MEDICINE AND SURGERY UNIT 2
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MEDICAL SCHOOL
MB ChB
YEAR 3
MEDICINE AND SURGERY
HANDBOOK FOR STUDENTS AND TEACHERS
2003-2004
YEAR 3 Medicine and Surgery
TABLE OF CONTENTS
Introduction 3
Objectives 3
Core clinical problems 3
Resources for learning 5
Patients 5
Teachers 5
Self-directed learning 6
i. Recommended books 6
ii. Videos, web-based materials etc 6
iii. Your suggestions 6
iv. Student selected components 7
Formal teaching 8
i. Tutorials and skills lab sessions 8
ii. General Practice Attachments 8
iii. Lectures 9
iv. Diabetes teaching 9
Assessments 10
Unit Assessment 10
i. Professional Behaviour 10
ii. Clinical assessment 10
iii. Written assessments 11
a. Case reports 11
b. Student selected components 11
c. Multiple choice exam 11
Formative assessment 12
Tutorial support 12
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
Appendix 4: Additional Medicine and Surgery B Assessments Information.. 30
Appendix 5: How to clerk a patient 32
Introduction
The primary purpose of the Medicine and Surgery Units in Year 3 is to build on the clinical skills you have acquired in the Basic Clinical Skills Unit in Year 2 so that you are able to:
a) make an assessment of a patient presenting with a common problem and come to a working diagnosis,
b) choose and interpret appropriate investigations to refine that diagnosis, and
c) outline a plan of management.
During the year you will complete two units in medicine and surgery – Medicine and Surgery A (introduction to the diseases of the cardiovascular and respiratory systems, vascular surgery, diseases of the ear, nose, throat and oral cavity) and Medicine and Surgery B (introduction to diseases of the gastroenterological, endocrine, renal and nervous system). The units have their major focus on different systems, but this is simply to ensure that you are exposed to most specialities. They have the same objectives, and you can’t forget the heart or abdomen just because it is in the other unit! You will be introduced to the common conditions affecting many systems of the body that will provide the foundation for the subjects you will cover in Years 4 and 5.
Objectives
By the end of the attachment you should be able to
• Take record and present a relevant history
• Examine a patient and elicit, demonstrate and interpret common physical signs
• Integrate the history and physical findings to construct a working diagnosis
• Formulate plans for investigation and treatment of the core clinical problems in the light of the available evidence base
• Demonstrate a professional attitude, including the need to
- Treat patients with courtesy and consideration
- Respect the dignity and privacy of patients and confidentiality of information
- Work efficiently and professionally with other colleagues within the team to maximise the interests of the patient
Core clinical problems
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.
1. Cardiovascular disease (cardiology and vascular surgery)
a) I have chest pain
b) I have high blood pressure
c) I get palpitations
d) I have a heart murmur
e) I am short of breath
f) My legs hurt when I walk
g) My fingers and toes hurt
h) I have an aortic aneurysm
i) I suffer from strokes
j) My leg is cold and painful
2. Respiratory disease
a) I have coughed up blood
b) I am wheezy
c) I am coughing up coloured sputum
3. Diseases of the ear nose and throat
a) I am dizzy
b) My voice has changed
c) My child can’t hear
d) I am deaf
e) My nose is blocked
f) I have a lump in my neck
g) I have mouth ulcers
4. Gastrointestinal and breast disease
a) I have pain in my abdomen
b) I have pain or difficulty in swallowing/I have been vomiting
c) I have vomited blood or have blood in my stools
d) I have gone yellow
e) I have noticed a change in my bowel habit
f) There is a lump in my abdomen
g) I have a breast lump
5. Neurological disease
a) I have a headache
b) I have had a blackout
c) I have a weak arm
d) I am dizzy/unsteady
e) I have weak legs
6. Endocrinology and diabetes
a) I am thirsty
b) I have lost weight
c) There is glucose in my urine
7. Urology and renal medicine
a) I have passed blood in my urine/ there is protein in my urine
b) I have stopped passing urine
c) I pass a lot of urine/ have to pass urine at night
d) I keep getting cystitis
e) I have lump in my testicle
f) I have pain in my loin
Core Curriculum
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.
Resources for learning
1. Patients
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.
Acute takes
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.
