MB ChB V
Study Guide
2010
Internal Medicine
Internal Medicine -MBChB V – Study Guide
2010
INDEX
Subject
Page
Weekly programme Internal Medicine
3
Learning opportunities
4
Assessment
5
Academic Afternoons
8
Clinical Rotation
9
Chest X-ray tutorial
9
Imaging sessions
9
Tuesday & Thursday afternoon case presentations
10
The problem list
11
Presentation technique
12
Week Programmes:

Diagnostic Radiology
17

General Internal Medicine and Geriatrics
18

Cardiology
20

Pulmonology
24

Rheumatology
26

Nephrology
27

Gastro-enterology
29

Haematology
30
Examination outcomes
38
Problematic physical signs
58
Assessment forms
60
Rotation Schedule
69
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Internal Medicine -MBChB V – Study Guide
2010
Weekly Programme: M.B., Ch.B. V, Internal Medicine
Date
Time
Activity
Monday
08:00-08:30
Weekly
meeting
08:30-09:30
Radiology (5th Year)
Rest of Day
Wards/Outpatients
08:00 – 16:00
Wards /Outpatients
UAH
16:00 – 17:00
Clinical case
presentations
08:00 - 09:00
Imaging session
09:00 – 13:30
Wards / Outpatients
5th Year: UAH
(committee room, Department
of Forensic Medicine and
seminar room at Dept of
Urology)
Committee room, Department
of
Medicine
or
to
be
announced)
UAH
13:30 – 14:00
Discussion
Tuesday
Wednesday
Venue
departmental
14:00 – 17:00
Thursday
Friday
Prof. CJC Nel lecture hall,
Universitas Hospital, 1st Floor
Dept. of Radiology, UAH UAH
Meet Dr Koning at Int Med
seminar room
Academic Afternoon
Kine 1 and 2 (venue may
change)
08:00 – 16:00
Wards /Outpatients
UAH
16:00 – 17:00
Clinical case
presentations
08:00-09:30
Case Presentations by
Registrars (compulsory
for all students)
Wards /Outpatients
(committee room, Department
of Forensic Medicine and
seminar room at Dept of
Urology)
Cine 1
Rest of Day
UAH
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Internal Medicine -MBChB V – Study Guide
2010
Learning opportunities
"Medicine is learned by the bedside and not in the classroom"
(Sir William Osler, 1849 - 1919)
5th YEAR
1.
Academic afternoons (4th and 5th year students combined): Wednesdays 14:00 17:00.
2.
Clinical rotations in firms including ward rounds (5th year: Universitas Hospital
only).
3.
Radiology tutorial: Mondays 08:30 - 09:30 at the department of Diagnostic radiology. It
is expected that you will also visit the following web site to cultivate your radiology
skills: http://www.learningradiology.com (see section on Department of Diagnostic
adiology).
4.
4.1
4.2
4.3
4.4
Imaging tutorials: Wednesdays 08:00-09:00 (Venues to be announced).
Weeks 1 and 2
Haematology
Weeks 3 and 4
Nuclear Medicine
Weeks 5 and 6
ECG’s (Cardiology)
Week 7
Dermatology
5.
Clinical case presentations: Every Tuesday and Thursday at 16:00 – 17:00 at the
Department of Medicine. The group will be divided in two for this activity. Students will
take turns to present. The main skills outcomes for this session are as follows: after the
9 week clinical rotation students should be able to:
*Present a patient in a problem-orientated way (see example at the end of this
document).
*To provide a reasonable and appropriate differential diagnosis for each problem.
*To devise a cost-effective management plan for each problem.
6.
6.1
Additional information:
Every patient contact should be seen as a learning opportunity. The registrar will
give instructions as to which patients should be clerked in a blue book.
It is your responsibility to attempt to see as many different clinical presentations as
possible. A list of suitable patients will also be made available every Monday morning.
6.3
A log book must be kept of your clinical experience (will be provided). This has
to be handed in at the end of the rotation.
6.2
NB
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Internal Medicine -MBChB V – Study Guide
2010
Assessment
5th YEAR GROUP A
The following activities will be assessed and will contribute to your module mark:
Date /Time
Subject /Activity
Format
Duration
9th March 2010 :
13:30-16:30
Test: Each student must be prepared to
answer questions covering the divisions of
medicine he or she has rotated through the
previous
nine
weeks
as
well
as
endocrinology, neurology and
infectious
diseases
Subjects
covered
in
the
academic
afternoons will also be assessed.
The Pharmacology covered in the Academic
afternoons will also be included
Formative assessment
Forms to be handed in at the end of each
week at the office of Mrs C Human, room
244.
Students who fail to hand in these
forms at the end of the rotation, will
not be allowed to write the semester
examination.
Evaluation of clinical skills by an examiner
(history-taking may also be observed).
Students must be prepared to examine any
organ system.
Written
3 hours
180 marks
Practical
Continuous
Practical /
clinical
30 min per case for
history taking and
clinical examination.
15 min with the
examiner
60 minutes
(6 x 10 marks)
11th March 2010
13:30 – 14:30
KINE1
Objective test: written test assessing clinical
aspects, including x-rays and laboratory
tests
Clinical
End of semester
examination.
Internal Medicine including

Cardiology

Neurology

Dermatology

Pharmacology
1) A written
paper consisting
of: 25 % MCQ’s
and 75 % short
answer
questions
2) *1 x clinical
case
Continuous
assessment
(clinical
rotations)
11th March 2010
07:30
20 May 2010
(written)
25 May 2010
(cases)
1) 3 hours
2) 30 min per case
and 15 min with the
examiner
1.
SEE FACULTY RULES AND REGULATIONS REGARDING PASSING/FAILING THIS MODULE
* Students who obtain an average mark of 60% or more for the clinical case (60%) and
Objective test (40%) combined AND who obtain a sub-minimum of 50% for the clinical
case will be exempted from the clinical case during the end-of semester examination.
Students who obtain an average mark of less than 60%, or who obtain less than
50% for the clinical case will have to present themselves for a clinical case during
the end-of semester examination.
NB
2.
Subject matter for tests may include topics previously covered during Phase II,
Academic Afternoons, and Tutorials.
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Internal Medicine -MBChB V – Study Guide
2010
Assessment
5th YEAR GROUP B
The following activities will be assessed and will contribute to your module mark:
Date /Time
Subject /Activity
Format
Duration
11th May 2010
13:30-16:30
Test:
Each student must be prepared to
answer questions covering the divisions of
medicine he or she has rotated through the
previous nine weeks as well as endocrinology,
neurology and infectious diseases
Subjects covered in the academic afternoons
will also be assessed.
The Pharmacology
covered in the Academic afternoons will also be
included.
Formative assessment
Forms to be handed in at the end of each week
at the office of Mrs C Human, room 244
Students who fail to hand in these forms
at the end of the rotation, will not be
allowed
to
write
the
semester
examination.
Evaluation of clinical skills by an examiner
(history-taking may also be observed).
Students must be prepared to examine any
organ system.
Written
3 hours
Practical
Continuous
Practical /
clinical
13th May 2010
13:30 – 14:30
Objective test: written test assessing clinical
aspects, including x-rays and laboratory tests.
Clinical
30 min per case for
history taking and
clinical examination.
15 min with the
examiner
60 minutes
(6 x 10 marks)
End of semester
examination.
Internal Medicine including

Cardiology

Neurology

Dermatology

Pharmacology
1) A written
paper
consisting
of: 25 %
MCQ’s and
75 % short
answer
questions
2) *1 x
clinical case
Continuous
assessment
(clinical
rotations)
1 Clinical case:
13th May 2010
07:30
20 May 2010
(written)
25 May 2010
(cases)
1) 3 hours
2) 30 min per case
and 15 min with the
examiner
1. SEE FACULTY RULES AND REGULATIONS REGARDING PASSING/FAILING THIS
MODULE. * Students who obtain an average mark of 60% or more for the clinical case (60%)
NB
and Objective test (40%) combined, AND WHO OBTAIN A SUB-MINIMUM 0F 50% FOR THE
CLINICAL CASE, will be exempted from the clinical case during the end-of semester
examination. Students who obtain an average mark of less than 60%, or who obtain less than
50% for the clinical case will have to present themselves for a clinical case during the end-of
semester examination.
2. Subject matter for tests may include topics previously covered during Phase II, Academic
Afternoons, and Tutorials.
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Internal Medicine -MBChB V – Study Guide
2010
Marks and weighting of marks
1.
Theory mark:
The theory mark consists of the mark of class test 1. This mark contributes 50% to the
module mark.
2.
Clinical evaluation:
The mark for the clinical evaluation is calculated as follows: the average mark obtained
for the clinical case (60%) and the objective test (40%) - 80% and the average mark
obtained for the clinical rotations - 20%. This mark contributes 50% to the module
mark.
3.
Module mark:
The module mark is calculated as follows:
the theory mark and the clinical
evaluation mark each contribute 50% to the module mark.
4.
Semester examination:
The semester examination consists of a 3-hour paper (25% MCQ’s and 75% short
answer essay questions). Students who obtained less than an average mark of 60% for
the clinical case (60%) and the objective test (40%), OR WHO OBTAINED LESS THAN
50% FOR THE CLINICAL CASE during rotation have to do a clinical case as well (same
format as during the rotation). An average mark of 50% for the clinical cases is
required for a pass.
5.
Final mark:
The final mark is calculated as follows: the module mark contributes 50% and the
semester examination 50%. A final mark of 50% is required to pass on condition that
the sub-minimum criteria are met.
Sub-minima:
Theory: To pass a student must obtain a combined mark of at least 50% for the theoretical
components of the module and the semester examination.
Clinical evaluation:
To pass a student must obtain a combined mark of at least 60% for the clinical case (60%)
and Objective test (40%), with a sub-minimum of at least 50% for the clinical case during the
rotation. If the combined mark is less than 60%, or the marks for the clinical case is less than
50%, a clinical case has to be seen during the semester examination. To pass this, the student
has to obtain at least an average mark of 50% for the clinical cases and Objective test and
50% for the clinical case during the semester examination.
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Internal Medicine -MBChB V – Study Guide
2010
Final Examination (November 2010)

Written component:
One 3-hour paper (25% MCQ’s and 75% short answer questions) – 15 November

Clinical component:
3 Clinical cases with three different pairs of examiners. (22 – 25 November)
The final marks obtained in the 4th and 5th year will contribute 25% each to the
final mark. Pass requirements: The clinical and the theory components must be
passed separately.
Clinical component: Two out of the three clinical cases must be passed and the
average mark for the 3 cases must be at least 50% in order to pass the final
examination. Where the average mark of the 3 cases is between 45 and 50%, but
the clinical performance of the student during the rotation has been satisfactory,
the student may pass, with the proviso that the theory component has been passed as
well.
Theory: A mark of 50% is required for the final paper in order to pass. Where the
mark for the theory paper is between 45 and 50%, but the theory marks of the 4 th
and 5th year are satisfactory, the student may pass, with the proviso that the clinical
component has to be passed as well.
Academic afternoons
The academic afternoons are scheduled for Wednesday 14:00-17:00. Attendance of these
afternoons is compulsory for all students in the 4 th and 5th year. You will have no obligation to
any other department on this afternoon. Attendance will be monitored.
The goal of the academic afternoons is for you to eventually be able to:
1.
Accept the value and importance of a multi-disciplinary approach to clinical
problems.
2.
Understand and explain the relationship between disease processes and clinical
presentations.
3.
Manage commonly occurring medical problems by making use of a multidisciplinary approach when necessary, as well as through the application of
fundamental therapeutic principles.
It is imperative that you prepare for the academic afternoons, allowing you to gain the most
from this opportunity. The presentation style may differ depending on the topic and lecturers.
The interactive classroom performance system (CPS) will be used extensively during the
academic afternoons.
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Internal Medicine -MBChB V – Study Guide
2010
Clinical rotations
Universitas Hospital:
5th Year students are divided into 8 groups and rotate through the subspecialties (excluding
endocrinology and neurology) at Universitas Hospital according to the schedule provided.
The head of the firm or subspecialty will act as tutor, lecturer and mentor. He/she will also be
responsible for monitoring your presence and assessing your progress including signing of
necessary forms. Each firm is also in charge of one or more outpatient sessions per week.
The functioning of the firm and what is expected of you will be explained to you by the
consultant in charge of the firm. It is important that you take part in all the activities of the
firm, which is a necessary component of team building. Your training in Internal Medicine is
based on directed student learning with a strong emphasis on opportunistic learning. The list
of clinical presentations to be discussed in the academic afternoons as well as those for the
tutorials have been carefully selected to form the background of the knowledge necessary for
you to become a competent and skilful clinician.
All patients admitted to hospital must be clerked. Specific forms (“Blue Books”) are being
made available for this activity. This will ensure that you cultivate sound clinical habits. This
activity forms a very important part of your assessment. It will be expected of you to present
your patient(s) during ward rounds. By clerking as many patients as possible you will ensure
that you come into contact with most of the important and common clinical presentations
during your training period. Examples of how to prepare a problem list and a standardized
presentation style can be found in this document.
Chest X-ray tutorial (5th Year students only)
This takes place every Monday morning from 08:30-09:30 in the seminar room, Department of
Diagnostic Radiology, Universitas Hospital. The interpretation of a chest X-ray is an essential
skill that will also be assessed during ward rounds, in casualty, in outpatients and also during
your final assessment at the end of the 5th year. It is also expected of you to master the
appropriate
radiology
curriculum
to
be
found
at
the
following
website:
http://www.learningradiology.com. (See section on Diagnostic Radiology).
Imaging sessions (5th Year students only)
This takes place during the 5th year on Wednesdays between 08:00 - 09:00 in venues to be
announced. These sessions allow you to review the indications for and the interpretation of
important imaging techniques and examinations utilized in Internal Medicine. Your knowledge
of these topics will be assessed during written examinations and during your clinical case at
the end of your rotation, as well as in the final examination.
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Internal Medicine -MBChB V – Study Guide
2010
Tuesday and Thursday afternoon clinical case presentations
Outcomes
At the end of this series of interactive training sessions the student should be able
to:







evaluate, assess and integrate data collected during the consultation
formulate a problem list
assess the problems on the problem list and compile an appropriate differential diagnosis
for each problem
formulate a management plan
convert the collected data into a written record
use available information sources appropriately and effectively (written, including
the formal South African guidelines, and electronic)
communicate effectively with a colleague about a patient (develop your interpersonal
skills) including the skill to consolidate clinical findings into a summary, a problem
list and a differential diagnosis
Proposed structure of presentation









