Professional Documents
Culture Documents
● Structure of Training 11
●Medical Emergencies 12
Appendix:
Detailed Curricula:
I. Post-Exposure Prophylaxis
III. Dermatology
IV. HIV
V. Pulmonology
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
WELCOME TO FINAL YEAR INTERNAL (ADULT) MEDICINE
It is hoped that your relatively short time in final year medicine will be a useful learning
experience and that you will obtain a good grounding in internal medicine.
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 4030, 623 2951 Ext 2585
FAX 627-5184
Year 4
Secretary: Ms. Janelle Timothy
Office (EWMSC) Phone/Fax 663 4332 or 645 2640 ext 2926
EMAIL : Adult Medicine Unit, EWMSC
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
THE OBJECTIVES OF THE MEDICINE CLERKSHIPS
1. To develop the skills of history taking and examination of all systems in the adult.
3. To recognize and respond to the needs of your patients: - medical, social and
psychological.
medical jurisprudence.
In brief, we teach through service AND you learn through service. At the end
of the FINAL CLERKSHIP the student should have the proficiency level of an
intern.
WARD WORK
● 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 0800 to 1600 hours.
● The unit must be covered from 0800 to 1600 hours on weekdays and on post call
days including weekends
● Units run best when they operate as a team. If you complete your ward work early
then you are expected to help out on the other ward.
● 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.
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
● On call:
o Students to remain with the on call unit until 8.00 PM.
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 and including weekends where you are on call
or posstcall, you are expected to remain with your unit until completion of
jobs.
● Absence from work: 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 work 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.
● Absence from any examination: According to University Regulations, if you are
absent for an examination component, you must have your sick leave validated by
the Health office in Main Campus. Failure to do so will result in your absence
counting as failed opportunity of the examination.
2. Clinical responsibilities:
● You are not allowed to document in patients’ notes as this is not medico-legally
acceptable.
● 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,
ABD, 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.
o Reflexes must be recorded in the case notes as follows:
B T S K A Pl
RHS
LHS
- = no reflex, + = hyporeflexive
++ = normal, +++ = hyperreflexive
↑, →, ↓ = for the plantar responses
Problem List: the problem list is dynamic and may be changed as new
information arises
S (subjective i.e. symptoms)
O (objective i.e. signs; pathology results, radiology results)
A (your assessment of progress and any new problems)
P (plan)
● Handover of critical cases on call: there must always be a handover of critical cases
between students (and of course between doctors) when on call. This will usually
take the form of a verbal discussion followed by a review of the notes and patient.
● Consultations – asking another unit for advice:
o Can only be authorized and signed by the registrar or consultant
o There must be verbal as well as written communication with the unit from
whom we are requesting advice.
o The name of the doctor and the unit consultant with you have communicated
must be recorded in the patient’s notes.
● All deaths must be reported to the consultant and a note drafted to the Medical
Chief of staff
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
4. Role of Students in the Department of Medicine
● To attend all consultant led ward rounds
● To attend all post call and on call ward rounds and to present patients they have
clerked. On the on call days and post call days’ attendance at these ward rounds
will supersede any formal teaching sessions.
● Students should lead the ward rounds.
● To follow up on their admissions and to keep daily records of the performance
of their patients as outlined above.
● To undertake such responsibilities as are assigned by the junior doctor in charge
of the ward and this should include: investigations, results of investigations,
keeping the patient notes updated with results, checking on therapy given.
● Whatever you do MUST contribute to improving patient care and it is this that
will determine your ward-based assessment.
● When students are involved in patient care on the medical wards they must be
supervised by the junior or senior medical staff who must be present on the
wards while students are doing their jobs.
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.
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
6. Procedures performed
● 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.
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
1. YOUR ASSESSMENT: Year 5
● 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 including MCQs, EMQs, IRQs Report
writing (E.g. prescription, death certificate, discharge form, medical report
etc.) and OSCE (80%)
o IRQs consist of a series of MCQs about a pathology result including ECG or
Chest X-ray or CT scan or a lab test report which is shown as part of the
question
o Ward work assessment, which includes professional behaviors, team
working, communication and history taking, relations with patients, clinical
knowledge and reasoning, time and stress management (about 10%)
o Presentations, projects, self-assessments and other observations (about 2%).
o 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
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
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 need to approach the Deputy Dean’s office to repeat the whole clerkship
for eight weeks.
o If a student fail in OSCE/WRITTEN alone and scored 50% or more in the overall
assessment, then the student will be allowed to re-sit the OSCE/WRITTEN with the
next group or as decided by the Deputy Dean.
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:
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
FOURTH AND FIFTH YEAR CORE CURRICULUM
Year 4 Year 5
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. Sandy/Dr Ramlackhansingh/Dr. Esack)
1. CVA/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)
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
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) ( - 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
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
STRUCTURE OF TRAINING IN INTERNAL MEDICINE DURING YEAR 4 & 5
OF THE MB.BS PROGRAMME
The rotation will be as follows and involving all three major hospitals (POSGH,
EWMSC, SFGH), Sangre Grande Hospital (SGGH) and Tobago Regional Hospital
(TRH).
Training in internal medicine will last 16 weeks over the final two years of the MB.BS
programme, with eight (8) weeks in each of years 4 and 5.
The start hospital will be determined in Year 4 such that ALL hospitals have an
approximately equal number of students with FOUR (4) weeks being spent in training
in any one institution and another four (4) weeks in a second institution as determined
by the rotation schedule shown below.
The clerkship exam (COSCE) will be held in weeks 6 through 8 of any clerkship. These
dates will be stated in advance but may be altered by the adult medicine unit at short
notice depending on the availability of examiners. Students will always be advised of
such changes in advance.
Week 1 2
Year 4 Weeks 1 - 4 POSGH or SFGH or SGGH EWMSC
or TRH
▼ ▼ ▼
Year 4 Weeks 5-8 EWMSC POSGH or SFGH or SGGH
or TRH
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
MEDICAL EMERGENCIES
1. Gastrointestinal bleeding
4. Status epilepticus
5. Shock
8. Hypoglycemia
14. Coma
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
PHLEBOTOMY PROCEDURE – VENIPUNCTURE
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
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
RADIOLOGY-IN-MEDICINE MODULE
1. CXR
2. CT of Chest
3. CNS Radiology
5. CT – Abdomen
6. MRI: CNS
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.
