MBBS III HANDBOOK
THE DEPARTMENT OF MEDICINE
Kamuzu Central Hospital
Lilongwe Campus, College of Medicine
2013/14
Name: ___________________________
DEPARTMENT OF MEDICINE
Department of Medicine; Kamuzu Central Hospital
POB 149, Lilongwe 3
Department of Medicine, College of Medicine
University of Malawi
Private Bag 360, Chichiri; Blantyre 3
Academic Lead, Campus Lilongwe
Department of Medicine, Kamuzu Central Hospital
Head of Department
Dpt of Medicine, Kamuzu Central Hospital
Dr. med. Clara Schlaich, MPH
e-mail: Clara.Schlaich@jhu.edu
phone: 0996265576
Dr. Jonathan Ngoma
TABLE OF CONTENTS
1. INTRODUCTION
3
2. OUTLINE OF MBBS III MEDICAL ATTACHMENT
5
3. KCH DEPARTMENT OF MEDICINE WEEKLY ORGANIZATION.................................. 9
4. WARDS AND OUTPATIENT CLINICS .......................................................................... 10
5. POSTEXPOSURE PROPHYLAXIS (PEP) to PREVENT HIV INFECTION .................. 11
.
6. REQUIREMENTS OF MBBS III MEDICAL ATTACHMENT
12
7. ASSESSMENT............................................................................................................... 13
8. ORIENTATION TO COLLABORATING INSTITUTIONS
14
9. EXAMPLE OF A CASE WRITE UP ............................................................................... 15
10. STUDENT LEAVE REQUEST FORM
................................................ 20
11. LEARNING OBJECTIVES ........................................................................................... 21
13. STUDENT ADMISSION FORM of KCH DPT of MEDICINE (Case write up) ............ 29
INTRODUCTION
In October 2012 the Lilongwe Campus of the College of Medicine was established.
Starting with the academic year 2012/2013 teaching of MBBS 3 in Community Health,
Medicine, Pediatrics, Surgery and Pediatrics is conducted within the clinical Dept´s at
Kamuzu Central Hospital and in the new Lilongwe Campus facilities
Welcome to the Department of Medicine at Kamuzu Central Hospital!
Your 3rd year Medicine Attachment is a 7 week rotation based in the Department of
Medicine at Kamuzu Central Hospital. The Light House Trust, Partners in Hope Hospital
and University of North Carolina Project are additional teaching sites and will contribute
to your teaching experience. Faculty from the Queen Elizabeth Central Hospital will
come to Lilongwe for your teaching.
The Medical Department at Kamuzu Central Hospital is organized in 4 Teams: A, B, C
and D. Each team is consisting of a Head of Firm (usually a Medical Specialists and
Lecturer), consultants, Registrars, Interns and you – the Students! You will be assigned
to one of the teams and follow their routine. Each team has one day out of 4 when it
admits patients in the Short Stay Unit and follows these patients on the wards until they
are discharged from the wards. You will also see patients in the in- and outpatient clinics,
in the High Dependency Unit.
It is our hope that your medicine rotation will be complimentary in terms of its
educational value with what you learnt during preclinical years and with what you will
learn in other departments.
The philosophy of modern medical education is to provide learning opportunities to
students, and it is the responsibility of the student to make the most of those
opportunities. Therefore there has been a move from teacher-centered education to
learner-centered education which more closely reflects the responsibility you will need
to take for your own ongoing education throughout your medical career.
Basic Professional Expectations of Third-year Students
1. Ensure that patient welfare is your first priority when dealing with all patients. Always
inform your clinician if you have any concern while clerking a patient.
2. Follow through on all tasks assigned to you by members of your medical team.
If you are unable to do this inform your team. Be honest: Faking signatures or giving
wrong excuses for not attending or preparing is not acceptable.
3. Attend all activities on time. If you must be absent, get permission in advance.
4. Dress professionally. The way you dress makes a statement about your school,
hospital, and the medical profession; it may influence the way you are perceived by
your patients. If you have any question about what constitutes professional dress,
consult the coordinator.