Select a new patient in consultation with your consultant or registrar
Clerk the patient to the best of your ability in a blue book (including side-room
investigations). Do not hesitate to ask the consultant for assistance or to help you to
elicit any signs or to interpret findings
Ensure that basic special investigations previously performed are being brought to
the lecture hall (e.g. chest X-ray, ECG, laboratory investigations, etc.)
Present a summarized version of the relevant points in the history (may include I
mportant negative aspects) to the group where-after a short discussion will take place
and a preliminary problem list will be compiled on the white board. A student from
the group will be asked to act as scribe.
Proceed by presenting mainly the positive clinical findings including the sideroom investigations to the group where-after a short discussion will again take place to
enable members of the group to clarify uncertainties.
The group will now formulate a final problem list and an appropriate differential
diagnosis for each problem will be compiled. Compare this problem list with your
own previously formulated problem list.
The future management of the patient will now be planned in consultation with
the group and available special investigations will be discussed (X-ray chest, ECG,
etc).
The student who presented the patient will now get the opportunity to end the session
with a brief summary of the case (the short version required during ward round or in
the examination situation)
Bring a copy of Davidson’s Principles and Practice of Medicine and Tally and Connor’s
Clinical Examination along to verify facts or signs in the event of any uncertainty.
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Internal Medicine -MBChB V – Study Guide
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The Problem List
Definition:
The database you have acquired after clerking the patient is processed into a list of problems
that tells you what is wrong with the patient. The term “problem” is preferred over “diagnosis”
and includes anything regarding the patient’s medical condition that is abnormal, requires
management in its own right or anything that contributes to disease. Problems are thus
identified from the clinical database.
Characteristics of a problem and the problem list 1:

Any symptom, sign, abnormal side-room finding or special investigation which may
contribute to disease; psychological or socio-economic problems that may influence the
patient’s health are also included in the problem list.

This list should represent the highest possible resolution of the patient’s problems based
on the data accumulated thus far. It is sometimes possible to enter a diagnosis to the
problem list. Question marks are not allowed on the problem list.

Problems must be prioritized without separating it into active or passive problems.

Each problem that requires management in its own right should be entered as a
separate problem, i.e. in the case of a patient with cirrhosis of the liver, jaundice
and ascites the ascites will be listed as a separate problem but not jaundice.

Previous health problems that have been fully resolved are excluded from the problem
list; but previous important operations are included.

The problem list is dynamic and is regularly revised as long as new developments
take place regarding disease progression and the availability of test results.
In summary: a problem list may contain:

isolated abnormalities that require management in its own right
symptom, a sign, an abnormal special investigation, etc)
a cluster of clues (for example nausea, vomiting, diarrhoea and fever)
a syndrome 2 (i.e. Biventricular heart failure, hyperthyroidism, etc)
a diagnosis (e.g. meningococcal meningitis)
a patho-physiological state (e.g. oedema, central cyanosis, etc.)
drug induced problems
psychological problems
socio-economic problems







(may
be
a
Pitfalls
Student commonly experience the following problems:

Failure to group related clues into a cluster but to list symptoms or signs as
separate
problem.

Failure to raise each diagnosis or problem to the highest possible level of
resolution
with the information on hand.

Forming an opinion or making a definite diagnosis before adequate information has
been obtained.
Dorland’s Medical Dictionary
Problem Solving in Clinical Medicine: From Data to Diagnosis. Paul Cutler, 3 rd Edition. Williams and Wilkens.
1
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Internal Medicine -MBChB V – Study Guide
2010
Example
A fifty-two year old alcoholic male patient who has cirrhosis of the liver is admitted to the
hospital with a massive upper gastrointestinal haemorrhage. After a 24 hour work-up
concomitant with his emergency treatment, he is found to have the following problems:
1.
2.
3.
4.
5.
6.
7.
8.
A massive upper gastrointestinal haemorrhage
Chronic alcoholism
Cirrhosis of the liver secondary to problem nr. 2
Benign prostatic hyperplasia
Hyperglycaemia
Infiltrate right upper lobe
Unemployed
Divorced
Problems 1, 2 and 3 are quickly apparent. The cause of the haemorrhage is still not clear and
therefore this problem cannot be raised to a higher level at this stage (a differential diagnosis
may be offered).
The prostatic condition is being recorded for the first time based on symptoms that existed for
three years plus the finding of a markedly enlarged prostate on rectal examination. It may or
may not require attention in the near future and must be watched.
Problem 5, the hyperglycaemia, was found on routine blood studies.
unknown (a differential diagnosis may be offered).
The cause is still
Problem 6, an asymptomatic finding noted on chest radiograph is probably a separate problem,
but it too will require present and future investigations (a differential diagnosis may be
offered).
Problems 7 and 8 may relate to problem 2.
Presentation technique during ward rounds
Due to the large number of patients that must be seen by the consultant during a ward round
sufficient time is not available for a student to present each patient in depth. To circumvent
this problem a short, concise and uniform style of presentation based on the problem list and
differential diagnosis is proposed. This abbreviated way of presenting a patient should not
exceed 5 minutes.
A summary of the RELEVANT points (including appropriate important negative aspects) from
the history and physical examination must be included to explain or defend a particular
problem/differential diagnosis.
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Internal Medicine -MBChB V – Study Guide
2010
The following style or technique is recommended (also recommended for presenting exam
cases):
1.
Introduction
of
patient
or
opening
statement:
(name,
age,
gender,
occupation/social role, marital status, place of residence, date of admission and
reason for admission).
2.
Problem list: The rules applicable to the compiling of a problem list must be applied.
Should adequate information be available in the database it may be possible to include a
diagnosis into the problem list.
3.
Relevant points from the history and examination: You are encouraged to state the most
important relevant points from the history and physical examination that support each of
the problems on the problem list. Under no circumstances should all the notes you have
made while clerking the patient be read out to the consultant during ward round. It is
expected of you to analyse, organize and interpret (=assessment) your physical findings
in order to compile a problem list.
4.
A final brief summary of the patient’s problem or most important problems, including the
most likely differential diagnosis should now be provided. This final assessment should
be a summary and not a repetition of previous information. Such a summary or
assessment could be done follows: “In summary this is ..........(name, age, gender)
who presented with .........(short summary of problem list). My differential diagnosis
include the following: ............”
Example 1
Introduction/opening statement:
Mr de Bruyn is 45 years old. He worked underground for 6 years in a gold mine in Welkom
where he lives.
He was referred by his general practitioner after he presented with
progressive dyspnoea of short duration. He is married, has 2 children and is presently
unemployed. He was admitted two days ago and his problem list is as follows:
Problem list:

Left sided pleural effusion, productive cough3 and haemoptysis4

Dypnoea5 grade 1

Anaemia6

Cervical lymph adenopathy

Unemployed

Previous exposure to silica dust7
Relevant points from the history and examination:
The patient’s chief complaint is that of progressive dyspnoea over the past 3 weeks that was
accompanied by left-sided pleuritic chest pain. He complains of a productive cough and noticed
specks of bright red blood in his sputum (haemoptysis). He has lost weight but his appetite is
normal. He does not complain of night sweats, has never smoked and was not in contact with
a person with tuberculosis as far as he knows. He previously worked underground for 6 years
in a gold mine but was declared redundant last year and is still unemployed. He and his family
3
May indicate infection, requires further investigation and may eventually require separate management.
4
Has a diagnostic prediction value (malignancy) and may become massive and therefore needs daily reassessment.
Needs regular follow up and may require a therapeutic parasynthesis if severe.
5
6
7
May be related to problem number 1, but may have another differential diagnosis for example HIV.
This should remain definitely on the problem list since it has medico-legal implications.
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Internal Medicine -MBChB V – Study Guide
2010
lives with relatives in Welkom. He was previously in good health and has not had any
operations. He does not use any medication at present.
He appears chronically ill and has a BMI of 19 kg/m 2. The mucus membranes appeared pale
but no clubbing or halitosis was noted. Shotty enlarged lymph nodes were present in posterior
triangle of the neck. His respiratory rate was 17/min and stony dullness to percussion was
detected in the left posterior chest area. A small area of bronchial breathing was present over
the upper area of dullness. The trachea was central and the cardiac examination was normal.
Assessment (summary and differential diagnosis):
In summary, this is a 35-year old unemployed mineworker that presented with dyspnoea,
haemoptysis and a left sided pleural effusion. My differential diagnosis include the following:

Pulmonary tuberculosis

Malignancy

Pulmonary embolus
When you present a patient at a ward round, the third part of the database should also be
presented (special investigations). Special investigations will then also form part of the most
important information presented during a ward round.
Example 2:
Introduction/opening statement:
Our patient is the 68-year old Mrs. le Roux, a widow with 2 children from Bloemfontein. She is
a retired teacher and receives a pension. She was referred by her general practitioner with a
history of sudden onset of weakness on the left side a week ago.
Problem list:

Stroke (7 days ago) in the distribution of the right middle cerebral artery.

Atrial fibrillation

Digoxin therapy8

An elderly9 patient

Type 2 diabetes (1992)

Diamicron 80 mg two bd

Essential hypertension for the past 15 years (well-controlled on treatment)

Systolic murmurs over both femoral arteries.
Relevant points from history and physical examination:
Type 2 diabetes was diagnosed 13 years ago and is currently controlled with oral
hypoglycaemic agents and a diabetic diet. A week ago she woke up one morning unable to
move her left arm and left leg. Her level of consciousness was not suppressed, she had no
visual disturbance and her speech was normal. She also swallows normally. During the past
week she regained some strength in the left leg and left arm. She has a previous history of
palpitations and mild hypertension. Her current medication includes Digoxin 0.25 mg daily, an
Pharmapress 10 mg daily and Diamicron 80 mg ii bd. She has not had any operations, is of
sober habits and has never smoked. She wears glasses and can still read. She has no history
of previous TIA’s, angina pectoris or intermittent claudication.
8
9
The patient may be taking Digoxin for rate control, but digitalis toxicity may also cause atrial fibrillation. She may
also have impaired renal function (an elderly person, history of hypertension and type 2 diabetes) and therefore a
serum digitalis level should be requested and her renal function should be assessed.
The fact that she is an elderly person means that the reserve function of several organ systems may be diminished
(more susceptible to atrial fibrillation, hypoglycaemia, etc).
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Internal Medicine -MBChB V – Study Guide
2010
On examination the patient lay comfortably flat in bed and communicated without any
problems. She was well orientated for both place and time. An upper motor neuron weakness
of the 7th cranial nerve on the left side was noted. The rest of the cranial nerves were normal
on examination including fundoscopy. Muscle tone was slightly increased in the left arm and
left leg. Power: left arm was 3/5 and the left leg 4/5. The sensory examination was normal
including vibration sense in both feet. No cerebellar signs were present. Her blood pressure
was 140/85 mm Hg lying down in the right arm and atrial fibrillation with a pulse rate of
86/min was present. Both carotid pulses were present and no murmurs were heard but
systolic murmurs were present over both femoral arteries. The rest of the clinical examination
did not reveal anything of note. Her feet appeared normal and the Uricheck 9 dipstick
examination of the urine was normal.
Summary (assessment and differential diagnosis):
In summary, this is the 68-year old Mrs. le Roux with a previous history of type 2 diabetes and
hypertension, currently presenting with a stroke in the region of the right middle cerebral
artery and atrial fibrillation. I would consider the following conditions in my differential
diagnosis:

Embolic stroke due to atrial fibrillation or

A cerebral infarction due to macro vascular disease.
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Internal Medicine -MBChB V – Study Guide
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WEEK
PROGRAMMES
16
Internal Medicine -MBChB V – Study Guide
2010
DIAGNOSTIC RADIOLOGY
September 2010
Dear MBChB V student
In order to assist you in revision of Radiological images for the exams, we recommend that
you work through the 13 indicated modules on http://www.learningradiology.com. You can
work through this in your own time and at your own pace. The following “heading” will appear
on the screen: Home lectures notes images archives med students miscellaneous. Quizzes.
Select Med Students by clicking on it. The list of 13 Modules will appear on the screen (see
attached print-out).
We recommend that you work through each of the modules which consist of varying numbers
of slides. Most of the modules include a self evaluation at the end that will give you an
indication of your knowledge of that module.
It is recommended that you select the Flash option (see attached print-out) at each module, as
the files are smaller than the PowerPoint files and load faster.
We trust that you will benefit tremendously by this form of revision.
We wish you all the best of luck in your preparation for the exam.
Kind regards
PROF CS DE VRIES
DEPARTMENT DIAGNOSTIC RADIOLOGY
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Internal Medicine -MBChB V – Study Guide
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GENERAL INTERNAL MEDICINE AND GERIATRICS
Universitas Hospital