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
STUDENT-LEAD WARD ROUNDS
o The student should then discuss the major problems being managed at present and
o The student should also relate the discharge plan for the patient
o The student should in the presentation show how pathology results are being used in
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
THE CASE HISTORY IN MEDICINE
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 atleast 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.
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
PROCEDURES IN MEDICINE
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 AEP
O Lumbar puncture
NEPHROLOGY
O Ultrasound kidneys
O IVA / retrograde pyelography
O Kidney biopsy
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
HAEMATOLOGY
O Use of blood counting machines
O Bone marrow aspiration and trephine
O Hemoglobin electrophoresis
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
Recording a Procedure in the Medical Notes of Your Patient
Plan – your follow up plan for the patient including any post procedure precautions
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
Example
Date and Time of Procedure : 15th May 2010, 0900 hrs
Name of Procedure : Arterial Blood Gas
Consent :Verbal, pros and cons explained and rationale for test
Indication for procedure : Respiratory distress
Doctor Carrying put procedure : Dr. T ABGH (House officer)
Assistants : Medical Students GHTD, FGEQ, DFTY
Plan –
1. Bandage to wound
2. Blood sample to ABG machine in ice immediately.
Signature
Name
Designation
Signature
Name
Designation
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
REPORT WRITING – A COMMUNICATION SKILL
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.
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
GUIDELINES IN WRITING PRESCRIPTIONS
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)
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
SAMPLE OF HOSPITAL PRESCRIPTION
Prescription:
RX Doxycycline 100 mg
Disp #14
Sig: Take 1 capsule bid x 7 days
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
OBJECTIVES:
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
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
Duration of Therapy:
a) Prescriptions for a duration that is substantially different from normal standards
b) Not specified
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
APPENDIX i
INFECTION PREVENTION AND CONTROL UNIT
GENERAL HOSPITAL, PORT OF SPAIN
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.
In Medium and High Risk Situations i.e. Exposure to moderate or large quantities of
blood or body fluids or secretions from a potential source of HIV infection with muco-
cutaneous penetration e.g. – Needle stick injuries, other sharp objects etc.
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
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
● 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
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
APPENDIX ii
INFECTION PREVENTION & CONTROL UNIT POSGH JULY 2005
PROCEDURES FOLLOWING EXPOSURE TO
BLOOD-BORNE
PATHOGENS IN THE WORKPLACE
EXPOSURE INCIDENT
IMMEDIATE ACTION
▪ Wash exposed skin with soap and water.
▪ Flush mucous membranes (mouth, eyes, and nose) with
water.
▪ Remove soiled garments
▪ Note time of incident
▪ Report to Head nurse/Nurse in charge
Negative
Positive
Report to Infection Prevention
- Rapid HIV test done on exposed
And Control Unit
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
APPENDIX iii
DERMATOLOGY CURRICULUM
For Year 5 Medical Students (Clinical)
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:
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
(vi) Viral skin diseases
● Herpes simplex
● Herpes zoster
● Viral warts – common and genital
● Molluscum contagiosum
(viii) Infestations
● scabies
● lice
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
(xiii) Common skin manifestations of systemic disease
▪ Renal disease
▪ Hepatic disease
▪ Internal malignancy
▪ Thyroid disease
▪ Diabetes
▪ Haematological disorders including malignancy, iron deficiency
Anaemia, pernicious anaemia
▪ Drug allergy
2. Clinical Dermatologhy
Rona Mackie
REFERENCES:
1. Textbook of Dermatology
Champion, Burton, Ebling
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
APPENDIX iv
HIV CIRICULUM
HIV in Adult Medicine Curriculum:
Years 4 & 5 Undergraduate Medicine
Course description
Title: HIV Disease in Adult Medicine: Years 4 & 5 Undergraduate Medicine
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
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Purpose of the Course
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:
Specific Objectives:
Assignments
1. The student will be expected to clerk at least 1 patient with HIV infection.
Clerking of a patient will involve:
a. Presenting complaint
b. Complete history
c. Examination of all systems of the patients
d. A description of what investigations that 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
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
Timeline of important events in the evolution of the
global HIV/AIDS epidemic in the last century
1981
First cases of new immunodeficiency disease in gay men in US
1982
Same immunodeficiency disease diagnosed in Europe
Disease named AIDS by the CDC in US, and SIDA in France and Spain
1983
Heterosexual spread of AIDS documented
1984
Retrovirus isolated by Montagnier group at Pasteur Institute in France, shown to be the
cause of AIDS by Robert Gallo laboratory
1985
Blood test for HIV licensed by FDA
1986
LAV and HTLV-III renamed HIV
“Slim” disease (AIDS) widely recognized in Africa
1987
AZT introduced as first anti-HIV medication
1988
First World AIDS Day held on December 1
1989
ddI made available as part of expanded access program as second HIV drug.
1990
Ryan White dies and Ryan White CARE Act becomes law
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
8–10 million HIV-infected persons worldwide
1991
Red ribbon becomes an international symbol of AIDS awareness
ddC approved AZTand ddC used in combination for first time
1992
India funds National AIDS Control project with >15% of its health budget
1993
Transmission of AZT-resistant virus documented
3TC approved for clinical use
1994
AZT shown to reduce mother to child transmission of HIV
1995
First HIV protease inhibitor approved
AIDS named leading cause of death in US of persons25–44 of age
1996
First use of HAART with dramatic clinical responses
1997
Deaths from AIDS in developed world begin to drop due to HAART
1998
Glaxo-Wellcome cuts price of AZT by 75% due to evidence that the drug reduces mother-
to-child transmission in developing world
Content
∙ Rapid Tests
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
∙ ELISA
∙ Western Blot (WB)
∙ PCR (viral load)
∙ CD4 count
Laboratory evaluation: CD4 count, viral loan, CBC with diff, U&E, LFT’s, fasting
glucose, PPD, syphilis, toxoplasmosis, CMV, fasting lipids, hepatitis serologies, baseline
CXR, Pap smear in women.
