Professional Documents
Culture Documents
Appendix:
Detailed Curricula:
I. Post-Exposure Prophylaxis
II. Procedures Following Exposure
III. Dermatology
IV. HIV
V. Pulmonology
VI. Nephrology
VII. Oncology
VIII. Metabolic Medicine Module
IX. Endocrinology
X. Neurology
XI. Cardiac Medicine Module
XII. Sample Case History
It is hoped that your relatively short time in final year Internal Medicine will be a useful
learning experience. Many COVID-19 restrictions have now been lifted and there has been
a return to face to face teaching and clinical activities. It is of course important that we
remain vigilant and continue to monitor COVID-19 infections to ensure that our teaching
environment remains safe and accessible.
Port of Spain General Hospital is the hub for Year 5 medical students. All students must
spend at least 4 weeks at POSGH unless there are untoward circumstances making this
impossible. Under such circumstances students must discuss their situation directly with
the course coordinator BEFORE the start of the clerkship.
This is a busy clerkship and the volume of work can at times be overwhelming. Do not
hesitate to seek advice should you be unsure about any aspect of patient management or if
you have any personal problems that may preclude a good performance in this clerkship.
WE ARE INTERESTED IN YOU and we want YOU TO BE the best doctor that you can
be.
There are several associate lecturers in the various hospitals and their names are included in
the abbreviated curriculum for year 4 and year 5.
CONTACTS
Year 5
Secretary: Ms. Heather-Joy Stephen
Office (POSGH) direct line 623 4030FAX 627-5184
Year 4
Secretary: Ms. Janelle Timothy
Office (EWMSC) Phone/Fax 663 4332 or 645 2640 ext 2926
EMAIL: Adult Medicine Unit, EWMSC
1. Take an accurate history from an adult client in accordance with the guidelines
provided in the course material
2. Perform competent examinations of all organ systems in the adult
3. Integrate a multi-disciplinary approach to patient care
4. Analyse the medical, social and psychological needs of patients
5. Device efficient and thorough medical documentation in keeping with evidence
based medicine
6. Chooses to integrate patients’ rights and the basic tenets of medical jurisprudence in
their practise as a medical professional
7. Utilises a team based approach for the management of patients
8. Performs common medical procedures with supervision and minimal complications.
At the end of the FINAL CLERKSHIP the student should have the proficiency
level of an intern.
We consider that it is your privilege to see our patients and our honor to have you
on our unit. This final year is an apprenticeship year, use it wisely.
At least one student to each ward (male/female) for each medical unit.
Daily rounds with the unit doctors.
You are to be punctual in reporting to your respective ward at the start of each day
and remain available from 8:00am to 4:00pm.
The unit must be covered from 8:00am to 4:00pm on weekdays, and on post call
days (including weekends and public holidays)
Units run best when they operate as a team
At the start of each day you should ascertain from the nurse in charge of the ward
whether there are any patients on outlying wards.
On call:
o Students to remain with the on call unit until 8:00pm.
o You are expected to clerk patients per on call
o Where possible, you should choose patients with differing conditions
o On the post call ward round (including weekends and public holidays)
where you are on call or posstcall, you are expected to remain with your unit
until completion of jobs.
Absence from the clerkship: you are expected to call the consultant, registrar, co-
ordinator and the clerkship secretary well in advance if you are unable to turn up to
work on any one day. You must then provide an explanation in writing stating the
days taken off on the first day of your return to work and leave this in the academic
office. Failure to follow this guideline may result a clerkship grade of “F” or other
similar penalty.
2. Clinical responsibilities:
Clerking of Admissions: You are expected to clerk patients on call in accordance
with your training and as shown in the case history books: ALL SYSTEMS MUST
BE EXAMINED FOR EACH ADMISSION (General condition, skin, chest, CVS,
ABDO, CNS).
Students must submit 10 case histories (5 from each hospital) which are assessed by
a Lecturer, Consultant, Registrar or a DM resident in Medicine Department or
Medicine units. One of the case histories must be presented to a designated full-
time lecturer, which will be weighted high (25% of all case histories) than the
remaining.
Post call ward rounds supersede teaching sessions.
5. Communication skills
In the final year you are expected to have a reasonable ability to communicate
with patients and staff. Your skills in this area will continue to develop after
graduation therefore you should not expect too much of yourself.
Communication with patients and family : if you are in doubt it is best to leave
this to doctors BUT you MUST observe how this is done.
o You should never attempt to break bad news for the first time to patients
or family unless a registered medical practitioner approves this AND is
present during the interview.
o You must explain to patients any test you are going to do e.g. a blood
test
o You are expected to retrieve test results from the laboratory or radiology
departments but this must always be done in a professional manner
o You must be able to communicate with the various categories of nursing
staff and ward assistants always being careful to explain what you are
doing.
o The NURSE-IN-CHARGE is the senior nurse managing the ward. You
must always report to her and your supervising junior or senior doctor
when you first arrive on the ward during the day. You should always
seek the nurse’s advice before seeing patients you do not know.
o Always examine patients, especially female patients in the presence of a
nurse or student colleague who will be a witness to your professional
approach and who will constructively critique what you have done in an
appropriate manner.
Kindly note that communication here refers to this in all its forms and includes
written and oral communication between doctors.
Your prime responsibility is to our patients to whom you are expected to display
concern, empathy, to whom you have a duty of care and for whom you are
expected always to do your very best.
You are expected to maintain cordial and mutually respectful relationships with
all ward and laboratory staff.
The dress code is:
Female medical staff – white coats at all times, arms to be bare below
the elbow, no slippers, no exposed midriffs, no jeans, no jewelry on
hands or wrists with the exception of wedding rings/ bands.
Male medical staff – shirt jac, no T-shirts or polo shirts, no tie, no jeans,
no slippers, no jewelry on hands or wrists with the exception of wedding
rings/ bands.
Video/audio recording or photographing the teaching sessions without
permission is forbidden.
May be modified by the Department or Adult Medical Unit at any time but
generally will include the following. [The weighting of each component may vary
from time to time as determined at short notice by the Department, though where
possible adequate notice will be given.]
o You may be assessed on any of the items mentioned in this booklet and the
accompanying rubric-based booklet
o An end of clerkship written exam and OSCE will be done
The written exam consists of 40 MCQ’s and will contribute 40% of
your total grade
The OSCE will include manned examination stations and unmanned
clinical scenario stations. It will contribute 40% of your total grade.
o During the second half, all students must show adequate attendance in their ward
work including call and postcall and teaching sessions to successfully complete the
clerkship. An attendance record is created by the Group leader for each class and all
students are to sign and have this co-signed by the senior doctor/tutor. Failure to
achieve 75% attendance will result in the clerkship having to be repeated; the
examinations cannot be taken if 75% is not achieved.
o All students must pass both end of clerkship OSCE, WRITTEN and overall
assessment to successfully complete the Adult Medicine course in Year 5.
o If a student fail in the overall clerkship assessment or both the OSCE and written,
the student will need to approach the Deputy Dean’s office to repeat the whole
clerkship for eight weeks.
o If a student fail in OSCE or WRITTEN alone and scored 50% or more in the overall
assessment, then the student will be allowed to re-sit the failed component. THIS
RE-SIT MUST BE DONE WIH THE NEXT GROUP.
a) If the repeat OSCE/WRITTEN score is 50% or more, then the overall
clerkship mark will be considered as 50%. The student will receive a Grade
C and 2.0 GPA quality points.
b) Whereas if the repeat OSCE score is less than 50%, the student will be
required to approach the Deputy Dean’s office to repeat the whole clerkship
for eight weeks.
Grading system. The grading system for Adult Medicine clerkship is as follows:
CARDIOVASCULAR CARDIOVASCULAR
(Dr. R. Ali/ Dr. N. Seecharan) (Dr. R. Ali/ Dr. N. Seecharan)
1. Coronary artery disease including ACS Increased knowledge of therapeutics
2. Hypertension Increased knowledge of therapeutics
3. Valvular Heart Disease Cardiac Failure
4. Cath Lab orientation
RESPIRATORY RESPIRATORY
(Dr. S Sakhamuri) (Dr. S. Sakhamuri)
Asthma, COPD & Bronchiectasis Tuberculosis & other Infectious Lung Diseases
Pleural Diseases Pulmonary Vascular Diseases
Spirometry & other Pulmonary Function tests Interstitial Lung Diseases
Pneumonias Lung Cancer
Respiratory Failure
ARDS & Mechanical Ventilation
Chest X-ray, Chest CT and ABG interpretation
ENDOCRINOLOGY ENDOCRINOLOGY
(Prof. Teelucksingh) (Prof. S. Teelucksingh/ Dr. C. Lalla)
DM/hypoglycaemia Increased knowledge of management
Metabolic syndrome Increased knowledge of management
Thyroid disease Increased knowledge of management
Hypercalaemia, hypocalaemia
Hyponatraemia
NEUROLOGY NEUROLOGY
(Dr. S. Sandy/Dr Ramlackhansingh ) (Dr. Sandy/Dr Ramlackhansingh)
1. Stroke/TIA 1. Headache
2. Meningitis 2. Parkinson’s Disease
3. Cerebral Abscess 3. Upper Motor Neuron Diseases
4. Lumbar Puncture 4. Lower Motor Neuron Diseases
5. Patients with Dizziness
6. Subarachnoid Haemorrhage
FUNDUSCOPY FUNDUSCOPY
(Optometry School) (Dr. S. Sandy/ Optholmology Clinic)
1. Hypertensive Retinopathy Increased knowledge of management
2. Diabetic Retinopathy
3. Papilledema
4. Optic atrophy
DERMATOLOGY DERMATOLOGY
( Dr. N. Hallai) ( Dr. A. Cumberbatch)
Please see Dermatology Curriculum Please see Dermatology Curriculum
GASTROINTESTINAL GASTROINTESTINAL
(Dr. M. Rahman)
1. GI Bleed Increased knowledge of management
2. IBD Increased knowledge of management
3. Liver disease/liver failure Increased knowledge of management
4. Pancreatic Diseases Increased knowledge of management
RENAL RENAL
(Dr. B. Mohammed/ (Dr. E. Mohammed)
Dr. L. Roberts)
1. Acute Renal Failure Nephrotic Syndrome
2. Chronic renal failure Nephritic Syndrome
3. HIV nephropathy Acute Gomerular Nephritis
Anuria & ESRD
RHEUMATOLOGY RHEUMATOLOGY
(Dr. H. Dyaanand - SFGH) ( Dr. David King - St. James Medical Complex)
1. RA 1. RA
2. SLE 2. SLE
3. Gout 3. Gout
4. OA 4. OA
5. MCTD 5. MCTD
6. Spondarthritides 6. Spondarthritides
HAEMATOLOGY
(Dr. Charles)
1. Nutritional Anaemia
2. Blood film
3. Thalassaemia
4. Sickle Cell Disease
5. Iron Deficiency Anaemia
6. Anticoagulation
1. Gastrointestinal bleeding
4. Status epilepticus
5. Shock
8. Hypoglycemia
14. Coma
MATERIALS
Safety needles 22G (grey)
Syringe
Appropriate blood collection tubes
Laboratory forms
Tourniquet (rubber gloves may be used)
Alcohol swab
Dry swab
Tray (to hold all materials)
PROCEDURE
Collect all materials
Label forms and blood tubes at nurses station from patient’s file for ONE patient
at a time, just before going to the bedside of that patient
At bedside:
Ask patient to identify his/ her name and date of birth and cross check information
written on forms and blood tubes
*If patient incapable of confirming information, consult nurse or relative (if by
bedside)
Explain procedure and its indication to patient
Venipuncture:
Select an appropriate vein
Apply tourniquet
*Ensure no running IV fluids on this hand
Palpate selected vein (to ensure it’s not sclerosed)
Clean area in a circular motion- starting centre going outwards
Allow skin to dry
Perform venipuncture
Remove tourniquet
On withdrawal of needle apply pressure to puncture site with dry swab
THANK PATIENT
Remove all materials from bedside
Place sharps in sharps bin
1. CXR
2. CT of Chest
3. CT of Head
5. CT – Abdomen
7. Doppler studies
8. Assessment as part of the End of Clerkship OSCE in which x-rays shown will be
given to the students with a short case history.
The goal is the complete and seamless integration of pathology results and
pathophysiological parameters into the management of the medical patient.
Objectives of Pathology Module during the year 5 clerkship in Internal Medicine. At the
completion of this clerkship the student should:
5. Submit case histories illustrating all of the above using one clinical case that
the student has managed. This may involve a patient who has been discharged
or one where a post-mortem was done.
1. Case Histories: results of lab tests on call and action taken on call including ECGs
and radiology
COURSE DESCRIPTION/RATIONALE:
Pathology is a clinical discipline and the infusion of pathology into the year 4 clinical
clerkships is aimed at helping the student to understand how abnormal structure and
function of organs contribute to the pathogenesis and manifestations of disease.
Additionally, the students are exposed to the functioning of the clinical laboratories, which
allows them to appreciate the role of the laboratories in assisting with clinical diagnosis.
LEARNING OUTCOMES:
On completion of this clerkship the student should be able to:
Anatomical Pathology
Chemical Pathology:
Haematology:
Microbiology
Describe the guidelines for proper collection, transport, storage and submission of
clinical specimens to the laboratory
Discuss current antimicrobial drugs, the empiric and specific applications of
antibiotics, mode of action and the basis of selective prescribing
Select and interpret microbiological and serological tests according to the
differential diagnosis
List and describe the current available diagnostic tests for the different infectious
diseases
Discuss the effective use of the various microbiology laboratory services in the
diagnosis and management of patients with infectious disease.