Welcome to the firm. Please report to the registrar / intern at ward 6A immediately after
the radiology tutorial on Mondays.
Medical Staff: Prof WF Mollentze, Dr G Harris, Dr Mariëtte Harmse (SMO), rotating
Registrar, and rotating Intern. Nursing staff: Ward 6A: CPN BN Palada; SPN’s: DK
Lebakeng, MJ Morweng; PN’s: PI Pommer, NJ Mahlehle, Motlhabane; Staff Nurses: LV
Nyamakazi, M Moruri; and Mr Tlahadi (ward secretary). Outpatient staff: Matron
Austin, and Sr van Huyssteen.
This firm admits patients requiring care at a tertiary level including geriatric patients,
patients with multi-system pathology not belonging to any of the subspecialties
at
Universitas Hospital, patients with medical problems discharged from Multidisciplinary
Intensive Care and still in need of hospital care, and patients admitted with overdose and
poisoning (referred from level 2 hospitals).
This firm also admits patients addicted to drugs such as heroin and cocaine for
withdrawal. Three beds are available in ward 3A for this purpose. Dr Mariëtte Harmse,
senior medical officer, takes responsibility for this service. When she is not available, the
registrar and intern from this firm take over.
The registrar and intern conducts ward rounds at least twice a day. You are expected to
join the team for these rounds – enquire from the registrar/intern what is required from
you regarding after hours and week-end duties. You must also visit and examine your
patients on your own and report any new/important information immediately to the
registrar or intern (e.g. electrolyte disorders, DVT, shock etc.).
Every patient admitted to our wards must be properly clerked by the student in
the “blue book” (including side-room investigations). Daily follow-up notes must be
written in the space provided in the “blue book”. Patients will be divided among students.
You must assist the registrar/intern with administrative duties such as obtaining
results of special investigations, keeping files tidy and entering test results where
appropriate in the flow-chart in the patient’s chart.
The consultant conducts two formal ward rounds during the week: Tuesdays at 14:00
and Fridays at 09:15. Please be on time and see to it that your patients’ clinical notes, Xrays etc. are up to date and available for the round. You will also be provided with a form
used to summarize each patient. This form must be completed for each patient and
handed to the consultant at the start of the ward round (one form for each new patient.)
Out-patient clinics are conducted on Tuesday and Wednesday mornings. The registrar will
allocate patients to you to be seen on your own. After you have completed your
assessment, please discuss your patient with the registrar or consultant.
Thursdays immediately after the case presentation, students must go to the Omega
Service Centre for the Aged at Heidedal to assist dr. Harmse with an outreach primary
health care outpatient clinic. Please return to the wards after the clinic has been
concluded.
18
Internal Medicine -MBChB V – Study Guide

o
o
2010
o
Study material:
Good Medical Practice (Chapter 1, Davidson’s and Practice of Medicine, 20 th Edition)
Good Prescribing (Chapter 2, Davidson’s Principles and Practice of Medicine, 20th Edition),
SAMF 7th Edition (page 1 and 2: Prescribing in the elderly)
Aging and Disease (Chapter 7, Davidson’s Principles and Practice of Medicine, 20 th
Edition),
Poisoning (Chapter 9, Davidson’s Principles and Practice of Medicine, 20th Edition). An
academic afternoon will also be devoted to poisoning and overdose during the twoyear cycle.
Issues in older people (panels in chapters in Davidson’s, especially those
mentioned in Box 7.15, page 171).
Syncope and Presyncope (Davidson’s Principles and Practice of Medicine, 20 th Edition,
Chapter pp 551-554); Dizziness, Blackouts and Funny Turns (pp 1165-1167)
Handouts: Geriatric topics from MAE 324 and Tutorials.

Map (Omega Service Centre for the Aged):
o
o
o
o
De Wetsdorp
De Wetsdorp
Rd, (to
Rd,
Pelonomi)
(to Pelonomi)
OMEGA
OMEGA
GARAGE
GARAGE
BRIDGE
BRIDGE
ROBOT
ROBOT
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Internal Medicine -MBChB V – Study Guide
2010
CARDIOLOGY
1.
Introduction
On account of the high incidence of coronary artery and cardiac valve diseases in the
population, ischaemic cardiac disease and valve lesions are common at Universitas
Hospital. As part of your training it is important to become familiar with these two
diseases. We assume that you already have a basic knowledge regarding the above.
This knowledge will therefore not be repeated during your residency, but will be
elaborated upon, thereby enhancing your insight in clinical cardiology.
2.
Practical exposure
During your residency you will be exposed to the cardiologic diagnostic procedures. We
expect you to familiarise yourself with the following four groups of cardiologic conditions:
 The acute coronary syndrome and all facets of angina and acute myocardial infarct.
 All aspects of cardiac valve lesions.
 Skill and experience with the reading of ECG’s
 Insight in the diagnosis, management and treatment of cardiac failure and the
cardiomyopathies.
3.
Prescribed material
The most recent edition of MEDIKOVS is available at the Department of Family Medicine
at a fee. If you wish to photocopy the booklet at own cost, you can collect it at the
secretary, Ms F van der Heever, Department of Cardiology. It is important to acquire this
booklet as soon as possible after commencement of your residency, as most of the
important cardiology topics are contained in it.
4.
Tutorials
On Thursdays, Prof Marx will present a discussion on specific topics. Dr Van der Merwe
will present an ECG discussion once a week. You are expected to know four stated
cardiologic conditions during the discussions – as fourth-year students you have already
had complete lectures on this.
Please make arrangements with the consultant
concerned.
Prof. Marx – Tel: (051) 405 3390 (cell) 082 566 7778
Dr. van der Merwe – 082 557 1915
5.
Admission rounds
These will take place daily (Mondays to Fridays) from 07:00 to 08:00 in the Coronary
Unit, and Prof Theron will be in attendance. During these rounds, patients who had been
admitted the previous day will be discussed.
6.
On call list
A consultant and registrar are on call every day. One or two students must be available
at all times to consult new patients in the Referral Room of the Cardiology Division. You
are expected to draw up a student on call list with the relevant contact numbers
available. Students who are on call must contact the registrar on a daily basis so that all
patients that are dealt with in Cardiology can be seen by the student concerned as well.
During that time you will accompany the patient to the ward and handle his/her blue
book and special investigations.
Thereafter you will be the designated student
responsible for this patient. During the afternoon rounds the consultant could question
you about the condition of the patient, results of special investigations and your opinion
on the management of the patient
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Internal Medicine -MBChB V – Study Guide
2010
7.
Ward duties
Occur daily (Mondays to Fridays) from 08:00 to 09:00.
It involves the following:

Seeing and examining the patients
All new admissions must be clerked in a “Blue Book”. After completion of the
examination, you will make follow-up notes and record this in the blue book.

Arranging special investigations
The special investigations you will be exposed to are the following:

Blood tests

ECG’s

Heart sonars

Stress ECG’s

Isotope tests

X-rays
You will make arrangements for these tests to be performed by filling in request forms.
Please note: you will not personally perform the tests. If the results of the tests that had
been performed the previous day are already available, you are expected to record this in
the blue book.
8.
Blue books
The blue books form the basis of your Cardiology residency mark; therefore, refrain
from using the registrar’s notes. This book reflects your knowledge, the patient’s
condition and your approach to the patient’s illness. Exposition of the principal complaint
is particularly crucial. Feel free to ask for assistance should you be uncertain of a clinical
sign or symptom. Record your name, the consultant’s name and the name and address
of the patient’s general practitioner in each blue book. The books must be kept up to
date and may not be removed from the ward.
9.
Diagnostic procedures
You are expected to attend two heart catheterisation procedures, two sonographic
examinations and two stress ECG’s in your own time, the aim being to expose you to all
the procedures that are performed regularly. You need not know the technical aspects of
these examinations, but we wish you to gain insight in the indications for the
examination and the information that you could expect to obtain from the examination.
The patient may question you before an examination is to be performed on him/her, in
which instance you must briefly explain the procedure. Therefore ensure that you know
what each procedure involves.
Inform the persons concerned beforehand of you intention to attend the procedure. The
person(s) are:

Heart Catheterisation Laboratory – Sisters Sadie, Felix and Fourie

Heart sonars – Mrs E. van den Heever

Stress ECG’s – Mrs. R. Steenkamp
Make use of the assistance of Mrs Steenkamp and all the other technical personnel in
order to become familiar with the correct performance of a standard ECG.
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Internal Medicine -MBChB V – Study Guide
10.
2010
Ward rounds
Afternoon rounds
Occur daily (Mondays to Sundays) in the afternoon. The consultants are available in the
Coronary Unit at 08:00 in the morning – you can then establish when and where the
afternoon round is to take place as well as which consultant and registrar you are to work
with. Everyone is expected to attend the afternoon rounds. You can utilise this time to
ask questions about the patients or procedures. Owing to working pressure and the fact
that Cardiology involves a considerable amount of emergency and on call work, the
round will not always be at the same time. Therefore, keep in contact with the
consultant and registrar on call.
Morning rounds
Occur on weekends (Saturday and Sunday) in the morning. The necessary arrangements
are made with the consultant on call for the weekend. You are in Cardiology only for two
weekends.
11.
Calculation of marks
Your Cardiology residency mark is calculated on the basis of the following:
Blue books
Your case presentation during the 07:00 to 08:00 rounds will serve as basis for your.
The blue books, however, are taken into account as well. Follow-up notes as well as
results of special investigations must be recorded in the blue books.




Presentation of Cases in Department of Cardiology
Evaluate and present patients with valve lesions as follows:
Anatomy
Pathology
Aetiology
Complications
Example:
(a) Mrs X is a 37-year old black woman with mitral stenosis and with the
complication of a
dysrhythmia.
the student must summarize the patient as follows:
Mrs X suffers from chronic rheumatic endocarditis involving the mitral valve in the form
of mitral stenosis and with the complication of atrial fibrillation and a previous
cerebrovascular accident.
(b) With regards to patients with ischaemic heart disease students are expected to evaluate
and present patients as follows:

History that would lead to the clinical diagnosis of e.g. angina, unstable angina,
myocardial infarction.

Risk factors.

Cardiac functional status.

Concommittant atherosclerotic disease.
Attendance list
Your attendance list in respect of your attendance of diagnostic procedures must be handed in
to the secretary on the last morning.
Discussions
This applies to discussions during admission rounds, ward rounds and tutorials.
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12.
2010
Name list
A name list of your group must be handed in on the first morning to the secretary, Ms F
van den Heever/J Booysen, Department of Cardiology.
PROPOSED TIME ALLOCATION
Monday – Friday
07:00
08:00
10:00
12:00
–
–
–
–
08:00
10:00
12:00
16:00
16:00
Admission round
Ward work
Cardiology Clinic attendance
Seeing new patients
Attendance of diagnostic procedures
Coronary Unit round and Ward round
Saturday – Sunday
AM
Ward round
PM
Ward round
Prof H du T Theron
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Internal Medicine -MBChB V – Study Guide
2010
PULMONOLOGY
Welcome to this very important rotation! Respiratory conditions form a significant component
of clinical practice (and examinations!). During the residency in Pulmonology you should take
the opportunity to gain as much exposure as possible to the clinical features of respiratoryrelated disorders.
Please note: Time not specifically allocated is devoted to fulfilling ward duties, attending the outpatient
clinics (Mondays, Tuesdays and Thursdays), admitting new patients, and self study.
Monday:
08h00: Statistics meeting, CJ Nel Lecture Hall Universitas Hospital (first floor).
08h30: X-ray discussion Dept Radiology.