Antiretroviral Drugs:
Know:
When to start therapy
When to change therapy
Common Combinations used
Common combinations to avoid
When to start therapy
When to change therapy
Common drug interactions
Common side effects
COMPLICATIONS OF HIV/AIDS
1. Chest Medicine
b. Histoplasmosis
- Aetiology
- Relationship to CD4 count
- Clinical presentation: hepatosplenomegaly, lymphadenopathy, cough,
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
chest pain( CNS, GI, cutaneous manifestations smaller%)
- Investigations: histoplasma antigen (resp secretion, blood, urine), biopsy of
involved tissue
- Prevention
- Prophylaxis
- Treatment; IV Amphotericin B followed by oral Itraconazole
c. Tuberculosis
- Aetiology
- Clinical presentation; LTBI-asymptomatic, Active TB-is influenced by
the degree of immunodeficiency.
- Diagnosis of latent TB infection (LTBI)
- Diagnosis of active TB infection
- When to start treatment
- What treatment to start
- Monitoring active TB disease
- Management of common adverse events-GI reaction, skin rash
- ART in the mgt of TB
- Optimal timing of imitation of ART
- Immune Reconstitution and Paradoxical Reaction-exaggerated
inflammatory response-fever, worsening of resp. status break through
meningitis.
- Management of treatment failure
- (see pulmonary medicine syllabus)
d. MAC
-Aetiology
-Clinical presentation: fever night sweats, weight loss, pancytopenia
-Investigations: sputum/AFB, alkaline phosphates, blood culture, CXR
-Treatment: Clarithromycin +Ethambutol
-Prophylaxis: Azithromycin or Clarithromycin
e. Cryptococcus
- Aetiology
- Clinical presentations (asymptomatic/symptomatic with/without
dissemination)
- Investigations
-Treatment
f. Pneumonia
- Aetiology
- Clinical presentation: similar to HIV negative patients
g. MAI Infection
- Mode Transmission
- Prior to HAART, occurred in 35% of all patients
- Relation to CD4 count (<50)
- Clinical presentation: fever, sweats, weight loss, chronic diarrhoea,
vomiting and abdominal pain.
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- Findings: multi-systemic
- Diagnosis: ABF + ve, culture, blood cultures (to check for dissemination)
- Treatment
- Prophylaxis
h. Kaposi Sarcoma
i. Lymphoma
j. Cor pulmonale
2. Gastrointestinal
a. Oral
-Aphthous ulcers
-Thrush (oral candidiasis) associated with burning or pain
-Oral hairy leukoplakia
-Kaposi’s Sarcoma
b. Esophagitis
-Candidiasis: Clinical presentations, painful dysphagia,
Treatment - fluconazole
-CMV: confirmation-biopsy-“owl’s eye inclusions”
-HSV, apthous ulcers, pill-induced
c. Enterocolitis
-Bacterial (usually acute): Salmonella, Shigella, Compylobacter, Yersinia, C.
difficile
-Protozoal (usually cronic): Giardia, Entamoeba, Cryptosporidium, Isospora,
Microsporidium, Cyclospora
-Viral (CMV, adenovirus)
-Fungal (histopplasmosis): MAC; AIDS enteropathy
d. GI Bleeding
-CMV
-Kaposi’s sarcoma
-Lymphoma
f. Hepatitis Band C
-Incidence in HIV infected individuals
-Mode of acquisition and carriage rate
-Treatment
-Management of treatment failure
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
-Prevention
g. Wasting
-Definition: Loss of > 10% body weight without obvious cause
-Geographical distribution: developing world mainly
-Peripheral fat loss (fat redistribution syndrome) associated with HAART.
3. Ophthalmologic
4. Cutaneous
5. Cardiac Disease
a. Cardiomyopathy
b. HIV related dilated cardiomyopathy common but not usually symptomatic
c. Drug induced.
d. Ischaemec Heart Disease and protease inhibitor related dyslipidaemias
e. Pericaardial effusion
- Clinical presentation
- Investigation-CXR, ECHO, ECG, lipid profile
- Management
6. Endocrine Disease
a. Hypoadrenalism
b. Hypopituitarism (rare)
c. Adrenal inefficiency (CMV adrenalitis)
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
7. Renal Disease
8. Neurological Diseases
∙ Cerebral Toxoplasmosis
- Clinical presentation- Short history of fever
confusion, seizures and focal signs follow
raised intraccranial pressure as a common complication
- Investigations CT or MRI-ring enhanced lesion, toxoplasma IgG Antibody,
sterotacticCT guided needle biopsy
-Differential diagnosis: CNS lymphoma, mycobacterial infection (esp TB),
fungal infection (cryptococcus), bacterial abscess, chagas disease, rarely PML
-Treatment: pyrimethamine and sulfadiazine or clindamycin
- Prophylaxis-TMP-SMX.
The year 4 & 5 HIV medicine module consists of the following sessions:
Assessment/Evaluation:
Teaching Strategies:
The department of medicine employs several teaching strategies, which will include
1. Guided lectures
2. Bedside teaching
3. Small group teaching
4. Non lecture strategies (projects, group discussions and co-operative learning
Resources:
1. Do not forget that the ward patients are your most valuable resource.
2. Patients in the medical outpatients’ clinics.
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
Readings:
Course Calendar:
Year 4:
Year 5:
Chest disease
Renal disease
Eye disease
GI disease
Grading System:
As for year 4& 5 Internal Medicine course please follow internal medicine syllabus
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
APPENDIX v
PULMONMARY MEDICINE MODULE:
CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE
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.
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Pulmonary 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. Pulmonary medicine is one of
several disciplines within internal medicine.
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.
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The student is expected to characterize each of these symptoms by onset (where, when
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
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role of arterial blood gas analysis[respiratory alkalosis, the asthmatic with a
normal or elevated PCO2], indications for a chest radiograph
i. Ward management: When to discharge, PEFR monitoring, training in use
of inhaled medications.
j. Intensive care: indications, discharge.
k. Community management of asthma: PEFR monitoring, grades of asthma
severity, GINA guidelines. Goals in treatment of asthma in the community:
abolition of symptoms, prevention of asthmatic exacerbations, life style
issues.
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
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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
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?