5. Protect yourself from infection and injury: Wear appropriate protective equipment (such
as gloves, sturdy shoes, face masks). Rest before you come to work, never drink
6.
7.
8.
9.
alcohol before work. If you feel sick, report to your team member, if you don´t feel
comfortable to do a procedure in a patient, talk to your consultant.
Treat every member of the health care team, and every patient with respect.
Make sure your handwriting is legible and ensure every note includes your name (also
in BLOCK LETTERS) and role.
Preserve confidentiality, do not discuss patients in public places and destroy all papers
with patient specific information that are not part of the medical record. Do not look in
the chart (paper or electronic) of any patient for whom you are not caring.
If there are any circumstances that that do not allow you to follow these rules talk to the
3rd year coordinator as soon as possible.
Top 5 Ways to Excel during your Internal Medicine attachment
1. Be actively involved in the care of your patients to the greatest extent possible. Go the
extra mile for your patients. You will benefit as much as they will. The more you put in,
the more you will gain.
2. Read consistently and deeply about the problems your patients face. Read about
topics before your tutorials. Raise what you learn in your discussions with your team
and in your notes. Educate your team members about what you learn whenever
possible.
3. Learn to do clear and concise presentations as early as possible. This will make you
more effective in patient care and gain the confidence of your supervisors to allow you
more involvement in patient care.
4. Be enthusiastic, ask questions and be willing to speak up – share your thoughts in
teaching sessions, share your opinions about your patients’ care, constructively
discuss how to improve the education you are receiving and the systems around you.
5. Actively seek feedback and reflect on your experiences.
Any concerns?
If there are any concerns or problems, academically or in your private life if they
influence your academic performance –speak to the third year academic head. She will
keep this information private unless discussed with you otherwise. The aim will be to
find individual solutions and support to keep you in the program.
2. OUTLINE OF YOUR MEDICAL ATTACHMENT
STRUCTURE OF THE ATTACHMENT:
You will be joining the medical department for 7 weeks. The teaching is organized in
theme weeks, a theme being an important field of medicine. Theme-weeks are (the
order may change):







Introduction
Respiratory Medicine
Cardiology
Gastroenterology
Neurology
Renal Medcine & Endocrinology
Haematology & Oncology/ Exam Week
This is to give you an overview how your weekly timetable is roughly going to be
structured. It may vary slightly from week to week. Please consult your updated
timetable for current details.
OUTLINE MEDICAL ATTACHMENT MBBS III
SCHEDU
LE
8:00-9:30
10:0012:00
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
Departmental
Hand-over
Case
presentation
Departmental
Hand-over
Case
presentation
Departmental
Hand-over
Case
presentations
students
Students only
at UNC
Pharmacology
lecture
Students only
with x-rays
Teaching
Ward
Rounds
12:0014:00
14:0018:00
At Partners in
Hope
Clinics
and/or
Clinics
GMC
Short Stay
Unit*
Short Stay
Unit*
Short Stay Unit*
and/or
and/or
and/or
Ward Work
Ward Work
Ward Work
Practical
Skills
Core Case
PBL 1
Seminars
Practical Skills
Teaching
Ward
Rounds
Office Hour
academic
lead 13:0014:00
Lunch break
Seminars
Seminars
Seminars
SATURDAY/
SUNDAY
Seminars
PBL 2
* Students join their team on call (A,B,C,D) for Short Stay Unit
Admitting
team to cover
Short-Stay
Unit, High
Dependency
Unit, Ward*
COMMON HANDOVERS
The Department has a common handover in the morning and a shorter handover in the
afternoon. You are required to join the common departmental morning handover, every
Monday, Wednesday, Friday at 8 a.m. (sharp!). It takes place in the handover room in
Ward 2, Renal Unit (CW2).