Thereafter meet Dr. Karin Snyman (or the Pulmonology Registrar) in
ward 3B, who will discuss your duties and programme for the
Pulmonology rotation.
11h00: Lung function discussion and demonstration at Lung Function Laboratory (Tel 051 405
3610/53610) for the students. Contact person: Mr A Smit.
Tuesday:
The programme of the Pulmonology Division (Ward 3B and clinic)
16h00-17h00: Case presentations at Internal Medicine
Wednesday:
08h00: Ward duties ward 3B
09h30: Consultants round
16h00-17h00: Academic Afternoon Seminars (Faculty)
Thursday:
The programme of the Pulmonology Division (Ward 3B and clinic)
06h00-17h00: Case presentations at Internal Medicine
Friday:
08h00-09h00: Departmental Academic presentations, Cine I; followed by ward work 3B;
witnessing of bronchoscopies at the bronchoscopy theatre
Public holidays, weekends and afternoon rounds:
Duties as pre-arranged with the registrar on call.
Ward duties:
1.
Admission of new ward cases in the prescribed format (Internal Medicine/Pulmonology).
After completion of a new admission, formulate the clinical problem statement and/or
compile a problem list. It is important to remain involved regarding the further planning
and management of the patient.
2.
Clinical assessment of your patients every morning.
3.
Daily follow-up notes in the admission file in the SOAP format. (Subjective,
Objective, Assessment, Plan) as guided by Registrar/Medical Officer during rounds.
4.
Tasks relating to your patients as allocated by medical officer or registrar.
Remember to observe the necessary safety measures with regard to sharp objects
during procedures such as venesections.
Should the opportunity arise, you may
assist the doctor with procedures e.g. pleural paracenthesis.
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Internal Medicine -MBChB V – Study Guide
2010
Clinic responsibilities:
Attend clinic consultations with the consultant or registrar until pardoned. You will be exposed
to the spectrum of conditions managed on an outpatient basis.
Theoretical knowledge:
Essential knowledge as in the Pulmonology chapter in Davidson’s, the Academic Afternoon
Seminars (including COPD, asthma, bronchus carcinoma, pleural diseases, respiratory
infections), the Monday and Tuesday tutorials and the pharmacology of respiratory diseases
SAMF pp. 481-499.
Clinical Capabilities:
1.
Please ensure that you are familiar with history-taking and clinical examination
techniques with regard to the respiratory system (Talley and O’Connor).
2.
You must know the indications for any special investigations requested on your patient
and be able to discuss the planned management.
3.
Please ensure that you have a systematic approach towards the interpretation of
chest X-Rays and lung functions (flow volume loop).
Case presentations in the ward:
During ward rounds you will be expected to present your patients. Please follow the format as
prescribed by the dept of Internal Medicine.
Please initiate the presentation with the following patient-related information:
1.
Name
2.
Age
3.
Occupation
4.
Residential area
Be prepared to present in any one of the following formats:
1.
Problem-based summary (Clinical problem statement) NB: Risk factors/Associated
complications or
2.
Problem list or
3.
Full presentation
Diagnostic and therapeutic procedures:
Bronchoscopies are performed on Friday mornings. Please utilise the opportunity to witness at
least two bronchoscopies. Keep record of other procedures performed or witnessed in the
ward, clinic or referral room.
Evaluation:
The following are taken into account when students are evaluated during their rotation:
1.
Clinical capabilities
2.
Execution of ward duties and responsibilities
3.
Attitude towards patients, personnel and work
4.
Knowledge
Conclusion:
Please enjoy the Pulmonology rotation! We trust that you will regard this as an informative
and educational experience. Feel free to discuss any uncertainties with the doctors or other
staff of the Respiratory unit.
Dr M Prins, Consultant, Div Pulmonology
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Internal Medicine -MBChB V – Study Guide
2010
RHEUMATOLOGY
Date
Time
Activity
Venue
Monday
08:00 - 08:30
Statistics and program of the
week
Prof. CJC Nel lecture hall,
Universitas Hospital, 1st Floor
08:30 - 09:30
Ward rounds and orientation
Ward 6A
09:30 – 13:00
Rheumatology clinic:
patients
Rheumatology clinic
14:00 – 15:00
15:00 – 17:00
Journal club
Writing up and admission of
patients in the ward
07:30 – 09:00
09:00 – 12:00
112:00 –
16:00
07:30 - 09:00
Academic ward round
Ward work
Self study
09:00 – 11:00
Formal discussions by
students, registrars and
consultants
Ward work
Academic afternoon
Tuesday
Wednesday
11:00 – 13:00
14:00 – 17:00
Thursday
Friday
New
Ward work and preparation
for academic discussion
07:30 – 08:30
08:30 – 14:00
Ward work
Outpatients at UAH –
Rheumatology clinic
14:30 – 16:00
08:00 - 09:00
09:00 – 13:00
Self study
Presentations
Lupus clinic
Cine 2
UAH Lecture Hall
Outpatients – UAH
26
Internal Medicine -MBChB V – Study Guide
2010
NEPHROLOGY (one week)
Bloods taken, and iv infusions placed, in patients with chronic renal disease should only be done
on the dorsum of the hands to preserve veins for fistulas in future!
NB
Monday:
08h00: Stats meeting CJ Nel lecture hall 1st floor Universitas hospital
After this meeting the students should go to ward 5A and meet the registrar and
medical officer for a ward round. Then the patients admitted under nephrology should
be divided amongst the students and a blue book should be filled in for each (unless
otherwise instructed by the consultant). The student should be familiar with the
following information regarding the patient:
(a)
(b)
(c)
History and examination with a problem list this must be done by the student
themselves and presented in accordance with internal medicine guidelines, important to
have a differential diagnosis. It is important for all students to look at the physical
signs of each others patients as well.
Medication the patient is using, The indication, mechanism of action and important sideeffects
The diseases considered under the differential diagnosis (Davidson’s or notes) read up
briefly
Patients progress The initial problem list must be updated as progress in diagnosis and
management develop
Tuesday:
07h30: Continue with admitting patients and prepare for the round later
10h00: Ward round, registrar will present the patients but the student will have to
demonstrate the clinical signs, discuss assessment and the differential diagnosis
Wednesday:
07h30: Ward round – decide on urines to be examined and bring fresh (warm)
specimens down to the clinic (OPD) at about 9h00
09h30: Nephrology clinic OPD and make an appointment with the staff at the dialysis
unit for a brief overview of dialysis on Thursday
Thursday:
07h30: Ward round
09h00: Transplant OPD
10h00: Dialysis discussion in the renal unit with the nursing personnel as arranged on
Wednesday
Friday:
07h30:
08h00:
09h30:
11h00:
Patient discussion ward 5A
Departmental academic meeting
Audit meeting ward 5A
Student marks
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Internal Medicine -MBChB V – Study Guide
2010
Saturday and Sunday:
½ The students come on the Saturday and the rest on the Sunday for the ward round starting
at 8h00 in ward 5A
After
1
2
3
the week you should be able to:
Examine urine
Inform your patient regarding the practical aspects of renal replacement therapy
Have examined several patients with important renal diseases such as acute and
chronic renal failure, nephrotic syndrome and hypertension
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Internal Medicine -MBChB V – Study Guide
2010
GASTROENTEROLOGY
Monday
08:00
Internal Medicine statistics meeting
09:00
Meet the registrar in word 7B – Admission of all patients in the ward –
new and old. Ward work with registrar and intern.
Tuesday
17:00
Ward round with the registrar and intern.
08:00
Ward round and ward work with the registrar and intern.
10:00
Attend endoscopy list after ward work has been completed.
15:00
Grand ward round with consultants, registrar, intern, dieticians, social
worker and physiotherapist. Meet in gastro-unit.
Wednesday
16:00
Student presentations – Dept Internal Medicine
08:00
Ward round and ward work with registrar and intern
10:00
Attend endoscopy list after ward work has been completed
12:30
Academic ward round with consultant, registrar and intern. Meet in
Ward 7B
Thursday
14:00
Academic afternoon for students
08:00
Ward round registrar and intern. Ward work and self study for the rest
of the day
Friday
Weekends
16:00
Student presentations – Dept Internal Medicine
08:00
Department Internal Medicine registrar’s case presentations.
09:00
Gastroenterology outpatients in the gastro-unit
12:30
Ward round consultants, registrars and interns. Meet at Ward 7B
Weekend ward rounds arranged with registrar and consultant on call.
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Internal Medicine -MBChB V – Study Guide
2010
HAEMATOLOGY
Dear Student
Welcome to Haematology. We hope your time with us wil not only be an educational, but also
an enjoyable experience and trust that you would be able to make maximum use of you time
at Haematology.
Monday:
08:00 –
08:30
08:30 –
12:00
13:00 –
14:00
14:00 –
17:00
Tuesday:
09:00 –
11:15
11:15
Wednesday:
08:00 –
09:00
09:00 –
10:00
10:00 –
12:00
12:00 –
12:30
Afternoon:
Thursday:
08:00 –
09:00
09:00 –
13:00
14:00 –
15:00
Note:
Friday:
08:00 –
09:00
09:30 –
11:30
11:30 –
Internal Medicine Meeting
Ward round at National Hospital. Divide and get to know your patients.
Orientation by Dr Mike Webb and Registrars.
Clinic Discussion (compulsory for 5th Years) at Universitas, Haematology,
Committee Room, 417.
Ward work
Academic Ward round at National
Ward work
Imaging session
Videos – Dept Haematology (Mrs M Oosthuizen, R416).
Thrombophilia Clinic, Dept Haematology, Universitas
Thrombophilia clinic discussion, Dept Haematology, R417
Ward work – National
Academic program – Committee Room, Dept Haematology, R 417, Universitas
Ward work – National
Microscope session – Registrars – Dept Haematology, Routine Laboratory
Every first and last Thursday of the month there is a Hemophilia Clinic, Dept
Haematology, Universitas, from 10:00 – 13:00
General Internal Academic hour –Cine 1. If no General Internal Academic hour,
the Ward-round starts at 08:00 at National
Multidisciplinary academic ward round, National Hospital
Ward work, National
NB
NO SNEAKERS AND JEANS PLEASE
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Internal Medicine -MBChB V – Study Guide
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Haematology is not only a very exciting and rapidly developing subject, but also an integral
part of medicine in general. Haematological illnesses influence every organ and system in die
body, for example pregnancy, surgery, gastro-enterology, psychiatry and neurology. You will
be faced with a full blood count every day of your life as a doctor. The ability to interpret this
would thus enable you to diagnose and treat your patient early and accurately. Although we
often deal with rare diseases, we can still learn the general principles involved in these
diseases. Their diagnoses might be rare but they present with common things like back pain,
hepatosplenomegaly, tiredness, lymphadenopathy, anaemia or bleeding. These are common
problems and the principles in the approach to these common problems will be accentuated.
Ward work:

During this week, a few patients will be appointed to each student.

We expect that you treat this patient as if jou are his or her own doctor. That means that
you must see your patient every day. The ward work on this patient will be your
responsibility.

When you leave the ward, confirm with Medical Officer or registrar about
whether they might require your help later in the day and when and where you should
meet.

Every patient must have complete notes in their files every day with your name and
year group next to it.

We expect a urine dipstix result on every patient.

Have the patient’s latest blood and X-ray results ready on the ward round and integrate
them in your problem list.
NB
The breaking of sensitive information:

Be careful with sensitive information. The diagnoses of HIV, cancer or a serious
illness will be discussed with the patient and his or her family by the medical officer or
registrar.