Course Content:
Anatomical Pathology
Core clinical problems
Anaemia
Chest infections
Diagnostic procedures
Haematemesis (UGIB)
Haematochezia (LGIB)
Lump in neck and thyroid swellings
Shock
Stroke
Sudden death
Urinary symptoms
Pathological Disorders
Atherosclerosis and its complication
Cirrhosis of the liver and its complications
Congestive cardiac failure
Diabetes Mellitus
Essential hypertension
Fatty liver
Myocardial infarction
Pneumonia
Pulmonary thrombo-embolism and deep vein thrombosis
Pyelonephritis
Rheumatic heart disease
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 18
Sickle cell anemia
Spread of cancer
Sudden death
Surgical Pathology
Colonic polyps
Colorectal carcinoma
Gastric carcinoma
Inflammatory bowel disease
Lower GI haemorrhage
Lung carcinoma
Peptic ulcer disease
Prostate carcinoma
Renal carcinoma
Thyroid disease including nodular goiter and carcinoma
Upper GI haemorrhage
Chemical Pathology
Microbiology
Bacteriology
Virology
Parasitology/Mycology
Immunology
During the 8-week clerkship students are exposed to the pathology of conditions, practical
application of clinical chemistry and chemical pathology. The common metabolic disorders
are discussed and the biochemical findings of current or interesting cases are presented on
ward rounds and didactic teachings. Students are exposed to haematology and are actively
involved in filling out request forms, performing venipuncture and participate in ward
rounds with a haematologist. The students have the opportunity to do histories and elicit
signs to arrive at differential diagnoses and suggestions for investigation and management
of the patient.
Students are also exposed to microbiology in the clinical clerkships when they
encounter infectious disease in patients.
ASSESSMENT:
The assessment will be part of the end of clerkship assessment and will be tested using
Multiple Choice Questions Single Best. There will be a blueprint with pathology and the
allied disciplines of chemical pathology, anatomical pathology, pharmacology,
haematology and microbiology accounting for 30% of the total questions
The cases that you clerk when on call are to be presented on the post call ward round OR in
clinic where possible. You are required to do at least 10 histories one of which must be
marked by a University Lecturer. The latter will account for 25% of your history marks.
Histories can only be presented to persons involved in the patient’s care. Only consultants,
registrars and part 2 DM students will be allowed to correct your history. You are required
to present five histories in your first half of the rotation and a further 5 in the second half.
You will receive a grade: A, B+, B, C, F. The criteria for keeping an acceptable medical
record are as follows;
4. History: PC, HPC, PMH, PSH, DH, allergy history, FH, SH (please include
activities of daily living for elderly patients; smoking history. Alcohol use) and
where appropriate, occupational history
7. Plan
The Minimum Criteria for achieving a grade of C in a case history is validity of both
criteria below:
(c) You do not necessarily have to get the right diagnosis as it is understood
that the student is here to learn
Higher grades than ‘C’ necessarily require greater degrees of appropriate differential
diagnosis and details of management with demonstration of appropriate responses to
results of investigation.
RESPIRATORY
O Arterial Blood Gas
O Thoracocentesis
O Spirometry
O Chest tube insertion
O Bronchoscopy
CARDIOLOGY
O ECG: set and interpretation
O Stress Test
O Echocardiogram
O Radionuclide cardiac evaluation
O Cardiac catheterization / angiography
O Pacemaker insertion
GASTROENTEROLOGY
O Upper GI endoscopy
O Lower GI endoscopy
O Use of proctoscope
O Barium enema
O Barium meal / swallow
O Liver Biopsy
NEUROLOGY
O EMG
O EEG
O VEP
O CT scan
O Lumbar puncture
NEPHROLOGY
O Ultrasound kidneys
O IVA / retrograde pyelography
O Kidney biopsy
HAEMATOLOGY
O Use of blood counting machines
O Bone marrow aspiration and trephine
O Hemoglobin electrophoresis
Plan – your follow up plan for the patient including any post procedure precautions
Plan –
1. Bandage to wound
2. Blood sample to ABG machine in ice immediately.
Signature
Name
Designation
Signature
Name
Designation
At the end of your two years in the clinical school, you should be able to communicate with
medical and paramedical colleagues in writing in any of the following ways. You should be
able to
5. Write up a prescription.
The body of a prescription is the same regardless of the field or specialty of medicine the
prescription comes from. Pharmacists require certain information be included on a
prescription and a prescription is not legally allowed to be altered by any person, even a
physician after it is written. If a doctor makes a mistake, he is required to re-write the
prescription from a new page.
Some of the information contained on a prescription pad must be put in place by the pad
manufacturer, such as:
The name, address, and phone number of the practitioner (for private practice)
Lines for the patient name, age, address and the current date
Line for refill amount
Line for the physicians signature
The letters Rx (not always included)
Prescription:
RX Doxycycline 100 mg
Disp #14
Sig: Take 1 capsule bid x 7 days
OBJECTIVES:
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 28
Understand the importance of properly written prescriptions
Understand the correct format for writing prescription medications
Understand proper procedures for writing controlled substance prescriptions
Understand methods for avoiding prescription writing errors.
Omissions:
a) DAW (Dispense as written)
b) Refill quantity
c) Dosage form
d) Length of therapy/quantity
e) Patient allergies
f) Date
g) Route
h) Signature
Dose or Directions:
a) Dose significantly different from normal standards
b) Error in dose
c) Prescriptions for unavailable dosage forms/strengths
d) Misleading, incomplete or confusing directions
e) Take as directed
f) PRN directions or refills
g) Unclear dose based on a concentration
h) Sustained release dosage forms
Legal Requirements:
a) Omissions of patient's address
b) Prescriptions refills for drugs such as codeine, morphine, methadone etc.
c) Partial fillings of drugs such as codeine, morphine, methadone etc.
d) Generic prescribing for unavailable or inappropriate prescriptions
Quantity:
a) Unclear amount
b) Odd amount
c) Prescription for an amount that doesn't exist
COVID – 19 Regulations
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 30
As of January 2022 we remain in the Coivd – 19 pandemic. Medical training has clearly
been disrupted by this pandemic but at the St. Augustine Campus of UWI we have been
granted certain privileges to ensure clinical medical training continues. It is important that
we continue to observe the guideline set out by the MOH to enable continued clinical
training.
Below are the relevant guidelines as set out by MOH. As the pandemic evolves the
guidance will also changed and any updates will be passed on to you as they become
available.
• Clinical students who have opted to engage in clinical training will sign a revised consent form at the start
of
Þ The revised consent forms will be completed and signed by the student and submitted to the Office
of the Dean.
Þ Students who choose not to engage in clinical training will sign the revised deferral of participation in
clinical training/rotations form and will defer with no academic or financial penalty (Appendix 2).
Þ Students who return to clinical work may thereafter choose to discontinue clinical training and make
• All students must complete and pass the Faculty Infection Prevention and Control (IPC) course before being
• Until restrictions have been lifted, students will not be assigned to Accident & Emergency Departments or
Operating Theatres, and students will not be allowed to witness or partake in any aerosolizing procedures.
2. CLINICAL WORK
• Couse/clerkship coordinators in Medicine, Dentistry, Optometry, Nursing and Pharmacy should provide to
the
Administrative Assistant the listing of students to be assigned to each hospital at least 2 days prior to the
start of the rotation. This data will be entered into the FMS Clinical Student database to monitor student
• Faculty will ensure that students follow the Ministry of Health-approved COVID-19 guidelines when
engaged
• Students will also adhere to the COVID-19 guidelines of the specific Regional Health Authority and
hospital to
• Students will submit appropriate documentation to cover absence from clinical teaching because of COVID-
19
quarantine or infection. If course/clerkship attendance requirements are not met, there may be a delay in
• Faculty will ensure that students follow the Ministry of Health-approved guidelines for written and clinical
• Students who are unable to present for summative examinations because of exposure to or symptoms of
COVID-19 will qualify for deferral of examination and sit the exam without penalty at the next available
sitting. A formal written request for deferral must be submitted to the Office of the Dean by the student.
Þ If the next available sitting will result in delay of academic progression, where feasible, approval will
be sought from the Board of Undergraduate Studies for student assessment without academic delay.
4. STUDENT MONITORING
• Students should engage in self-monitoring. If a student develops respiratory symptoms or signs suggestive
of
COVID-19 infection, (s)he will immediately inform the course/clerkship coordinator and follow the national
• Appendix 6 demonstrates the detailed procedure for faculty and students to follow, in the event of exposure
to/development of COVID-19. This is a most recent draft, currently under revision* and awaiting final
• Students will complete the online SARS-Co-V-2 Syndromic Surveillance and Contact tracing form daily.
This
will allow the Faculty to monitor trends and develop interventions that may be required for optimal safety.
• Course /clerkship coordinators will ensure that all COVID-19 guidelines are posted on myeLearning for
easy
access by students and will conduct mid-rotation feedback sessions with students to identify and resolve any
1. During face-to-face sessions, a maximum of TWO students will attend at any ward round at any one
time but a maximum of FOUR may be assigned to any one unit.
2. Proper hand washing techniques will be observed.
3. At any time, students will be 2 metres apart from each other and the lecturer, except on ward
rounds.
4. Students are to wear surgical masks, face shield (optional at their own expense) and gloves when
examining the patient.
5. The student’s examination of the patient would be limited to five minutes.
6. All patients (simulated or real) to whom students are exposed will be asymptomatic (with respect to
COVID-19) and not a known contact of any COVID-19 patient.
7. Students will be expected to self-monitor for symptoms and report any symptoms to the course
coordinator and adhere to national protocols published by the MOH should such symptoms arise.
8. Exposure of students to aerosol-generating procedures will be avoided.
9. In the case of the MBBS students, their time on the wards will be limited from 0800 hrs to 1600 hrs
during the period when they will be assigned to the ward.
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 32
10. Teaching will not be undertaken in high-risk hospital environments e.g. Emergency Departments
and
wards with COVID-19 patients.
11. Students will limit interactions with members of RHA staff and maintain social distancing and PPE at
all times except during patient encounters.
12. Students will be expected to keep a log of patient interactions to facilitate contact tracing if
needed.
13. The respective RHA will be expected to receive advance notification by at least 48 hrs of the dates
of
assignment of students to wards / RHA facility through written notification to the relevant RHA Head
of Department and copied to the respective RHA CEO from the UWI programme director (i.e. HOD or
School Director or Head of the Optometry Programme).
Programmes offering teaching across most RHAs – These are the MBBS, Nursing and Pharmacy
programmes.
All students will follow the Public Health Institution requirements of the respective RHA at the time of
entry
to the institution
Programmes offering teaching only at the NCRHA – These are the Optometry, Veterinary and Dentistry
programmes. The students in these programmes will follow the general guidelines with some
modifications.
The RHA will not have to be informed of students’ assignments as they occur within environments
completely
under UWI supervision and some modifications to the general procedures above will occur because of
mandates from the local relevant professional body.
Students are referred to their Schools for full details of the proposal for each programme.
1. All candidates and invigilators will complete the COVID-19 screening tool available at
https://www.apple.com/covid19/ on the morning of the exam. The result must indicate that
they “do not need to get tested for COVID-19 at this time” indicating that they are at LOW RISK
for COVID-19. If students do not fall into this category, the current Public Health Regulations will apply.
2. We propose the use of the JFK Auditorium (Main Campus), Student Recreation Centre (EWMSC), and
the
Dental School new building (EWMSC) for these examinations. Alternatively, one venue (JFK Auditorium
on the
Main Campus) would satisfy the relevant health protocols.
3. The candidates will be separated to allow for social distancing.
4. The room(s) and all furniture will be sanitized prior to use and again at the end of the
examination.
5. All candidates and invigilators will adhere to physical distancing of at least 6 feet (2 metres).
6. All candidates will sit at a previously unoccupied desk. The desk will not be reused once vacated by a
candidate and prior to cleaning.
7. Since all the candidates are frontline health care workers, they will all wear surgical masks for
the duration of the examination.
8. Invigilators will also wear masks which can be non-surgical masks or as determined by campus
policy.
9. All persons (candidates and invigilators) will have their temperature checked on arrival at the
examination venue. If temperature > 37.4 degrees Celsius, recheck in 10 minutes. If still febrile,
they should not be allowed to enter the examination room and the current public health
regulations will apply.
If you have had an injury with a needle or any other sharp instrument, or have come in
contact with splashes of blood or body substances or human bites, follow these steps.
1. Wash thoroughly with soap under running water. Note the source of the exposure.
3. Have two blood samples taken from the source patient (with consent) and label
them properly:-
i. A purple top tube with 5-7mls of blood for Microbiology laboratory ,
POSGH for ELISA and/or Rapid HIV test
ii. A purple top tube with 5mls of blood for TPHL/CAREC for HIV and
HBV tests
4. Report to Infection Prevention & Control Nurse during the hours of 8.00a.m. –
4.00p.m. from Monday to Friday. Report to Nursing Supervisor in the Night
Sister’s office during the house of 4..00p.m. to 8.00a.m. from Monday to Friday
and 8.00am. – 8.00a.m. on Weekends and Public Holidays. Unique I.D. is
formatted and will then be given to the exposed person.
