND CRITICAL CARE
Learning objectives
 Understanding the application of basic physiology to the cardiovascular, respiratory
and metabolic events, normal and abnormal, occurring during anaesthesia
 List the common medical conditions likely to increase perioperative risk and the
principles of their management
 Recognise critical events perioperatively
 Identify the critically ill patient, in particular sepsis and the systemic inflammatory
response syndrome following major surgery
 Describe principles of management of critically ill patients, with particular emphasis on
oxygen therapy and fluid balance
 Outline approaches to the management of acute pain, particularly post-operatively, and
of chronic pain, emphasising the multidisciplinary nature of the pain team

Emergencies all M unless indicated

This includes most of the important medical and surgical emergencies. If at all possible
students should see these on the wards and particularly in A and E departments. It may
not be possible to obtain first-hand experience for all of these but awareness of how to
recognise them is essential as is knowledge of the principles of management. all M
unless indicated
Cardiac arrest
Anaphylaxis
Severe sepsis
Meningitis
Hypovolaemic shock secondary to haemorrhage
Acute arrhythmias (supraventricular and ventricular)
Complete heart block
Acute left ventricular failure
Malignant hypertension
Acute arterial occlusion

Status asthmaticus
Tension pneumothorax
Respiratory failure
Haematemesis
Variceal haemorrhage
Perforated ulcer S
Acute obstruction S
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Acute liver failure/encephalopathy

Hypoglycaemia
Diabetic ketoacidosis
Non-ketotic hyperosmolar coma
Lactic acidosis
Acute adrenal insufficiency
Severe hypercalcaemia (esp. in malignancies)
Hypo- and hypernatraemia

Poisoning salicylates, paracetamol, opiates, tricyclics, methanol,

lithium, digoxin
Head injury
Chest and abdominal trauma
Severe burns

Status epilepticus
Acute paraparesis/paraplegia
Acute renal failure

Malaria

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 Section 9

My E-portfolio

E-portfolio is a:

 PLACE to keep all your information in one place

 PROCESS that facilitates your learning and development

This takes effort. E-portfolio is YOURS to: Record, Reflect, Share and Feedback

Record
– Keep evidence of your skills, activities,
events
– Track your progress
– Celebrate your achievements
– Use your records as a basis for
applications (e.g. for jobs)
Reflect
– experience > evaluate > learn >
apply = improve
– How well are you doing it?
– What and how can you improve?
– How can you develop further?

Share Feedback
– Submit work for feedback – To/from your peers
• To tutors (inc. formal assessments) – From your tutors
• To peers

– Participate
• Learn from others’ experience
• Showcase yourself

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E-portfolio was piloted last year and is now being expanded across Years 1, 2 and 3. It aims to
eventually cover all six years of the curriculum.
What does E-portfolio look like in Year 3?

Year 3 E-portfolio Activities 2010 - 2011

Se De
Oct Nov Jan Feb Mar Apr May Jun
    p c
● FORM                    
DE/GE – Clinical
1 Worksheet (Part 1)
DE/GE – Clinical
2 Worksheet (Part 2)
Y3 - Expanded Case
3                    
study
Y3 - Clinical
4                    
Communication
● PROFILER                    
5 Y3 – Patient Clerking                    
6 Clinical Skills Logbook                    
Professional Skills
7                    
Logbook
8 Exams Reflection                    
● THOUGHTS                    
For recording
Significant Event
9 Analyses (SEA),
experiences and
reflections                  
● FOR UPLOADING                    
Y3 – End of Attachment
Assessment forms
Y3 - Oral Presentation
  Feedback form                    

The Expanded Case Study is a summative assessment to be sent to your allocated Firm Lead
via the e-portfolio gateway before 25th February 2011. (If your Firm Lead cannot access
PebblePad due to technical reasons, the assessment needs to be printed and handed to your
Firm Lead. Please check whether your Firm Lead can access e-portfolio before you submit your
work.) Your Firm Lead will then gateway you a feedback form which you need to print off and
hand in to your TCO. DE/GE students also complete the Clinical Worksheets to be printed off
and shared with Firm Leads before 15th October 2010.

The other activities are primarily for your own learning, but you are expected to complete
them and they can be used as evidence of course participation. You may also wish to share
some of them with your Firm Lead (e.g. by emailing or printing the activity), but please discuss
this with your Firm Lead first.

Some activities are specific to Year 3 (e.g. Expanded Case Study, Clinical Communication and
Patient Clerking). Others are for you to record your own experiences and skills throughout your
medical school career (e.g. Clinical Skills Logbook, Professional Skills Logbook, Exams
Reflections and ‘Thoughts’). This helps you track your progress and learn by reflecting on your
experiences.

