Home > MEDICINE AND SURGERY UNIT 2
APPENDIX 1
APPENDIX 2
APPENDIX 3
APPENDIX 4
APPENDIX 5
MEDICAL SCHOOL
MB ChB
Introduction 3
Objectives 3
Core clinical problems 3
Resources for learning 5
Patients 5
Teachers 5
Self-directed learning 6
Formal teaching 8
Unit Assessment 10
Professional Indemnity 12
Firm Leaders 12
Quality assurance 12
Contacts 13
Student support 13
Student Health and Safety 14
Claiming Travelling Expenses 14
Appendix 1: Core curriculum and standards 15
Medicine and Surgery A 16
Medicine and Surgery B 21
Appendix 2: Examples of possible SSC topics 26
Appendix 3: SSC marking criteria 29
To guide you, we have drawn
up a list of common problems. By the end of the two medicine and surgery
attachments you should expect to feel competent in assessing a patient
presenting with any of these problems, and in planning investigations
and treatment.
The curriculum you received in Year 2 has been extended to cover the material you need to cover in the Year 3 Medicine and Surgery Units (Appendix 1). These are the basic skills you need to acquire and on which you may be tested. Remember that you are expected to have retained the skills you acquired in your first clinical attachment – irrespective of the system to which they relate - and that you may also be tested on these.
These provide by far the most
important resource for your learning. You will be allocated to medicine
and surgery firms during the attachment, and should ensure that all
patients under the care of the firm are allocated for clerking. You
should aim to follow them throughout the course of their admission and
learn from them and their experiences. In the modern NHS, patients are
often admitted under one team but have their care transferred to another
team during the admission. You will learn by far the most from the patients
you have seen all the way through from admission to discharge. You will
have to use your initiative to achieve this. In addition, the patients
you see during your general practice attachments will give you the chance
to learn more about chronic problems and the wider impact of illness
on the lives of patients and their families
In medicine and surgery, the patients admitted as an emergency offer the greatest learning opportunities. Make sure that you take advantage of this by clerking and presenting as many patients as possible when you are on take. This is also an opportunity for you to see and learn about many of the investigations and practical procedures that form part of the objectives.
You will be required to attend
four medical and four general takes during your attachment to Medicine
and Surgery B, including weekends. Attendance will include staying until
late evening or overnight (see below)
and presenting cases on post-take rounds. A consultant signature will
be required on each occasion to confirm satisfactory attendance. Any
problems with fulfilling this requirement must be discussed in full
with the unit tutor, and will be included in the report on your performance.
The following attendance is expected of a student on take:
Monday-Thursday: Join take team at 5 pm, or earlier if no other teaching commitments, and stay until at least 12 midnight. Attend post-take round the following morning
Friday: Join take team as soon as day-time teaching commitments completed,
stay until the end of the evening post-take round.
Saturday-Sunday: Join take team at 12 noon, stay until the end of the evening post-take
round.
The consultant and trainee
staff on your firm are ready to help you achieve the objectives of the
course. Some of your learning will come from timetabled teaching sessions,
but much more will be informal. You will also have the chance to attend
clinics and operations in which teaching is much more opportunistic.
Patient care is a team effort and many people are involved. You will learn a lot from all team members – health care professionals and others. People are often very busy but you will find that, if you demonstrate an enthusiasm for learning, they generally like to teach when they can. Going down to the radiology department or other investigations with your patient will teach you much more than a book, and seeing what physiotherapy or dietary assessment actually involves is much more informative than hearing it referred to it in a lecture.
Expect to have to supplement your learning by reading books and papers. Read around a clinical problem at the same time as you see a person with the condition. This way knowledge is much easier to retain. You should become well acquainted with at least one general textbook for medicine, and for surgery. The clinical skills books recommended in year 2 will be useful for revision of the basics.
Recommended books
Other recommended books (All available in the Medical School Library)
Videos, web-based materials etc.
In some topics you will be
allocated a session for watching surgical videos and self-directed learning
on the computers in the student IT room. Useful websites will be bookmarked
but please feel free to add to these if you find a site you feel might
benefit other students.
The cardiology, neurology and urology departments have written Web based tutorials covering the knowledge-based curriculum for their subjects. The urology tutorials can be found at http://www.bui.ac.uk/ and include self-assessment exercises. The neurology tutorials can be found on Blackboard and include tutorials, a neurology examination ‘crib sheet’ that you can print out and use, clinically based self assessment questions and also a message board for you to post questions about neurology that you find puzzling or difficult. The cardiology tutorials are also available on blackboard. We would appreciate constructive feedback about these sites and how they can be improved.
Your suggestions
We would like to establish a database of the useful learning resources you have identified. This will be of great value to colleagues in your year and in future years. If you find a useful website, book or review article please enter it on to the database on the Medicine and Surgery unit teaching sites accessed by logging on to Blackboard.
Student selected components
form a very important part of the learning opportunities on this unit
and are allocated 20% of the time you are attached to the unit and 15%
of the overall unit mark. The marking criteria for SSCs are given in
Appendix 3. They are intended to allow you a) to attain transferable
skills that will help you to continue the learning process that will
be required throughout your career and b) to learn about something that
is not absolutely core knowledge but is of interest to you.