5. The Nursing Supervisor or the Infection Prevention & Control Nurse will authorize
the Laboratory Technician to do a Rapid Test on a blood sample from the source
patient
6. Take the 5mls blood sample to the Laboratory for the Rapid Test to be done.
(Bacteriology Lab. 8.00a.m. to 4.00p.m. from Monday to Friday and
Biochemistry Lab. From 4.00p.m. to 8.00a.m. and during weekends and Public
Holidays)
7. Report to the Head Nurse or Nurse in Charge in the Accident & Emergency
Department who will arrange for the exposed person to be seen by the Accident &
Emergency Doctor.
10. The blood sample from the exposed person is sent to Microbiology Lab for baseline
HIV status-ELISA test, and a 5ml sample from the source must be placed in the
CAREC REFRIGERATOR. This sample will be taken to TPHL for HBV testing
11. The Rapid test on the source patient must be done within two hours of exposure.
The Report will be given to the Nursing Supervisor/Infection Prevention & Control
Nurse who will immediately contact the exposed person. The exposed person
should leave information with the Infection Prevention & Control Nurse or the
Nursing Supervisor as to where he/she can be contacted.
If the Rapid test of the source patient is positive and the exposed person is negative, he/she
is advised to take the Anti-Retroviral Medication for 28 days.
In Low Risk Situations i.e. Exposure to body fluids or secretions from a potential source
of HIV infection without any muco-cutaneous penetration, and also when the source is HIV
negative.
Counseling and follow up for four weeks
No ART
Re-evaluate for HIV antibodies after six weeks, three months and six months.
High Risk AZT 300MG BID + 3tc 150MG BID + Nelfinavir (Viracept)
1250mg bid daily for four weeks
OR
OR
When the pharmacy is closed, sufficient doses of the Anti-Retroviral Therapy medication
will be given to exposed in the Accident and Emergency department until such time that a
prescription can be filled.
A complete Blood Count, Liver Function Tests and Kidney Function Tests must be
done on the exposed person at the beginning of the prophylaxis, two weeks after
start of treatment and one week after completion of prophylaxis. This is done at the
Medical Research Foundation
The HIV-ELISA test for the exposed person is repeated at six weeks, three months
and six months irrespective of whether the source patient is positive or negative.
This is done at the Infection Prevention and Control Unit
Any side effects of the medication must be reported to your doctor immediately
Precautions during testing period (i.e. six months) after possible exposure
REFRAIN FROM:
4. Breastfeeding
Signed Signed
July, 2005
Approved by
Signed
EXPOSURE INCIDENT
IMMEDIATE ACTION
Negative Positive
Report to Infection Prevention - Rapid HIV test done on exposed
And Control Unit person before starting ART
- Continue PEP with ART for 28 days
- Check with Infection Prevention
Control Unit re policy
- Follow up with clinical monitoring
at Medical Research Foundation
The idea is not to make you dermatologists but to help you to make sensible decisions
about immediate therapy to relieve the patients’ distress, to help you to manage to the stage
of resolution the more common and uncomplicated disorders and to assist you in deciding
when to refer for further investigation and management.
a. Basic anatomy, physiology and pathology of normal skin and common disorders
such as eczema, psoriasis, urticaria.
b. The approach to the patient with skin disease so as to come to a reasonable
differential diagnosis at the end of the inquiry and examination.
c. Descriptive terms used for skin lesions e.g. macules, papules, hyperkeratosis,
lichenification.
d. The basic clinical features, aetiology and pathogenesis as well as baseline
management of the following:
(viii) Infestations
scabies
lice
2. Clinical Dermatologhy
Rona Mackie
REFERENCES:
1. Textbook of Dermatology
Champion, Burton, Ebling
HIV CIRICULUM
HIV in Adult Medicine Curriculum:
Years 4 & 5 Undergraduate Medicine
Course description
Overview
This course is designed to complete the training of the medical undergraduate student in
HIV/AIDS medicine within the context of general internal medicine over two rotating 8
weeks clerkships.
Prerequisite
A pass in the MB: BS Phase 1 examination.
Depending on availability of personnel and consistent with the service commitment of the
medical teachers involved.
Integration of the HIV teaching already occurs within the undergraduate curriculum but it
has now become a disease of national significance to this country and the Caribbean islands.
For this reasons it is being taught as a separate component of undergraduate adult medical
training. Training in HIV medicine will be closely related with other sub specialties
including Pulmonology, Gastroenterology, Urology, Cardiology, endocrinology, Venereal
Diseases, Nephrology and dermatology.
Over the course of the final to years of graduate training, students are expected to become
familiar with the management of HIV- associated conditions within and across these
specialties
The course covers the broad spectrum of medical conditions associated with HIV infection
in adult medicine. Students would be expected to elicit signs within each of the major
systems of the body and to integrate these with the history into a final clinical diagnosis.
This course is designed for students during the final 2 clinical years of undergraduate
medicine.
By the end of the course, the student will be expected to diagnose and initiate treatment of
the following major common HIV-associated conditions: PCP, TB, Oesophageal
candidiasis, chronic cryptosporidial diarrhoea, non-typhi salmonella septicaemia, CMV
retinitis, progressive multifocal leucoencephalopathy, cerebral toxoplasmosis, cerebral
lymphoma, chronic mucocutaneous herpes simplex, Kaposi’s Sarcoma, Non-Hodgkin’s
lymphoma, primary cerebral lymphoma. Students should be expected to understand the
differential diagnosis of these conditions and how to differentiate between these and other
medical conditions by laboratory and radiological investigations.
Instructor Information
This course spans two years of your training; the course content will be covered during your
year 4 and year 5 adult medicine clerkships as part of the already existing teaching program.
HIV disease is now a common condition as seen worldwide and also in the West Indies.
We hope that you will use this course to become familiar with the protean manifestations of
this condition and that you will be able to treat the various syndromes referred to with
confidence as an intern.
General Objectives: The objective of including HIV/AIDS-related education in the Medical school
curriculum is to produce a doctor with:
Course description
Overview
This course is designed to complete the training of the medical undergraduate student in
pulmonary medicine within the context of general internal medicine over two rotating 8
weeks clerkships.
Prerequisite
A pass in the MB:BS Phase 1 examination.
The course covers diseases of the chest or respiratory system and is also called
pulmonology, respirology, respiratory medicine, and pulmonary medicine or chest
medicine. Students would be expected to have been exposed to the rudiments of the chest
examination and history during Phase I training. This course is designed for students
during the final two clinical years of undergraduate medicine.
At the end of the course, the student will be expected to diagnose and treat the following
major common pulmonary conditions: asthma, COPD, lung cancer, pneumonia, pleural
effusion, tuberculosis, pulmonary embolism. The student will also be expected to
understand the differential diagnosis of these conditions and how to differentiate
between these and other medical conditions by laboratory and radiological
investigations.
Contact Information
Tutors: EWMSC - Dr. S. Sakhamuri, Dr.Bahall, Prof. S. Teelucksingh and Associate
Lecturers from Thoracic Medicine Unit.
Port of Spain General Hospital – Associate Lecturers from the Department of
Medicine at POSGH
Office: Department of Clinical Medical Sciences, Faculty of Medical Sciences, 2nd Floor,
Building 67, EWMSC, Mount Hope
Contact Phone: Department of Medicine EWMSC 663 4332;
POSGH 623-4030 or ext 2585
Content
Clinical presentation of pulmonary diseases
Dyspnoea, cough, sputum, haemoptysis, wheeze, chest pain, fatigue, sleep disturbance,
excessive snoring, confusion, ankle oedema, hoarseness, night sweats.
The student is expected to characterize each of these symptoms by onset (where, when
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 52
how), duration and evolution. Common causes of each of these symptoms.
Symptom severity:
Dyspnoea: MRC dyspnoea scale, New York Heart Scale,
Sputum: volume and purulence
Haemoptysis: clinical significance and management of massive haemoptysis. Causes of
haemoptysis – PE, LRTI, Tb, lung cancer, bronchiectasis, aspergillosis
Chest pain: severity, location of pain in relation to cause, pleuritic chest pain
Chest History
Past Medical History: importance of comorbidites eg cardiac, diabetes
Drug History: importance of retrospective diagnosis of lung disease from the drug history.
Adverse effects on the lung – ACEIs, beta-blockers, NSAIDs, drugs causing pulmonary
fibrosis
Allergy history and relation to chest diseases esp. asthma, angioedema
Smoking – definition of a pack year as a measure of smoking burden
Family – genetic basis of some lung diseases – cystic fibrosis, alpha-1 antitrypsin
deficiency, familial diseases
Occupational lung disease: occupational asthma, dusts and COPD, air pollutants and
cardiopulmonary diseases eg. effect on heart rate variability
Social: disease and socio-economic status eg. Tb, COPD, compliance
Pet history: pet related lung diseases: asthma, extrinsic allergic alveolitis
l. Asthma Therapeutics:
Delivery devices – spacers, MDIs, Dry powder devices
Reliever medications - beta-2 agonists short and long acting
Preventer medications: long acting beta-2 agonists, inhaled
steroids, LTRAs, PDE inhibitors, Omalizumab
Avoidance measures: Allergens, smoking, dampness,
Pollutants, respiratory viruses
(2) COPD
a. Prevalence. Definition – role of spirometry
b. Aetiology: active smoking, smoking burden, genetics
c. Clinical presentation: cough and sputum, dyspnoea, acute exacerbation
d. Signs: hyperinflation, weight loss, signs of respiratory failure (central
cyanosis, flapping tremor, bounding pulse), pedal oedema, signs of
pulmonary hypertension (raised JVP, loud P2, tricuspid regurgitation)
e. Differential diagnosis
f. Investigations: spirometry, static lung volumes (air trapping), reversibility
testing, chest radiograph, arterial blood gas analysis (normal, acute
respiratory acidosis, compensated type 2 respiratory failure), ECG, FBC
g. Treatment of Acute Exacerbations of COPD: nebulisers, steroids,
antibiotics, controlled oxygen therapy, diuretics, physiotherapy, non-
invasive ventilation
h. Treatment of COPD in the community: goals in treatment, smoking
cessation strategies, beta-2 agonists, anticholinergics, theophyllines, inhaled
steroids, PDE inhibitors. Other: exercise, nutrition, vaccination, ambulatory
oxygen, pulmonary rehabilitation.
(3) Pneumonia
a. Definitions of pneumonia in the community and in hospital
b. Classification of pneumonias: CAP, Nosocomial, aspiration, relapsing,
pneumonia in the immunocompromised, geographical
c. Pathogens
d. Incidence and mortality
e. Clinical presentation
f. Signs
g. Differential diagnosis: asthma, CCF, IHD, pneumothorax, pleural effusion
h. Investigations
i. FBC, U&E, LFTs, CRP, ESR, ABG
ii. sputum, blood cultures, urine tests
iii. serology
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 55
iv. Radiology
i. Prognostic factors: age, comorbidity etc
j. Complications: lung abscess, Empyema, screening for lung cancer
k. Treatment of community acquired and nosocomial pneumonia
i. treated in the community
ii. admitted to hospital: nursing care, drugs, fluids,
l. Follow-up management: CXR, lung function. When are they indicated?
(7) Tuberculosis
a. Definition
b. Clinical epidemiology of TB: West Indies, world-wide, why TB is an
important public Health problem. The five most common causes of death
world-wide.
c. Clinical presentation of tuberculosis; pulmonary TB, extra pulmonary
manifestations: lymph node TB, tuberculous meningitis, other.
d. Risk factors: diabetes, immunodeficient states including AIDS/HIV –
tuberculosis as an AIDS defining illness.
e. Diagnosis: may be clinical but importance of bacteriological diagnosis.
Sputum, bronchial specimens, gastric lavage (children), biopsy
f. Clinical descriptions of TB cases: ‘smear positive’ and ‘sputum smear
positive’ TB.
g. Differential diagnosis
h. Notification and Public Health Law
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 57
i. Organisation of TB services
j. TB treatment: drug sensitivity is always required, use of 4 drugs,
interactions, drug resistant TB, DOT
k. Prevention and Control of TB: control of TB in hospitals, Contact tracing
and examination of contacts: Mantoux, Heaf tests, Chest radiograph. BCG
vaccination and chemoprophylaxis.
l. Bovine TB, opportunistic mycobacterial infection eg MAI
In the study of each of these diseases, the principles of history taking and examination will
be emphasized.
Students will be expected to be able to describe the investigation of these diseases and the
principles of management and knowledge of drugs used where applicable.
Specific details of management including doses of drugs used will be required for acute
severe asthma and acute pulmonary embolism. The role of the intensive care unit in the
management of acutely decompensate pulmonary diseases will be discussed.
Goals/Aims
The knowledge base developed during the year 4 training in internal medicine will be
expanded in year 5. All diseases discussed during year 4 will be reviewed during bedside
sessions and a few other pulmonary diseases will be discussed.
Seven very common pulmonary diseases have been chosen for the core pulmonary
medicine in your syllabus. Patients with these diseases should be easily clerked on the
medical wards of San Fernando General Hospital and Port of Spain General Hospital or
chest wards at the EWMSC. These diseases of the lungs will be discussed in terms of
disorders of the airways, lung parenchyma or pleura in order to illustrate a simple model of
understanding pulmonary diseases.