CASE PRESENTATIONS
“Student´s only” case presentations (4 students each session) take place on Tuesdays
and Thursdays with one faculty member to give you feedback. Venues are the
Campus, the UNC lecture hall and the Partner’s in Hospital (shuttle bus will leave 7:30
sharp from Campus). The session include four student presentations each, whereby
you will be presenting an interesting case of a patient that you have clerked on the
wards.
On Mondays (starting in the 2nd week of your assignment) there will be four 3rd year
students presenting a case each in the departmental handover. Patient presentations
should be Power Point presentations (max 5-8 slides). Please make sure that the
computer/projector is set up and running well before the meeting starts to not cause
any delay to the meeting.
If there is any insecurity in choosing an appropriate case, please contact the Academic
lead.The Case presentations will not be graded. However you will be getting a verbal
and written feedback, with a statement “fail”, pass”, “credit”. If you “failed” you will have
to repeat the case presentation.
How to do a successful case presentation:
-Clerk the patient thoroughly
- Discuss the case with your clinician
-follow the rules for a good power point presentation
-Use the structure given in the “blue book”
-avoid typing errors
- practice your presentation, do not read from the slides
- read up on the topics
- speak slowly and with confidence, raise your voice!
PROBLEM BASED LEARNING (PBL)
PBL sessions have a part 1 and part 2. You will work together with a tutor. In the
session on Friday, the tutor will confront you with a case which you then will discuss
within the group. You are to identify problems which you shall try to solve within the
group (elect a student preceptor!) on the basis of the knowledge that some of the
group members may already have. Open questions and unresolved problems will be
investigated by every student. By the end of the session your tutor will also hand in
some learning objectives to make sure your group is not missing any important topics.
The case will be rediscussed on the basis of your newly gained knowledge in the
session on Thursday the following week. The tutor will only try to guide your
discussion, but is not supposed to lecture.
SEMINARS/ SPECIALITY TEACHING
These are seminars of 45 mins duration which will cover learning contents that you
would have formerly encountered during fourth year and which due to the curriculum
changes will now have to be covered in 3rd year. We try to fit the contents of the
speciality teaching into the respective theme week, but there are some fields of
medicine which do not have a theme week of their own, hence you will find some
specialty teaching which does not fit thematically into the week. Not all the content of
the learning objectives will be covered by the formal classroom lectures. You are
expected to cover all topics named in chapter 10 by self study. Remember: you will
benefit most from the classroom teaching if you read the topic up before you come to
the class!!! Some guidance for reading you will find in the CMS.
CLINICS
You are supposed to attend two out of the following clinics ONCE: General Medicine
Clinic, Diabetes Clinic, in –patient HIV clinic or Light House ART clinic, Oncology
Clinic, Partners in Hope private clinic. Your attendance shall be signed by off the
respective clinician at the END of the session (don´t ask for multiple signatures at the
end of assignment!! You won´t get them).
ON-CALLS SHORT STAY UNIT
You will spend two afternoons on-call with your team in the Short Stay Unit. During the
week, this will be from 2-8 p.m, on weekends from 8 a.m. to 2 p.m. You are free to
choose any appropriate day for you, either weekends or weekdays. You are welcome
to do additional days. The Short Stay Unit offers fantastic opportunities to clerk and
present lots of interesting and acutely ill patients, and to perform lots of procedures.
Please bring your logbook and get your signatures!
PRACTICAL PROCEDURES
You are expected to perform a minimum number of certain practical procedures.
These are listed in your logbook. Whenever you have performed a practical procedure,
have it signed in your logbook by the tutor who witnessed it (asking for multiple
signatures at the end of assignment will not be accepted!!).
The “typical nursing procedures –nasogastric tubes, urinary catheters, s.c. and i.m.
injections and blood-glucose testing- can be signed by the nurse in charge.
PATIENT WORK-UPS
You are required to work up a minimum of 18 patients during your medicine
attachment. A work-up may be on an inpatient or outpatient, in the Short Stay or High
Dependency Unit and should include the following:
1) A written history and physical examination.