Use the opportunity to watch and see what they say to the patient and especially
how the information is transferred.
Presentations:
We want to use this week to give you the opportunity to practice making a problem list.
Please study and use the examples from you study guides. Take care to prepare the problem
statement before the ward rounds. If anything is unclear, discuss it with the registrar or
medical officer.
What is important?
This is just a guideline. Try to read up about every patient that you have – this way you
will learn the most. Always ask yourself “why?”. Do not take anything for granted and
don’t be afraid to ask questions to the consultant, the registrar and the medical
officer – everybody here is enthusiastic to help you. If we do not know, we usually
will know where to find the answers.
NB
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Internal Medicine -MBChB V – Study Guide
2010
The following is a guideline of the most important sections in Davidson’s. The page numbers
refer to Davidson’s Principles and practice of Medicine 19 th “print” chapter 19. The lectures
that you had in the previous years, including the basic physiology is also important. (MEQ224,
GKV202, INM419).
Page nr:
890 – 891
892 – 894
894 – 897
897 – 900
900 – 902
902 – 909
910 – 914
914 – 921
922 – 924
924 – 925
925 – 929
929
937
938
938
942
– 936
– 938
–
–
– 945
945 – 946
946 – 947
947 – 948
948 – 953
–
953 – 954
955 – 956
Clinical examination in blood disorders – Core knowledge (also see Talley and
O’Connor’s, chapters about hematological clinical examinations).
Functional anatomy and haemopoiesis – Read through for interest and
understanding the principles.
Major functions of blood cells – Core knowledge. Fig 19.6. – know the main
causes.
Haemostasis – Core knowledge. Main topics will be discussed in the
tutorial.
Investigation of blood diseases – Important – you will deal with this every day of
your life as a doctor.
Core knowledge.
Blood products – Core knowledge. Again things that you will deal with every
day.
Anaemias – Core knowledge.
Congenital anaemias – know main headings – detail is less important (take
note : G6PD deficiency is common in Africans.
Acquired hemolytic anaemia. The most important is warm auto-immune
hemolysis. The rest; just main headings.
Hemoglobinopathies – just main headings concerning the clinical picture and
principles of treatment and diagnosis.
Acute leukemias – just main headings and principles.
CLL – clinical picture and diagnosis.
Myelodysplastic syndromes – just main headings – no detail.
Prolymphocytic leukemia and hairy cell leukemia – not important.
Paraproteinaemias – know what is MGUS and a paraprotein and possible
causes; Waldenstrom (no detail). Myeloma – know what it is; clinical
picture, how to diagnose it and the principles of treatment (no detail).
Complications and their management is important (also important for
Internal Medicine in general).
Aplastic anaemias – clinical picture and most important causes.
Myeloproliferative disorders – clinical picture, diagnosis and definitions of
each.
Bleeding disorders – Core knowledge, Fig. 19.51 (NB!)
Coagulation disorders – You have to recognize it and know when to suspect a
coagulation disorder, clinical picture and principles of treatment and diagnosis.
Hemophilia B and Von Willebrand – just definitions; acquired bleeding disorders
just main headings; factors deficient in liver disease; DIC – Core knowledge.
Venous thrombosis – Fig. 19.56. Important to know about genetic diseases like
Protein C, S, Factor V Leiden and PG2O210A.
Know main headings.
Antiphospholipid syndrome – more important and common.
Treatment of venous Thrombo-embolism – Core knowledge.
The discussions in the tutorials are core knowledge, as well as the matters
indicated in the module guide. We hope that you will have a very pleasant and
great learning experience at haematology. – Don’t hesitate to ask if there are
any questions or doubts.
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Internal Medicine -MBChB V – Study Guide
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HAEMATOLOGY AND CELL BIOLOGY
Practical approach to hepatosplenomegaly, splenomegaly and lymphadenopathy
Hepatosplenomegaly
Example:
There is hepatosplenomegaly, the spleen is enlarged……cm below the left costal margin. The
liver is palpable at…..cm below the right costal margin; it is non-tender, firm and smooth (now
look for clinical anaemia, lympadenopathy and signs of chronic liver disease).
No other signs or clinical anaemia only:
Myeloproliferative disorders.
Lymphoproliferative disorders.
Cirrhosis of the liver with portal hypertension (less likely if there are no other signs of chronic
liver disease).
Hepatosplenomegaly plus palpable lymph nodes‫٭‬
Chronic lymphocytic leukaemia.
Lymphoma.
Other conditions to be considered would include infectious mononucleosis (? sore throat),
infective hepatitis (? jaundice) and sarcoidosis.
Signs of chronic liver disease:
Cirrhosis of the liver with portal hypertension.
Other causes:
Hepatitis B (? jaundice, tattoo marks)
Brucellosis (? farmerworker)
Weil’s disease (? jaundice, sewerage worker or fell into canal)
Toxoplasmosis (glandular fever-like illness)
Cytomegalovirus infection (glandular fever-like illness)
Storage diseases (e.g. Gaucher’s – spleen is often huge; glycogen storage disease)
Amyloidosis (? underlying chronic disease)‡
Other causes of portal hypertension (e.g. Budd Chiari syndrome = hepatic vein thrombosis).
Infantile polycystic disease (in some variants of this, children have relatively mild renal
involvement but hepatosplenomegaly and portal hypertension).
Common causes on a world-wide basis
Malaria
Schistosomiasis
Kala-azar (visceral leishmaniasis – uncommon in S Africa)
‫٭‬These conditions can also occur without palpable lymph nodes.
‡Though hepatosplenomegaly can occur in primary and myeloma associated amyloidosis, it is
commoner in the secondary form. Other organs particularly involved in secondary amyloidosis
are kidneys (nephrotic syndrome), adrenals (clinical adrenocortical failure may occur) and
alimentary tract (rectal biopsy). Conditions associated with secondary amyloidosis include
rheumatoid arthritis (including juvenile type), tuberculosis, leprosy, chronic sepsis, Crohn’s
disease, ulcerative colitis, ankylosing spondylitis, paraplegia (bedsores and urinary infection),
malignant lymphoma and carcinoma.
Splenomegaly (without hepatomegaly)
Why
1.
2.
3.
4.
5.
6.
do you think it is a spleen?
Can’t get above it
Descends prominently on inspiration
Distinct edge and medial notch
Not ballottable
Percussion dullness over spleen/Traube’s space#
+/- audible rub
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Internal Medicine -MBChB V – Study Guide
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# Traube’s space = A crescent-shaped space about 12 mm wide, just above the costal
margin. It is due to gas in the stomach which produces a vesiculotympanitic sound.
Example:
There is a mass in the left hypochondrium. On palpation I cannot get above the mass, it has a
notch, and on inspiration moves diagonally across the abdomen. The percussion note is dull
over the left lower chest wall and over the mass. I think this is the spleen enlarged at … cm.
Likely causes* to be considered are:
Very large spleen†
1.
Chronic myeloid leukaemia (Philadelphia positive in 90%)
2.
Myelofibrosis
3.
Lymphoma
4.
Chronic malaria
5.
Kala-azar (visceral leishmaniasis – rarely, if ever seen in South Africa, but may become
more common with increasing migration from other countries)
Spleen enlarged 4-8cm (2-4 finger breadths)
The above causes and:
1.
Myeloproliferative disorders‡ (e.g. CML, Myelofibrosis)
2.
Lymphoproliferative disorders§ (e.g. lymphoma and CLL)
3.
Cirrhosis of liver with portal hypertension (spider naevi, jaundice, etc.)
4.
Thalassaemia
5.
Storage diseases (e.g. Gaucher’s)
Spleen just tipped or enlarged 2-4cm (1-2 finger breadths)
The above causes and:
1.
Myeloproliferative disorders‡ (e.g. PV, ET)
2.
Lymphoproliferative disorders§ (? Palpable lymph nodes)
2.
Cirrhosis of liver with portal hypertension (spider naevi, jaundice, etc.)
3.
Infections such as:
3.1
Glandular fever (?throat, lymph nodes)
i.
Infectious mononucleosis (EBV)
ii.
Cytomegalovirus
iii.
Toxoplasmosis
3.2
Infectious hepatitis
3.3
Subacute baterial endocarditis (?heart murmur, splinter haemorrhages,etc.)
3.4
Protozoal (e.g. malaria)
4.
Infiltrations (e.g. amyloidosis, sarcoidosis)
5.
Connective tissue diseases (e.g., RA☼, SLE, PAN)
* To help you remember some common causes to mention in the examination, we have given
the three or four most common causes of a spleen of a particular size. An alternative way of
dividing up splenomegaly which can be found in many text books is:
1.
Infectious and inflammatory splenomegaly (e.g. SBE, infectious
sarcoidosis)
mononucleosis,
2.
2.1
2.2
Infiltrative splenomegaly
Benign (e.g. Gaucher’s, amyloidosis)
Malignant (e.g. leukaemias, lymphoma)
3.
Congestive splenomegaly (e.g. cirrhosis, hepatic vein thrombosis)
4.
Splenomegaly due to reticuloendothelial hyperplasia (e.g. haemolytic anemias,
ITP)
† Gaucher’s disease and rapidly progressive lymphoma may also cause a huge spleen. Chronic
congestive splenomegaly (Banti’s syndrome = splenomegaly, pancytopenia, portal
hypertension and gastrointestinal bleeding) may also cause massive splenomegaly. A huge
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Internal Medicine -MBChB V – Study Guide
2010
spleen developing in a patient with polycythemia rubra vera, is usually due to the development
of myelofibrosis.
‡ When listing the causes of splenomegaly or hepatosplenomegaly in the limited time of the
examination, to use the term myeloproliferative disorders in its broadest interpretation is a
useful way of covering several conditions in one phrase. If asked to explain it, one can mention
the separate entities of CML, PV, ET and myelofibrosis.
§ The lymphoproliferative disorders ar chronic lymphocytic leukaemia, lymphoma,
Waldenstrom’s macroglobulinaemia, myeloma and acute lymphoblastic leukaemia.
Splenomegaly is very rare in myeloma, except in cases with light chain deposition disease.
☼ Felty’s syndrome = uncommon but severe subset of seropositive rheumatoid arthritis
complicated by granulocytopenia and splenomegaly.
Other causes of splenomegaly:
Other infections (brucellosis, typhoid, miliary TB, trypanosomiasis, echinococcosis)
Other causes of congestive splenomegaly (hepatic vein thrombosis, portal vein obstruction,
schistosomiasis, chronic congestive heart failure)
Pernicious anaemia and other megaloblastic anaemias (rare) (? pallor, subacute degeneration
of the cord; Note: associated organ-specific autoimmune diseases, especially autoimmune
thyroid disease, diabetes, Addison’s, vitiligo, hyperparathyroidism)
Generalized lymphadenopathy:
Example for presentation:
There
is
generalized
lymphadenopathy
with/without….cm
splenomegaly
(or
hepatosplenomegaly). The likeliest causes would be a lymphoproliferative disorder like
lymphoma or CLL or an underlying infection.
Differential diagnosis:
1.
Lymphoproliferative disorders (rubbery and firm)
1.1
Lymphoma
Non-Hodgkin
Hodgkin
Leukaemia
1.2
CLL
ALL
2.
2.1
2.2
2.3
3.
Infections
Viral
HIV
Infectious mononucleosis due to EBV (glandular fever)
Cytomegalovirus (CMV) (glandular fever-like illness)
Parasitic
Toxoplasmosis (glandular fever-like illness)
Bacterial
Tuberculosis
Brucellosis
Secondary syphilis
Other
Sarcoidosis (?erythema nodosum or history of)
Collagen vascular diseases e.g. SLE, RA
Thyrotoxicosis (?exophthalmos, goiter, tachycardia, etc.)
Drugs, e.g. phenytoin (pseudolymphoma)
There are a large number of other causes of generalized lymphadenopathy, but these are the
most important ones. In a patient with generalized lymphadenopathy where a biopsy is
needed, the first choice would be a cervical or supraclavicular node. Nodes from the axillary
and inguinal areas often show reactive changes that may make a histological diagnosis
difficult. On the other hand, if there is a very large abnormal node in the inguinal or axillary
35
Internal Medicine -MBChB V – Study Guide
2010
areas, but not in the cervical or supraclavicular regions, then biopsy the biggest node,
irrespective of the location.
Localized lymphadenopathy:
Differential diagnosis:
1.
Local acute or chronic infection
2.
Metastases from carcinoma or solid tumour
3.
Lymphoma, especially Hodgkin’s disease
Diagnostic significance of localized lymphadenopathy in specific locations
A.
1.
1.1
1.2
2.
a.
b.
c.
d.
3.
4.
Epitrochlear lymphadenopathy
Lymphoproliferative disorders
Non-Hodgkin lymphoma
CLL
Infectious
Miliary TB
Infectious mononucleosis
Secondary syphilis
Localized pyogenic infection
Sarcoidosis
Intravenous drug abuse
B.
1.
2.
3.
Inguinal lymphadenopathy
Venereal disease*
Perianal sepsis or malignancy
Lymphoma
C.
1.
2.
3.
Occipital lymphadenopathy
Scalp infection (e.g.fungal)
Viral (e.g. rubella)
Neoplasm
D.
1.
2.
3.
4.
Cervical lymphadenopathy
Infectious mononucleosis; other viral infection
Streptococcal infection
TB (e.g. scrofula)
Lymphoma
E.
1.
2.
3.
Axillary lymphadenopathy
Catscratch disease; dogbite
Lymphoma
Lung or breast cancer
* Groove sign = adenopathy above and below the inguinal ligament is said to be classic of
Lymphogranuloma venereum (LGV)
36
Internal Medicine -MBChB V – Study Guide
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HAEMATOLOGY AND CELL BIOLOGY
CONSULTANTS
Prof P N Badenhorst
53043
Cell:
082 773 6025
(6356 SD/KK)
Prof V Louw
53043
Cell:
072 768 9024
(6777 SD/KK)
Dr Marius J Coetzee
53116
Cell:
082 550 1968
(6357 SD/KK)
Dr Frieda Pienaar
Cell:
083 262 0651
(6740 SD/KK)
Dr Lelanie Pretorius 52910/53288
Cell:
072 434 9487
(6360 SD/KK)
Dr Debbie Jafta
52910/53288
Cell:
082 782 0203
(6359 SD/KK)
Dr R Weyers
52910/53288
Cell:
083 626 3494
(6044 SD/KK)
Dr Jan-Gert Nel
52910/53288
Cell:
083 415 9856
(6040 SD/KK)
Dr E Mberi
52910/53288
Cell:
071 330 9447
(6800 SD/KK)
Dr J Joubert
52910/53288
Cell:
082 687 7773
(7104 SD/KK)
Dr JG Nel
52910/53288
Cell:
083 415 9852
(6040 SD/KK)
Dr M Harmse
52910/53288
Cell:
084 625 7888
(6412 SD/KK)
52137
Cell:
083 451 2425
(6734 SD/KK)
Dr C Barret
52137
Cell:
082 771 8104
(6308 SD/KK)
WARD / SAAL 29
4052081
WARD / SAAL 30
4052136
REGISTRARS
WARD
KONSULTANT –
Dr Mike Webb
REGISTRAR
JAN 072 395 0268
NONTOBEKO 7480
RIKUS 7234
HYMNE 072 242 9737
ROSY 079 521 9467
ROWAN 7326
37
Internal Medicine -MBChB V – Study Guide
2010
Exam Outcomes
38
Internal Medicine -MBChB V – Study Guide
2010
INTERNAL MEDICINE
General
At the end of the course the student should be able to identify and manage the most
commonly occurring medical conditions including medical emergencies.
ENDOCRINOLOGY
Knowledge outcomes
At the end of the Internal Medicine rotation students should be able to:

explain the clinical presentation of commonly occurring endocrinological and metabolic
conditions (i.e. endocrine hypertension, diabetes mellitus, etc)

describe the clinical manifestations and management of the most commonly thyroid
conditions

describe the clinical manifestations and management of the most common parathyroid
conditions

describe the clinical manifestations and management of the most commonly occurring
conditions of the adrenal gland

describe the clinical manifestations and management of the most commonly occurring
conditions of the endocrine pancreas

describe the clinical manifestations and management of the most commonly occurring
hypothalamic and pituitary conditions

describe the clinical manifestations and management of newly diagnosed diabetes

describe the clinical manifestations and management of the hyper- and hypoglycaemic
emergencies

describe the long-term complications of diabetes mellitus including risk factors, clinical
features and management

describe the basic pharmacology of hypoglycaemic agents including insulin preparations

describe the principles of the management of diabetes in adolescents, pregnancy and in
the elderly

describe the principles involved in the management of diabetes in the peri-operative
period

discuss the aetiology, pathophysiology, clinical manifestations, and complications of
obesity

classify the dyslipidaemias, describe the clinical features and the pharmacological
management of the most commonly occurring hyperlipidaemies.

briefly discuss the clinical manifestations and management of the porphyrias commonly
occurring in South Africa

discuss the epidemiology, risk factors, clinical manifestations and management of
osteoporosis
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Internal Medicine -MBChB V – Study Guide
2010
Skills outcomes
At the end of the rotation the student should be able to (in patients with commonly
occurring endocrinological and metabolic conditions):

take an appropriate history and perform an appropriate clinical examination in order to

formulate a problem list and established a differential diagnosis

to request in a cost effective way and interpret special investigations

to provide a patient with newly diagnosed diabetes with basic survival skills
including
dietary guidelines, injection techniques, self-monitoring techniques, foot
care,
exercise guidelines, early recognition and management of the symptoms of
hypo-and
hyperglycaemic emergencies

to communicate in a sensitive and effective way with the patient and the patient’s
family
Source documents
1.
Appropriate modules in Phase II
2.
Appropriate discussions during the Academic Afternoons and tutorials
3.
3.1
3.2
3.3
3.4
Davidson’s Principles and Practice of Medicine 19th ed.
Chapter 10, pp 325 – 336
Chapter 15
Chapter 16
Chapter 20 (osteoporosis)
4.
Clinical Examination. Tally and O’Connor, 4 th ed, chapter 9
5.
Discussions during clinical rotation
RHEUMATOLOGY
Knowledge outcomes:
At the end of Phase III students should be able to:

Describe the basic anatomy and physiology of the muscular skeletal system (Davidson’s
p 962 – 969)

Describe and to integrate the most important symptoms and signs of rheumatological
conditions in order to compile a differential diagnosis (Talley and O’Connor and
Davidsons’s p. 958 – 962 and p. 974 – 987)

Discuss the epidemiology of the major rheumatological conditions with regards to
demography, age, sex and genetic groups (Epidemiology for each of the categories)

Discuss the basic differences and similarities of the following categories of
rheumatological conditions including there complications:
a)
Inflammatory poli-arthritis (including rheumatoid arthritis and psoriatic arthritis
(Davidson’s p. 1002 – 1007)
b)
Sero-negative spondil-arthropathies (Davidson’s p. 1007 – 1012)
c)
Crystal arthropathies (including gout, pseudo-gout) (Davidson’s p. 1012 – 1020)
d)
Degenerative (mechanical) joint diseases (including osteo arthritis) (Davidson’s p.
996 – 1001)
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Internal Medicine -MBChB V – Study Guide
2010
e)




Soft tissue rheumatism (local and generalized) and fibromyalgia (Davidson’s p.
1023 – 1025)
f)
Arthritis associated with infections (septic arthritis, tuberculosis, Brucellosis and
reactive arthritis). (Davidson’s p. 1020 – 1021)
g)
Systemic connective tissue diseases (SLE, scleroderma, mixed connective tissue
disease,
polimar ascites/derma-derma
ascites and sjörgrin syndrome).
(Davidson’s p. 1034 – 1040)
h)
Systemic vasculitis (Davidson’s p. 1040 – 1044)
To describe the basic relationship between musculoskeletal symptoms and systemic
diseases.
(malignancies, endocrine conditions, metabolic conditions, neuropathic
conditions and sarcoidosis). (Davidson’s p. 1045 – 1046)
To discuss the management of the major rheumatological conditions (nonpharmacological and pharmacological management). (Davidson’s p. 988 – 996) The
principals of management of the musculoskeletal disorders.
To explain to a patient the plan for long-term management including follow-up visits and
to explain when a patient with a rheumatological condition should be referred for a
specialist management.
To explain the prognosis of the most commonly occurring rheumatological conditions.
Skills outcomes:
At the end of Phase III students should be able to:

Take a thorough and appropriate history from a patient with a rheumatological
condition;

To perform a thorough and systematic clinical examination of the most commonly
involved joints and joint areas: hands, wrists, elbows, shoulders, lower back, hips,
knees, ankles and feet.