You are reminded of the contents of the Code of Conduct agreement relating to access to patients and clinical work which you signed at the beginning of the Clinical course. You must adhere to this at all times. To refresh your memory, the major points are reiterated in the Year 3 Handbook.
2. Teachers
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.
3. Self-directed learning
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
General
• Kumar P, Clarke M. Clinical Medicine
• Souhami RL, Moxham J. Textbook of Medicine
• Burkitt RG, Quick CRG, Deakin PJ. Essential surgery: problems, diagnosis and management
• Garden OJ, Bradbury AW, Forsythe JLR. The principles and practice of surgery
Other recommended books (All available in the Medical School Library)
• C.O'Callaghan and B.M.Brenner. The kidney at a glance. Blackwell Science Ltd
• Brewer S, Cranston D, Nobel J, Reynard J. Urology: a handbook for medical students
• J Pickup and G Williams. Textbook of Diabetes. Blackwell
• A Levy and S Lightman. Endocrinology. Oxford Core Texts.
• J Hampton. The ECG made easy. Churchill Livingstone
• R. Corbridge, Modern ENT practice: an essential guide. Arnold
• M.S. McCormick, W.J. Primrose, I.J. Mackenzie. A new short textbook of otolaryngology. Arnold
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 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
Introduction
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:
a) To obtain and report on experience in a speciality or technique you may not encounter in the basic curriculum (e.g. cardiac surgery, renal dialysis etc.)
b) To undertake a literature or web-based study of a particular topic or treatment, perhaps leading to proposals for further research or management guidelines
c) To develop educational materials or information resources (computer or paper-based) for patients, relatives, medical students or health care professionals on a particular topic
d) To undertake a survey or audit on some aspect of health care delivery. This might be from the perspective of the consumers or the deliverers
e) To combine these to produce a detailed case report on one or two patients including the patients’ and/or families perspective of their illness or management, with a full discussion of the literature on the condition and/or its management.
This list is only intended to give you some guidance. We hope that many of you will come up with other ideas. Try and vary the type of SSMs you do through the year and not simply do a library based SSC each time.
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.
Practicalities of the SSC within Medicine and Surgery A and B:
1. You need an idea – a list of suggested SSCs is available in Appendix 2 and on the Medicine and Surgery A and B Unit sites on Blackboard, though we would encourage you to think up your own idea.
2. You need a supervisor. If you are planning to choose a title from our list of suggestions, supervisors have already been identified. If you have an idea of your own, you also need to identify someone to supervise the project for you in which case you must get them to sign a Supervisor Acceptance Form that can be found on Blackboard or from the unit SSC administrator. Many supervisors are very happy to help and advise you with your project. It is therefore worth considering how easy or otherwise it would be for you to visit your supervisor to make use of their support when making your selection.
3. You need to register your SSC with the SSC administrator (For Medicine and Surgery A with Sylvia Finch (Sylvia.finch@bristol.ac.uk), and for Medicine and Surgery B with Sharon Byrne (Sharon.byrne@bristol.ac.uk)). You must e-mail the appropriate unit SSC administrator with a list of four projects in which you are interested indicating your order of preference by the end of the first week of the block. If someone else has already registered for your first preference, you will be allocated to your second preference etc. Only one student can do each project in each block and allocation will be strictly on a first-come first-served basis. You will be notified by e-mail of the name and contact details of your supervisor.
4. You need to define exactly what you think what you are going to get out of the project, and to draw up a plan. You should make an early appointment with your supervisor to discuss your plans.
5. You need to spend the equivalent of one day per week on your SSC. How this is timetabled will depend on your teachers, but you should try to make sure that you get to work on this project within the first two weeks of the unit
6. If you are encountering problems, seek help from your supervisor in the first instance. Otherwise contact the relevant unit SSC administrator who will direct you to the most appropriate person.
7. The completed report must be submitted to the unit SSC administrator 1 week before the end of unit assessment. If you have not done so, you will fail the unit. It is entirely up to you to make sure this happens – no one will chase you. You should send your SSC to the unit SSC administrator electronically. If, for any reason, this is not possible please send two copies to Sylvia Finch) at the Radiology Dept, Bristol General Hospital Guinea St. Bristol BS1 6SY(for Medicine and Surgery A) or to Sharon Byrne at the Department of Neurology, Frenchay Hospital, Bristol, BS16 1LE (for Medicine and Surgery B). You will receive an e-mail from the unit SSC administrator confirming that she has received your project. You must print out this receipt and keep it as proof that you have submitted your SSC.