2) A problem list with differential diagnosis, a diagnostic plan, a therapeutic
plan, and a patient education plan for each problem.
3) A concise case presentation to the attending or supervising physician.
An example of a written up case is given at the end of the handbook
You may wish to use the departmental admission forms as template for your clerkship.
If you thoroughly fill that form, this counts as a patient You will find them on the wards.
But you may use any form you wish or type your write-up by computer as long as the
standard format is followed:
 IDENTIFYING
 SOCIAL HISTORY
INFORMATION
 REVIEW OF
SYSTEMS
 PRESENTING
COMPLAINT
 PHYSICAL
 HISTORY OF
EXAMINATION
PRESENT ILLNESS
 LABORATORY
 PAST MEDICAL
STUDIES
HISTORY
 ASSESSMENT
 FAMILY MEDICAL
 PLAN
HISTORY

Students are encouraged to do in-depth reading about their cases in any standard
medical textbook. The case presentation should be a concise, 5 minute or less,
summary focusing on the information and findings PERTINENT to the present illness.
What is pertinent will depend entirely on the problem(s) for which the patient is seen.
These cases will form part of your continuous assessment. Students should record
these cases in the student log book for evaluation at the end of rotation.
PROBLEM ORIENTED MEDICAL RECORDS
Students should make daily rounds on their hospital patients and gain experience
writing progress notes in the SOAP format i.e. SUBJECTIVE, OBJECTIVE,
ASSESSMENT, PLAN. If a patient from your firm is admitted to the High Dependency
Unit or the Intensive Care Unit you will find it interesting to follow the patient´s clinical
course in these settings. However you are not required to write notes in these units.
RECOMMENDED TEXTBOOK
Textbook chosen for history taking and physical examination is the departmental “Blue
Book” edited by EE Zijlstra. You receive personal copies of the Malawi National
Treatment guidelines and Tb and HIV guidelines. Use them for your reference.
However it is essential that you supplement with other books e.g. Hutchison’s Clinical
methods by Michael Swash. You will find additional textbook in the “student pantry” at
the telemedicine unit. Also you receive soft copies of the WHO x-ray book and
“neurology in Africa”. You must read these books till the end of your rotation.
CONSULTANT EVALUATIONS
Each student will have two formal feedback evaluations during the clerkship. One
feedback will be done midway through attachment and another one at the end.
Feedback sessions are meant to be mutual, and the student is more than welcome to
give his/her feedback to the Department.
ABSENCES
The Medicine Department has adopted the following policy on absenteeism: Students
may have up to two days of excused absences during the clerkship. If the student is
absent for three or more days, they have to be made up. All requests for leave must
be approved by the year coordinator in the department.
3. DEPARTMENT OF MEDICINE WEEKLY ORGANIZATION-INPATIENT AND OUTPATIENT
SERVICES
SCHEDULE
MONDAY
TUESDAY
Hand-over
Ward Rounds
13:00-15:30
ART
Clinic*
14:3015:30
Postgrad
uate
teaching
FRIDAY
Hand-over
Hand-over
Hand-over 7:30
Grand Round 8:00-9:00
Hand-over
Case
presentation
interns/registr.
Ward
Rounds
Pharmacology
talk
(1st / 3rd week)
X-ray talk 9:00-10:00
(2nd / 4th week)
Diabetes Clinic
Hematology
/FNA Clinic
Cancer Clinic*
Diabetes Clinic
from 11:00
Ward Rounds
GMC
GMC
from
11:00
ART
clinic*
SATURDAY/
SUNDAY
Optional:
Ward
Rounds
OPD ART
Cancer
Clinic
ART clinic*
Cancer Clinic*
Ward Rounds
Bweila Tb Ward round
Senior Staff meeting
(1st / 3rd week)
THURSDAY
Outreach - District Health Clinics
9:00-12:30
Case presentations
students
Outreach - District Health Clinics/ Tb Ward
8:00-9:30
WEDNESDAY
Hematology
Clinic
12:30-13:00
Journal Club
or
Morbidity and
Mortality
statistics
Join admitting
team to cover
Short-Stay Unit,
High
Dependency
Unit, Wards.