To compile an appropriate problem list and differential diagnosis after the clinical
evaluation of a patient;

To request in a cost-effective way special investigations in an individual patient
(Davidson’s p. 966 – 974)

To participate in the management of a rheumatological patient (pharmacological
and non-pharmacological);

To provide the patient with appropriate advice regarding management and
prognosis
including special cases like pregnancy and other medical conditions.
CARDIOLOGY
General outcomes:
At the end of Phase III students must be able to:
1.
Demonstrate their ability identifying the important cardiovascular causes of:

Chest pain

Dyspnoea

Palpitations

Syncope

Oedema
2.
To make a preliminary diagnosis after an appropriate history by clinical reasoning.
3.
To elicit normal and abnormal signs to confirm the diagnostic hypophysis.
4.
The utilization of appropriate investigations to confirm a clinical diagnosis.
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Internal Medicine -MBChB V – Study Guide
5.
6.
2010
To formulate a management plan including the appropriate pharmacological
management of a patient.
How the burden of cardiovascular diseases could be reduced by primary and
secondary prevention strategies.
Specific outcomes
At the end of Phase III students should be able to:
a)
Investigations

To recognise the basic radiological appearance of cardiac enlargement and
pulmonary congestion and to put these changes in context of the underlying
patophysiology.

To interpret the basic ECG abnormalities.
b)




Angina pectoris
To recognise the clinical presentation of angina pectoris.
To request and interpret appropriate investigations to confirm the diagnosis
and to establish the seriousness of the underlying coronary vascular disease.
To recognise the cardiovascular risk factors in individual patients.
To initiate immediate appropriate management.
c)

Acute myocardial infarction
To recognise acute myocardial infarction and to utilize appropriate
investigations to
confirm the diagnosis.

To initiate appropriate initial management to limit infarction size.

To control pain of acute myocardial infarction.

To recognise early life-threatening complications and to initiate further appropriate
management for the medium and long-term.
d)

Heart failure
To recognise left and right heart failure by taking an appropriate history and
to
perform an appropriate physical examination.
To explain the clinical findings in relation to the underlying patophysiological
changes.
To explain the role of radiography, electrocardiography and echocardiography
in
the diagnosis of heart failure.
To initiate the appropriate management of a patient with heart failure
including
appropriate pharmacological and non-pharmacological treatment.



e)






Valvular heart disease
To recognise the possibility of significant valvular lesions in a patient with cardiac
disease.
To recognise rheumatic fever and other causes of valvular disease.
To recognise and evaluate systolic and diastolic murmurs.
To explain how a patient with valvular disease should be appropriately
investigated.
To recognise and to interpret the importance of complications in a patient with
valvular heart disease.
To explain the appropriate management as well as the prophylactic measures
in
a patient with valvular heart disease.
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Internal Medicine -MBChB V – Study Guide
f)




2010
Arrhythmias
To recognise the most common arrhythmias including: (ventricular extra systoles
and tachycardia, atrial fibrillation, supraventricular tachycardia as well as
bradycardia and heart block).
To initiate appropriate investigations.
To initiate appropriate management.
To explain to a patient cardiac passing and pass maker function to a patient.
HAEMATOLOGY AND CELL BIOLOGY
Hepatosplenomegaly
Outcomes:
At the end of this module students should be able to do the following in patients with
haematological diseases:

To take an appropriate history and to perform an appropriate clinical examination.

To compile a problem list and the differential diagnosis and to request appropriate
investigations and to interpret these investigations.

To formulate an appropriate management plan or to explain when a patient should be
referred for a specialist management.

To communicate sensitively with patients about their malignancies.
At the end of this module students should be able to explain the following
procedures:

The ordering and administration of blood products.

How a bone marrow aspiration and biopsy is performed
At the end of this module students should be able to explain the following in patients
with haematological diseases:

The diagnosis and management of the most common anaemia’s.

The diagnosis and the principles of management of the most common haematological
malignancies.

The diagnosis and management of the most common causes of splenomegaly and
lymphadenopathy.

The diagnosis and basic management of the most common bleeding tendencies.

Interpretation of a full blood count.

The principles involved in the selection of blood products.
At the end of this module students should be able to conduct themselves
professionally regarding to the following:

The conveying of serious information including bad news to a patient and the patient’s
relatives.

To maintain a professional relationship with healthcare workers including those in
the diagnostic laboratories and blood bank.

The most appropriate management of a patient taking into account demography,
social factors, the current healthcare system and budget.
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Internal Medicine -MBChB V – Study Guide
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Educational methods
To manage inpatients as well as outpatients with haematological disorders under direct
supervision.
To participate in tutorials.
The preparation of a portfolio case.
References and source material
Handouts provided for: MEQ224, GKV202 and academic afternoons handouts provided during
imaging sessions
Davidson’s Principles and Practice of Medicine, 19th edition: Chapt. 19
Clinical examination, Tally and O’Connor, 4 th edition: Chapt. 7
Assessment of student learning
Specific outcomes
Students must be able to:
Take an appropriate history from a
patient with a haematological disorder
and to recognise physical signs.
To make an appropriate
synthesis of the information obtained.
To request appropriate haematological
investigations.
To
decide
on
an
appropriate
immediate and long-term plan of
management and explain
when to refer a patient
based on the problem list.
To explain the pathogenesis, natural
history and management of each of
the most commonly occurring
haematological diseases.
To explain the appropriate
routine used of a diagnostic
haematological-laboratory.
Assessment criteria
Students must be able to list the
symptoms of the most commonly
occurring
haematological
conditions and to examine the
relevant organ systems.
Explain the pathogenesis of the
most commonly
haematological conditions
and indicate how specific
haematological investigations can
be used to investigate these
disorders. Students must also be
able
to
interpret
commonly
requested haematological
investigations.
To explain the principles of
management of the most
commonly occurring
haematological conditions as well
as to explain when to refer a
patient for the next level of care.
To explain the pathogenesis,
natural history and management
of each of the most commonly
occurring
haematological conditions.
To explain the most
commonly haematological
investigations, how
specimens should be
collected and transported
and to comment on the
validity of results.
Assessment task
To take a history and to
conduct the physical
examination of the patient
and/ or OSCE.
To summarize a patient’s
problem during a clinical
evaluation or OSCE or a
paper case/portfolio case.
To make decisions during a practical
examination.
(Clinical case) or during an
OSCE or making use of a
Paper case/portfolio case.
To respond in a vivar or
written assessment.
To respond in a vivar or
written assessment.
44
Internal Medicine -MBChB V – Study Guide
2010
NEPHROLOGY
You are expected to master the following outcomes during Phase III:
The level of knowledge of students rotating is not on the same level. Students who start their
rotation in January could not be expected to have the same level of knowledge as students
that rotate during October. Therefore, all the outcomes for nephrology for the MB ChB course
are provided, but those marked an asterisk must be mastered during your rotation.
A.
General:
Knowledge outcomes:
1.
The student must be able to describe how disease processes of the kidneys may
influence or change the following:
1.1
the normal anatomy of the kidneys and urinary tract
1.2
the normal physiology of the kidneys and urinary tract
2.
The students must be able to discuss the indications, limitations and dangers (evidence
based) of special investigations commonly used to determine renal function and
structure. The use of radiological contrast agents is especially important.
Skills outcomes:

The student must be able to demonstrate that he or she can take a complete history and
perform a complete physical examination in a patient presenting with a renal disease.

The student must be able to demonstrate that he/she could be able bimanuallypalpate
the kidneys.

The student must be able to perform a rectal examination to evaluate the prostate.

The student must be able to explain to a patient how to collect a midstream urine
specimen in the correct way.

The student must be able to do and interpret urine analysis – including microscopy.

The student must be able to place a urinary catheter in an aseptic way in males and
females.

The student must be able to request special investigations in a save and cost-effective
way according to the needs of a specific patient.

The student must be able to recognise the following clinical syndromes, discuss the
most important causes of these syndromes, to formulate a diagnostic plan, discuss
the broad management guidelines as well as the criteria for referral for specialist
care.
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Internal Medicine -MBChB V – Study Guide
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2010
Specific clinical problems:
Acute nephritis syndrome
Knowledge outcomes:
The students should be able to:

Define acute nephritis syndrome

Discuss the differential diagnosis including the most common glomerulonephritis
that can present in such a way for instance post infective glomerulonephritis and
rapidly progressing glomerulonephritis.

Discuss the basic mechanisms of the immune response.

Discuss the clinical signs of post streptococcal glomerulonephritis.

To discuss the investigations necessary to confirm the diagnosis.

To discuss the basic pharmacology or immunosuppressive agents including serious
side-effects (especially glucocortocoids).
Skills outcomes:
The student must be able to:

Diagnose acute nephritic syndrome after the clinical evaluation of the patient.

To propose a diagnostic plan for the specific patient to recognise those patients who
should be referred for specialist care (discuss indications for referral).

To manage blood pressure and fluid balance in these patients.
Nephrotic syndrome
Knowledge outcomes:
The




student must be able to discuss or explain the following:
The definition of nephritic syndrome
The important causes
The mechanisms of oedema and how to distinguish between them.
The complications of nephritic syndrome independent of the cause.
Skills outcomes:
The





student must be able to:
Diagnose nephritic syndrome in a patient after clinical evaluation.
Propose a management plan for the specific patient.
To recognise the patient that should be referred for specialist care (indications for
referral).
To discuss the broad management of a patient with nephritic syndrome including
the use of diuretics, dietary manipulation and how to prevent complications.
To explain the condition to the patient.
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Internal Medicine -MBChB V – Study Guide
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Renal failure
Acute renal failure
The student must be able to discuss or explain the following:

The difference between acute and chronic renal failure

The classification of renal failure into pre-renal and post-renal categories, the most
common causes of each type and how to distinguish between the different types.

The changes in homeostasis that follows renal failure and especially the lifethreatening changes such as hypercalaemia, hypertension and fluid overload.

The indications for dialysis

The different forms of dialysis
Skills outcomes:
The student must be able to:

Distinguish between acute and chronic renal failure.

To propose a management plan for a specific patient, especially to differentiate.between
pre-renal failure from acute tubular necrosis.

To identify patients that should be referred for specialist care.

To manage the life-threatening complications of renal failure such as hypercalaemia,
hypertension and fluid overload.

To recognise those patients in need of dialysis.

To explain the basic treatment options to a patient.
Chronic renal failure
Knowledge outcomes:
The
1.
2.
3.
4.
student must be able to explain or discuss the following:
The common causes of chronic renal failure.
The effect of chronic renal failure on the different systems of the body.
To understand the principles and consequences of impaired renal function on the
pharmacokinetics of drugs.
To understand the mechanisms of progression of renal failure that is independent of
the cause.
Skills outcomes:
The student must be able to:
1.
Recognise the systemic manifestations of renal failure in a patient.
2.
To explain the different forms of renal replacement therapy to a patient referring to
the advantages and disadvantages of each.
3.
Modify the dose of drugs according to renal function.
4.
To introduce practical methods aimed at limiting the progression of renal function
(independent of the cause of renal failure).
5.
To manage patients who are not suitable for renal replacement therapy conservatively.
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Hypertension
Knowledge outcomes:
The
1.
2.
a.
b.
3.
4.
5.
6.
student must be able to discuss or explain:
Normal control of blood pressure.
The definition of hypertension and the grading of hypertension in South Africa:
the secondary causes of hypertension
how to screen patients in a cost-effective way for these
Complications of hypertension.
The different forms of hypertensive crises.
The other risk factors for arteriosclerosis.
The basic pharmacology of anti-hypertensive agents.
Skills outcomes:
The student must be able to:







To measure blood pressure correctly.
Recognise the clinical complications of hypertension.
Advice a patient with regards to lifestyle modifications that may assist in blood
pressure control and to reduce the risk of arteriosclerosis.
To select anti-hypertensive agents according to specific patient characteristics and co
morbidities.
To recognise patients that should be referred for specialist care.
To recognise and manage hypertensive crises.
To motivate patients to comply with management.
Water electrolyte and acid-based disturbances
Knowledge outcomes:
The student must be able to discuss or explain the following:

The causes and symptoms of the common electrolyte derangements, especially
sodium, potassium and calcium.