8. It is wise to start thinking about the subject of your external SSC as soon as possible. If you want do to a research or audit project you will need to get approval from the relevant committee and this can take many months.
Summary of SSC dates:
| | | | |
| |Dates |SSC Registration deadline |SSC Completion deadline |
|Block 1 |1st September 2003 | | |
| |to |5th September 2003 |24th October 2003 |
| |31st October 2003 | | |
|Block 2 |3rd November 2003 | | |
| |to |7th November 2003 |16th January 2004 |
| |23rd January 2004 | | |
|Block 3 |26th January 2004 | | |
| |to |30th January 2004 |19th March 2004 |
| |26th March 2004 | | |
|Block 4 |29th March 2004 | | |
| |to |2nd April 2004 |28th May 2004 |
| |4th June 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.
General Practice Attachments
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:
• to see clinical cases in a relaxed environment including patients’ own homes
1. to experience the selective use of history and examination and hypothesis testing
2. to see less well differentiated illness
3. to see the emotional and physical response to illness
4. to see the interaction of social and psychological factors with physical illness
5. to appreciate the interaction between primary and secondary care
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.
Diabetes teaching
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
Assessments
Your progress on the unit and your attainment of the aims and objectives of the course will be assessed in a number of ways. You will have both summative and formative assessments. To pass the unit you need to pass all three parts of the summative assessment. Merits and distinctions will be awarded on the basis of a composite mark for the clinical examination, SSC (project plus case reports) and the multiple choice question examination.
Summative assessments
1. Professional Behaviour
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.
2. Clinical assessment (50% of overall unit assessment)
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 ( ).
3. Written assessments (50% of overall unit assessment)
i. Student selected component (15% overall)
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.
ii. case report (5% overall)
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
iii. Multiple choice exam (30% overall)
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.
Formative assessments
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.
Firm Leaders
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
Unit Organiser:
Professor Michael Rees (Dept of Radiology, Bristol General Hospital) Tel: 928 2731
(m.rees@bristol.ac.uk) Fax: 928 2319
Unit Administator and SSC administrator:
Sylvia Finch (Dept of Radiology, Bristol General Hospital) Tel: 928 2731
(sylvia.finch@bristol.ac.uk) Fax: 928 2319
Examinations Lead:
Mr Desmond Nunez (Dept of ENT, Southmead Hospital) Tel: 959 6222
(d.a.nunez@bristol.ac.uk)
Medicine and Surgery B
Unit Organisers:
Dr Polly Bingley (Division of Medicine, Southmead Hospital) Tel: 959 5337
(polly.Bingley@bristol.ac.uk)
Miss Jane Blazeby (Division of Surgery, Level 7, BRI) Tel: 928 2336
(j.m.blazeby@bristol.ac.uk)
Curriculum translator
Miss Rachel English (Division of Surgery, Level 7, BRI) Tel: 928 2336
(Rachel.English@bristol.ac.uk)
SSC administrator
Mrs Sharon Byrne (Neurology, Frenchay Hospital; am only) Tel: 970 1212 Ext 2979
(Sharon.byrne@bristol.ac.uk).
Student support
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@
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.
YEAR 3 Medicine and Surgery
Core curriculum and standards
Underlying principles:
1. These are the core curriculum and standards for the a student completing Year 3 Medicine and Surgery units, not the end of the MB ChB course
2. They build on the curriculum of the Year 2 Clinical Attachment and those of the Medicine and Surgery A and B units are complementary
3. They reflect that the majority of teaching on these courses is done by generalists (physicians, surgeons and general practitioners) rather than specialists teaching about their area of expertise
4. The emphasis in the Year 2 clinical attachment is on history taking and clinical examination of the different body systems. This is extended in the 3rd year so that students can assess common clinical problems in a sensible, analytical and problem-solving way.