Join Ward
rounds of teams
Afternoon
Afternoon Hand-over
Afternoon Hand-over
Hand-over
Monday –Friday Telemedicine lectures between 10:00-17:00; see monthly schedule
Daily: Cover of Short Stay and Consultations to other Dpts: AdmittingTeam A, B, C or D, after hours: Interns on call
Ward Rounds (4A, 4B): Daily by teams A,B,C,D. HDU and Dialysis: Daily rounds by assigned consultant (monthly) intern/registrar (weekly)
* ART Inpatient and Cancer Clinic by UNC, Light House and KCH
15:45-16:30
Afternoon Hand-over Afternoon Hand-over
4. WARDS AND OUTPATIENT CLINICS
 Ward 4A: Female Medical Ward
 Ward 4B: Male Medical Ward
 HDU: High Dependency Unit (in ward 4A)
 Ward 2: Hemodialysis Unit (in renovation)
 Short Stay Unit: Admitting and Short-stay ward (8 beds)
 Diabetic Clinic: Medical Specialist Clinic OPD II Tuesdays from 11:00
 General Medicine Clinic: Medical Specialist Clinic OPD II Wed from 11:00
 Light House Trust ART Clinic: Tuesdays and Wednedsays 8:00
 In-patient HIV clinic: Medical Specialist Clinic Monday, Wednesday and
Thursdays from 13:00 in OPD 1
 Partner’s in Hope Clinic: Outpatient private clinic every morning
 Oncology /Hematology Clinic: Medical Specialist Clinic Tuesday, Thursday
Ward 2 UNC room from 9:00 a.m.
 Bweila Hospital Tb Ward: Specialist Ward rounds Tuesday or Friday from
9:00-11:00
5. POSTEXPOSURE PROPHYLAXIS (PEP) to PREVENT HIV
INFECTION FOR MEDICAL STUDENTS AT KAMUZU
CENTRAL HOSPITAL
If you had a needle prick or spilled blood or body fluid on eye, mouth or damaged skin
there is a risk of becoming infected with HIV:
PEP should be considered. It is available to you at Kamuzu Central Hospital with no
costs at all times! What to do?
- Report to your senior clinician immediately
- Do not delay, best prevention of HIV infection, if PEP medication is started within 2
hours of injury. You may start PEP even if you have not done an HIV test. But you must
do the test ASAP. Best is: Know your status before you have an injury!
- Remember to clean area of injury thouroughly first with water and soap or in case of
the the eyes, plenty of water
HOW TO GAIN ACCESS at KCH
AT ALL TIMES: High Dependency Unit (HDU), Dpt of Medicine
DURING OFFICE HOURS (Mo-Fr 7:30- 16:00): LIGHT HOUSE
Wash your hands after procedures and clinical examination, wear gloves
Use hand lotion to prevent eczema, dryness of skin, Cover cuts and
abrasions of skin
Make sure you are immunized against Hepatitis B before you start your
clinical assignement, Know your HIV status
Rest well before work, no alcohol
Sound knowledge of procedures, prepare your work space, take your time
As a 3rd year Medical Student you must have a clinician supervising any
invasive procedure; do not do any procedures in non-cooperative patients
6. REQUIREMENTS OF THE MEDICAL ATTACHMENT
1)
You will complete at least 18 history and physical exams during the clerkship and
have the write-up and problems list evaluated by your intern, registrar or consultant,
as well as orally presented the cases to a senior doctor.
2)
You will have three dedicated patients on the ward who you have to manage on a
daily basis under the supervision of your senior team members.
3)
You will present two cases of patients you have clerked during one of the morning
handovers, one of which shall be a common departmental handover.