Students will be expected to attend the Medical Grand rounds at the POSGH during their
training at POSGH and to answer simple questions about the cases discussed during these
sessions.
Students are expected to be aware of the latest therapeutic strategies employing evidence-
based medicine. This information may be accessed via the various approved websites.
By the end of their 2 years’ training in pulmonary medicine, students will expect to have
reached an internationally accepted standard in their knowledge and management of
pulmonary diseases within general internal medicine.
General Objectives
Specific Objectives
At the end of the course you will be able to
1. define the symptoms and signs of pulmonary disease
2. state common causes (pulmonary and non-
pulmonary) of each symptom or sign mentioned above
3. define each of the major diseases in this syllabus
4. integrate the symptoms and signs of pulmonary
disease with the clinical presentation of each of the pulmonary
diseases studied in this course
5. differentiate between the different conditions using the history,
examination and investigations discussed during this course
6. state the treatment of acute asthma and acute PE
7. discuss treatment options of pulmonary diseases
8. differentiate between tuberculous infection and tuberculous disease
in clinical presentation and management
9. discriminate between different arterial blood gas results and their
causes
10. use abnormal spirometric results in the differential diagnosis of
chest diseases
Assignments
1. The student will expected to clerk at least 1 patient with each of the first 7
pulmonary diseases described in the content section above and to present and discuss
each case with any instructor. Clerking of a patient will involve
a. Presenting compliant
b. Complete history
c. Examination of all systems of the patients with special
emphasis on the chest examination
d. A description of what investigations were done and should be
done with details of results where applicable
e. Treatment and response to treatment
f. Follow-up plan for the patient including discharge
Assessment/ Evaluation
The purpose of the assessment would be to help you to appreciate where you have reached
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 60
in attaining the goals set out in this syllabus and to stimulate you to continue to study
internal and pulmonary medicine.
Your assessment will take the following forms
(1) A written examination based on structured questions or MCQs
(2) Evaluation of a project and coursework
(3) Grading of cases clerked
Teaching Strategies
The Department of medicine employs several teaching strategies which will include
1. guided lectures,
2. bed side teaching,
3. small group teaching,
4. non-lecture strategies: projects, group discussions, role play, co-operative learning
Resources
1. Patients on the medical and surgical wards, POSGH, are our most valuable
Resource.
2. Patients in the medical outpatients’ clinics.
Readings
1. Davidson’s Principles and Practice of Medicine: respiratory medicine chapter.
2. Kumar and Clarke: respiratory medicine chapter.
3. West JB. Respiratory physiology – the essentials.
4. Approved Websites: ATS (Amer Thoracic Society), ACCP (Am College of Chest
Physicians), NIH (Nat. Institute of Health USA), NICE (Nat. Institute of Clinical
Excellence), SIGN (Scottish Intercollegiate Guidelines Network), BTS (Brit
Thoracic Society), ERS (Eur Resp Soc), PUBMED.
Other websites should be discussed with the instructor before use.
Course description
Overview
This course is designed to complete the training of the medical undergraduate student in nephrology
within the context of general internal medicine over two rotating 8 weeks clerkships.
Prerequisite
A pass in the MB:BS Phase 1 examination.
At the end of the course, the student will be expected to diagnose and treat the following major
common renal conditions: Acute and chronic renal failure, anuria, interstitial nephritis,
rhabdomyolysis, hepatorenal syndrome, acute upper urinary tract infections, renal stones and
renovascular diseases. The student will also be expected to understand the differential diagnosis
of these conditions and how to differentiate between these and other medical conditions by
laboratory and other investigations.
Welcome to the Nephrology component of the Internal Medicine Programme. We hope that you
will see this course as an extension of the learning initiated during your first three years of training.
In the first year of internal medicine (year 4 undergraduate) we emphasize knowledge of the
underlying disease processes and the acquisition of an accurate history and examination. In the final
year our emphasis is on diagnostic skill, investigation and treatment of common renal diseases and
their differentiation from other diseases. The best advice we can give you is that learning is patient-
centred and not text-book centred, though your text books will provide a useful resource. We hope
you enjoy your brief time with us in this exciting field.
Contact Information
Renal History
Past Medical History: importance of comorbidites eg anaemia, cerebrovascular incidences,
hypertension and/or cardiac problems, diabetes, liver problems, dyspnoea, skin and even recurrent
infections.
Intake/output: Importance of amount of fluid intake and loss. Eating habits.
Passing urine: How is it best described? Dysuria, strangury, urgency and frequency, polyuria,
nocturia, oliguria/anuria, incontinence, urge or stress incontinence, nocturnal enuresis
Drug History: Drug abuse, importance of retrospective diagnosis of renal disease from the drug
history. Adverse effects– ACEIs, Angiotensin receptor antagonists, NSAIDs. Kidney toxic,
Aminoglycosides, amphotericin, lithium, ciclosporin and tacrolimus, and in overdose paracetamol.
Drug for HIV disease.
Allergy history all aspects.
Smoking – definition of a pack year as a measure of smoking burden
Family – genetic basis of some kidney diseases – polycystic kidney disease. Familial diseases in
general.
Social and occupational history: living or working in hot environment. Exposure to organic solvents,
working with aniline dye. Socio-economic status.
Ethnic or geographical situation: Nephropathia epidemica (hanta virus) mainly in Europe and
Russia. Balkan nephropathy. Systemic lupus erythematous with nephritis in the far east, severe
hypertension or diabetes mellitus with renal failure more common in patients of African origin.
IV. Biopsy: Indicated in the diagnosis and assessment of parenchymal renal disease. Low
complications rate.
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 64
V. Chest radiograph: Fluid (overload) estimation, position of the diaphragm and to exclude lung
infiltrations.
VI. Arterial blood gases: Technique of taking ABG, technique of local anaesthetic, Allen’s sign,
Interpretation of ABG and the Henderson-Hasselbach Equation, Biochemistry of
measurement of pH, CO2, O2, HCO3. To distinguish the degree of metabolic acidosis versus
the decreased ventilation due to interstitial lung oedema.
In the 4th year the main focus is on the principles of history taking and examination. Students will be
expected to be able to describe the investigation of these diseases and the principles of management
and knowledge of drugs used where applicable.
In the 5th year focus is on the medical and integrated treatment not least the pharmacological and non
invasive treatment .
The knowledge base developed during the year 4 training in internal medicine will be expanded in
year 5. All diseases discussed during year 4 will be reviewed during bedside sessions and a few
other renal diseases will be discussed.
Patients with kidney failure diseases should be easily clerked on the medical wards of San Fernando
General Hospital, Port of Spain General Hospital or the EWMSC. These diseases will be discussed
in terms of pathophysiology in order to illustrate a simple model of understanding kidney diseases.
Collection and presenting findings fitted to the SOAP format will be emphasized.
Students will be expected to attend the Medical Grand rounds at the EWMSC and POSGH during
their training at EWMSC respectively POSGH and to answer simple questions about the cases
discussed during these sessions.
Students are expected to be aware of the latest therapeutic strategies employing evidence-based
medicine. This information may be accessed via the various approved websites.
By the end of their 2 years’ training in nephrology, students will expect to have reached an
internationally accepted standard in their knowledge and management of renal diseases within
general internal medicine.
General Objectives
The years 4 & 5 nephrology module consists of 1 session per week for 8 weeks (each year) either at
POSGH or at EWMSC. You will be provided with a seasonal timetable at the start of the course.
Specific Objectives
At the end of the course you will be able to
Assessment/ Evaluation
The purpose of the assessment would be to help you to appreciate where you have reached in
attaining the goals set out in this syllabus and to stimulate you to continue to study internal medicine
and nephrology.
Your assessment will take the following forms
(1) A written examination based on structured questions or MCQs
(2) Evaluation of a project and coursework
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 67
(3) Grading of cases clerked
Teaching Strategies
The Department of medicine employs several teaching strategies which will include
1. guided lectures,
2. bed side teaching,
3. small group teaching,
4. non-lecture strategies: projects, group discussions, role play, co-operative learning
Resources
1. Patients on the medical and surgical wards are our most valuable resource.
2. Patients in the medical outpatients’ clinics.
Readings
The student should use sound judgment when searching information from various other websites.
If the student has doubts on the validity of a site, the student is encouraged to discuss the
information with the instructor.
Cancer biology
2.1 Functional anatomy
2.2 Physiology
2.3 Pathology
2.4 Molecular biology
Patient management
3.1 Patient management including referral and multidisciplinary management
3.2 Quality of life, therapeutic ratio and resource costs
3.3 Uncertainty and information management
Diagnosis
4.1 Clinical examination
4.2 The diagnostic process
Treatment
5.1 General principles of treatment
5.2 Principles of surgery
5.3 Principles of radiotherapy
5.4 Principles of systemic therapy
5.5 Principles of palliative care
5.6 Follow-up and relapse
Communication skills
6.1 Psychosocial and cultural significance of cancer
6.2 Communication and counselling
6.3 Education of patients
6.4 Family and community support
Ethics
7 Ethics and professionalism
Clinical experience
8 Five essential cancer clinical experiences
11
Objective 1.3
Prevention, screening and family risk
a) Describe methods for the primary and secondary prevention of cancer, including
measures that employ a public health approach, as well as those depending on
individuals and their doctors.
b) Describe the methods of screening for cancer and pre-malignant conditions.
c) Demonstrate an understanding of the scientific evidence for the utility of screening, the
difference between population-based screening and surveillance of individuals, and
cost-effectiveness issues.
d) Discuss environmental control and behavioural and chemical approaches to the
prevention of cancer.
e) Demonstrate an understanding of the psychosocial impact of screening and staging
investigations on the patient.
f) Demonstrate ability to take family history.
✔ Prerequisite knowledge
■ Basic epidemiological concepts including: prevalence; incidence; specificity;
sensitivity; predictive value; screening v diagnosis; cost-benefit analysis; and
prevention strategies.
IDEAL ONCOLOGY CURRICULUM FOR MEDICAL SCHOOLS
12
1.3 Representative questions that suggest the required depth of knowledge
1. Elizabeth Smith, a 54 year-old long-standing patient is seeing you in a follow-up visit for
a settling U.T.I. You decide it is time she had a mammogram and suggest this to her.
She replies: "Why should I do that and what good would it do me?" What is your
answer?
Essential in answer
■ Mammographic screening of women over 50 years of age has been shown to
improve survival and produce better outcomes in populations that are screened.
2. John Smith, the 54 year-old husband of Elizabeth is seeing you for a routine insurance
check-up. During the course of the visit he asks you about cancer. He smokes 10
cigarettes a day, drinks "socially", is modestly overweight and has a younger brother
with colorectal cancer. He then specifically asks for a PSA test, as he is worried about
prostate cancer. What course of action and relevant explanations would you offer to
him?
3. With respect to screening for common cancers in Australia, select the best answer:
(a) Mammography has been advocated in Australia for asymptomatic women aged
<40 years.
(b) Pap smears can be discontinued when the woman ceases regular sexual activity.
(c) A normal result for prostate specific antigen (PSA) excludes a diagnosis of prostate
cancer.
(d) A family history of familial adenomatous polyposis increases the probability of
malignancy in an anxious 27 year-old female who reports altered bowel habit.
Answer: (d)
IDEAL ONCOLOGY CURRICULUM FOR MEDICAL SCHOOLS
13
Objective 2.1
Functional Anatomy
Demonstrate an understanding of the anatomical basis of cancer assessment such as:
vascular supply (eg. liver); lymphatic drainage patterns (eg. breast); and anatomical
relationships of relevance to oncology (eg. pelvis).
✔ Prerequisite knowledge
■ General anatomy.
2.1 Representative questions that suggest the required depth of knowledge
1. Describe the modes of potential spread of breast cancer in the upper outer quadrant
of the left breast.
Essential in answer
■ Direct extension – skin, chest wall.
■ Lymphatic spread – axillary nodes, internal mammary nodes, supraclavicular nodes.
■ Haematogenous spread – bone marrow, lung, liver, brain.
2. A patient has a squamous cell carcinoma of the apex of the left lung (Pancoast
tumour).
Describe the possible structures involved in local progression, and their effects.
Essential in answer
■ Brachial plexus (lower roots; C8/T1) – pain, weakness in small muscles of hand.
■ Cervical ganglion (sympathetic nerve) – Horner’s Syndrome.
■ Chest wall invasion – pain, mass.
■ Supraclavicular extension – pain, mass.
2. In a cancer patient with renal impairment, chemotherapy doses should be (select the
best answer):
(a) Decreased.
(b) Increased.
(c) Unchanged.
(d) Reviewed.
Answer: (d)
IDEAL ONCOLOGY CURRICULUM FOR MEDICAL SCHOOLS
15
Objective 2.3
Pathology
a) Describe the concept of carcinogenesis.
b) For the common cancers, demonstrate an understanding of microscopic and
macroscopic findings, including pathological features from pre-malignant to
malignant stages of cancer.
c) Describe patterns of spread of common cancers.
d) Demonstrate an understanding of the role and purpose of molecular pathology
particularly the prognostic and/or predictive values of receptors and other targets.
✔ Prerequisite knowledge
■ Cell biology.
3. A 65 year-old man has been diagnosed with rectal cancer. Describe possible
Methods of cancer spread.
Essential in answer
■ Vascular and lymphatic systems.
■ Direct spread.
■ Trans-coelomic spread.