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vii. Investigation – bronchoscopy: (washings, brushings, biopsy),
Indications: Persistent cough, Dyspnoea, Haemoptysis,
Abnormal CXR, Inhalation of a foreign
object, Dx of asthma, lung ca, bronchitis, lung
inf, examine a congenital deformity
Contraindications: Unstable low BP, Arrythmias, Recent
heart attack or heart disease, Bleeding
problems, Allergy to lidocaine, Unstable
asthma, Restricted TMJ
Major Complications (0.5%): Respiratory depression,
Pneumonia, Pneumothorax, Airway
obstruction, Cardiorespiratory distress,
Arrhythmias, Pulmonary oedema, major
haemorrhage
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(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
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
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e. Diagnosis of OSA
f. Treatment: behaviour modification, nCPAP, surgery and oral devices,
tracheostomy. Pharmacotherapy- modafinil.
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.
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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
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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
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
(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
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Thoracic Society), ERS (Eur Resp Soc), PUBMED.
Other websites should be discussed with the instructor before use.
APPENDIX vi
NEPHROLOGY MODULE
CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE
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.
The course covers diseases of the kidneys and the urinary system and is often called nephrology,
when the focus is on internal medicine and urology when the focus is on surgery. Students would be
expected to have been exposed to the rudiments of the examination of the kidneys 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 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
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
Content
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.
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I. Urine analysis:
Macroscopic examination: appearance, odour, volume
Biochemical examination: Gravity, pH, glucose, ketones, proteinuria, haematuria, bilirubin
and urobilinogen, nitrite.
Microscopic examination: Cells (red, white, epithelial cells or malignant cells). Casts
(hyaline, granular, red cells, white cells, crystals
Microbiological examination: Morphological assessment of pathogens
II. Biochemical assessment of renal function. Urea and creatinine, sodium and potassium,
bicarbonate, calcium, protein and albumin, phosphate, urate and haematological status.
Immunological screening.
IV. Biopsy: Indicated in the diagnosis and assessment of parenchymal renal disease. Low
complications rate.
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 .
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 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.
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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
(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.
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Adult Medicine Unit / UWI & Dept. Medicine / POSGH
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.
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APPENDIX vii
ONCOLOGY CURRICULUM: Years 4 & 5
Objectives
Area Objective Topic
Public health
1.1 The role of cancer in population health and illness
1.2 Cancers – epidemiology, risk factors
1.3 Prevention, screening, and family risk
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
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Area: Public Health
Objective 1.1
Appreciate the significance of cancer as a health problem in Australia and throughout the
world.
Objective 1.2
The role of cancer in population health and illness
Appreciate the significance of cancer as a health problem in Australia and throughout the
world.
Cancers – epidemiology and risk factors
a) Describe the epidemiological concepts of morbidity (incidence and prevalence),
mortality, relative risk and survival in relation to common cancers.
b) Discuss the role of statistical information, including surveillance and monitoring data,
and understanding the medical practitioner’s need to be able to access numerical
information.
c) Discuss the purpose of cancer registries.
d) Describe risk factors for various malignancies – genetic and non-genetic.
e) List the most frequently diagnosed malignancies and the most common causes of
cancer death in Australia; describe in a general way how these are different in different
parts of the world.
f) Describe the differential rates of cancers and their outcome in Indigenous and non-
Indigenous Australians and the reasons behind them.
g) Describe the differing outcomes of cancers, in general, between rural and urban
populations and the reasons behind them.
✔ Prerequisite knowledge
■ Statistical concepts of relative and absolute values.
■ Inherited and acquired risk factors.
■ DNA structure and function.
■ Mendelian genetics.
1.2 Representative questions that suggest the required depth of knowledge
1. Describe the role of epidemiology in establishing causes of cancer and identifying risk
factors for cancer. Give examples of causes of cancer and risk factors for cancer and
explain the differences between them.
Essential in answer
■ Concept of risk – definitions, relative v absolute risk
■ Concept of causation.
■ Understanding of data collection.
2. Answer, in language you would use, the question from 45 year-old Mabel Jones: "What
caused my bowel cancer doctor? And what are the risks that other members of my
family will get cancer?"
Essential in answer
■ Knowledge of risk factors for colorectal cancers.
■ Knowledge of genetics of colorectal cancers.
3. What proportion of breast cancer patients have an identifiable genetic cause?
(a) 1%
(b) < 5%
(c) 5-10%
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(d) 30%
Answer: (c)
4. Which conditions are associated with an increased risk of colon cancer?
Essential in answer
■ Ulcerative colitis.
■ Crohn’s disease.
■ Familial polyposis.
■ Other familial conditions including hereditary non-polyposis coli syndrome
(HNPCC).
■ Benign polyps of the bowel.
■ Previous colon cancer.
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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.
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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
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him?
Essential in answer
■ Knowledge of environmental and lifestyle risk factors.
■ Knowledge of the genetics of colorectal cancer.
■ Knowledge of the controversy regarding PSA screening.
■ Recognition that smoking, overweight and familial risks are, on balance, more
significant issues than PSA levels for this patient.
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)
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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.
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Area: Cancer biology
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Objective 2.2
Physiology
Describe the principles of handling of chemicals (by cells): drug metabolism, handling of
carcinogens.
✔ Prerequisite knowledge
■ Cell biology.
■ Organ function.
■ Normal physiology.
2.2 Representative questions that suggest the required depth of knowledge
1. What is the blood/brain barrier?
Essential in answer
■ Concept of sanctuary sites.
■ Knowledge of mechanisms of fat solubility and molecular size.
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)
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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.
2. What are the roles of Tumour Angiogenesis Factor and Tumour Necrosis Factor in
neoplasia?
Essential in answer
■ Knowledge of new blood vessel formation.
■ Knowledge of abnormal cytokine production.
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.
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■ Biochemistry.
■ Functional anatomy.
■ Genetics.
■ Oncological physiology.
■ Pathology.
2. You have referred Mrs Briggs, a 47 year-old woman, to a general surgeon who you
went to university with because she has a suspicious lump in her left breast. Mrs
Briggs asks you about the multidisciplinary clinic that she has read about in the
National Health and Medical Research Council consumer guide. How do you respond?
Essential in answer
■ Knowledge of multidisciplinary management of cancer.