4)
You will attend a minimum of two different of the following clinics at least once:
Diabetic and General Medical Clinic, ART clinic (Light House), in-patient HIV clinic,
Cancer/Oncology clinic.
5)
You will perform a required minimum set of practical procedures as listed in your
logbook. If you do extra procedures/activities they will be merited in the continuous
assessment.
NB: All formal requirements must be signed by a clinician (intern, registrar, consultant)
on the same day. Signatures cannot be given on retrospect. Nursing procedures (NGT,
Foly cath, im,s.c.injections MRDT, BG can be signed by nurse in charge).
7. ASSESSMENT
Continuous assessment
To pass this you will need to:
1. Conduct yourself in a professional manner at all times during the attachment as
laid out in the professional expectations listed above.
2. Satisfy the senior doctors you work with that you have adequately meet the
objectives of this attachment
3. Adequate completion of your logbook including:
 Clerking of at least 18 patients including write up and presentation
of the cases to a medical intern, registrar or consultant.
 Participate in weekly presentations during the morning handovers
 Attend at least two in- or outpatient clinics during your rotation
4. Have not been absent for more than 2 days or made up time of longer
absenteeism
Clinical Skills: the grade of the OSCE´s and Long Case are averaged up (60/40)
Objective Structured clinical examination; OSCE
This clinical exam will focus on your ability to perform a systematic physical examination.
You will be expected to elicit the abnormal findings and interpret your findings to be able
to come up with a list of causes for these. Additionally you will have to interpret an y-ray
and a n ECG.
Long case
This clinical exam will focus on your ability to perform a complete history and physical
examination on one patient, to present your findings clearly and concisely, and to be
able to come up with a problem list and differential diagnosis in an appropriate order.
This exam will be done at a time convenient to you and your examining consultant at
some stage during the final two weeks of your attachment. It is your responsibility to
arrange a time for this.
Written exam
The written exam consists of short answer and multiple choice questions that refer to
learning objectives. This exam will focus on your ability to come up with a differential
diagnosis and determine which aspects of the history and physical examination would be
most helpful in narrowing the diagnosis.
Grading scheme
This clinical rotation will be graded as passed or failed only. The pass mark is 50%
To pass you must receive a pass, credit or distinction in any of the above mentioned
three components. Each component will receive a grade, but the final grade is pass/fail
only.
Grades: 75—100 = distinction
65—74
= credit
50— 64 = pass
45- 49
= marginal fail
0-44
= undoubted fail
The student must pass each component independently during the rotation to be
deemed to have passed the rotation successfully!!
8. COLLABORATING INSTITUTIONS
THE LIGHT HOUSE TRUST
Lighthouse Trust, a Public Trust and recognized Center of Excellence for integrated HIV
prevention, treatment, care and support in Malawi, works in close coordination with the Ministry
of Health (MOH), Kamuzu Central Hospital and Lilongwe District Health Office (DHO) to
operate two large integrated HIV testing, treatment and care clinics in Lilongwe, Malawi: one
on the campus of Kamuzu Central Hospital (KCH) and another at Bwaila Hospital, the Martin
Preuss Centre (MPC). Currently, combining both Lighthouse and MPC clients, Lighthouse is
the largest single provider of ART in Malawi with over 18, 000 adults and children alive on ART
by June 2012. Lighthouse provides HIV Testing and Counseling to over 3, 500 clients per
month, cares for over 180 bed ridden patients under Home Based care and over 5, 000
patients under the psychosocial and treatment adherence program call Ndife Amodzi.
Lighthouse is a Training Centre for HTC, integrated ART/PMTCT and Palliative care.
University of North Carolina University Project /Tidiziwe Clinic
The University of North Carolina Project-Malawi (UNC Project) is a collaboration between the
University of North Carolina at Chapel Hill and the Malawi Ministry of Health. It is based on the
campus of Kamuzu Central Hospital in Malawi's capital, Lilongwe.