■ Implantation.
4. Describe how knowledge of ER PR and HER2 status in breast cancer will dictate
prognosis and treatment?
Essential in answer
■ Hormone responsiveness.
■ Role of hormonal treatment.
■ Role of Herceptin.
2. A patient who has breast cancer comes to you with some information on breast
cancer from the internet. She is very worried and has a lot of difficulty knowing what
to believe. What do you tell her about retrieving useful information from the internet?
Essential in answer
■ Critical appraisal.
■ Knowledge of useful websites.
■ Encouragement of use of well written evidence based literature in addition to
web-based information.
■ Awareness of other sources of information such as breast cancer support services
and the Lymphoedema Association.
4. A randomised phase III trial was performed between drug X and Docetaxel as second
line
therapy for metastatic non-small cell lung cancer. Fifty patients were randomised to
each arm and when comparing objective response rates no significant difference was
found between the two arms p>0.05. Discuss the possible meanings of this result.
Essential in answer
The numbers may not provide sufficient power to detect a clinically meaningful
difference so it is not necessarily a negative study, but an indeterminate result. Is
objective response rate the best endpoint in this situation?
25
2. A common management of early breast cancer is wide excision. What are the aims of
this treatment?
Essential in answer
■ Adequate pathological margin around invasive and intraductal cancer.
■ Breast conservation.
■ Good cosmetic outcome.
3. Radiation treatment to the breast after wide excision of cancer reduces the local
recurrence rate at five years to:
(a) 0
(b) 5 - 10%
(c) 10 - 20%
(d) 40%
Answer: (b)
4. Discuss why different surgeons may have different local recurrence rates after
surgical resection of rectal cancer.
Essential in answer
■ Experience.
■ Training.
■ Number of cases per year.
■ Type of cases referred.
5. What are the long-term effects of lymph-node dissection for melanoma of the leg?
Essential in answer
■ Lymphoedema.
■ Infection risk.
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 83
IDEAL ONCOLOGY CURRICULUM FOR MEDICAL SCHOOLS
32
Objective 5.3
Principles of radiotherapy
a) Describe the principles of radiobiology.
b) Discuss the principles of radiotherapy: loco-regional treatment with either curative or
palliative intent; when administered with curative intent it might be primary therapy or
adjuvant to the primary modality.
c) Describe the salient features of delivering radiation treatment using equipment such as
linear accelerators and brachytherapy machines. This should include a general
description of treatment simulators, bunkers and the treatment planning departments.
d) Describe the general features of brachytherapy treatment, including the use of
different isotopes placed with a variety of techniques in various anatomic sites, most
prominently for ca cervix and ca prostate.
e) Recognise the clinical indications for radiotherapy.
f) Evaluate the outcomes of radiotherapy including: efficacy, short and long-term side
effects, costs and quality of life.
g) Recognise the common complications of radiotherapy and understand their
management.
h) Discuss the integration of radiotherapy with other modalities.
i) Demonstrate an understanding of the access problems associated with radiotherapy
and how this may affect patient choice.
2. During regular use of morphine for chronic pain control, what is the oral equivalent to
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 86
10mg of subcutaneous morphine sulphate?
(a) 60mg?
(b) 30mg?
(c) 10mg?
(d) 3.3mg?
Answer: (b)
The answer requires an understanding that oral morphine has only about one third of
the bioavailability of parenteral morphine when used regularly ie. three times the dose
is required. The required oral dose for a one-off dose is six times.
1. For which cancers are there effective salvage treatment for recurrent disease that
offers a >25% chance of cure? (select the best answer/s, more than one may be
correct)
(a) Hodgkin’s disease.
(b) Rectal cancer.
(c) Breast cancer initially treated by lumpectomy and radiotherapy.
(d) Lung cancer.
(e) Glioblastoma multiforme.
Answer: (a and c)
2. What would you tell a patient about the purpose and limitations of follow-up after
conservative treatment of colon cancer?
Essential in answer
■ To detect manageable recurrence.
■ To document treatment-related toxicity.
■ To establish outcomes including but not exclusively survival.
■ Recognition of non-clinical incentives that may drive the desire for follow-up
(financial, medico-legal, patient related).
4. What are the two major side-effects which should be discussed with a man who is
about to undergo radical surgery for prostate cancer and how would you discuss
their management.
Essential in answer
■ Impotence and incontinence. In the management of impotence, pharmacological
and mechanical treatments can be discussed and counselling for the man and his
partner may be necessary.
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 88
IDEAL ONCOLOGY CURRICULUM FOR MEDICAL SCHOOLS
40
Objective 6.2
Communication and counselling
a) Illustrate an ability to communicate the bad news of a diagnosis of cancer to a
patient, their family and “significant others” in a sensitive manner, addressing
concerns, fears and expectations, while making sure a realistic prognosis is
explained and ensuring that appropriate confidentiality is observed.
b) Be aware that the impact of receiving bad news interferes with patients’ ability to
comprehend fully the important information being presented to them. Illustrate the
ability to assess a patient’s realistic understanding of their situation and to
individually tailor verbal and written information provided according to patient
preferences and understanding.
c) Provide supportive counselling for the patient and carers, both personally and by
referral to expert help.
d) Demonstrate an understanding of how to explain the risks and benefits of options
for management to the patient and their significant others, so that active
participation in the management process is encouraged.
e) Facilitate informed consent for participation in clinical trials.
✔ Prerequisite knowledge
■ Basic counselling and communication skills, including eliciting the patient’s
agenda in relation to the doctor’s agenda; being able to listen.
■ Patient-centred counselling skills, including the importance of appropriate
location and the amount of time devoted to the task.
■ Knowledge of the process of grief and loss.
■ Knowledge of support groups (physical and internet).
41
IDEAL ONCOLOGY CURRICULUM FOR MEDICAL SCHOOLS
Area: Ethics
45
IDEAL ONCOLOGY CURRICULUM FOR MEDICAL SCHOOLS
Objective 8
Clinical experience
Many important clinical skills must be learnt by experience. The five cancer clinical
experiences that medical students need before they graduate include:
a) Talking with and examining people affected by all stages of cancer.
b) Talking with and examining people affected by all common cancers.
c) Observing all components of multidisciplinary cancer care.
d) Seeing shared decision-making between people with cancer and their doctors.
e) Talking with and examining dying people.
Definitions:
■ Examine – experienced the salient features (eg. seen, felt).
■ Talk with – discuss symptoms, effects, plans and reflections.
■ All stages of cancer – early, locally advanced, locally recurrent and advanced.
■ All common cancers – breast, prostate, lung, colorectal, melanoma, gynaecologic,
lymphoma and leukaemia.
■ All components of multidisciplinary cancer care – includes people preparing for,
undergoing and having had cancer surgery, chemotherapy, radiation therapy,
palliative care and other supportive care.
Course Description
Title
Metabolic Diseases: Year 4 & 5 Undergraduate Medicine
Overview
This course is designed to complete the training of the medical undergraduate student in
metabolic medicine within the context of general internal medicine over two rotating 8
weeks clerkships.
Prerequisite
A pass in the MBBS Phase 1 examination.
Organisation of the Course
This course is taught in two modules:
Metabolic diseases fall within the areas of expertise of both physicians and
chemical pathologists. This course is designed to integrate the foundation
knowledge learnt in Pre-Clinical years in the basic sciences of Biochemistry and
the Chemical Pathology clerkship with clinical practice.
Contact Information
Tutors: EWMSC - Professor T. Seemungal, Professor S. Teelucksingh, Dr. S. Sakhamuri
and Associate Lecturers from Internal Medicine Unit.
Port of Spain General Hospital – Prof. T. Seemungal, Prof. S. Teelucksingh and
Associate Lecturers from the Department of Medicine at POSGH
Office: Department of Clinical Medical Sciences, Faculty of Medical Sciences, 2nd Floor,
Building 67, EWMSC, Mount Hope
Contact Phone: Department of Medicine EWMSC 663-4332;
POSGH 623-4030 or ext 2585
E-mail: terence.seemungal@sta.uwi.edu
Content
Clinical Presentation of Metabolic Diseases
History Taking
Physical Examination
Signs & Symptoms
Investigations
Specific Metabolic Diseases
o Disorders of Carbohydrate Metabolism
Diabetes Mellitus
o Disorders of Lipid Metabolism
Dyslipidaemia
o Disorders of Nutrition
Obesity
Vitamin & Mineral Deficiency
o Disorders of Protein Metabolism
Metabolic myopathies
Metabolic polymyopathy
Metabolic polyneuropathy
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 94
Metabolic Emergencies
Symptoms:
Nonspecific – Exercise intolerance, Weight loss, Poor wound healing, Fatigue, Chills
CNS– Seizures, Neuropathic ulcers, Visual Disturbances, Dizziness
CVS– Palpitations, Diaphoresis
RS – Dyspnoea, Tachypnea
GIT– Vomiting, Diarrhoea, Nocturnal diarrhoea, Jaundice, Polyphagia, Dry mouth
GUS / Reproductive – Polyuria, Polydipsia, Impotence, Urinary Retention
MSS – Ataxia, Growth Problems, Muscle (pain, wasting, weakness, cramping), Bone
abnormalities, Problems with movement
Hair & Skin – Rash, Alopecia, Skin thinning, Lipodystrophy, Abnormal pigmentation
Signs:
Signs of Dehydration – Sunken eyes, Decreased skin turgor, Hypotension,
Tachycardia
Respiration – Tachypnea, Accessory muscles of Respiration, Nasal flaring,
Breathing pattern – eg. Kussmaul (metabolic acidosis), Cheyne-Stokes (acompanies
brain damage, heart failure, uremia, and respiratory depression)
Cardiac – Arrythmias, Tachycardia
BMI – Obesity, Underweight, Fat distribution
Cutaneous – Acanthosis nigricans, Xanthelasma, Dermatological and
Rheumatological manifestations of Autoimmune disease
Physical Examination:
General
Examination of ALL the systems of the patients
Complete Neurological Examination – Including Mental State Exam
OGTT / HbA1c
Water Deprivation Test
Specific Objectives
o G6PD deficiency
o Diabetes Mellitus
Diabetes mellitus
Diagnose diabetes and glucose intolerance disorders
o OGTT
o HbA1c >6.5%
Classification:
o Insulin-dependent diabetes mellitus
o Non-insulin-dependent diabetes mellitus
o Maturity Onset Diabetes Mellitus of the Young (MODY)
o Gestational Diabetes
o Other
Give basic dietary advice, emphasizing its importance as first line therapy in Type 2
patients
In the event of dietary failure institute appropriate therapy
Recognize the need for insulin treatment in diabetic patients
Institute insulin therapy
Educate patients in the use of insulin syringes, injection pens, home blood glucose
monitoring and urinalysis
Give advice about the insulin dose adjustment
Provide life style advice with regard to employment, driving, exercise, weight control
and smoking
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 99
Advise with regard to avoidance of complications in the eye, kidney, peripheral
nerve, foot and cardiovascular systems
Screening for, prevention and treatment of microvascular, macrovascular,
neurological and other complications to optimise the intermediate and final
outcomes of diabetes
Signs of peripheral neuropathy eg. Glove-Stocking distribution of neuropathy,
Neuropathic ulcers, Slipping Slipper Sign
Pharmacology of Oral hypoglycaemic agents [5 Commandments – Class of Drug,
Mechanism of Action, Indications, Contraindications, Side Effects]
Insulin resistance altering therapies
Glycaemic control in type 1 and 2 diabetic patients in a way that minimises the
impact on health and optimises long-term disease outcomes
Have a working knowledge of the management of diabetic metabolic emergencies eg.