The sort of thing you may consider would be:
You have to undertake an SSC in each of the year 3 units, with a further period of SSC time at the end of the year. The SSC report you produce at the end of each unit must ‘stand-alone’, but you may wish to design for yourself a programme of SSCs that are loosely linked to allow you to cover an area in more detail. The end of year SSC period is a good opportunity to build on the work undertaken in one of your unit SSC. You might, for example, use one of the unit SSCs to undertake a literature review in a topic and make preparations (e.g. develop study design, apply for ethical approval) for a piece of research that you complete in the summer. If you are considering making a video, CD or creating a website as your project please ensure that your supervisor has the appropriate equipment as we cannot provide any funding for SSCs.
Summary of SSC dates:
Dates |
SSC Registration deadline |
SSC Completion deadline |
|
Block 1 | 1st
September 2003
to 31st October 2003 |
5th September 2003 |
24th October 2003 |
Block 2 | 3rd
November 2003
to 23rd January 2004 |
7th November 2003 |
16th January 2004 |
Block 3 | 26th
January 2004
to 26th March 2004 |
30th January 2004 |
19th March 2004 |
Block 4 | 29th
March 2004
to 4th June 2004 |
2nd April 2004 |
28th May 2004 |
4. Formal teaching
Tutorials and skills lab sessions
Some core problems and clinical skills will be covered in tutorials. The course organisers at the trust will arrange these where you are based. They will include student-led sessions are likely to require preparatory work on your part.
During this unit you will have
two half-day sessions with your year 3 GP. The purpose of these sessions
is to provide further teaching and experience in the way that the core
clinical problems for this unit present and are managed in primary care
settings. For example most people with abdominal pain present initially
to a GP and only a small proportion of them ever reach a hospital. How
do GPs take a history and examine patients to work out how to treat
them, and to determine which patients need hospital referral?
In primary care, the problems are often more recent and less serious. It is particularly important to consider ‘the whole person’ and how factors in the patient’s personality, family, past history and social environment affect the presentation of the problem and how best to manage it.
The objectives of the GP attachments are therefore to:
Attendance is very important.
At each teaching session the GP will have cancelled their normal surgery and will have invited 2 – 4 patients for you to interview and examine. It is important that you do not let them down, or the GPs who have dedicated time to teach you. Your GP will have sent you dates for your teaching sessions in each block. If one of these dates clashes with an important teaching session at the hospital, please contact the GP to re-arrrange it, giving him or her at least 2 weeks notice.
You will be able to practice and improve your skills in history taking, examination, diagnosis, and patient management in this small group environment.
If you have any administrative problems with the GP attachments please contact the GP teaching administrator, Sally Sterland, on 954 6639. For any other problems please contact Dr Salisbury by e-mail on c.salisbury@bristol.ac.uk .
Lectures
During the unit you will have two days of integrated system teaching on the Monday of week 1 and the Friday of week 9. These core topics will be included in the end of year examination.
The last week of your first
Medicine and Surgery unit (week 9) will be dedicated to teaching diabetes.
This week will comprise a mixture of lectures, and small group teaching,
and will be delivered centrally.
First Block: Diabetes
course: Report to Level 9 Lecture theatre, BRI on Monday
October 27th 2003, at.10.00 am
Second Block: Diabetes course: Report to Level 9 Lecture theatre, BRI on Monday January 19th 2004, at.10.00 am
This teaching is delivered to students doing both Medicine and Surgery A and B. Full timetables will be issued at the start of the course.
CONTACTS:
Dr Polly Bingley Diabetes and Metabolism, Medical School Unit, Southmead
(Diabetes Course Organiser) Tel 0117 959 5337
Polly.bingley@bristol.ac.uk
Miss Bethan Sait Diabetes and Metabolism, Medical School Unit, Southmead
(Diabetes Secretary) Tel 0117 959 5337
Bethan.sait@bristol.ac.uk
In preparing students to qualify
as doctors, the University has the responsibility to ensure not only
that your clinical skills and knowledge are adequate but also that you
display appropriate behaviour towards patients, staff and society in
general. Skills and factual knowledge can be objectively assessed
by the formal examinations that take place at the end of most clinical
attachments.
The Faculty relies upon the
clinical teachers who closely supervise your work to report behaviour
which displays an inappropriate attitude. Following consultation
with their colleagues, teachers will assess you as satisfactory or not
in the following categories: appearance, attendance and punctuality,
attitude and behaviour.
Your teachers should point
out anything which they perceive as unsatisfactory to you during your
teaching so that you have an opportunity to address the issue.
Teachers will be asked to provide positive feedback on your attitude/behaviour.
However, if a problem remains then it will be reported to the Clinical
Dean and you will be asked to discuss the issue with him.
The Clinical Dean will seek a resolution of any problems highlighted.
This assessment is relatively
new to the Medical School. Its implementation has been agreed
jointly between staff and student representatives. Further
information is available through the Clinical Dean’s website.
The summative OSCEs for
both Medicine and Surgery A and B will take place in the 9th
week of your second Medicine and Surgery attachment and each will consist
of a mixture of stations which will test clinical skills, communication
skills, practical procedures, interpretation of common investigations
and understanding of some treatment of the core problems as outlined
in the core curriculum in Appendix 1. The marks for each unit will
be considered separately, and you will be required to pass both.
Further details about the OSCE are included in Appendix 4 at the back
of this book and additional explanatory notes and advice are available
on the Galenicals web-site (http://www.medici.bris.ac.uk/galenicals/unihome.htm ).
Your Student selected component
report contributes 15% of your overall unit assessment mark (see
above). The completed SSC report must be handed in one week before
the end of the unit. If you have not done so, you will fail the
unit. The marking criteria are given in Appendix 3.