■ Knowledge of specialist v non-specialist management of cancer.
■ Ability to review management in light of evidence.
3. Write a submission to a hospital administration justifying the establishment of a
multidisciplinary breast clinic in your large teaching hospital.
Essential in answer
■ Knowledge of the different disciplines that contribute to successful cancer
management.
■ Knowledge of models that integrate disciplines.
■ Understanding of cost-benefits.
3. How does the general quality of a patient’s health impact on their probability of survival
when cancer is diagnosed?
Essential in answer
■ Understanding of measurement of performance status.
■ Understanding of impact of performance status on survival.
■ Understanding of side-effects.
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?
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causes and how would you establish a diagnosis?
Essential in answer
■ Metastatic lung cancer.
■ Non-malignant causes.
■ Establish diagnosis – plain X-Ray films, bone scan, CT, biopsy.
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Objective 5.2
Principles of surgery
a) Describe the aims of surgical treatment of cancers and the general principles of
common procedures.
b) Demonstrate an understanding of the range of surgical options and the ways these are
affected by the integration into multi-modality care.
c) Recognise clinical indications for surgery of common cancers.
d) Evaluate the outcomes of surgery, including efficacy, short and long-term side-effects,
financial costs and quality of life.
e) Describe the general and specific pre-operative factors that influence surgical decision
making.
f) Discuss the effect surgery may have on body image, including the role of
reconstructive surgery.
g) Recognise the common complications of cancer surgery and understand their
management.
h) Discuss interactions with other modalities of therapy, both pre and post-operatively.
✔ Prerequisite knowledge
■ Principles of pre-operative assessment.
■ Principles of post-operative management including pain control.
■ General complications of anaesthesia and surgery eg. deep venous thrombosis,
lymphoedema, pneumonia.
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5.2 Representative questions that suggest the required depth of knowledge
1. Your patient is a fit 65 year-old man with prostate cancer. You are discussing radical
(not nerve sparing) prostatectomy as a treatment. What probability would you quote
him of these significant side-effects occurring after surgery?
Impotence occurs:
(a) < 5%
(b) 20%
(c) 50%
(d) 80%
Answer: (d)
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%
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(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.
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. What are the aims of systemic adjuvant therapy (treatment given after definitive
surgery) in breast cancer and what are some of the recognised indications for
consideration of such therapy?
Essential in answer
■ Aims – to reduce risk of death or recurrence or to delay these events in women
with breast cancer.
■ Indications – node positive BC, large primary tumours, women considered at
“high” risk of recurrence.
More detail than this would be considered of greater than required standard
(ie. high-grade tumours, pre-menopausal, vascular invasion).
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Objective 5.5
Principles of palliative care
a) Demonstrate an understanding of the importance of the patient in decision making
processes and the influences that affect their choices.
b) Explain the role and structure of palliative and supportive care in the multidisciplinary
management of advanced cancer.
c) Explain considerations of when and how palliative care should be introduced.
d) Demonstrate the assessment of pain and other symptoms, including nausea, fatigue,
confusion, drowsiness and cachexia.
e) Discuss principles of both pharmacological and non-pharmacological pain relief and
the palliative management of other symptoms.
f) Demonstrate an understanding of "end of life" issues that confront patient, family and
physician:
■ Physical effects of advanced cancer;
■ Psychosocial aspects of terminal cancer, support (religious, cultural, spiritual,
existential), loss and bereavement;
■ Ethical aspects of “end of life” decision-making.
g) Demonstrate understanding of the Palliative Care Act(s).
h) Demonstrate appreciation of cultural aspects of end of life care.
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i) Demonstrate adequate communication skills, including breaking bad news and
discussion of end of life care.
j) Demonstrate understanding of utility of procedures to relieve symptoms eg. ascitic and
pleural taps.
✔ Prerequisite knowledge
■ History of palliative care in the health care system (1950 to present).
2. During regular use of morphine for chronic pain control, what is the oral equivalent to
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)
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(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).
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2. Discuss different cultural attitudes to death and dying.
Essential in answer
■ Knowledge of the “western” society model v Indigenous v Asian etc.
■ Part of continuum v major event.
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.
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6.2 Representative questions that suggest the required depth of knowledge
1. At the consultation in which you must tell a patient a diagnosis of cancer
(select the best answer/s):
(a) The most important thing is to cover all important aspects of management and
prognosis in the initial interview, to give a comprehensive statement about the
patient’s condition.
(b) Due to the need for confidentiality, the information is best given to the patient
on his/her own.
(c) Patient autonomy dictates that all management options should be presented
immediately to achieve informed consent.
(d) Most details of the discussion will be lost once the patient hears the diagnosis
and will need repetition at a later date.
Answer: (d)
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cancer treatment (symptom management and recognition of symptoms that
require medical review).
✔ Prerequisite knowledge
■ Information technology skills.
■ Introduction to screening of populations and case-finding in individuals.
■ Patient-centred communication skills.
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Objective 7
Ethics and professionalism
a) Demonstrate an understanding of the effects on health professionals of caring
for patients with cancer and of the ways in which the stresses of this work can
be managed appropriately.
b) Discuss the bioethics of issues such as access, equity and resource allocation, as
well as medical care at the end of life.
c) Identify the key medico-legal issues in diagnosis, screening/early detection,
management, evidence-based guidelines, defensive medicine, commutative
justice, distributive justice, social justice, physician-assisted suicide, euthanasia.
d) Discuss principles, elements and role of informed consent in patient decision
making.
✔ Prerequisite knowledge
■ Understanding of broad medico-legal principles, patient consent, autonomy and
privacy.
Area: Ethics
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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.
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APPENDIX viii
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.
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lipid, protein and carbohydrate metabolism, disorders of calcium metabolism, bone
disorders and inborn errors of metabolism.
Contact Information
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
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
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o Fluid & Electrolyte Imbalance
▪ Metabolic myopathies
▪ Metabolic polymyopathy
▪ Metabolic polyneuropathy
▪ 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
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Metabolic Disease History:
Physical Examination:
▪ General
o Vital Signs – BP, P, R, T, Blood Glucose, Sp02
▪ OGTT / HbA1c
▪ Water Deprivation Test
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Specific Objectives
o G6PD deficiency
o Diabetes Mellitus
Diabetes mellitus
▪ Diagnose diabetes and glucose intolerance disorders
o OGTT
o HbA1c >6.5%
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International Diabetes Foundation Global Guideline for Type 2 Diabetes. 2005.