Diabetic Ketoacidosis
Ability to educate diabetic patients about self-care, monitoring of glycaemic control
and prevention of complications
The Metabolic Syndrome (epidemiology and definition)
Lipoproteins
1. Very low-density lipoprotein (VLDL)
Synthesised continuously by liver
Carries 60% triglycerides and some cholesterol
Enzymic degradation to intermediate density lipoprotein (IDL) and then LDL
2. Low-density lipoprotein (LDL)
Formed from IDL by hepatic lipase
Major carrier of cholesterol
Binds to, and levels regulated by feedback on to, hepatic LDL
receptor
3. High-density lipoprotein (HDL)
Synthesised in gut wall and liver
Carries cholesterol from periphery to liver
Inverse association with ischaemic heart disease
4. Chylomicrons
Carry dietary lipid from gut to liver
Broken down by lipoprotein lipase in portal vessels to free fatty
acids
Hyperlipidaemias
1. Can be primary or secondary
2. Atherosclerotic disease associated with high total cholesterol and LDL
3. HDL protective
Primary disorders
2. Familial triglyceridaemia
Autosomal Dominant
Plasma turbid
Associated with eruptive xanthomata, pancreatitis, retinal vein
thrombosis, hepatosplenomegaly, lipaemia retinalis
Treat with diet and fibrates
3. Disorders of Nutrition
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 103
Overnutrition (Obesity)
o Diagnosis of obesity
Classification BMI(kg/m2)
Principal cut-off points Additional cut-off points
Underweight <18.50 <18.50
Severe thinness <16.00 <16.00
Moderate thinness 16.00 - 16.99 16.00 - 16.99
Mild thinness 17.00 - 18.49 17.00 - 18.49
18.50 - 22.99
Normal range 18.50 - 24.99
23.00 - 24.99
Overweight ≥25.00 ≥25.00
25.00 - 27.49
Pre-obese 25.00 - 29.99
27.50 - 29.99
Obese ≥30.00 ≥30.00
30.00 - 32.49
Obese class I 30.00 - 34-99
32.50 - 34.99
35.00 - 37.49
Obese class II 35.00 - 39.99
37.50 - 39.99
Obese class III ≥40.00 ≥40.00
Hypercalcaemia
Causes
o Primary hyperparathyroidism (adenoma of parathyroid gland)
o Malignancy – PTH-related protein and bone metastases,
Commonly breast, kidney, thyroid, squamous cell tumours
Calcium intake (and milk-alkali syndrome)
Vitamin D
Tertiary hyperparathyroidism
Hyperthyroidism
Sarcoid – macrophages in lesions produce 1,25 vitamin D3
Thiazides
Lithium
Addison’s
Theophylline toxicity
Phaeochromocytoma
Familial hypocalciuric hypercalcaemia
Features
As underlying condition, plus
Lethargy, malaise and depression
Polyuria and polydipsia
Weakness
Confusion and psychosis
Constipation
Peptic ulceration
Nausea
Renal stones
Nephrocalcinosis
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 108
Pseudogout
Proximal myopathy
Diabetes insipidus
Pancreatitis
Treatment
Aggressive rehydration
Bisphosphonate (pamidronate)
Frusemide
Steroids
Hyperparathyroidism
Primary
o Single adenoma in > 80%
o Multiple in around 5%
o Commonest in women aged 40–60
o Carcinoma very rare
o Results in ↑PTH, ↑serum and urinary calcium, ↑alkaline
phosphatase and ↓serum phosphate
o Causes increased osteoblasts and osteoclasts with woven
osteoid and osteatitis fibrosa cystica
Secondary
o Due to hypertrophy of glands in response to chronic
hypocalcaemia (eg. in renal failure)
Tertiary
o Consequence of long-standing secondary hyperparathyroidism.
Further gland hyperplasia raises calcium levels. Treatment is parathyroidectomy.
Features
Muscle weakness
Neuromuscular excitability
Confusion, seizures
Tetany
Alopecia
Brittle nails
Cataracts
Dental hypoplasia
Treatment
Supplementation of calcium, vitamin D3
Hypoparathyroidism
Causes
Parathyroidectomy (intentional and accidental)
Autoimmune
Receptor defect (pseudohyperparathyroidism)
Di George syndrome
Clinical features
Short stature
Round face
Short neck
Shortening of the metacarpals and metatarsals
Causes of hyperphosphataemia
Renal failure
Hypoparathyroidism
Acromegaly
Vitamin D excess
Overintake of phosphate
Tumour lysis syndrome
Causes of hypophosphataemia
Intravenous glucose
Deficiency during parenteral feeding
Recovery phase of DKA
Primary hyperparathyroidism
Renal tubular disease
Vitamin D deficiency
Alcohol withdrawal
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 111
Osteomalacia/rickets
Decreased mineralisation of osteoid
Causes
o Calciopenic
Vitamin D deficiency
Impaired calcium metabolism
o Phosphopenic
Proximal renal tubular disease
Clinical features
Pain
Deformity
Fractures
Proximal myopathy
Raised alkaline phosphatase
Paget’s disease
Increased bone turnover with abnormal new bone turnover
Causes pain, deformity, arthritis, nerve compression, fractures, sarcoma
↑↑ALP
Calcium only raised with immobility
Diagnosis – clinical, typical X rays or bone scan
Treatment: analgesia and bisphosphonates
Know the range of therapeutic drugs which have a role in altering bone turnover.
Direct and interpret range of radiological and biochemical tests to assess bone
disease.
Choice of drugs and assessment of their effectiveness.
The range of osteogenesis imperfecta and how it influences adult life.
Renal osteodystrophy.
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 112
Understand bone turnover and different biochemical bone markers.
Treatment of attacks
(i) High-carbohydrate diet
(ii) Haematin
(iii) Opiate analgesia
(iv) Fluid restriction for hyponatraemia
(v) Conservative management of seizures, as antiepileptics can
precipitate attacks
Pseudohyponatraemia
Hyperlipidaemia
Hyperproteinaemia
Abnormal ADH release
Hypothyroidism
Severe potassium depletion
ADH-like substances
Oxytocin
DDAVP
Unmeasured osmotically active substances stimulating osmotic ADH
release
Glucose
Alcohol
Mannitol
Syndrome of inappropriate ADH secretion (SIADH)*
Stress
Surgery
Nausea
Causes of hypernatraemia
Dehydration
Iatrogenic (administration of hypertonic sodium solution)
Diabetes insipidus
Osmotic diuresis
(a) Total parenteral nutrition
(b) Hyperosmolar diabetic coma
Causes of SIADH
Malignancy
Bronchus, bladder, prostate, pancreas
Lymphoma
Ewing’s sarcoma
Mesothelioma
Thymoma
Drugs
Opiates
Carbamazepine
Oxytocin
Chlorpropamide
Phenothiazines
TCAs
Cytotoxics (vincristine, cyclophosphamide)
Rifampicin
Porphyria (drug induced)
Primary
o Childhood onset
o X-linked/dominant
o Tubular receptor abnormality
Secondary
o Hypercalcaemia
o Hypokalaemia
o Renal disease
o Chronic pyelonephritis
o APKD
o Post obstruction
o Sarcoidosis
o Drugs: Lithium
Demeclocycline (used to treat SIADH)
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 118
Amphotericin
Glibenclamide
Causes of polyuria
1. Excessive intake
Alcohol
Primary polydipsia (lesion of hypothalamus)
Psychogenic polydipsia
2. Osmotic diuresis
Diabetes mellitus
CRF
ARF (diuretic phase)
Diuretics
Diabetes insipidus (cranial and nephrogenic)
3. Hypokalaemia
4. Hypercalcaemia
5. Obstructive uropathy
6. Tubulointerstitial disease
Investigation of polyuria
-Record fluid intake
-Record urine volume (if ,3l/24 hrs and normal biochemistry excludes
significant abnormality)
-Blood glucose, U&E, calcium
-Urinalysis
-Early morning urine osmolality
-Water deprivation test
(a) To identify the cause of polyuria and/or polydipsia
(b) Hourly urine and plasma osmolality measured until 3% of bodyweight lost
(c) Injection of DDAVP (synthetic ADH)
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 119
Interpretation of the Water Deprivation Test
Potassium Metabolism
Potassium is the major intracellular ion. Excretion of potassium is increased by
aldosterone.
Causes of hypokalaemia
Decreased intake
Oral (uncommon except in starvation)
Parenteral
Renal
Thiazide diuretics
Loop diuretics
Renal tubular damage
Mineralocorticoid excess
Hyperkalaemia
Causes
Spurious
o Haemolysis
o Delayed separation of serum
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 121
o Contamination
o Excessive intake (parenteral, oral)
Decreased excretion
o Acute oliguric renal failure
o Chronic renal failure
o (Mineralocorticoid deficiency (Addison’s disease)
o Hypoaldosteronism
o Drugs
Spironolactone
Amiloride
Triamterene
ACE inhibitors
NSAIDs
Ciclosporin
Redistribution
o Acidosis
o Rhabdomyolysis
o Tumour lysis syndrome
o Digoxin poisoning
ECG changes
o Tenting of T waves
o Reduction in size of P waves
o Increase in PR interval
o Widening QRS complexes
o Disappearance of P waves
o Further QRS widening
o Sinusoidal waveform
Treatment
o IV calcium gluconate (stabilises cardiac membranes)
Causes
Renal loss
o Loop/thiazide diuretics
o Alcohol
o DKA
o Volume expansion
o Hypercalcaemia
Nephrotoxic drugs
o Aminoglycosides
o Cisplatin
o Ciclosporin
o Amphotericin
GI loss
o High-volume diarrhoea
o Malabsorption
o Other small bowel disease
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 123
o Acute pancreatitis
o
Primary renal magnesium wasting
o Rare familial condition
Hypermagnesaemia
Causes
(a) Magnesium infusion
(b) Magnesium enema
(c) Oral magnesium overdose
(d) Renal failure
(e) Adrenal insufficiency
(f) Milk-alkali syndrome
(g) Theophylline toxicity
(h) Lithium
Treat with iv calcium if symptomatic
Acid-Base Homeostasis
Metabolic Acidosis
Metabolic Alkalosis
With or without Respiratory compensation
Other disorders of fluid, electrolyte and acid-base balance
Respiratory acidosis
- Hypoventilation leading to increased CO2and acidosis
- Causes
(a) COPD
(b) Severe asthma
(c) Obesity
(d) Neuromuscular disorders leading to hypoventilation
(i) Guillain–Barré
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 125
(ii) MND
(iii) Myasthenia gravis
(iv) Muscular dystrophy
(v) Flail chest
(vi) Severe kyphoscoliosis
(e) Muscle relaxants
Respiratory alkalosis
Hyperventilation leading to low CO2levels and alkalosis
Causes
(a) Psychogenic
(b) Pulmonary disease
(c) Altitude
(d) Right to left shunt
(e) CO poisoning
(f) Salicylates
(g) Acute liver failure
Metabolic alkalosis
o Vomiting
o Potassium depletion
o Hyperaldosteronism
o Rapid diuresis
o Fulminant hepatic failure
o Milk-alkali syndrome
o Forced alkaline diuresis
Lactic acidosis
Type A
(a) Poor tissue perfusion with or without hypoxia
(i) Exercise
(ii) Post epileptic seizure
(iii) Shock
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 126
(iv) Severe hypoxia
Type B
(a) Administration of drugs or metabolic disturbance leading to increased production
of lactate
(i) Metformin
(ii) Alcohol
(iii) Recovery from DKA
(iv) Liver failure
(v) Paracetamol poisoning
(vi) Thiamine deficiency
Osmolar gap
Normally gap between serum osmolality and calculated osmolality is < 10
If the value is greater then this suggests another osmotically active substance in the
blood
Calculated with formula
2(Na+ + K+) + urea + glucose
Causes of raised osmolar gap
Methanol
Ethylene glycol
Diethylene glycol
Ethanol
Iron
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 127
o 4 g in normal human body, two-thirds in haemoglobin
o 20 mg/day in normal diet; only 10% absorbed
o Fe2+more readily absorbed than Fe3+
o Transferrin one-third saturated normal
o Ferritin increased in iron overload (NB: acute-phase protein), decreased in deficiency
o Plasma iron varies ++
Haemochromatosis
o Autosomal recessive
o Commoner, more severe in men
o Gene on chromosome 6
o Features: micronodular cirrhosis chondrocalcinosis, pseudogout, skin bronzing,
diabetes, cardiomyopathy, arrhythmias
o Diagnosis: raised serum iron and ferritin. Transferrin > 45% saturated. Liver biopsy
o Treatment: venesection, desferrioxamine
Wilson’s disease
o Autosomal recessive
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 128
o Gene on chromosome 13
o Abnormality of caeruloplasmin formation, hence accumulation of copper in body
o Features: acute/chronic hepatitis, cirrhosis, Kayser–Fleischer rings, CNS symptoms,
arthropathy, RTA.
o Diagnosis: low caeruloplasmin, high urinary copper, liver biopsy, KF rings
o Treatment: penicillamine (copper chelator), liver transplant
Treatment
Fluid Replacement
o Usual deficit ~6L in DKA and ~9L in HHS
o IV insulin
Lactic Acidosis
o Patient may be comatose, ill looking but not dehydrated
o Acetone/ketone breath
Hypoglycaemia
o RBG < 50 mg/dL
Resources
1. Patients on the medical and surgical wards, POSGH, are our most valuable resource
2. Patients in the medical outpatients’ clinics.
Readings
1. Guidelines for Common Medical Emergencies: T. Seemungal et al
2. Davidson’s Principles and Practice of Medicine: Metabolic Diseases.
3. Kumar and Clarke: Metabolic Diseases.
4. Oxford Textbook of Medicine
5. Harrison’s Principles of Internal Medicine
6. Royal College of Physicians Curriculum for Higher Specialist Training in Metabolic
Medicine
7. Royal College of Chemical Pathologists Training Board
8. Approved Websites:
International Diabetes Federation http://www.idf.org/
American Diabetes Association http://www.diabetes.org/
http://www.diabetesjournals.org/
ENDOCRINOLOGY MODULE:
CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE
Overview
This course is designed to complete the training of the medical undergraduate student in
endocrinology medicine within the context of general internal medicine over two rotating 8 weeks
clerkships. It is more inclined to appreciate the diseases of high prevalence in Trinidad and Tobago.
Prerequisite
A pass in the MBBS: Phase 1 examination.
The course covers diseases of the endocrine system. Students would be expected to have been
exposed to the rudiments of examination and history during Phase I training. This course is designed
for students during the final two clinical years of undergraduate medicine.
Content
Clinical presentation of endocrine diseases
A list of common symptoms associated with endocrine diseases are as follows:
Constipation: Hypothyroidism,
Hypocalcaemia.
Anaemia
Renal Failure
Occult Malignancy
Depression
↓Pigmentation: Hypopituitarism
SYNDROMAL SYMPTOMATOLOGY
It is important to remember that hormones control so many aspects of body function
that the manifestations of endocrine disease are protean and it is sometimes easier to
identify the symptoms as belonging to a syndrome!!!