You are required to write up or present
one patient case history. This patients should illustrate a core problem
from one of the groupings related to your current attachment (i.e.
cardiology, respiratory medicine, ENT, vascular surgery or radiology
for Medicine and Surgery A, and gastrointestinal and breast disease,
neurological disease, endocrinology and diabetes, or urology and renal
medicine for Medicine and Surgery B). This case report should include
the key points of the history, examination and investigations with your
conclusions about the diagnosis. This should be followed by a section
on the management and progress up to discharge. The case history
should therefore cover the whole admission and discussion of the underlying
condition and management options as well as the initial clerking. In
Medicine and Surgery A and B, you will be required make a formal presentation
of this case to your teachers and colleagues towards the end of the
unit, and to answer their questions on it. Your mark for this case will
be assigned on the basis of their comments
Your knowledge will be assessed
in a multiple choice question exam held in June 2004. The paper will
include questions covering Medicine and Surgery A and B (including Diabetes
Week), IST Teaching and GP Attachments and may include questions of
the extended-matching format. The marks for each unit will however be
considered separately, and you will be required to pass both.
You will be expected to have acquired at least the amount of knowledge
relating to the core problems consistent with having read the relevant
chapters of basic medicine and surgical textbooks, as well having attended
the lecture teaching.
Full details of the summative
assessments in Year 3 and the requirements for progression into Year
4 are given in the Year 3 Handbook. Failure in these examinations
will require re-takes in July 2003 and will usually result in the loss
of opportunity to carry out the end of year Post examination SSC.
These assessments will be performed towards the end of your first Medicine and Surgery attachment and will provide you with feedback on how your are progressing so that you are made aware of any areas on which you particularly need to focus in your second attachment. The assessment does not contribute to your overall unit mark
The formative assessment in
both units will be an OSLER (objective structured long examination record).
In this assessment you will be watched by an examiner while you take
a history from a patient and examine them (in about 45 minutes, including
recording your findings) and will then be asked to discuss the case.
The examiner will be assessing your ability to take a history, examine
a patient, record the information, make a reasonable diagnosis or differential
diagnosis and outline a management plan – i.e. how well you progressing
towards achieving the objectives of the Year 3 Medicine and Surgery
units. This is an excellent way to judge how a student is getting on,
and it is currently part of the final MB BCh exam. An aide memoire
to the ‘full clerking’ is included in Appendix 5. We think that,
even if you are not particularly polished at this stage, the OSLER will
provide you with very useful feedback.
Tutorial support
You will be allocated a tutor
who will meet with you regularly throughout your attachment to the unit.
The purpose of these meetings is to make sure that your are clear about
the aims and objectives of the unit and that you are achieving these,
and that you making satisfactory progress with your self-directed learning.
Your tutor may also be able to help if there are problems with the delivery
of teaching that is timetabled for you.
Professional Indemnity
Students are reminded that they are expected to become members of one of the medical defence organisations – either MPS or MDU. This costs nothing and ensures that you have indemnity for professional activities in non-NHS-owned establishments such as hospices and GP surgeries. You should protect yourselves against this risk.
Each firm of students should
appoint a firm leader (or clerk) whose responsibilities are to provide
liaison with the Lead Clinician, General Practitioner and Clinical Sub-Dean
or Clinical Dean. He/she should also ensure that rotas are
set up so that each student has an equal share of outpatient clinic
attendance, on-take experience and patients with a spectrum of conditions
to see independently.
Quality assurance
This will be assessed by questionnaires
which will be distributed at the end of the course.
Contacts:
Medicine and Surgery A
Examinations Lead:
Mr Desmond Nunez (Dept of ENT, Southmead Hospital) Tel: 959 6222
Medicine and Surgery B
Unit Organisers:
(polly.Bingley@bristol.ac.uk)
(j.m.blazeby@bristol.ac.uk)
If you are experiencing problems
of an academic or personal nature, advice should be sought from the
appropriate Undergraduate Teaching Co-ordinator or the Clinical Dean.
Undergraduate teaching co-ordinators
BATH Dr W N Hubbard Education Centre
Consultant Physician Royal United Hospital
Bath BA1 3NG
Tel 01225 825479
Fax 01225 825479
maureen.jacobs@ruh-bath.swest.nhs.uk
BRI Mr N Rawlinson Dolphin House
Consultant, A&E Bristol Royal Infirmary
Marlborough St
Bristol BS2 8HW
Tel 0117 928 3912
Fax 0117 928 2151
Nigel.Rawlinson@bristol.ac.uk
FRENCHAY Dr D Smith Academic Centre
Consultant Physician Frenchay Hospital
Bristol BS16 1LE
Tel 0117 918 6764
Fax 0117 970 1691
David.Smith38@virgin.net
SOUTHMEAD Mr J Morgan Southmead Hospital
Consultant Surgeon Westbury on Trym
Bristol BS10 5NB
Tel 0117 959 2435
morgan_jdt@southmead.swest.nhs.uk
WESTON Dr D Paterson Weston General Hospital
Consultant Pathologist Grange Road
Weston Super Mare BS23 4TQ
Tel 01934 636363 x 3315/3321
David.Patterson@waht.swest.nhs.uk
CLINICAL DEAN Dr Clive Roberts Centre for Medical Education
39-41 St Michael’s Hill
Tel 0117 954 6518
Mob 07850 908760
C.J.C.Roberts@bristol.ac.uk
Student Health and Safety:
Statement by the University’s Health and Safety Committee dated 25 January 1999:
“Students are reminded of
their duties to other members of the University, including visitors,
referred to in the Faculty Introduction in the undergraduate prospectus.