The mission of UNC Project-Malawi is to identify innovative, culturally acceptable, and affordable
methods to improve the health of the people of Malawi, through research, health systems
strengthening, prevention, training, and care.
UNC Project; Tidziwe Centre
Private Bag A-104; Lilongwe; MALAWI
Partners in Hope Clinic, Lilongwe, Malawi
9. EXAMPLE OF A COMPREHENSIVE CASE WRITE-UP
A “comprehensive write-up” will be a complete history and physical examination in standard
Problem-Oriented Medical Record form or a problem-focused ambulatory note (see following
example) and will include:
a) A complete Problem List, with problems designated as "active" or "inactive/resolved" with
dates
b) A comprehensive Assessment with differential diagnoses of undiagnosed problems
(including rationale for including/ excluding diagnoses) or discussion of diagnosed
problems
c) Plans, divided into diagnostic, therapeutic and educational plans
d) Literature References
e) the student's name, printed and signed
f) Abbreviations: Since medical records are communication devices, abbreviations should
NOT be used because their meaning is not universal among all readers of the medical
records. Specifically, students should NOT use error-prone abbreviations, symbols and
dose designations (see Appendix D).
USING THE STABDARD STUDENT ADMISSION FORM OF THE KCH DPT
OF MEDICINE WILL SATISFY THESE REQUIREMENTS. YOU CAN USE
THIS FORM OR USE THE FORMAT BELOW.
EXAMPLE of In-patient History and Physical Examination
PROBLEM LIST
Problem
Date Onset
ACTIVE Problems
No.
1.
1990s
Allergic reaction to sulfa
(rash, peeling skin)
2.
3.
4.
5
2000
2001
29 Oct-09
I Nov-09
Date
Resolved
Inactive/resolved
Problems
2000s
Hx of cervical cancer
Hypertension
GI bleed
Anemia
Date of Admission: 30 January 2010
Date of Exam: 1/Feb/10
ID: 55 –year old woman who is a school teacher
History from: Patient and her daughter, who gave good history. Not all medical records not
available
RE: Admission to HDU
Presenting Complaint: "Bloody stools" for 3 days
History of Present Illness: The patient is a 55-year old married woman with history of
hypertension since the year 2001. She has been in good health over the past one and half
years until October 29, 2002, when she began passing bright red blood per rectum along with
"dark black clots" and "black stools". The patient says she has had more than 10 bowel
movements of this kind within the last 3 days. She has been feeling weak for the last one day
and half and has had some "near-fainting" episode after which she found herself drenched
with sweat, as if "someone dumped a bucket of water over my head". The patient's daughter
says that the patient may have experienced a brief loss of consciousness (less than 30
seconds.) during this "near-fainting" episode, as she stopped talking for a short period of time.
On the morning of October 30, 2002, the patient was brought to the QECH. At this time the
bleeding had ceased and her only complaint was weakness. She was described as being
stable, and her admission hemoglobin was 12.2 g/dl. She was observed in 4B with the hope
of discharging her the following day. During the night of the admission, the patient again
began to pass bright red blood per rectum, but without black clots. She says she passed 3
bloody bowel movements during that nights.
The patient says she has never had any prior episodes of rectal bleeding. She had
experienced some constipation the week before, and had used glycerol suppositories, which
had given relief. She has no fever, nausea, vomiting, diarrhea, sick contacts, chest pain,
shortness of breath, recent weight changes or changes in appetite. She also says she has
had occasional abdominal pain for a few months, but no history of previously diagnosed
GERD or peptic ulcer disease.
Past Medical History
Adult illnesses: Cervical cancer – in 2000
Hypertension- first aware of diagnosis in 2001
Childhood illnesses not asked
The patient has no history of bleeding disorder, liver disease, diabetes mellitus,
myocardial infarction or renal disease.
Hospitalizations/Surgeries:
1980, 1983, at QECH- birth of her children
2000 at QECH- Hysterectomy, reason for CIN.