5. They are minimum standards, i.e. all students should be at this level by the end of the Medicine and Surgery A and B unit
6. These standards should be used for the OSCE exams at the end of the Medicine and Surgery A and B units
7. They acknowledge the need to develop clinical skills to recognise both the normal and the clearly abnormal
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)
A. Cardiac system
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 |
3. Diagnostic tests/medication of cardiovascular system
|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 |
4. Equipment
|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|
B. Respiratory system
1. History and evaluation of symptoms
|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 |
2. Examination of respiratory system
|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 |
3. Diagnostic tests/medication of respiratory system
|Chest X-ray and other diagnostic |Recognise clear cases of pneumonia, pneumothorax, pleural effusion, lung mass and |
|tests |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 |
4. Equipment
|Peak Flow Meter |Demonstrate correct technique for measurement of Peak Flow |
|Respiratory Function tests |Observe and know basics of referral criteria |
C. Otorhinolaryngology
1. History and evaluation of symptoms
|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. |
2. Examination of ear, nose and throat
|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. |
3. Diagnostic tests
|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 |
4. Equipment
|Tuning Fork (512 or 256Hz) |Familiar with correct use |
|Otoscope |Familiar with correct use |
D. Maxillofacial surgery
1. History and evaluation of symptoms
|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 |
2. Examination
|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 |
3. Diagnostic tests
|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 |
E. Vascular Surgery
1. History and evaluation of symptoms
|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 |
2. Examination
|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 |
3. Diagnostic tests
|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)
A. ABDOMINAL SYSTEM
1. History and evaluation of symptoms
|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 |
2. Examination
|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 |
3. Diagnostic tests
|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 |
4. Equipment
|Proctoscope/sigmoidoscope |Identify and appreciate their role |
B. BREAST
1. History and evaluation of symptoms
|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 |
2. Examination
|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 |
3. Diagnostic tests
|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 |Identify signs of diabetic ketoacidosis and hyperosmolar non-ketotic state, and |
|comatose patient |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 tests / therapeutic interventions in diabetes mellitus
|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 |Examine visual fields and identify obvious bitemporal hemianopia |
|pituitary | |
4. Calcium metabolism
|Hypercalcaemia an hypocalcaemia |Identify constellation of symptoms associated with (i) hypercalcaemia, and ask |
| |appropriate questions to formulate a differential diagnosis aend (ii) hypocalcaemia |
Diagnostic tests / medications in endocrinology
|Thyroid function tests |Interpret TSH and free thyroid hormone results |
|Cortisol replacement and long term steroid |Describe use and side effects of corticosteroid therapy |
|use | |
RENAL/UROLOGICAL
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 |
2. Examination of renal/urology system
|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 |
3. Diagnostic tests of renal/urology system
|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. |
D. NEUROLOGICAL SYSTEM
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. |
3. Diagnostic tests of nervous system
|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):
Surgery
• The patients journey through a major resection for hepatic or pancreatic cancer.
• Enteral nutrition in patients undergoing GI surgery.
• The problems facing patients undergoing elective surgery for colorectal cancer requiring a stoma
• Discuss advances in imaging of colorectal cancer.
• Radiotherapy for rectal cancer.
• Discuss the influence of patients groups in the treatment and management of breast cancer
• Reconstruction after mastectomy.
• Literature study of breast infections
• Multiple endocrine neoplasia type 1
• Scoring systems in acute pancreatitis
• Blunt abdominal trauma – how is it best investigated
• Discuss the falling mortality in acute appendicitis in the UK
Gastroenterology
• Examine the evidence for a link between MMR and inflammatory bowel disease
• What is it like to have coeliac disease
• GI endoscopy past, present and future
• Review the web-based resources for patients in gastroenterology
• Do any treatments work for irritable bowel syndrome?
• How does H.pylori cause ulcers?
• Can the mortality from GI bleeding be reduced?
• Are there alternatives to liver transplantation?
• How does alcohol damage the liver?
• Discuss the ethical issues surrounding tube feeding in neurological disease
• The impact of malnutrition in hospital patients
• Modern techniques for nutritional support
Why do patients with dyspepsia present to their General Practitioner? How should these patients be managed in Primary Care?
Renal
• Visit a dialysis centre, assess patient perceptions etc
• Follow a kidney transplant, pre-op, op and post-op
• Acute renal failure (literature based): why mortality still so high? how can it be improved? what are recent advances in management?