It is foreseeable, based on
national statistics for workers in this discipline, that some members
of this course may experience allergic reactions to the exposure to
animals/chemical agents.
It is essential that, as soon
as it is known, any student who has an existing or who develops any
medical condition that may affect their ability to participate fully
in the course of study should inform their supervisor. This will
enable the student and the University to discuss and agree appropriate
health and safety procedures to facilitate continued study.”
Claiming Travelling Expenses
Students may claim the usual
return bus fare to the university from Trust where they are in residence
to attend teaching delivered centrally.
Claim forms are available from
the Clinical Dean’s Office, Medical Education Centre.
Completed forms should be submitted to the office within a month of
the end of the attachment
PLEASE CHECK YOUR EMAIL, THE CLINICAL DEAN’S OFFICE WEBSITE, HOSPITAL NOTICEBOARDS AND THE YEAR 3 NOTICEBOARDS IN THE MEDICAL SCHOOL AND the Clinical Dean's office, 39-41 St Michael's Hill REGULARLY. INFORMATION PERTINENT TO YOUR STUDIES IS OFTEN POSTED VIA THESE MEANS.
Core curriculum and standards
Underlying principles:
Core curriculum for Medicine and Surgery A
(introduction to diseases of the cardiovascular and respiratory systems, vascular surgery, diseases of the ear, nose, throat and oral cavity)
1. Common symptoms of cardiovascular disease
Chest pain | Explore basic
characteristics including site, radiation, precipitating, relieving
and associated factors
Identify specific history and assoc features of angina and myocardial infarction pain, and distinguish from other causes of chest pain Assess severity (nil, ordinary exertion, severe exertion, rest) |
Breathlessness | See Respiratory
Curriculum
Identify specific history of Shortness of Breath on Exertion, Orthopnoea and Paroxysmal Nocturnal Dyspnoea Identify assoc symptoms of cardiac failure |
Palpitations | Identify history of frequency and rhythm of heart beat and associated symptoms |
Dizziness/blackouts | Identify history of sudden faintness, with or without ensuing loss of consciousness, which may be cardiovascular in origin |
Leg pain | Identify specific history and assoc features of intermittent claudication, acute ischaemia of leg and deep vein thrombosis |
2. Examination of the cardiovascular system
General examination | Recognise clear
pallor, central and peripheral cyanosis
Identify the constellation of signs of cardiac failure |
Pulse | Ability to measure
radial pulse, rate and rhythm
Compare radial and apex pulses Examine radial, brachial, femoral, popliteal, posterior tibial and dorsalis pedis pulses and classify correctly as normal, weak or absent. Identify clear deep vein thrombosis in calf and thigh |
Blood pressure | Demonstrate correct
method of measuring blood pressure, including applying cuff, inflating
and deflating at right rate, and identifying Korotkov sounds
Identify clearly raised level of blood pressure |
JVP | Demonstrate correct
method of measuring JVP
Identify clearly elevated JVP |
Murmurs | Detect clear cardiac murmur and classify as systolic or diastolic |
Lungs | See Respiratory
Curriculum
Recognise clear basal crackles |
Oedema | Identify ankle and sacral oedema |
Chest X-ray and other imaging | Ability to measure
cardio thoracic ratio, and recognise cardiomegaly
Recognise clear pulmonary oedema..Awareness of the use of MRIand CT and nuclear medicine in the diagnosis of cardiovascular anatomy and pathology |
ECG | Recognise features
of a normal ECG, rate and rhythm
Identify cardiac arrhythmias: AF, ectopic beats Identify clear myocardial infarction |
Use of GTN | Describe use as diagnostic test, technique, side effects |
Cardiac pacing | Have observed. Broadly know indications and risks. |
Cardiac catheterisation +/- angioplasty | Have observed. Broadly know indications and risks. |
Electro physiology studies | Awareness of use of these studies |
Exercise testing | Have observed. Broadly know indications and risks |
Echocardiography | Awareness of the use of these studies and recognition of examples |
Breathlessness | Explore precipitants,
relieving factors, speed of onset and progression of breathlessness,
and associated symptoms.
Associate type of breathlessness and assoc symptoms with common causes: asthma, COPD, pneumonia, pulmonary embolism, lung cancer Assess severity (nil, ordinary exertion, severe exertion, rest) |
Chest pain | See cardiovascular
curriculum
Identify specific features of pleuritic chest pain |
Cough | Explore nature of cough (dry, productive) precipitants, relieving factors, speed of onset and progression, and associated symptoms |
Sputum/Haemoptysis | Explore nature of sputum (mucoid, purulent, haemoptysis) and associated symptoms |
Wheeze /Stridor | Identify clear description of wheeze and stridor and associate with common causes |
General examination | Identify noisy breathing, clubbing, cyanosis, cervical lymphadenopathy, signs of smoking, recent weight loss |
Shape of chest wall | Identify barrel, pigeon and funnel chests and clear thoracic scoliosis |
Respiratory movements | Assess respiratory
frequency and depth.