35
PLEASE NOTE: You must NOT break patient confidentiality. Remember to ANONYMISE all
your work in reference to patients – only include age and gender, and NOT the patient’s name,
date of birth or hospital number.

For further information on e-portfolio, please see the Year 3 QuickStart guide (paper/intranet), or
the online How-To guide via: http://tinyurl.com/2wq39r3 Additional information can also be
found on: www.imperial.ac.uk/medicine/elearning/eportfolio.

36
 Section 10
FORMULARY OF DRUGS
Please use the following table as a basis for a personal list of drugs and look up all the
new drugs you come across in the BNF and standard recommended books. Comments
may include patient response, possible side-effects, potential interactions with other
drugs.
Comments
Pharmacological
class
Indication
Drug

37
 Pharmacological
Drug Indication Comments
class

38
 Pharmacological
Drug Indication Comments
class

39
 Pharmacological
Drug Indication Comments
class

40
 Pharmacological
Drug Indication Comments
class

41
 Pharmacological
Drug Indication Comments
class

42
 Pharmacological
Drug Indication Comments
class

43
 Pharmacological
Drug Indication Comments
class

44
 Pharmacological
Drug Indication Comments
class

45
 Pharmacological
Drug Indication Comments
class

46
 Pharmacological
Drug Indication Comments
class

47
 Pharmacological
Drug Indication Comments
class

48
 Pharmacological
Drug Indication Comments
class

49
 Section 11
ATTAINMENTS IN PATHOLOGY
During clinical attachments in Years 3 and 5, you should undertake the following tasks
in pathology practice. The list is not exhaustive, merely representative of the pathology
skills and knowledge applicable to the practice of medicine.
You may be examined in some aspects of these as part of general medicine, pathology,
or in an OSCE or PACES, since pathology is key to the study of medicine. These skills
are all part of everyday medical and surgical practice and should therefore form part of
following through a patient in hospital.
The following may be examined in YEAR 3 are marked with an asterisk in the right hand
margin. *

As you make these observations, or gain these skills, you might wish to tick them off on
this list.

Cellular Pathology
1 Observe a cervical smear sample being taken and be able to discuss the
possible results.
2 Observe a frozen section from an operation being cut and reported by the
attendant pathologist
3 Attend a multi-disciplinary team meeting (any of the specialities) at which a
pathologist is present.
4 During your surgical attachment follow a surgically-excised specimen from
formalin-fixation to diagnosis in the pathology department.
5 Observe a fine needle aspiration of any site, for example lymph node, breast or
thyroid and be able to discuss the advantages and disadvantages of this
procedure.

Some of these will be done in outpatients.

Chemical Pathology/Clinical Chemistry

1 Observe, follow-up and interpret blood gas results from a patient from ITU *
2 Observe, follow-up and interpret a low serum sodium from a *
post-operative patient
3 Meet a patient with type II diabetes and discuss with the patient the *
possible complications of this disease
4 Look at an abnormal liver function test from a patient and attempt to *
interpret the results
5 Look at the case notes of a patient with high serum calcium and note the *
symptoms caused by high calcium levels
6 Observe and interpret urine dipstick testing for pH, glucose, ketones, *
bilirubin, blood and protein.

50
Haematology
1 Observe how a patient is identified and a blood sample is taken for blood *
grouping/cross-matching
2 Observe how patient identity and details of blood for transfusion are *
checked and how a blood transfusion is monitored
3 Meet a patient with sickle cell disease and be able to describe the clinical *
features of a painful crisis
4 Attend an anticoagulant clinic and observe how therapy is monitored and *
doses are adjusted
5 Observe a patient receiving either prophylactic or therapeutic heparin and *
be able to explain how the dose is decided and whether or not therapy requires
monitoring

Immunology
1 Know how to send a blood sample for cryoglobulins to the laboratory
2 Know how patients with systemic lupus erythematosus are monitored
3 Know how self-injectable adrenaline is administered
4 Meet a patient with an autoimmune disease or transplant and discuss the
immunosuppressive drugs they take and the requirement for monitoring for drug
toxicity

Microbiology
1 Observe how blood culture is taken aseptically after thorough disinfection of skin
2 Observe how a sample of cerebrospinal fluid is taken aseptically after thorough
disinfection of skin
3 Observe how a "Dipstick" is used to test a sample of urine and how the *
result is interpreted
4 Know how to instruct a patient to collect a mid-stream specimen of urine *
5 Observe how to collect wound swabs from deeply-infected sites, without skin
contamination

51