▪ Classification:
o Insulin-dependent diabetes mellitus
o Non-insulin-dependent diabetes mellitus
o Maturity Onset Diabetes Mellitus of the Young (MODY)
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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
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▪ 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
▪ 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)
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fibrinogen, smoking
▪ Identify Vascular Complications Of Hyperlipidaemia
▪ Recognise Cutaneous And Other Signs Of Hyperlipidaemia
▪ Identify clinical features of genetic dyslipidaemias (xanthelasma, xanthoma-
tendinous, eruptive and planar, corneal arcus, lipaemia retinalis) and evidence of
macro- and micro-vascular disease.
▪ Give basic dietary advice to patients with hyperlipidaemia
▪ Interpret and critically appraise biochemical and genetic investigations for
dyslipidaemia
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
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3. HDL protective
Primary disorders
1. Familial hypercholesterolaemia
▪ Autosomal dominant
(i) Heterozygotes ≈1:500
(ii) Homozygotes very rare
▪ Around 400+ defects in LDL receptor known
▪ Defect in the receptor means half-life of LDL in plasma is prolonged, leading to
increased serum levels
▪ Heterozygotes
(i) Total cholesterol 9–15 mmol/l
(ii) 6–8 times increased risk of IHD (MI at young age)
(iii) Xanthelasma and tendon xanthoma
▪ Homozygotes
(i) Xanthomas in early childhood
(ii) MI as child
▪ Treat with diet and statins
2. Familial triglyceridaemia
▪ Autosomal Dominant
▪ Plasma turbid
▪ Associated with eruptive xanthomata, pancreatitis, retinal vein
thrombosis, hepatosplenomegaly, lipaemia retinalis
▪ Treat with diet and fibrates
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3. Lipoprotein lipase deficiency
▪ Rare
▪ Autosomal Recessive
▪ Failure to break down chylomicrons
▪ Raised triglycerides
3. Disorders of Nutrition
▪ Overnutrition (Obesity)
o Diagnosis of obesity
Classification BMI(kg/m2)
Principal cut-off
Additional cut-off points
points
<18.
Underweight <18.50
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
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▪ Dietary calcium deficiency
▪ Dietary selenium deficiency
▪ Dietary zinc deficiency
▪ Deficiency of other nutrient elements
▪ Other nutritional deficiencies
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o Assessment of nutritional requirements of patients
▪ With acute disease eg. Cerebrovascular Accident
▪ With chronic disease eg. Inflammatory Bowel Disease, CVA,
Malabsorption
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▪ Vitamin D
o Mostly made in skin by action of UV light
o 25 – hydroxylated in liver
o Hydroxylated again to 1,25-OH D (calcitriol) in kidney
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
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▪ Renal stones
▪ Nephrocalcinosis
▪ 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.
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Hypocalcaemia
Causes
o Hypoparathyroidism (including pseudohypoparathyroidism)
o Chronic renal failure
o Low levels of vitamin D3
o Hyperphosphataemia
o Hypomagnesaemia
o Sepsis
o Respiratory alkalosis
o Calcium deposition (eg acute pancreatitis)
o Carcinoma of prostate
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
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▪ Receptor defect (pseudohyperparathyroidism)
▪ Di George syndrome
Diagnosis (hypoparathyroidism)
▪ ↓Calcium, ↓PTH
▪ Pseudohypoparathyroidism
Receptor defect leading to resistance of target tissues to PTH
X-linked dominant
↓Calcium, ↑PTH
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
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▪ Renal tubular disease
▪ Vitamin D deficiency
▪ Alcohol withdrawal
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
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disease.
▪ Choice of drugs and assessment of their effectiveness.
▪ The range of osteogenesis imperfecta and how it influences adult life.
▪ Renal osteodystrophy.
▪ Understand bone turnover and different biochemical bone markers.
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(iv) Hypertension
(v) Tachycardia
(vi) Motor polyneuropathy
● Commonly precipitated by hepatic enzyme-inducing drugs, eg
alcohol, phenytoin, oral contraceptives, sulphonamides,
rifampicin, benzodiazepines
● 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
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o Homocysteinuria
▪ 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
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▪ Osmotic diuresis (hyperglycaemia, severe uraemia)
▪ Diuretics
▪ Adrenocortical insufficiency
▪ Tubulointerstitial disease
▪ Unilateral renal artery stenosis
▪ Recovery post ATN
Gastrointestinal
▪ Vomiting
▪ Diarrhoea
▪ Haemorrhage
▪ Fistula
▪ Obstruction
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
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▪ Bronchus, bladder, prostate, pancreas
▪ Lymphoma
▪ Ewing’s sarcoma
▪ Mesothelioma
▪ Thymoma
Pulmonary disorders
▪ Pneumonia
▪ Abscess
▪ TB
▪ PEEP
▪ Asthma
Central nervous system
▪ Encephalitis
▪ Meningitis
▪ Trauma
▪ Subarachnoid haemorrhage
▪ Guillain-Barré syndrome
▪ Hydrocephalus
▪ Acute psychosis
▪ Acute intermittent porphyria
Drugs
▪ Opiates
▪ Carbamazepine
▪ Oxytocin
▪ Chlorpropamide
▪ Phenothiazines
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▪ TCAs
▪ Cytotoxics (vincristine, cyclophosphamide)
▪ Rifampicin
▪ Porphyria (drug induced)
▪ Primary
o Childhood onset
o X-linked/dominant
o Tubular receptor abnormality
▪ Secondary
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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)
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
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-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)
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
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▪ Metabolic alkalosis
▪ Insulin
▪ Alpha-adrenergic antagonists
▪ Beta-adrenergic agonists
▪ Vitamin B12or folic acid when correcting megaloblastic anaemia
▪ Total parenteral nutrition (TPN)
▪ Hypokalaemic periodic paralysis
▪ Pseudohypokalaemia
▪ Hypothermia
Increased excretion
Gastrointestinal
▪ Purgative abuse
▪ Vomiting
▪ Villous adenoma
▪ Severe diarrhoea
▪ Ileostomy/uterosigmoidostomy
▪ Fistulae
Renal
▪ Thiazide diuretics
▪ Loop diuretics
▪ Renal tubular damage
▪ Mineralocorticoid excess
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▪ Apparent mineralocorticoid excess
(a) Liquorice
(b) Carbenoxolone
▪ Cushing’s syndrome
▪ Bartter’s syndrome
▪ Renal tubular acidosis type 1 and 2
Hyperkalaemia
Causes
▪ Spurious
o Haemolysis
o Delayed separation of serum
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
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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)
o IV insulin and dextrose
o Calcium resonium
o Frusemide
o Salbutamol nebulisers
o Dialysis
Magnesium
Hypomagnesaemia
1. Usually associated with low Ca2+and low K+
2. Associated with ventricular arrhythmias, fits, tetany and paraesthesiae
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