Identify clear tachypnoea, intercostal recession and hyperventilation |
Percussion | Identify dullness
and resonance over different lung areas
Identify clear pleural effusion and pneumothorax |
Breath sounds | Identify normal breath sounds. Identify clear cases of localised and generalised wheezes (rhonchi) and pitch (high medium, low), crackles (crepitations) and pleural rub, and associate with common causes. Identify localised or generalised reduced breath sounds |
Voice sounds | Identify normal, and clearly increased and decreased voice sounds |
Chest X-ray and other diagnostic tests | Recognise clear
cases of pneumonia, pneumothorax, pleural effusion, lung mass and fractured
ribs
Appreciate absence of radiological signs in some serious conditions –asthma, pulmonary embolus. Awareness of the use of other diagnostic methods ie. CT and nuclear medine in the diagnosis of respiratory disease and pulmonary embolus |
Use of bronchodilator | Demonstrate correct technique for use of bronchodilator MDI and adult spacer device |
Peak Flow Meter | Demonstrate correct technique for measurement of Peak Flow |
Respiratory Function tests | Observe and know basics of referral criteria |
Deafness | Establish onset, progression and severity of deafness. Assess level of handicap. Identify associated symptoms including earache, discharge, tinnitus and vertigo. Risk factors including previous infection, noise exposure and family history |
Dizzy | Establish nature, frequency, and duration of episodes of dizziness. Identify associated symptoms including tinnitus, deafness, nausea and vomiting. Identify aggravating factors such as head position and hyperventilation. |
Ringing in ears | Determine characteristics of tinnitus, aggravating factors and level of distress. Assess associated symptoms including deafness, discharge, earache and vertigo. Identify risk factors including noise exposure. |
Hoarseness | Assess duration and severity of voice problems. Identify associated symptoms including stridor, dysphagia, sore throat and risk factors including smoking and vocal abuse |
Difficulty swallowing | Establish onset, progression and degree of difficulty with swallowing and whether with fluids and/or solids. Associated symptoms such as weight loss, hoarseness, stridor and indigestion. |
Neck lump | Explore symptoms related to the lump: pain, duration, and change in size. Identify associated symptoms including hoarseness, dysphagia, sore throat, and weight loss. Assess risk factors including smoking and excess alcohol. |
Blocked nose | Assess severity, duration, onset and side(s) affected. Explore associated relevant symptoms including rhinorrhoea, postnasal drip, sneezing, itching and facial pain and pressure. Identify history of atopy and associated diseases including asthma, hay fever and eczema. |
Ear | Assess hearing loss with Weber and Rinnes tuning fork tests. Inspection of pinna and external auditory meatus. Otoscopic examination of ear and recognition of features of tympanic membrane. |
Nose | Inspection of external nose and anterior nares. Knowledge of techniques of examination of the nasal cavity and postnasal space, including anterior rhinoscopy and rigid nasendoscopy. |
Throat | Assessment for dysphonia and stridor. Inspection of oral cavity and oropharynx. Awareness of methods of examination of the larynx and hypopharynx, including indirect laryngoscopy and flexible laryngoscopy. |
Neck | Inspection and systematic palpation of the neck with assessment of size, shape, position, mobility and consistency of the neck lump. Assessment of transillumination of lump and presence of bruits. |
Audiogram | Understand the principles of pure tone audiometry and be able to interpret findings in common causes of deafness |
Tympanometry | Understand the principles of tympanometry |
FNA | Understand the role and process of FNA of neck lumps |
Tuning Fork (512 or 256Hz) | Familiar with correct use |
Otoscope | Familiar with correct use |
Mouth ulcer | Assess duration, associated symptoms, relevant predisposing factors |
Odontalgia | Location, duration, severity, radiation, associated symptoms |
Temporomandibular pain | Location, duration, severity. Association with tooth-grinding, malocclusion, psychosomatic factors |
Facial deformity | Awareness of congenital versus acquired. Functional effect on speech, breathing, etc. Psychological effect. |
Facial fracture | Awareness of symptoms arising from facial fractures ie pain, swelling, diplopia, malocclusion, symptoms of intracranial or cervical trauma |
Mouth ulcer | Size, shape, number, location |
Leukoplakia / erythroplakia | Size, shape, degree, location, induration, ulceration |
Jaw mass | |
Facial deformity | Examination and assessment |
Facial fracture | Examination for deformity and disability: cranial nerves, occlusion, airway obstruction |
Stomatitis/Glossitis | Appearance, localised/generalised |
Radiology | Awarenes of the value of plain radiology and other imaging techniques x-rays |
Blood tests | Relationship of anaemia and other systemic diseases with oral ulceration, stomatitis and glossitis |
Claudication pain | Assess distance and severity. Duration. |
Ischaemic rest pain | Severity, duration |
Symptoms of leaking/ruptured aortic aneurysm | Differentiating symptoms from other causes of back pain. Shock. |
Numbness and paraesthesiae of periphery | Duration, extent, associated symptoms |
Varicose veins | Duration, extent, associated pain, and other symptoms |
Peripheral vasospasm | Constellation of symptoms |
Amaurosis fugax | Typical presentation |
Transient ischaemic attacks | Typical presentation, and relation of symptom complexes to arterial site of origin |
Carotid bruit | Auscultation |
Aortic aneurysm | Palpation technique and size assessment. Surface mark the aortic bifurcation. |
Peripheral pulses | Palpation technique |
Peripheral skin/nails/hair changes | Types, degree, significance |
Varicose veins | Basic anatomy of deep and superficial venous drainage of the leg. Recognition of a varicose vein. |
The diabetic foot | Assess feet for signs of diabetic foot disease, including typical deformity and distribution of ulcers. Screen for peripheral neuropathy and peripheral vascular disease. |
The vasospastic hand/foot | Appearance of transient and established vasospastic changes |
ABPI | Value, meaning and unreliability in diabetes |
Duplex ultrasound | Indications and meaning of result |
Arteriography | Indications, complications and meaning of result |
Treadmill testing | Indications and meaning of result |
Diagnosis of diabetes | Interpret plasma glucose results using the WHO criteria for diagnosis of diabetes mellitus |
Plain abdominal film | Usefulness and limitations in aortic tree disease |
CT and MRI | Awareness of the usefulness of these tests in the diagnosis of vascular disease. |
Core Curriculum for Medicine and Surgery B: (Introduction to diseases of the gastroenterological, endocrine, renal and nervous systems)
Pain | Explore basic
characteristics – site, radiation, and nature of pain.