Endocrinology History
Drug History: importance of retrospective diagnosis of endocrine disease from the drug
history. A dosage schedule and a side effects profile should be noted for any drug in use!!
Previous use of any antithyroid drugs, thyroid hormone or any radio-iodine (131I) treatment
can→ Hypothyroidism.
Any Radiation therapy for carcinoma? → Hypothyroidism
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 138
Any steroid or mineralocorticoid replacement for eg. In hypopituitarism or hypoadrenalism?
Allergy History
Social History
What is the patient’s alcohol intake?
Does the patient smoke?
Many of these conditions are chronic and carry with them serious complications. You need
to determine how well the patient is coping and ask about conditions at home and work as
these will have an important impact on the success of treatment.
THYROID DISEASE
Thyrotoxicosis Hypothyroidism
General Signs of weight loss and anxiety Signs of obvious mental and
Inspection physical sluggishness.
Frightened facies
Evidence of ‘Myxoedema
Madness’.
Legs Pedal oedema (pitting) - Sign of Non-pitting oedema
CCF which may be precipitated by
thyrotoxicosis in the elderly. Signs of peripheral
(Apathetic Hyperthyroidism) neuropathy
Alopecia
Reddened gland? →
Suppurative thyroiditis
Percussion-
Change from resonant to
dull may indicate a
retrosternal goitre (not a
very reliable sign)
Auscultation-
Any Bruits?
PITUITARY DISEASE
Panhypopituitarism Acromegaly
General inspection Short stature( Failure Characteristic face and
of GH secretion body habitus as
before closure of the described below.
epiphyseal plates)
Complete absence of
secondary sexual
characteristics (if
Gonadotrophin failure
occurred before
puberty)
Psuedogout
Testicular atrophy
in♂- small, firm
testes.
Thickened skin
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 142
Osteoarthritic
changes(skeletal
overgrowth)
Carpal tunnel
syndrome secondary to
soft tissue overgrowth
(Phalen’s sign)
Palpate for
greasy skin
Transfrontal scars? →
Hypophysectomy
scars
Splayed teeth
Prognathism-
protrusion of the jaw
Hoarse voice
↓ in nipple Gynaecomastia
pigmentation
Spleenomegaly
Renal enlargement
BP
ADRENAL DISEASE
Cushing’s Syndrome Addison’s Disease
General inspection Standing: Observe front, back Look for
and sides Vitiligo
Plethora +/-
polycythaemia
Acne
Hirsutism in the ♀( in
the presence of
androgen excess)
Telangiectasia
Funduscopy-
visual field defects
optic atrophy
papilloedema
Hypertensive
changes
Diabetic changes
Palpate for
Adrenal masses ( a
large adrenal
carcinoma will be
palpable over the
adrenal area)
Hepatomegaly
secondary to fat
deposition.
Palpate for:
Bony tenderness of the
vertebral bodies ( ←
crush fractures from
osteoporosis secondary
to an anti-vitamin D
effect and ↑ urinary
calcium excretion which
both affect the bone
matrix)
NB.
Cushing’s disease is specifically pituitary ACTH overproduction while,
Cushing’s Syndrome could be secondary to excessive steroid hormone production
from any cause.
Signs suggesting that adrenal carcinoma may be the underlying cause include:
1. A palpable spleen
2. Signs of virilization in the ♀
3. Gynaecomastia in the ♂
Signs that suggest that ectopic ACTH production may be the cause include:
1. Absence of the Cushingoid body habitus
2. More prominent oedema and hypertension
3. Marked muscle weakness
Significance of hyperpigmentation:
1. An extra adrenal tumor
ADDISON’S DISEASE
This can be part of an autoimmune polyglandular syndrome:
Type I
1. Chronic Mucocutaneous Candidiasis
2. Hypoparathyroidism
3. Addison’s Disease.
Type II
1. IDDM
2. Autoimmune thyroid Disease
3. Addison’s Disease
4. Myasthenia Gravis
CALCIUM METABOLISM
Primary Hyperparathyroidism Hypoparathyroidism
‘stones’ (renal stones) → neuromuscular tetany
‘bones’ (osteopenia and
psuedogout)
‘abdominal groans’
( constipation, peptic ulcer
and pancreatitis)
‘psychological moans’
(confusion)
Hyperreflexia
Monilial infectionof
the nails?
Other Check BP ↑?
DIABETES MELLITUS
General Inspection Look for any evidence of dehydration- osmotic
diuresis (glycosuria) can → massive fluid loss.
Face
Eyes Visual Acuity? – Retinal disease?
Any change in the shape of the lenses?
Funduscopy:
1. Rubeosis- new blood vessel formation over the
iris that can→ glaucoma.
2. Cataracts- sorbitol deposition in the lens.
3. Non- proliferative retinal changes?
Haemorrhages- Dot (inner retinal layers) and blot
(in the superficial nerve fibre layer).
Microaneurysms- vessel wall damage
Exudates- Hard or soft ( cotton wool spots with a
fluffy appearance)
4. Proliferative changes? Changes in the blood
vessels in response to ischaemia
New vessel formation? → vitreal haemorrhage?
→ Retinal detachment?
Any laser scars (small brown or yellow spots)
secondary to photocoagulation of new vessels by
laser therapy.
In the interpretation of the results of endocrinological investigations the normal range of values for
the following hormones should be known
LH ♂ 2-10 U/L
♀ follicular 2-10U/L
♀ post menopausal > 20 U/L
TSH deficiency
Measure random serum thyroxine
Note that TSH is often detectable in pituitary disease, due to inactive
isoforms in the body
GH deficiency
The student should know that this should only be investigated if GH replacement
therapy is being contemplated. Know that GH levels are commonly undetectable, so
a choice from a range of stimulation tests is required:
1 hour after going to sleep
Frequent sampling during sleep
Post-exercise
Insulin induced hypoglcaemia
Clonidine
arginine
glucagon
2. THYROID DISEASE
Hyperthyroidism
Serum T3: ↑ (particularly in T3 thyrotoxicosis).
Serum T4:↑ but in the upper part of the normal range.
TSH: < 0.1 mU/L.
131I uptake and TRAb are of diagnostic value in Graves when exopthalmos, goitre
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 153
and pretibial myxoedema are not present.
LFTs: slightly ↑ bilirubin, alanine aminotransferase and GGT; ↑ ALP from bone and
liver
U&E’s: Mild hypercalcemia
Urinalysis: Associated diabetes mellitus and ‘lag storage’
Hypothyroidism
TFTs: serum T4↓ and TSH ↑ (>20mU/L)
Non-specific tests-CE’s: ↑ LH and CK
Lipid Profile:↑ cholesterol and TGs
U&E’s: ↓Na+
ECG- sinus bradycardia
Low voltage complexes
ST/T wave abnormalities
3. PARATHYROID DISEASE
Students should know that before interpretation of any of the following values the total
calcium measurements need to be corrected if serum albumin is ↓.
PTH measurements
Urinary calcium
U&E’s: Ca, PO34-
Alkaline phosphatase
4. ADRENAL DISEASE
Investigations for Cushing’s syndrome have been discussed.
Addison’s disease
Cortisol levels.
Synacthen test.
U&E’s: ↓Na+,↑K+
Renin and aldosterone measurements in a recumbent position
Blood glucose
TFTs
CBC (pernicious anemia)
Full autoantibody screen ( Abs against adrenals, gonads, thyroid, pancreatic beta
cells and parietal cells)
CXR to rule out Tuberculosis ( causes adrenal calcification)
5. DIABETES ( this would be considered in greater detail in both the specific objectives and
the metabolic curriculum)
Objectives:
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 154
1. Diabetes mellitus:
• Recognize the important recent studies and various treatment modalities for prevention of
diabetes including lifestyle modification and medical therapy and their rationale.
• Recognize various treatment modalities for therapy for type 2 diabetes utilizing
sulfunylurias, biguanides, a-glucosidase inhibitors, and thiozolidinediones, and the site
of action of each agent in the pathogenesis of type 2 diabetes.
• Recognize the importance of recent clinical trials on the use of Ace inhibitors and
angiotensin receptor blockers in prevention of deterioration of nephropathy in diabetes
as well as their role in prevention of type 2 diabetes in those patients with impaired
glucose tolerance.
2. Thyroid disorders:
• Evaluate how various aspects of thyroid function may affect cardiac function and the
theory behind such actions.
• Apply the knowledge from clinical trials for treatment of thyroid cancer and measurement
of the outcome of such therapies.
• Evaluate thyroid storm and Myxedema coma and their etiopathology and treatment.
3.Hypertension:
• Use the latest advances and diagnostic maneuvers to differentiate between hypertension
due hyperaldosteronism, Cushing's, and pheochromocytoma as well as hypercalcemia
and hyperthyroidism.
• Diagnose by imaging method between hyperparathyroid and thyroid disease; the medical
versus surgical management; and theory behind each method.
• Describe the management of hyper and hypocalcemic crises and the theory behind such
therapies.
5. Adrenal disorders:
• Describe the clinical signs and differential diagnosis of pheochromocytoma and the
pathogenesis of this tumor in multiple endocrine adenomatosis (MEA).
• Describe how various medicines may interfere with urinary tests in the work-up of
pheochromocytoma and what may be done to avoid these problems.
6. Pituitary disorders:
• Describe the pathogenic pathways for the development of Cushing' s disease and how to
diagnose by use of radiological manipulation.
• Be able to tell the percent surgical success for the major pituitary tumors (acromegaly,
Cushing's, and prolactinoma).
9. Gonadal dysfunction:
• Diagnose male hypogonadism and prevalence in the general population verses individuals
with type 2 diabetes.
• Diagnose hypogonadism in the female including primary and secondary amenorrhea and
how to distinguish, diagnose, and treat such conditions.
• Explain the latest theory regarding the evolution of the polycystic ovary syndrome (PCOS)
and the effect of insulin on the evolution of such a syndrome.
• Explain the role of PCOS in the development of metabolic syndrome and the latest theory
on managing such patients by medical intervention.
• Recognize the controversy regarding hormone replacement therapy and the data presented
to justify or discourage the use of such hormones in different populations.
• Describe the use of appropriate medications in regard to efficacy, cost, and side effects in
various endocrine disorders.
In the study of each of these diseases, the principles of history taking and examination will be
emphasized.
Students will be expected to be able to describe the investigation of these diseases and the principles
of management and knowledge of drugs used where applicable.
Goals/ Aims
The knowledge base developed during the year 4 training in internal medicine will be expanded in
year 5. All diseases discussed during year 4 will be reviewed during bedside sessions and a few other
pulmonary diseases will be discussed.
The common endocrine diseases have been chosen for the core endocrine medicine in your syllabus.
Patients with these diseases should be easily clerked on the medical wards of San Fernando General
Hospital and Port of Spain General Hospital or chest wards at the EWMSC.
Students will be expected to attend the Medical Grand rounds at the POSGH during their training at
POSGH and to answer simple questions about the cases discussed during these sessions.
Students are expected to be aware of the latest therapeutic strategies employing evidence-based
medicine. This information may be accessed via the various approved websites.
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 157
By the end of their 2 years’ training in endocrine medicine, students will expect to have reached an
internationally accepted standard in their knowledge and management of endocrine diseases within
general internal medicine.
General Objectives
5.MEDICAL KNOWLEDGE
Applies relevant clinical and basic science knowledge of the following medical
conditions
Uncontrolled diabetes
Chronic Diabetes Mellitus
Thyroid Disease
Adrenal insufficiency
Hypercalcaemia
Cushing’s Syndrome
The student should begin to demonstrate a progression in the content knowledge
and analytical thinking with well formulated differential diagnoses and
management plans.
Specific Objectives
At the end of the course you will be able to
• Learn inpatient consultation management and efficient outpatient management of patients with
endocrine disorders
• Learn inpatient and outpatient management of patients with diabetes mellitus, including
ketoacidosis, non-ketotic hyperosmolar coma, simple glycemic control, management and prevention
of diabetic complications, and adjusting insulin and/or oral hypoglycemic therapy for procedures or
surgery.
• Recognize and treat life threatening endocrine disorders such as thyroid storm, myxedema coma,
hypertensive crises from pheochromocytoma, and adrenal crisis.
• Efficiently evaluate the endocrine systems of acutely and chronically ill patients, including the role
of stimulation and suppression testing and imaging studies
Assignments
1. The student will expected to clerk at least 1 patient with any of the
Endocrine diseases described in the content section above and to present and
discuss each case with any instructor. Clerking of a patient will involve
a. Presenting compliant
g. Complete history
h. Examination of all systems of the patients with special emphasis on
the chest examination
i. A description of what investigations were done and should be done
with details of results where applicable
j. Treatment and response to treatment
k. Follow-up plan for the patient including discharge
2. Students may be given a short project
Assessment/ Evaluation
The purpose of the assessment would be to help you to appreciate where you have reached in
attaining the goals set out in this syllabus and to stimulate you to continue to study internal and
pulmonary medicine.
Your assessment will take the following forms
(4) A written examination based on structured questions or MCQs
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 160
(5) Evaluation of a project and coursework
(6) Grading of cases clerked
Teaching Strategies
The Department of medicine employs several teaching strategies which will include
1. guided lectures,
Resources
1. Patients on the medical and surgical wards, POSGH, are our most valuable Resource.
2. Patients in the medical outpatients’ clinics.
Readings
APPENDIX x
NEUROLOGY MODULE:
CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE
Course description
Prerequisite
A pass in the MBBS Phase 1 examination.