• What is the future of organ transplantation (literature based) animal organs, cloning, organ culture etc, also widening use of living unrelated kidney donors.
Neurology
• Follow a patient who has had a stroke from admission to discharge and comment constructively on their management whilst in hospital, drawing on published evidence where possible.
• Design a patient information sheet for people with migraine
• Discuss the psychological and social impact of epilepsy
• Alcohol poisons nerve – how and why?
• Epilepsy surgery – the way forward
• Respiratory support for people with motor neurone disease – ethical or criminal
• Examination of the lower / upper limbs- on CD-rom (group project)
• Beta interferon – what the patients’ think
• Complex disability - how it impacts on the family
• Investigation of the young stroke
• MS- future research prospects
• Neurological consequences of HIV and AIDS
Diabetes, endocrinology and metabolism
• Write an information leaflet for patients on tablet treatment/ diabetic retinopathy and how to prevent it/ benefits of exercise/starting insulin etc.
• A review for websites useful for a newly diagnosed patient or a patient with a newly diagnosed complication
• Islet transplantation – the current status
• Should screening for diabetes be introduced?
• How could length of in-patient stay of people with diabetes be reduced?
• Impotence in diabetes – aetiology and management
• Insulin infusion pumps - who should get them?
• Non-invasive glucose monitors – what is available and what works?
• What advice can we give patients on the use of ACE inhibitors in diabetes?
• Is MacDonald’s bad for health?
• Design a national plan for reducing the future incidence of type 2 diabetes
• Why are people with diabetes more likely to have heart attacks?
• Should we operate on obesity?
• Graves disease – review the possible treatment options
• Ghrelin – Review of a recently identified hormone
• Discuss risks and benefits of various treatment options for postmenopausal osteoporosis
• Acromegaly: Meet with and write a case study of a patient with acromegaly with particular regard long term medical and social consequences
• Atrial fibrillation in thyrotoxicosis - is it a bad thing?
• Accompany a patient having radioactive iodine therapy for hyperthyroidism. Describe the experience from the patient’s perspective.
Radiology
• Websites for users of radiology services
• Analysing radiologists reporting errors
• Computer aided analysis of radiological images (lung)
Cardiology
• How would you explain to a patient the benefits and risks of taking medication for high blood pressure
• Discuss the benefits of screening of patients for coronary disease
• An audit: the use of stress testing in ischaemic heart disease
• A case study: a patient suffering from a MI focusing on management of his condition
• Acute coronary syndrome – definition and patient information
• Cardiac amyloid disease
• Cardiovascular complications of cocaine
• Chelation therapy for heart diseases, is there any evidence?
• Drug therapy & plaque stability
• High altitude pulmonary oedema
• Identification and treatment of coronary risk factors in patients who have had a myocardial infarction
• Long QT Syndrome pathology & treatment
• Percutaneous transluminal coronary angioplasty v. coronary artery bypass grafting as a treatment for ischaemic heart disease
• Nitrates in cardiology
• Student approach to the interpretation of ECGs
• The effects of steroid abuse on the cardiovascular system
• The pathophysiology & management of valvular heart disease
• The use of betablockers in Marfan syndrome
Respiratory medicine
• The investigation and management of suspected venous thromboembolism
• Assessment of school policy on asthma
• Cryptogenetic fibrosing alviolitis: A forgotten disease
• Discuss various smoking cessation strategies and their relative success
• Lung transplantation
• Management of cystic fibrosis
• How society copes with new diseases, using sleep apnoea as a model
• The epidemiology of TB in the UK. Looking into the likely causes for the recent resurgence of TB in the UK
• The pathophysiology & current management of ARDS
• The use of bronchoscopy as a medical imaging technique
• Pleural mesothelioma audit
• Pathology of malignant lung cancer
ENT
• The treatment of recurrent laryngeal nerve palsy
Vascular Surgery
• A Rough Guide to the abdominal aortic aneurysm
• Amputation through the ages
• Atherosclerosis and smoking
• Clinical management of acute limb ischaemia
• Compare & contrast interventional methods for repairing aortic aneurysms
• The causes, effects and treatment of venous leg ulceration
• Lower limb amputation
• The management of intermittent claudication
• Who gets peripheral vascular disease and how does it affect their lives?
• 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.