Identify foregut, mid gut and hind gut pain Identify biliary pain, pain of peritonitis, intestinal colic and obstruction |
Weight loss | Amount, duration, anorexia |
Dysphagia | Duration, grading, nature |
Reflux | Identify constellation of symptoms associated with reflux |
Vomiting/nausea | Explore amount, precipitating factors, colour, content, frequency |
Jaundice | Identify constellation of symptoms and history associated with obstructive jaundice and distinguish from other causes of jaundice |
Bowel habit | Assess nature (diarrhoea/constipation), frequency, consistency, colour, associated symptoms |
Rectal bleeding | Explore amount, colour, frequency, associated symptoms, description of stool including meleana and symptoms of anaemia |
Ascites | Identify history of ascites distinguish from other causes of abdominal swelling |
Abdominal/groin swellings | Explore history, onset, associated bowel symptoms – distinguish simple hernia history from impending obstruction/strangulation |
Perianal symptoms | Explore pain, itching, discharge, anal lumps |
General | Assess overall appearance. Identify nutritional problems, state of hydration, features of shock |
Hands | Identify clubbing, palmar erythema, Duputren’s contracture, flap |
Face/mouth | Examination for signs of anaemia, jaundice, mouth ulcers, spider naevi |
Lymph nodes | Examine the neck/axillae/groin for lymphadenopathy |
Abdominal inspection | Scars, masses, distension, discolouration |
Abdominal examination | Superficial and deep examination. Examination of the liver, spleen, kidneys, abdominal masses and ascites. |
Abdominal auscultation | Identify normal pattern and obstructive bowel sounds |
Hernias | Examination of groin hernia. |
Rectal examination | Discuss inspection and examination of the perianal area and per rectum examination |
Full blood count | Understand iron deficiency anaemia, inflammatory markers and abdominal disease |
Amylase | Interpretation of results |
Liver function tests | Interpretation of obstructive jaundice and differentiation from other forms of jaundice |
Plain CXR/AXR | Identify free intra peritoneal air, obstruction of the GI tract |
Urine | See renal/urology system |
Ultrasound/contrast studies | Understand the main role of these in abdominal investigations |
Proctoscope/sigmoidoscope | Identify and appreciate their role |
Lump | Explore symptoms related to the lump: pain, duration, and change in size. Relevant past history and history of risk factors |
Nipple discharge | Duration, amount, nature of discharge and related factors |
Lumps | Assess overall appearance of breasts, describe the lump: size, shape, site, position, mobility, and consistency. |
Lymph nodes | Examination of supraclavicular, axillary and groin nodes |
FNA | Understand the role and process of FNA |
Mammogram | Identify the investigation and understand its role in diagnosis and screening |
C. ENDOCRINE SYSTEM
1. Diabetes Mellitus
History and evaluation of symptoms
Diabetes | Identify characteristic symptoms associated with diabetes and symptoms suggesting urgent need for insulin. Be aware of common presentations of type 1 and type 2 diabetes |
Hypoglycaemia | Identify typical symptoms of hypoglycaemia and be aware of the range of hypoglycaemic warning experienced by patients |
Be aware of the social and psychological implications of this chronic condition on the life of a person with diabetes |
Examination for acute and chronic complication of diabetes
Assessment of the severely ill or comatose patient | Identify signs of diabetic ketoacidosis and hyperosmolar non-ketotic state, and assess the severity of dehydration and coma. Distinguish between the clinical pictures of hyper- and hypoglycaemic coma |
Eyes | Test visual acuity
using a Snellen chart
Perform direct ophthalmoscopy, and identify lesions of diabetic retinopathy and cataract on a photograph |
Feet | Assess feet for signs of diabetic foot disease. Screen for peripheral neuropathy and peripheral vascular disease. |
Diagnostic criteria | Interpret plasma glucose results using the WHO criteria for diagnosis of diabetes mellitus |
Urinalysis | Identify glycosuria, ketonuria, proteinuria and haematuria, on urine stick testing and describe their significance |
Capillary blood glucose measurement | Perform capillary blood glucose measurement and use the results to guide treatment adjustment |
Education | Describe the likely requirements of a person with diabetes for information, education and support, and the options for delivery of this |