The causes and symptoms of dehydration and fluid overload.

The composition of commonly used intravenous fluids.
Skills outcomes:
The student must be able to:
1.
Make a specific diagnosis in a patient with an electrolyte abnormality and to introduce
management.
2.
Interpret blood gas analysis appropriately.
3.
To put up an intravenous line.
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Internal Medicine -MBChB V – Study Guide
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The common tubulo-interstitial diseases
Knowledge outcomes:
The




student must be able to explain or discuss the following:
Micro organisms that commonly causes urinary tract infection.
Nephro-toxic drugs known to frequently cause tubulo interstitial disease.
The basic methods of prevention of urinary tract infection.
The basic pharmacology of anti-microbial agents.
Skills outcomes:
The student must be able to:



Diagnose urinary tract infection correctly and to propose appropriate management
according to the site of infection and sex of the patient.
To recognise complicated urinary tract infection.
To recognise the characteristic features of chronic pyelonephritis and analgestic
nephropathy on IVP.
Asymptomatic urinary abnormalities
Knowledge outcomes:
The student must be able to list the following:

The nephrological and urological causes
proteinuria.
of
asymptomatic
haematuria
and
Skills outcomes:
The



1.
2.
3.
student must be able to:
Distinguish between urological and nephrological causes.
Identify patients that should be referred for specialist care.
Basic knowledge of the following is necessary:
Hereditary kidney diseases for example polycystic kidney disease
Renal involvement in SLE and diabetes mellitus
The medical causes of renal stone disease
Sources
References
Clinical Notes
Provided in Phase II, Phase III, academic afternoons and tutorials.
Davidson’s Principles and Practise of Internal Medicine, 19 th edition: Talley and O’Connor.
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Internal Medicine -MBChB V – Study Guide
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NEUROLOGY
Please see study guide section on Neurology
GASTROENTEROLOGY
Knowledge outcomes:
At the end of Phase III students must be able to:

How commonly occurring gastro-intestinal diseases present.

To describe the clinical manifestations and management of commonly occurring oral
infections.

To describe the clinical spectrum and management of reflux esophagitis.

To compare the different forms of motility disorders of the oesophagus and and
table form.

To tabulate the differential diagnosis of dysphasia and odinophagia and propose
appropriate investigations and management of these disorders.

To discuss the clinical features and management of gastritis.

To discuss the clinical features and management of peptic ulcer disease.

To discuss the role and management of Helicobacter pylori in peptic ulcer disease.

Discuss the clinical features and management of malabsorption.

To explain the special investigations needed to investigate a patient with
malabsorption at the hand of a flow diagram.

Describe the clinical spectrum, diagnostic criteria as well as the management of
irritable bowel syndrome.

To describe the clinical features, complications and management of chronic
pancreatitis.

To describe the clinical features, complications and management of inflammatory
bowel disease.

To describe the differences between ulcerative colitis and Crohn’s disease in table
form.

To discuss the clinical features, causes and management of acute and chronic
diarrhoea.

To describe the differences between secondary and osmotic diarrhoea.

Discuss the causes and management of constipation.

Discuss the complications of diverticular disease.

Discuss the basic pharmacology of anti-acids, acid-suppressing drugs, surface- covering
agents, anti-prostaglandins and drugs that influence mortality.
Knowledge outcomes: (Diseases of the liver)
At the end of Phase III students should be able to:

To explain in patients with acites the difference between a transudate and an exudates
in table form.

To compile and describe the stepwise management plan for ascites.

Describe clinical features and management of spontaneous bacterial peritonitis.

Discuss the clinical features and management of a liver mass.

To discuss hepato toxic drugs or drugs associated with drug-induced hepatitis.

Discuss the causes, complications and management of portal hypertension.
50
Internal Medicine -MBChB V – Study Guide





2010
To explain how frequently occurring liver diseases may present.
Describe the clinical features and causes of acute hepatitis.
Describe the clinical features and causes of chronic hepatitis.
Discuss the clinical features and management of acute life-threatening liver failure.
Discuss the clinical features and management of chronic impairment of liver function &
discuss the causes, the diagnosis and management of hepaticencephalopathy (shortterm
and long-term management).
Skills outcomes:
At the end of Phase III students should be able to:

Take an appropriate history from a patient presenting with a gastro-intestinal disease.

To perform an appropriate clinical examination of a patient with a gastro-intestinal
condition (including the general examination).

To examine and document the liver, spleen and abdominal masses.

To make a clinical assessment of a patient presenting with a jaundice and to decide on
clinical grounds whether it is of hepato cellular origin or obstructive and whether acute or
chronic liver failure is present.

To examine a patient with acites and to perform a parasintesis.

To prepare a patient for liver biopsy.

To inform a patient about the different methods of investigating the gastro-intestinal
system including imaging methods.

To evaluate the patient with encephalopathy and to grade encephalopathy.

To examine a patient with chronic pancreatitis and to identify complications.

To examine a patient with inflammatory bowel disease and to identify systemic
complications.

To perform a vena section in a patient with liver disease.
References
Davidson’s Principles and Practise of Medicine, 19 th edition, Chapt. 17 and 18
Clinical Examination, Tally and O’Connor, Chapt. 5
Appropriate sessions in Phase II and Phase III including academic afternoons and tutorials
INFECTIOUS DISEASES
Knowledge outcomes:
At the end of Phase III students should be able to:
1.
To list the causing organism (s) and to discuss the clinical features, complications,
microbiological investigations, basic pharmacology and appropriate management of
each of the following infections:

Tuberculosis

Human Immuno-deficiency Virus (including all the important opportunistic
infections)

Sexually transmitted diseases

Malaria

South-African thick bite fever

Bilharzia

Herpes zoster and chickenpox in the adult

Infective mononucleosis (EBV and SMV)
51
Internal Medicine -MBChB V – Study Guide








2010
Brucellosis
Rabies
Systemic
fungal
infections
(Cryptococcus,
Histoplasmosis,
Candidiasis,
Aspergillosis)
Cystisarcosis and Eccinococcosis
Crim-Congo hemorrhagic fever
Fever and fever of unknown origin
SIRS and sepsis
Important organ specific systemic infections:
 Gastroenteritis and typhoid, cholera, amoebiases, food poisoning and traveller’s
diarrhoea
 Meningitis (Davidson’s p. 1192 -1202)
 Infective endocarditis (Davidson’s p. 463 – 467)
 Community acquired pneumonia (Davidson’s p. 524 – 532)
 Urinary tract infections and pyelonephritis (Davidson’s p. 628 – 631)
 Skin and soft tissue infections (including skin rash associated with specific
infections)
2.
The basic pharmacology of antimicrobial agents, antiviral agents, antifungal agents
(Davidson’s p. 137 – 146), anti-tuberculosis drugs and anti-parasitic agents.
3.
Vaccination in adults, the prophylactic use of antimicrobials and the isolation and
preventative measures and modification of common infections in South-Africa.
Skills outcomes:
At the end of Phase III students should be able to:

Apply universal preventative measures when drawing blood or when handling potential
infective human secretions.

To correctly collect the following samples for microbiological laboratory investigations
and transport: blood culture, sputum specimens, puss swabs, throat swabs, urine
specimens, stools specimens and cerebro-spinal fluid specimens.

To perform and interpret a Mantoux test.

To interpret microbiological reports including serological reports.

To recognise the radiological features of the most commonly infections.

To participate in the management plan of the most common infectious diseases.

To do pre- as well as post-test counselling in patients with HIV including their families.

To take appropriate preventative measures and to advice travellers to and from
South Africa.

To correctly notify infectious diseases in South Africa.
Sources/References
1.
2.
3.
4.
Phase II: Infectious Disease Module MJR 224
Academic afternoons and tutorials
Davidson’s Principles and Practise of Medicine, 17th Edition
South African Medicines Formulary
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Internal Medicine -MBChB V – Study Guide
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PULMONOLOGY
Knowledge outcomes:
At the end of Phase III students should be able to:

Discuss the functional anatomy and physiology of respiratory diseases (gas
exchange, ventilation, perfusion, and diffusion).

Describe the lung defence mechanisms.

Discuss the indications for imaging and the following special investigations in the
diagnosis of lung disease (chest radiograph, computed tomography (CT-chest),
ventilation-perfusion imaging, bronchoscopy, lung function testing, pleural aspiration
and biopsy.

Explain the major manifestations of lung disease: Dyspnoea, cough, sputum,
haemoptysis, chest pain, wheezes.

Define and discuss the causes and management of respiratory failure (type I and II,
acute and chronic).

Recognise the typical features of sleep disordered breathing.

Define chronic obstructive airways disease (COPD) and asthma and discuss important
aspects including the pathology, causes, complications, and management of the
obstructive airways diseases (COPD, asthma including acute severe and chronic
persistent asthma, bronchiectasis, and cystic fibrosis).

Define and discuss respiratory infections including pneumonia (community acquired,
nosocomial, aspiration, “atypical”, suppurative) and fungal infections
(aspergilloma,
allergic bronchopulmonary aspergillosis – ABPA).

Tuberculosis: See outcomes Infectious diseases.

Discuss the role of the physiotherapist, dietician and occupational therapist in patients
with lung disease.

Discuss the causes, clinical presentation, investigations, management and prognosis of
bronchus carcinoma, pleural and mediastinal malignancies.

Discuss the interstitial lung diseases including idiopathic pulmonary fibrosis
(cryptogenic fibrosing alveolitis), sarcoidosis, organic dust exposure (extrinsic allergic
alveolitis), inorganic dust exposure (pneumoconioses including silicosis, asbestosis, and
coal workers), and lung disease associated with systemic inflammatory diseases and
drugs.

Discuss the predisposing factors, clinical features, investigations and management of
venous thrombo-embolism.

Discuss the presentation, diagnosis and management of pleural disease including
pleural effusion, mesothelioma and pneumothorax.

Know the pharmacology of drugs used in the management of respiratory diseases
(with specific reference to COPD and asthma).
Skills outcomes:
At the end of phase III students should be able to:

Obtain a detailed respiratory history with specific attention to symptoms of lung
disease, occupational history, etc.

Perform a thorough examination of the respiratory system and recognise signs indicating
respiratory pathology e.g. cyanosis, clubbing, polycythaemia, etc.).

Discuss the indications for pulmonary function testing and be able to recognise
obstruction, restriction and reversibility on a flow volume curve.

Systematic interpretation of a chest X-ray.

Formulation of a clinical problem statement in a patient with respiratory disease.
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Internal Medicine -MBChB V – Study Guide
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GERIATRICS
General:
At the end of phase III students should be able to:

Demonstrate an understanding of the biology of aging.

Safely prescribe drugs to the elderly.
Frailty Syndrome
Knowledge outcomes:
At the end of Phase III students should be able to:

Discuss the demographics of the ageing population.

Discuss the physiology of ageing.

Define the frailty syndrome and discuss its consequences.

Explain the difference between frailty and disability.

Discuss the causes of the risk factors for falls in the elderly.

Define rehabilitation.

Discuss the indications for and principles involved in rehabilitation.
Skills outcomes:
At the end of Phase III students should be able to:

Assess a frail older person.

Assess an elderly person with the history of falling and formulate a management
plan.

Initiate, manage and participate in the rehabilitation of common conditions in the
elderly.
Diabetes mellitus in the elderly
Knowledge outcomes:
At the end of Phase III students should be able to:

Briefly describe the prevalence of diabetes mellitus in the elderly population.

Discuss the importance of glycaemic control in the elderly.

Discuss the pitfalls (including hypoglycaemia) of diabetes management in the elderly.

The pharmacological and non-pharmacological management of diabetes in the elderly.

The pharmacology of insulin and the oral hypoglycaemic agents in the oral context of an
elderly person.

Discuss the importance of microvascular complications in the elderly.

Discuss the macrovascular complications of diabetes in the elderly.
54
Internal Medicine -MBChB V – Study Guide
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Skills outcomes:
At the end of Phase III students should be able to:

Take an appropriate history and perform a thorough clinical examination in an elderly
patient suffering from diabetes mellitus.

Make an assessment of cardiovascular risk.

Initiate a comprehensive management plan including cardiovascular risk reduction.

Advice a patient on lifestyle modification.

Communicate effectively and sensitively with a patient regarding management,
side-effects of drugs, prognosis and compliance.
Thyroid disease in the elderly
Knowledge outcomes:
At the end of Phase III students should be able to:

Explain the unique clinical presentation of common thyroid disorders in the elderly.

Demonstrate how acute illness may influence thyroid function.

Explain the effect of iodide-containing drugs on thyroid function in the elderly.

Effectively communicate with an elderly person or caregiver about thyroid
conditions in the elderly.
Skills outcomes:
At the end of Phase III students should be able to:

Take an appropriate history and perform a thorough clinical examination in an elderly
patient presenting with a thyroid disorder.

Participate in the management of an elderly patient with a thyroid disorder.
Urinary incontinence
Knowledge outcomes:
At the end of Phase III students should be able to:

Briefly describe the anatomy and physiology of nutrition

Classify and briefly discuss the principles involved in the different of the different
types
of
incontinence
including
pharmacological
and
non-pharmacological
measures.
Skills outcomes:
At the end of Phase III students should be able to:

Take an appropriate history and perform a thorough clinical examination of a patient
presenting with the complaint of incontinence.

Compile a management plan including the cost-effective investigation of a patient
with incontinence.

Participate in the management of a patient with incontinence.