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
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Acid-Base Homeostasis
▪ Metabolic Acidosis
▪ Metabolic Alkalosis
▪ With or without Respiratory compensation
▪ Other disorders of fluid, electrolyte and acid-base balance
Metabolic acidosis
Normal anion gap
(a) Direct loss of bicarbonate (↑chloride)
(i) Diarrhoea
(ii) Pancreatic fistulae
(iii) Ureterosigmoidostomy
(iv) RTA
(v) Acetazolamide
(b) Ingestion of acidifying agents
(i) Ammonium chloride
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High anion gap
(a) DKA
(b) Lactic acidosis
(c) Renal failure
(d) Salicylate poisoning
(e) Methanol poisoning
(f) Ethylene glycol poisoning
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
(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
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(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
(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
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blood
Calculated with formula
2(Na+ + K+) + urea + glucose
Causes of raised osmolar gap
▪ Methanol
▪ Ethylene glycol
▪ Diethylene glycol
▪ Ethanol
Iron
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
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o Treatment: venesection, desferrioxamine
Wilson’s disease
o Autosomal recessive
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
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Metabolic Emergencies
▪ Diabetic Ketoacidosis (DKA)
o Mortality Rate <5%
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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
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Guidelines for Common Medical Emergencies: T. Seemungal et al
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/
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APPENDIX ix
ENDOCRINOLOGY MODULE:
CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE
Course description
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.
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Purpose of the Course
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.
Contact Information
Tutors: EWMSC - Professor S. Teelucksingh ,
Port of Spain General Hospital – Prof. T. Seemungal
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: tseemungal@aol.com
Content
Clinical presentation of endocrine diseases
A list of common symptoms associated with endocrine diseases are as follows:
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
● 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
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● Pretibial Myxoedema- bilateral
pink,brown, or skin colored ● Uncommon neurological
elevated dermal nodules and abnormalities associated
plaques. with hypothyroidism:
✔ Carpal (Phalen’s sign)
● Proximal myopathy- on squatting? and Tarsal tunnel
syndrome.
● Hyperreflexia ✔ Delayed ankle jerks.
✔ Muscle cramps
● Alopecia
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Eyes ● Exopthalmos ● Periorbital oedema
✔ Reddened gland? →
Suppurative thyroiditis
● Percussion-
✔ Change from resonant to
dull may indicate a
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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
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in♂- small, firm
testes.
● Thickened skin
● Osteoarthritic
changes(skeletal
overgrowth)
● Carpal tunnel
syndrome secondary to
soft tissue overgrowth
(Phalen’s sign)
● Palpate for
✔ greasy skin
● Splayed teeth
● Prognathism-
protrusion of the jaw
● Hoarse voice
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HTN and
Cardiomyopathy which
are all common in
acromegaly
Abdomen ● Hepatomegaly
● Spleenomegaly
● Renal enlargement
● BP
ADRENAL DISEASE
Cushing’s Syndrome Addison’s Disease
General inspection Standing: Observe front, back Look for
and sides ● Vitiligo
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water retention)
● Plethora +/-
polycythaemia
● Acne
● Hirsutism in the ♀( in
the presence of
androgen excess)
● Telangiectasia
● Funduscopy-
✔ visual field defects
✔ optic atrophy
✔ papilloedema
✔ Hypertensive
changes
✔ Diabetic changes
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subcutaneous tissues)
● 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 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
2. Enlargement of an ACTH- secreting pituitary adenoma following
adrenalectomy ( Nelson’s Syndrome)
● 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
● Dry skin
Legs ● Proximal Myopathy
● Monilial infectionof
the nails?
Other ● Check BP ↑?
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since fat metabolism is ↑ to compensate for the
lack of availability of glucose; excess Acetyl-
CoA is produced and converted to ketone bodies
by the liver.
Lower Limbs Inspect for vascular and neurological abnormalities of the
feet.
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.
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Abdomen ● PALPATE for hepatomegaly secondary to fatty
infiltration or haemochromatosis.
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
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FT3 3.0-8.8 pmol/
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
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
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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:
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.
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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.
4. Calcium:
• 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
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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
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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.
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
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●Recognize and initiates management for, and outlines therapeutic goals for:
✔ Uncontrolled Dm (Hyperosmolar states, DKA and Aasymptomatic
Hyperglycaemia)
✔ New onset Diabetes in an outpatient with monotherapy
✔ Dyslipidaemia
✔ Hypothyroidism in the young and the elderly
✔ Hypertension and Dyslipidaemia in the Diabetic patient
● The student should also be able to recognize and appreciate the management
of:
✔ Hyperthyroidism and the thyroid storm
✔ Adrenal insufficiency
✔ Hyperparathyroidism
✔ DM required combined therapy
● The student should also be able to appreciate the iniation of diagnostic
strategies in the management of
✔ Adrenal disorders
✔ Pituitary disorders
4. PROCEDURAL SKILLS
● Masters the cognitive, counseling and technical skills for
✔ Monofilament Ex
● Interpret the results of
✔ Fasting and post prandial glucose
✔ Cholesterol panel
✔ TSH determinations used for screening
✔ Microalbumin
✔ Thyroid hormone panels in sick hospitalized patients( euthyroid sick
patient)
✔ Thyroid uptake scan for Grave’s Disease, Factitious hyperthyroidism
✔ Calcium and phosphate labs
● Understands the indications for and begins to try to interpret the findings of
✔ Thyroid USS
✔ Thyroid uptake scan
✔ Bone density scans
✔ Pheochromocytoma screens
✔ MRI of the pituitary
✔ Visual field testing
✔ FNA of the thyroid
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.