The course covers disorders of the nervous system. Students would be expected to have
been exposed to the rudiments of the neurologic examination and history during Phase I
training. This course is designed for students during the final two clinical years of
undergraduate medicine.
At the end of the course, the student will be expected to diagnose and treat the following
major common disorders of the nervous system: headaches, raised intracranial pressure,
syncope, epilepsy, head injury, stroke, dementia, meningitis and encephalitis, brain tumour,
parkinsonism and movement disorders, multiple sclerosis, spinal cord and root dysfunction,
peripheral neuropathy and neuromuscular disorders. The student will also be expected to
understand the differential diagnosis of these conditions and how to differentiate between
these and other medical conditions by laboratory and radiological investigations.
Contact Information
Content
1. Headaches
2. Blackouts & loss of consciousness
3. Dizziness & vertigo
4. Weakness, altered sensation
5. Coma and brain death
6. Disordered cognition
7. Mood and behavior
8. Visual problems
9. Speech problems
10. Breathing and swallowing disorders
11. Incontinence
The student is expected to characterise each of these symptoms by;
a. onset (where, when how)
b. duration
c. evolution
And to know the i. nature
ii. mechanism
iii. common causes of EACH of these symptoms.
Neurologic History
Past Medical History: importance of comorbidites eg hypertension, diabetes, hyperlipidaemia,
atrial fibrillation, bacterial endocarditis, myocardial infarction (emboli), haematological disease.
Drug History: analgesic overuse, caffeine withdrawal, carbon monoxide, hormones (eg, estrogen),
The student should be aware that diagnostic procedures should not be used for preliminary
screening, except perhaps in emergencies when a complete neurologic evaluation is impossible.
Evidence uncovered during the history and physical examination should guide testing.
2. CT Scanning
Indications, limitations, acute vs chronic changes, contrast and non-contrast
Images
4. Electroencephalogram
Usefulness especially in seizure disorders
In the final year several further diseases will be discussed in addition to those studies
during the fourth year:
(14) Spinal cord and root dysfunction (including spinal cord compression)
a. Basic anatomy of spinal cord and its roots.
b. Effects of spinal cord dysfunction by segmental level
c. Symptoms , signs and cause of the following spinal cord syndromes;
- Anterior cord syndrome
- Brown-Séquard syndrome
- Central cord syndrome
- Conus medullaris syndrome
- Transverse myelopathy
- *Cauda equina syndrome (not a spinal cord syndrome- nerve root
dysfunction)
d. Classification of spinal cord compression as acute, subacute and chronic and their
symptoms and signs
e. Diagnosis using MRI vs CT in the elective vs emergency setting
f. Prognosis
g. Treatment principles including, immobilization, maintenance of oxygenation and
perfusion, supportive care, sometimes surgical stabilization,
possibly methylprednisolone for blunt injuries, long-term symptomatic care and
rehabilitation
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 169
(15) Functional symptoms as presentation of psychological disorder
a. Definition of a conversion disorder
b. Presentation
c. Diagnosis by; i. Excluding neurological disease
ii. Exclusion of feigning
iii. Establishing a psychological mechanism
d. Treatment principles including psychotherapy and cognitive behavioural therapy
In the study of each of these diseases, the principles of history taking and examination
will be emphasised.
Goals/ Aims
The knowledge base developed during the year 4 training in internal medicine will be
expanded in year 5. All diseases discussed during year 4 will be reviewed during bedside
sessions and a few other neurologic diseases will be discussed.
Seven very common neurologic diseases have been chosen for the core neurology module
in your syllabus. Patients with these diseases should be easily clerked on the medical or
neurology wards of San Fernando General Hospital, Port of Spain General Hospital and
EWMSC. These disorders of the nervous system will be discussed in terms of lesions of the
central nervous system and autonomic & somatic nervous systems with focus on basic
neuroanatomy in order to illustrate a simple model of understanding of disorders of
neurology.
Students will be expected to attend the Medical Grand rounds at the POSGH during their
training at POSGH and to answer simple questions about the cases discussed during these
sessions.
Students are expected to be aware of the latest therapeutic strategies employing evidence-
based medicine. This information may be accessed via the various approved websites.
By the end of their 2 years’ training in neurology, students will expect to have reached an
internationally accepted standard in their knowledge and management of disorders of the
nervous system within general internal medicine.
General Objectives
The years 4& 5 neurology module consists of 2 sessions per week for 8 weeks either at
POSGH or at EWMSC. You will be provided with a sessional timetable at the start of the
course.
Specific Objectives
3. The student will expected to clerk at least 1 patient with each of the first 7
neurologic diseases described in the content section above and to present and
discuss each case with any instructor. Clerking of a patient will involve
a. Presenting compliant
l. Complete history
m. Examination of all systems of the patients with special
emphasis on the neurologic examination
n. A description of what investigations were done and should be
done with details of results where applicable
o. Treatment and response to treatment
p. Follow-up plan for the patient including discharge
4. Students may be given a short project
Assessment/ Evaluation
The purpose of the assessment would be to help you to appreciate where you have reached
in attaining the goals set out in this syllabus and to stimulate you to continue to study
internal medicine and neurology.
Your assessment will take the following forms:
(4) A written examination based on structured questions or MCQs
(5) Evaluation of a project and coursework
(6) Grading of cases clerked
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 171
Teaching Strategies
The Department of medicine employs several teaching strategies which will include
1. guided lectures,
2. bed side teaching,
3. small group teaching,
4. non-lecture strategies: projects, group discussions, role play, co-operative learning
Resources
1. Patients on the medical and surgical wards, POSGH, are our most valuable
resource.
2. Patients in the medical outpatients’ clinics.
Readings
APPENDIX xi
Course description
Overview
Prerequisite
A pass in the MB:BS Phase 1 examination.
9. Year 4
10. Year 5
Cardiac medicine is one of several components of general internal medicine with which the
student is expected to become familiar over the two final years of undergraduate training in
the Faculty of Medical Sciences and integrates closely with other sub-specialties including
pulmonary medicine, cardiothoracic surgery and intensive care medicine. Over the course of
the final 2 years of undergraduate training, students are expected to become familiar with the
management of cardiac diseases within and across these specialties.
Cardiac Medicine as a Discipline within Internal Medicine
The Department of Clinical Medical Sciences is comprised of four units: Adult Medicine
(General Internal Medicine), Paediatrics and Radiology. Cardiac medicine is one of several
disciplines within internal medicine.
The course covers diseases of the heart or cardiovascular system and is also called cardiology
or cardiac medicine. Students would be expected to have been exposed to the rudiments of the
cardiovascular examination and history during Phase I training. This course is designed for
students during the final two clinical years of undergraduate medicine.
At the end of the course, the student will be expected to diagnose and treat the following major
common cardiac conditions: acute coronary syndromes (ACS), arrhythmias, pulmonary
arterial hypertension, valvular heart diseases and heart failure as well as predisposing
conditions. The student will also be expected to understand the differential diagnosis of these
conditions and how to differentiate between these and other medical conditions by laboratory
and radiological investigations.
85% of the global mortality and disease burden from cardiovascular disease
(including an estimated 32 million heart attacks and strokes yearly) is borne by
developing countries. (2006, Heart Institute of the Caribbean)
WHO forecasts indicate that the number of deaths in the region (Latin America and
the Caribbean) attributed to cardiovascular disease will increase by more than 60%
between 2000 and 2020, unless preventive measures are introduced. During the same
period, mortality from cardiovascular disease will only increase by 5% in the
developed world. (The Lancet, Volume 368, Issue 9536, Pages 625 - 626, 19 August 2006)
According to the WHO, “undetected billions are at high cardiovascular risk ... due to
hypertension, diabetes, high lipids, tobacco use, physical inactivity and unhealthy
diet". (2006, Heart Institute of the Caribbean)
In Jamaica and most of the Caribbean, cardiovascular disease is a leading cause of
death, disability and hospitalization and accounts for a major portion of local and
overseas health care spending. (2006, Heart Institute of the Caribbean)
The societal costs of diabetes in Latin America and the Caribbean were estimated at
$US65 billion in 2000. (2009, Caribbean Community (CARICOM) Secretariat: Summit on Chronic
Non-communicable diseases [CNCDs])
Also, we do not ask questions enough. Asking questions are a vital component of the learning
process. Use it! “The important thing is not to stop questioning. Curiosity has its own reason
for existing.” (Albert Einstein)
We do hope you enjoy your brief time with us in this exciting field.
Content:
The student is expected to characterize each of these symptoms by onset (where, when, how),
duration and evolution and have a knowledge of common causes of each of these symptoms.
History-
2. 12 lead ECG (recordings in acute MI, atrial fibrillation, sinus tachycardia, sinus
bradycardia, heart block- 1st, 2nd and 3rd degree, bundle branch block)
Clinical Pharmacology
Drugs-
a. ACE inhibitors
b. Angiotensin receptor blockers
c. Antiarrythmic drugs
d. Anticoagulants
e. Antiplatelet agents
f. Β- blockers
g. Calcium channel blockers
h. Digitalis
i. Diuretics
j. Inotropic drugs
k. Nitrates
l. Statins and other lipid-lowering agents
a. Hypertension
- Definition (essential & secondary)
- Pathophysiology
- Diagnosis
- Classification- JNC 7/8
- Treatment options- dietary, lifestyle, pharmacological
b. Dyslipidaemia
- Definition
- Diagnosis
- Complications and consequences
- Treatment options- dietary, lipid lowering drugs
c. Diabetes Mellitus
- Definition
- Classification
- Diagnosis (American Diabetes Association)
- Cardiovascular complications
- Treatment options
b. Non-viral
- Lyme carditis, toxoplasma gondii, chagas’ disease, rheumatic carditis
Clinical manifestations:
Presenting symptoms- pulmonary venous congestion, congestive heart failure,
cyanosis, collapse, hypoxic spells, haemoptysis, cerebral and pulmonary
complications, and arrhythmias.
Systemic manifestions- growth retardation, respiratory infections, cerebral
Adult Medicine Unit / UWI & Dept. Medicine / POSGH 178
complications, pulmonary vascular disease.
Physical examination- upper-lower extremities perfusion and pulse, splitting of heart
sounds, thrills, murmurs.
Outline the pathology, diagnosis (with the aid of changes in heart sounds, ECG,
echocardiography, chest x-ray and catheterisation) and management of the following:
a. Atrial Septal defects
b. Atrioventricular septal defects
c. Ventricular septal defects
d. Pulmonary stenosis
e. Aortic stenosis
f. Patent ductus arteriosus
g. Coarctation of the aorta
h. Tricuspid atresia
i. Ebstein’s anomaly of the tricuspid valve
j. Tetralogy of Fallot
k. Complete transposition of the great arteries
l. Common arterial trunk
m. Pulmonary atresia
a. Aortic stenosis
b. Aortic regurgitation
c. Mitral valve stenosis (include role of acute rheumatic fever)
d. Mitral valve regurgitation- role of rheumatic disease (include mitral valve
prolapsed)
e. Tricuspid stenosis
f. Tricuspid regurgitation
g. Acquired pulmonary valve disease
a. Definition
b. Clinical models of heart failure (systolic and diastolic HF, left and right sided HF,
high-output vs low-output HF)
c. Aetiology (myocardial disease, valve disease, pericardial disease)
d. New York Heart Association (NYHA) functional classification
e. Symptoms (breathlessness, fatigue, weakness, cough)
f. Examination (oedema, heart rate and rhythm, arterial and venous pulses, BP,
palpation of precordium, heart sounds)
g. Diagnostic tests (CBC, serum lipids, renal and hepatic function, BNP, CXR, ECG,
Echo, Stress testing, nuclear cardiology, MRI, angiography)
h. Management of acute and chronic HF
a. Definition
b. Clinical classification of pulmonary hypertension (Evian classification: Group 1
consists of PAH)
c. Primary & secondary PAH
d. Functional Classification
e. Clinical features (progressive exertional dyspnoea, angina of effort, syncope, right
heart failure, oedema, ascites, sudden death).
f. Investigations (arterial blood gases, CXR, ECG, Echo, MRI, pulmonary function
test, ventilation-perfusion lung scan, pulmonary angiography)
g. Diagnosis (including exclusion of secondary causes of PAH)
h. Management
(9) Arrhythmias
b. Causes of each
c. Clinical characteristics
d. Management (including CPR)
Patients- wards/clinics
Davidson’s Principles and Practice of Medicine
Kumar and Clark
Clinical Examination- Macleod
Oxford Handbook of Clinical Medicine
Websites- European Society of Cardiology, American College of Cardiology,
American Heart Association, International Diabetes Federation
References
APPENDIX xii
}
Pain in left forearm and
hand Headaches
Jitteriness x 3/52
Review of systems:
GENERAL: generally well but fatigued ºchange in sleep pattern, appetite or weight
CNS: headaches paraesthesia in left forearm and hand ºdizziness ºsyncope ºseizures
√ √
√
polydipsia ºpolyphagia
GU: √
occasional dysuria and increased frequency ºhaematuria vaginal pruritus
√
Summary:
Mrs. Cauldero, a 48-year-old female, is a known diabetic for 6 years who has been
managed non-pharmacologically, and presents with a one-week history of chest pains and a
three-week history of headaches, pain in left forearm and jitteriness.