Diet and lifestyle changes | Describe the principles of dietary and lifestyle advice in insulin-treated and non-insulin treated diabetes mellitus |
Oral hypoglycaemic agents | Describe indications, side effects and contraindications for metformin, sulphonylureas and other agents |
Insulin | Describe indications, technique of administration, principles of dose adjustment and side effects |
Hypoglycaemia | Treat hypoglycaemia in conscious and unconscious patients |
2. Thyroid Disease
Common symptoms of abnormal thyroid function
Thyrotoxicosis and hypothryoidism | Identify constellation of symptoms associated with (i) thyrotoxicosis, and distinguish from anxiety (ii) hypothyroidism, and distinguish from other causes of tiredness |
Examination of the thyroid
Thyrotoxicosis and hypothyroisism | Identify characteristic signs of (i) thyrotoxicosis including tremor, sweating, eye signs, and distinguish from anxiety (ii) hypothyroidism including slowness, hoarse voice, thin hair, dry skin, slow reflexes |
Thyroid gland | Examine the neck to identify the thyroid gland. Assess its overall size and consistency and describe any palpable masses |
3. Hypothalamo-pituitary-adrenal axis
Most common presentations of pituitary and adrenal disease
Adrenal overactivity and insufficiency | Identify constellation of symptoms and signs associated with (i) corticosteroid excess and (ii) primary and secondary hypoadrenalism |
Pituitary hormone excess and deficiency | Be aware of the constellation of symptoms and signs associated with (i) excess of prolactin/ACTH or growth hormone and (ii) deficiency of ACTH/gonadotrophins/TSH |
Compression of structures related to the pituitary | Examine visual fields and identify obvious bitemporal hemianopia |
Hypercalcaemia an hypocalcaemia | Identify constellation of symptoms associated with (i) hypercalcaemia, and ask appropriate questions to formulate a differential diagnosis aend (ii) hypocalcaemia |
Thyroid function tests | Interpret TSH and free thyroid hormone results |
Cortisol replacement and long term steroid use | Describe use and side effects of corticosteroid therapy |
1. History and evaluations of symptoms
Abdominal pain | Describe the symptoms and signs of renal & ureteric colic |
Urinary volume | Identify clearly abnormal urinary frequency and distinguish from polyuria. Identify oliguria/anuria. Aware of the significance of polyuria, nocturia and frequency |
Urine characteristics | Identify blood in the urine. Recognise that it may be the only manifestation of serious urinary tract disease. Be aware of the significance that frothy urine may indicate proteinuria. |
Urinary stream | Describe lower urinary tract symptoms including frequency, urgency, nocturia, dysuria, hesitancy, poor stream. |
Urinary incontinence | Distinguish urge and stress incontinence |
Uraemia | Identify the non-specific symptoms of uraemia: lethargy, pruritus, pigmentation, and loss of sensation |
Blood pressure | Be competent in correct measurement technique of blood pressure, and aware of importance of cuff size and Korotkov sounds. Familiar with automated methods of measurement and aware of role of ambulatory measurements |
Circulatory volume | Make use of examination of tissue turgor, jugular venous pressure and postural blood pressure measurements in clinical assessment of circulatory volume |
Kidneys | Be aware of techniques for kidney palpation and clinical characteristics of renal masses. |
Bladder | Percuss and palpate the bladder |
Prostate | To perform rectal examination under supervision and assess prostatic size, outline and texture. |
Scrotum | Identify normal
and clearly abnormal testicles by palpation. Identify scrotal swelling,
and distinguish testicular and epididymal swelling and hydrocoele, varicocoele.
Distinguish from inguinal hernia. Demonstrate transillumination of hydrocoele.
(See lumps and bumps curriculum) |
Oedema | Identify constellation of symptoms and signs associated with nephrotic syndrome, and distinguish from cardiac failure, venous insufficiency and hypoalbuminaemia of other cause |
Midstream urine sample | Technique for collection of clean samples. Interpretation of urine culture results |
Urine testing | Identify haematuria, proteinuria, glycosuria and ketonuria on urine stick testing. Be aware of the sensitivity of urinary dipsticks and the importance of thorough investigation of abnormalities |
Blood tests | Potassium: significance
of abnormal results and the effect of haemolysis.