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6. INTERPERSONAL SKILLS AND COMMUNICATION
● Effectively establishes rapport with patients and family
● Demonstrate empathy and caring toward your patients
● Communicates well with primary referring team and other consultants
● Presents on rounds in an organized and articulate fashion
● Functions as an effective team member
● Provides timely and thorough documentation of patient care.
● Demonstrate time management within the program
.
7. PROFESSIONALISM
● Strives for patient care and knowledge excellence
● Reliably accomplishes assigned tasks
● Demonstrates integrity, respect for others, honesty and compassion
● Demonstrates timely completion of administrative tasks and documentation
● Sets a tone of respect and collegiality for the team
● Acts as a role model for patient care and professional behaviour
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
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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
(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
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NIH (Nat. Institute of Health USA)
NICE (Nat. Institute of Clinical Excellence)
PUBMED
Other website should be discussed with the instructor before use.
APPENDIX x
NEUROLOGY MODULE:
CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE
Course description
Overview
This course is designed to complete the training of the medical undergraduate student in
neurology within the context of general internal medicine over two rotating 8 weeks
clerkships.
Prerequisite
A pass in the MBBS Phase 1 examination.
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Purpose of the Course
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
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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),
nitrates, proton pump inhibitors, antiepileptics.
Family History: hx of stroke, migraine and many metabolic, muscle, nerve, and inherited
neurodegenerative disorders
Social History: smoking, occupational, and travel history provides information about unusual
infections and exposure to toxins and parasites
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2. Coordination (fine finger movements, rapid alternating movements, finger-to-nose,
and heel-to-shin)
3. Involuntary movements
4. Pronator Drift
5. Tone (resistance to passive manipulation)
6. Bulk
7. Strength (shoulder abduction, elbow flexion/extension, wrist flexion/extension, finger
flexion/extension/abduction, hip flexion/extension, knee flexion/extension, ankle
dorsiflexion/plantar flexion)
D. Reflexes
1. Deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles)
2. Plantar responses
E. Sensation
1. Light touch
2. Pain or temperature
3. Proprioception
4. Vibration
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
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g. Treatment of i. Acute seizures and status epilepticus
ii. Posttraumatic seizures
and principles of long term treatment including drug choice, adverse drug effects,
surgery and vagus nerve stiulation.
(11) Dementia
a. Definition, classification into Alzheimer’s and non-Alzheimer’s type and different
pathophysiologies
b. Signs and symptoms (early, late and severe)
c. Differentiation of dementia from delirium with knowledge of common causes of
delirium
d. Differentiation of vascular dementia from Alzheimer’s disease (Hachinski score)
e. Diagnosis including clinical criteria, laboratory testing, neuroimaging and
neuropsychologic testing
f. Prognosis
g. Treatment including principles of patient safety, environmental measures, drugs
(cholinesterase inhibitors, NMDA (N-methyl-D-aspartate) antagonist, SSRI), caregiver
assistance and end of life issues.
(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
In the study of each of these diseases, the principles of history taking and examination
will be emphasised.
Goals/ Aims
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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
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3. define each of the major diseases in this syllabus
4. integrate the symptoms and signs of neurologic disease with the
clinical presentation of each of the neurologic diseases studied in this
course
5. differentiate between the different conditions using the history,
examination and investigations discussed during this course
6. discuss treatment options of neurologic diseases
7. discriminate between cerebrospinal fluid abnormalities in various
disorders
8. use abnormal CT Scan results in the differential diagnosis of
neurologic diseases
Assignments
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
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
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1. Patients on the medical and surgical wards, POSGH, are our most valuable
resource.
2. Patients in the medical outpatients’ clinics.
Readings
APPENDIX xi
CARDIAC MEDICINE MODULE:
CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE
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.
9. Year 4
10. Year 5
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Integration within the Undergraduate Programme in Medical Sciences
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
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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.
Contact Information
Tutors: EWMSC – Dr. R. Ali, Dr N. Seecheran
Port of Spain General Hospital – Prof. T. Seemungal
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: tseemungal@aol.com
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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)
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● Cardiac Computed Tomography- evaluating CAD
● Nuclear Imaging- evaluating myocardial perfusion, ejection fraction, shunts
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
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- Definition
- Diagnosis
- Complications and consequences
- Treatment options- dietary, lipid lowering drugs
c. Diabetes Mellitus
- Definition
- Classification
- Diagnosis (American Diabetes Association)
- Cardiovascular complications
- Treatment options
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d. Complications
e. Management 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
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
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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
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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)
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(11)Cardiac manifestations of systemic disease
● 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
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3. European Society of Cardiology Core Curriculum
APPENDIX xii
Presenting complaint:
Chest pains x 1/7
}
Pain in left forearm and
hand Headaches
Jitteriness x 3/52
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History of presenting complaint:
Mrs. Cauldero was diagnosed with gestational diabetes 22 years ago during her 2 nd
pregnancy, and again during her 3rd pregnancy.
She was diagnosed with diabetes mellitus approximately 6 years ago.
Her last clinic visit was 3/52 ago.
Today, she complains that despite being consistent with diet and exercise routines, her
fasting blood glucose levels measured at home have been consistently high for the past 3/52.
She has also been experiencing chest pains for the past 1/52, as well as pain in her left
forearm and hand, headaches, jitteriness and fatigue for the past 3/52.
Her chest pain
● Is usually felt on the left side of the chest, with occasional radiation to the back;
does not radiate to neck or arms
● Described as gripping in nature and severe
● Begins suddenly when she is at rest
● Lasts less than five minutes
● Not associated with cold sweats/ nausea/ palpitations/dyspnoea
● No aggravating or relieving factors identified
● Occasionally occurs several times per day
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
√
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● Endometriosis x 13 years
● Left sided diffuse goitre detected 1 year ago
º hypertension ºasthma ºsickle cell anaemia ºepilepsy
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.
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