Communicate effectively and sensitively with the patient about mechanisms involved,
management options and prognosis.
55
Internal Medicine -MBChB V – Study Guide
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Dementia
Knowledge outcomes:
At the end of Phase III students should be able to:

Discuss the epidermiology of dementia

Define dementia according to the DSM4 criteria

List the causes of dementia according to frequency (common, unusual and rare
causes)

List the reversible causes of dementia

Differentiate between dementia, delirium and depression

Briefly define mild cognitive impairment

Discuss the role of the general practitioner in the management of a patient with
dementia

Briefly discuss Alzheimer’s disease (including prevalence, patophysiology, clinical
features, diagnosis, management and prognosis)

Briefly describe the Wernicke Korsakov syndrome (including epidermiology,
patophysiology, the clinical features, management and prognosis)

Briefly describe vascular dementia including epidermiology, patophysiology, clinical
features, management and prognosis)
Skills outcomes:
At the end of Phase III students should be able to:

Take an appropriate history and perform a thorough clinical examination in a patient with
dementia.

Communicate effectively and sensitively with the caregiver of a patient with
dementia.

Request in a cost-effective way special investigations to rule out the reversible causes of
dementia.
Hypertension in the elderly
Knowledge outcomes:
At the end of Phase III students should be able to:

Define hypertension in the elderly.

Describe the epidemiology of hypertension in the elderly.

Classify hypertension.

Discuss the benefits of antihypertensive treatment in the elderly.

Define treatment thresholds and targets for hypertension in the elderly.

Discuss the management of hypertension in the elderly.
Skills outcomes:
At the end of Phase III students should be able to:

Take an appropriate history and perform a thorough clinical examination in an elderly
patient with hypertension.

Provide a cost-effective management plan hypertension in the elderly.

Deal with the acute and chronic complications of hypertension in the elderly.
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Internal Medicine -MBChB V – Study Guide
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Heart failure in the elderly
Knowledge outcomes:
At the end of Phase III students should be able to:

Define systolic and diastolic heart failure.

Demonstrate an understanding of the pathophysiology of heart failure.

Describe the management of heart failure in the elderly.

Discuss the prognosis of heart failure in the elderly.
Skills outcomes:
At the end of Phase III students should be able to:

Take an appropriate history and perform a thorough clinical examination in an elderly
patient with heart failure.

Participate in the management of heart failure in an elderly patient

Communicate effectively sensitively with the patient and / or caregiver about the
prognosis and management of a patient with heart failure
57
Internal Medicine -MBChB V – Study Guide
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PROBLEMATIC PHYSICAL SIGNS:
The Department of Internal Medicine places considerable emphasis on clinical methods and
competencies. The following is a list of signs and/or conditions that students traditionally have
problems with. In order to better understand and correctly demonstrate and interpret these
signs it is advisable that you find patients with these signs/conditions and that you ask your
consultant to evaluate your skills with the patient. If you satisfactorily demonstrate the
specific sign/condition, ask your consultant to sign the list. In this way we hope to insure that
you master the most important clinical competencies by the end of your rotation. You will also
be advised to repeat this exercise in the 5th year. Every Monday morning a list is compiled of
patients who are suitable for training opportunities. This list is available at the department.
Patients with certain conditions will sometimes be more regularly seen at an outpatient clinic ask your consultant in this regard.
Name:
Studentnr:
Date:
List of conditions
Signature of
Consultant
__/__/2010
Atrial fibrillation
__/__/2010
Pulsus paradoxus
__/__/2010
↑ Jugular venous pressure
Tricuspid incompetence including CV waves and pulsating
__/__/2010
liver
__/__/2010
Hepato-jugular reflex
Determine the position of apex beat (normal as well as
__/__/2010
displaced)
__/__/2010
Distinguish between LV hypertrophy and diffuse apex beat
Techniques to determine RV hypertrophy as well as the
__/__/2010
indications for each
__/__/2010
Mitral stenosis
__/__/2010
Mitral regurgitation
__/__/2010
Aortic stenosis
__/__/2010
Aortic regurgitation
__/__/2010
Prosthetic valve sounds
__/__/2010
Percussion technique (respiratory)
__/__/2010
Signs of consolidation
__/__/2010
Amphoric breathing
__/__/2010
Signs of pleural effusion
__/__/2010
Asterixis
__/__/2010
Spider angiomata
__/__/2010
Campbell de Morgan spots
__/__/2010
Splenomegaly
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Internal Medicine -MBChB V – Study Guide
Date:
List of conditions
2010
Signature of
Consultant
__/__/2010
Shifting dullness (ascites)
__/__/2010
Petechiae
__/__/2010
Diabetic retinopathy
__/__/2010
Disorders of eye movements
__/__/2010
7th Cranial nerve lesions (upper/lower)
__/__/2010
Grading of strength
__/__/2010
Muscle tone
__/__/2010
Tendon reflexes (NB ankle reflex)
__/__/2010
Clonus
NB
Hand in at end of rotation
59
Internal Medicine -MBChB V – Study Guide
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Assessment
forms
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Internal Medicine -MBChB V – Study Guide
2010
Assessment Form: MBChB V
Name:…………………………… Period: From____/____to____/____ Firm: …….…………
Formative assessment:

Clinical skills:
Strengths:
Area(s) that requires attention:

Professionalism: (Team work, communication, dress code, discipline, punctuality,
ethics, etc.)

Assessment discussed with the student:
Yes

No

Comments:
Summative assessment:
Category Marks
(%)
E
< 50
D
50
59
C
60
69
B
70
79
A
80+
Description
Clinically immature
Clinically mature
Lacks insight
Clinical skills and theoretical knowledge superficial
Clinically mature
Superficial insight
Clinical skills and core knowledge adequate
Clinically mature
Insight adequate
Breadth of theoretical knowledge
Clinically mature
Insight excellent
Excellent grasp of clinical medicine
Breadth of experience and theoretical knowledge
Final mark (%)
45
55
66
74
80
Name (Consultant): …………………..…………… Signature: ….……………………………
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Internal Medicine -MBChB V – Study Guide
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Assessment Form: MBChB V
Name:…………………………… Period: From____/____to____/____ Firm: …….…………
Formative assessment:

Clinical skills:
Strengths:
Area(s) that requires attention:

Professionalism: (Team work, communication, dress code, discipline, punctuality,
ethics, etc.)

Assessment discussed with the student:
Yes

No

Comments:
Summative assessment:
Category Marks
(%)
E
< 50
D
50
59
C
60
69
B
70
79
A
80+
Description
Clinically immature
Clinically mature
Lacks insight
Clinical skills and theoretical knowledge superficial
Clinically mature
Superficial insight
Clinical skills and core knowledge adequate
Clinically mature
Insight adequate
Breadth of theoretical knowledge
Clinically mature
Insight excellent
Excellent grasp of clinical medicine
Breadth of experience and theoretical knowledge
Final mark (%)
45
55
66
74
80
Name (Consultant): …………………..…………… Signature: ….……………………………
62
Internal Medicine -MBChB V – Study Guide
2010
Assessment Form: MBChB V
Name:…………………………… Period: From____/____to____/____ Firm: …….…………
Formative assessment:

Clinical skills:
Strengths:
Area(s) that requires attention:

Professionalism: (Team work, communication, dress code, discipline, punctuality,
ethics, etc.)

Assessment discussed with the student:
Yes

No

Comments:
Summative assessment:
Category Marks
(%)
E
< 50
D
50
59
C
60
69
B
70
79
A
80+
Description
Clinically immature
Clinically mature
Lacks insight
Clinical skills and theoretical knowledge superficial
Clinically mature
Superficial insight
Clinical skills and core knowledge adequate
Clinically mature
Insight adequate
Breadth of theoretical knowledge
Clinically mature
Insight excellent
Excellent grasp of clinical medicine
Breadth of experience and theoretical knowledge
Final mark (%)
45
55
66
74
80
Name (Consultant): …………………..…………… Signature: ….……………………………
63
Internal Medicine -MBChB V – Study Guide
2010
Assessment Form: MBChB V
Name:…………………………… Period: From____/____to____/____ Firm: …….…………
Formative assessment:

Clinical skills:
Strengths:
Area(s) that requires attention:

Professionalism: (Team work, communication, dress code, discipline, punctuality,
ethics, etc.)

Assessment discussed with the student:
Yes

No

Comments:
Summative assessment:
Category Marks
(%)
E
< 50
D
50
59
C
60
69
B
70
79
A
80+
Description
Clinically immature
Clinically mature
Lacks insight
Clinical skills and theoretical knowledge superficial
Clinically mature
Superficial insight
Clinical skills and core knowledge adequate
Clinically mature
Insight adequate
Breadth of theoretical knowledge
Clinically mature
Insight excellent
Excellent grasp of clinical medicine
Breadth of experience and theoretical knowledge
Final mark (%)
45
55
66
74
80
Name (Consultant): …………………..…………… Signature: ….……………………………
64
Internal Medicine -MBChB V – Study Guide
2010
Assessment Form: MBChB V
Name:…………………………… Period: From____/____to____/____ Firm: …….…………
Formative assessment:

Clinical skills:
Strengths:
Area(s) that requires attention:

Professionalism: (Team work, communication, dress code, discipline, punctuality,
ethics, etc.)

Assessment discussed with the student:
Yes

No

Comments:
Summative assessment:
Category Marks
(%)
E
< 50
D
50
59
C
60
69
B
70
79
A
80+
Description
Clinically immature
Clinically mature
Lacks insight
Clinical skills and theoretical knowledge superficial
Clinically mature
Superficial insight
Clinical skills and core knowledge adequate
Clinically mature
Insight adequate
Breadth of theoretical knowledge
Clinically mature
Insight excellent
Excellent grasp of clinical medicine
Breadth of experience and theoretical knowledge
Final mark (%)
45
55
66
74
80
Name (Consultant): …………………..…………… Signature: ….……………………………
65
Internal Medicine -MBChB V – Study Guide
2010
Assessment Form: MBChB V
Name:…………………………… Period: From____/____to____/____ Firm: …….…………
Formative assessment:

Clinical skills:
Strengths:
Area(s) that requires attention:

Professionalism: (Team work, communication, dress code, discipline, punctuality,
ethics, etc.)

Assessment discussed with the student:
Yes

No

Comments:
Summative assessment:
Category Marks
(%)
E
< 50
D
50
59
C
60
69
B
70
79
A
80+
Description
Clinically immature
Clinically mature
Lacks insight
Clinical skills and theoretical knowledge superficial
Clinically mature
Superficial insight
Clinical skills and core knowledge adequate
Clinically mature
Insight adequate
Breadth of theoretical knowledge
Clinically mature
Insight excellent
Excellent grasp of clinical medicine
Breadth of experience and theoretical knowledge
Final mark (%)
45
55
66
74
80
Name (Consultant): …………………..…………… Signature: ….……………………………
66
Internal Medicine -MBChB V – Study Guide
2010
Assessment Form: MBChB V
Name:…………………………… Period: From____/____to____/____ Firm: …….…………
Formative assessment:

Clinical skills:
Strengths:
Area(s) that requires attention:

Professionalism: (Team work, communication, dress code, discipline, punctuality,
ethics, etc.)

Assessment discussed with the student:
Yes

No

Comments:
Summative assessment:
Category Marks
(%)
E
< 50
D
50
59
C
60
69
B
70
79
A
80+
Description
Clinically immature
Clinically mature
Lacks insight
Clinical skills and theoretical knowledge superficial
Clinically mature
Superficial insight
Clinical skills and core knowledge adequate
Clinically mature
Insight adequate
Breadth of theoretical knowledge
Clinically mature
Insight excellent
Excellent grasp of clinical medicine
Breadth of experience and theoretical knowledge
Final mark (%)
45
55
66
74
80
Name (Consultant): …………………..…………… Signature: ….……………………………
67
Internal Medicine -MBChB V – Study Guide
2010
Assessment Form: MBChB V
Name:…………………………… Period: From____/____to____/____ Firm: …….…………
Formative assessment:

Clinical skills:
Strengths:
Area(s) that requires attention:

Professionalism: (Team work, communication, dress code, discipline, punctuality,
ethics, etc.)

Assessment discussed with the student:
Yes

No

Comments:
Summative assessment:
Category Marks
(%)
E
< 50
D
50
59
C
60
69
B
70
79
A
80+
Description
Clinically immature
Clinically mature
Lacks insight
Clinical skills and theoretical knowledge superficial
Clinically mature
Superficial insight
Clinical skills and core knowledge adequate
Clinically mature
Insight adequate
Breadth of theoretical knowledge
Clinically mature
Insight excellent
Excellent grasp of clinical medicine
Breadth of experience and theoretical knowledge
Final mark (%)
45
55
66
74
80
Name (Consultant): …………………..…………… Signature: ….……………………………
68
Internal Medicine -MBChB V – Study Guide
2010
Rotation Schedule
2010
Cardio
A+B
Gastro
C
Pulmo
D
Nephro
E
Geria
F
Haema
G
Derma
H
Rheuma
I
E
D
I
F
G
H
1
A+B+
C
2
C+E
A
B
H
D
I
F
G
E+G
H
A
B
C
D
I
F
G+F
E
H
I
A
B
C
D
F+H
G
I
A
B
C+E
H+I
D+B
G
F
E
A
I+D
F
C
G
H
E
A
B
D
I
F
C
G
H
B
A+E
3
4
5
D
6
C
7
8
9
For rotation report to the following wards:
Rheumatology
Ward 6A, Universitas Hospital
Pulmonology
Ward 3B, Universitas Hospital
Cardiology
Cardiology Clinic (Prof Theron)
Geriatrics
Ward 6A, Universitas Hospital
Gastroenterology
Ward 7B, Universitas Hospital
Nephrology
Ward 5A, Universitas Hospital
Dermatology
Department of Dermatology, National Hospital
69