Creatinine: strengths and weaknesses as a measurement of renal function. PSA: significance and role in screening Blood gases: interpretation of pH, bicarbonate and “base excess” |
Imaging | Awareness of imaging techniques commonly used in investigation of renal and urinary tract disease (ultrasound, plain abdominal X ray “KUB”, IVU/other contrast techniques, CT/MRI) and of the indications for choosing each of these. Able to identify major organs on normal CT abdomen. Able to interpret common signs on the IVU |
Urodynamics | Aware of free urinary flow trace patterns and the significance of post void residual bladder volume. |
Invasive investigations | Awareness of techniques of cystoscopy, and renal biopsy and of indications for these. |
1. Common symptoms of neurological disease
Headache | Able to elicit accurate history of headache and distinguish between benign headaches (tension headache, migraine) and serious headaches (meningitis, subarachnoid, haemorrhage, temporal arteritis). |
Weakness/immobility | Identify history of weakness, its pattern and mode of onset. Identify acute onset of stroke and TIA and be aware of the risk factors. |
Dizziness / unsteadiness | Identify clear history of vertigo. Awareness of other common causes of dizziness. Elicit a history of ataxia. |
Blackouts | . Identify clear history of generalised epileptic seizure and distinguish from vasovagal event. Aware of the principles of management of common epileptic conditions. |
2. Examination of nervous system
General examination | Identify signs of meningeal irritation and the skin rash associated with meningococcal septicaemia. Identify muscle wasting.. |
Cranial nerves | Demonstrate ability to examine all the cranial nerves particularly eye movements, pupil reactions, facial sensation, facial weakness (distinguish between an upper and lower motor neurone lesion), dysarthria, tongue weakness and wasting. |
Tone | Identify clearly increased and decreased muscle tone in upper and lower limbs. |
Power | Examine power in limbs. Distinguish constellation of signs of upper and lower motor neurone lesion. |
Reflexes | Examine the biceps, triceps, supinator, knee and ankle and plantar reflexes. Identify clearly increased and decreased/absent tendon reflexes. Awareness of the value of reinforcement. |
Tremor and co-ordination | Recognise the tremor of Parkinson’s Disease and distinguish from hyperthyroidism/anxiety/ benign essential tremor. Able to examine co-ordination in the upper and lower limbs |
Gait | Examine patient’s gait, and identify clear neurological abnormality due to major hemiplegic stroke, cerebellar disease and Parkinson’s Disease |
Speech | Recognise clear speech abnormality. Able to distinguish between dysphasia and dysarthria. |
Sensation | Examine limbs and trunk for fine touch, proprioception, vibration and pain sensation. Identify clearly reduced / altered sensation and pattern. |
CT scan of head | Recognise clear cerebral haemorrhage and infarct. |
EXAMPLES OF Possible SSC topics
(Further suggestions are available on the Medicine and Surgery Unit Blackboard sites):
Gastroenterology
Renal
Neurology
Diabetes, endocrinology and metabolism
Radiology
Cardiology
Respiratory medicine
ENT
Vascular Surgery
MARKING STRATEGY FOR SSMS
There will obviously be some diversity in the SSC projects and the students’ approach to them. In order to consider more than just factual content, please give a mark for the SSC in each of the following areas. Please remember that student has been allocated eight days for this SSC and the quality of the work should reflect this.
CONTENT
PRESENTATION
REFERENCES and SOURCE MATERIAL
STUDENT NAME: | |||||
SUPERVISOR: | |||||
SSC TITLE: | |||||
ORIGINALITY | CONTENT | PRESENTATION | REFERENCES | INDEPENDENT WORK | TOTAL
MARK |
Comments:
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ADDITIONAL MEDICINE AND SURGERY B ASSESSMENTS INFORMATION
The unit assessment consists of :
‘Must pass’ components:
Professional Behaviour assessment
Handing in an SSC and making a formal presentation of a case report
Written assessment
Clinical assessment
The final unit mark consists of :
Clinical assessment (50%): OSCE
Written assessment (50%):
Merits and distinctions will be based on your combined marks from clinical and written assessments for Medicine and Surgery B.
The OSCE will be held on the morning of the last Thursday of your second Medicine and Surgery attachment, (25th March 2004 or 3rd June 2004 ) between 08.30 and 17.30 hrs. Your OSCE in Medicine and Surgery A will be on the previous day. The exam will take place in the Academic Centre, Frenchay Hospital. Students will be divided into five groups with different start times. You will receive notification of the time to arrive by e-mail, and are expected to turn up in good time for the start.
Students are expected to be presentable and wear clean white coats, as patients will be present. ID badges must also be worn. You will need a pen, a watch and a stethoscope.
Content
You will rotate through 12 stations and the exam will last approximately 1� hours
For more detailed descriptions of the type of stations, please refer ‘The Second Clinical Attachment OSCE: what to expect’ on the Galenicals web-site
(http://www.medici.bris.ac.uk/galenicals/osce.htm).
In outline the stations will include:
Two 10-minute stations:
Ten 5-minute stations:
This list is only meant to give you some guidance as to what to expect. It is not intended to be a complete syllabus or curriculum. Other stations might be included in your exam.
Each station will have either an examiner, someone to instruct you what to do or clear written instructions, depending on content. There will be ‘marshals’ to tell where to go and make sure that everything is clear. There will not be any chance of you getting lost or going the wrong way.
The OSCE will draw its contents from the syllabus in the back of your course handbook. Other useful sources of information are i) the Galenicals’ website pages on the Second Clinical Attachment OSCE. The principals of this exam are the same though the content will be more focused on the AERON subjects, ii) the OSCE tutorial on the Galenicals’ website, iii) Appendix 4 of your Medicine and Surgery B handbook.
This must be handed in before the end of the unit, and, at your end of unit assessment with your tutor, you will be required to produce a copy of the e-mail you will receive from Sharon Byrne confirming receipt of the project. You must print this off and keep it. Your SSC must be handed in on time. This is non-negotiable. If your SSC is handed in late without prior agreement with the unit lead due to exceptional circumstances, you will fail
You are required to write up or present one patient case history. This patients should illustrate a core problem from one of the groupings related to your current attachment (i.e gastrointestinal and breast disease, neurological disease, endocrinology and diabetes, or urology and renal medicine for Medicine and Surgery B). This case report should include the key points of the history, examination and investigations with your conclusions about the diagnosis. This should be followed by a section on the management and progress up to discharge. The case history should therefore cover the whole admission and discussion of the underlying condition and management options as well as the initial clerking. In Medicine and Surgery B, you will be required make a formal presentation of this case to your teachers and colleagues at the end of the unit, and to answer their questions on it. The suggested format is a 10-minute presentation with overheads/powerpoint with 5 minutes for questions. Your mark for this case will be assigned on the basis of their comments
PJB/11.08.03
How to clerk a patient
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