ORIGINALITY
1. Fail. No original contribution from student in terms of idea or interpretation of subject matter
2. Poor. Pedestrian approach to subject
3. Average. Unoriginal idea but personalised approach by student
4. Good. Original idea / interpreted supervisor’s idea in novel manner.
5. Excellent. Student’s own idea. Showed outstanding imagination and originality.
CONTENT
1. Fail. Misinterpretation of the topic. Frequent factual errors. Inadequate coverage.
2. Poor. Minimal coverage and understanding of the topic. Muddled and confused thinking.
3. Average. Adequate but lacking depth
4. Good. Thorough, clear, concise and relevant account of subject
5. Excellent. Publication standard.
PRESENTATION
1. Fail. Very poor. Organisation confusing. No diagrams / inappropriate diagrams.
2. Poor. Poor structure/ organisation of the material. Extremely long /too short. Diagrams poor quality.
3. Average. Reasonable structure / organisation. Appropriate use of diagrams.
4. Good. Good structure with good use of text and diagrams.
5. Excellent. Textbook or publication standard presentation. Clearly labelled relevant diagrams.
REFERENCES and SOURCE MATERIAL
1. Fail. Very few, out of date references. Key facts in text not referenced. Not listed in appropriate format. No evidence that references actually read. Source material not quoted.
2. Poor. Limited references / source material. Inadequate literature search. Some key references missing.
3. Average. Adequately referenced / researched. Listed appropriately
4. Good. Good range of references/ sources with up to date material. Listed appropriately. Evidence of thorough background research.
5. Excellent. All key references included with clear evidence they have been read and critically analysed. Wide range of sources referenced (Web based material, newspapers). Appropriately listed.
INDEPENDENT WORK
1. Fail. Required a lot of staff effort and guidance / failed to recognise that some guidance required.
2. Poor. Needed frequent prompting. Dependent on supervisor for guidance.
3. Average. Reasonable level of independent work. Some prompting required. Aware of own limitations
4. Good. Worked independently. Appropriate liaison with supervisor
5. Excellent. Worked independently. Demonstrated high degree of initiative.
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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%):
- MCQ exam (30%)
- SSC (15%)
- Case report (5%)
Merits and distinctions will be based on your combined marks from clinical and written assessments for Medicine and Surgery B.
1. The Objective Structure Clinical Examination (OSCE)
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 1½ 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
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In outline the stations will include:
Two 10-minute stations:
• A clinical station (history): you will be asked to take a history from an actor playing the part of a patient complaining of one of the core clinical problems listed in the handbook.
• A clinical station (examination): you will be asked to examine a particular system and tell the examiner what you have found. The examiner will tell you
Ten 5-minute stations:
• Three or four short clinical examination stations covering neurology, nephrology, urology, breast disease, and endocrinology if not covered in longer stations: Some examples would be. a) partial neurological examination - previous stations have included sensory or motor examination of upper or lower limbs, cerebellar signs, particular cranial nerves etc. b) rectal examination on a mannequin, c) breast examination, d) examination of the thyroid, e) eye examination as relevant to general physical examination (e.g. ophthalmoscopy, visual acuity testing, visual fields etc), f) taking blood pressure properly!
• Communication skills: explaining something to a patient
• Two stations involving testing urine or interpretation of laboratory results, charts etc. relating to core problems and suggesting potential causes and follow-up investigations and management
• X ray interpretation: you will be given an X ray (see handbook for the types of things to expect) with an accompanying scenario and asked some questions related to diagnosis, aetiology, clinical presentation etc.
• Procedures: you will be asked to perform one of the procedures (on a mannequin if appropriate) listed in the handbook. These are things we expect you to have become familiar with while you are on the wards or in theatre or perhaps in a clinical skills session (e.g. taking blood, setting up an IV infusion (not inserting cannulae yet), aseptic technique etc. )
• Miscellaneous: This is a catch-all category that could include a) any aspect of the general examination which you should have brought with from your time in the first clinical attachment, and which you should have used during your clerking of patients on this unit e.g. part of the basic examination of the heart and lungs b) videos of patient histories c) photographs d) identification of commonly used instruments or special investigations as listed in the handbook e) duplication of one of the possibilities listed above.
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.
2. Student selected component (SSC)
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
3. Case reports
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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