Transfusions: During surgery for carcinoma of uterine cervix
HIV History: HIV test done during this admission is negative
Current medications: Atenolol 100mg once a day, Hydrochlorothiazide 25 mg
once/day
Aspirin- dosage unknown, last dose taken 10 days ago
Allergies: Penicillin ® reaction unknown; told by doctor not to take penicillin
Sulfa ® acute onset of "red rash and skin peeling in sheets" (1990s)
Cortisone ® face swelling
Family History: Patient's father died in his 40s from “liver cancer." Mother died in her
70s of a "stroke, and had diabetes mellitus. The patient has numerous siblings,
some of whom are step-siblings. One sister has diabetes. Two of the step-siblings
have died, causes unknown. Health status of the other siblings are unknown. There
is no family history of bleeding disorders.
Personal Profile/Social History: The patient is a married school teacher. She does not
smoke and has never smoked, does not take alcohol or illicit drugs. Her diet consists mostly
of maize meal. She doesn't each much fruit or vegetables.
Review of Systems:
Skin: Has no rash, itching, bruising.
Eyes: Reports no blurry vision, other visual disturbances.
Ears: Reports no hearing loss, tinnitus, pain, discharge, vertigo.
Nose: Has "allergies” which cause runny nose, sneezing, cough.
Mouth: Has no gingivitis, sore tongue, taste changes, dental problems
Throat: Reports no pain, voice changes
Pulmonary: Reports no chest pain, pneumonia, SOB, DOE, wheezing, sputum, hemoptysis
Circulatory system: Has no chest pain, palpitations, dyspnea, PND, orthopnea, edema,
syncope
GU: Reports no frequency, nocturia, polyuria, urgency, dysuria, hematuria, hesitancy, urinary
flow changes, retention, incontinence; has no history of kidney problems
Gynaecological history: See PMH.
Breast: Not asked
Sexual Hx: Not asked
Musculoskeletal system: repots no problems.
Nervous system: Has no history of head trauma, headaches, numbness, paralysis,
convulsions, seizures, tremor, gait disturbances, coordination changes
Mood: Not asked.
PE:
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General Appearance: Patient appears well-nourished, appearing her stated age.
She is lying comfortably in bed, in no evident distress. She is alert, oriented and
cooperative.
Vital Signs: Temp 96.0; Respirations 14; Oxygen sat 99% on Room Air; SupineHR 89, BP 147/64; Standing- HR 110, BP 131/54
Skin: Warm, dry, pale
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Head: Non tender over scalp
Eyes: Acuity not tested. PERRLA. Extraocular muscles function intact. Fundi
normal
Mouth: Mucosa pink, moist, slightly pale. No lesions or bleeding. No tonsillar
erythema or exudates.
Neck: Supple. Thyroid gland not enlarged, No enlarged lymph nodes, No jugular
venous distention; no carotid bruits.
Pulmonary: Lungs examination normal (percursion and auscultation)
Cardiac: No thrills, lifts or heaves. PMI palpated in left 5th ICS at the midclavicular
line, non-bounding. Rate and rhythm are regular, normal S1 and S2. No murmurs,
extra heart sounds heard.
Abdomen: Soft, non-tender, non-distended. Normal bowel sounds. Spleen and
liver not enlarged and no other palpable organs
Rectal (done by Registrar- reported as showing no masses but Bright red blood
on glove.
Extremities: Full motion in all extremities. No clubbing, cyanosis, edema. Patient
was slow to stand due to dizziness.
Neuro: Alert and oriented in person, time and place. Cranial Nerves: II - XII
grossly intact. Normal speech. Sensation normal to light touch, Normal power in
all extremities (examined biceps, triceps, knees and ankles) Babinski response
down going.
Admission lab results:
CBC: WBC 7.9, differential: Bands 7, Segs 50, Lymphs 37, Monocytes 5, Eos O,
Baso 1
Hgb 9.8 (was noted to have been 12.2, 2 days PTA),
Hct 28.
MCV 93.9, PT 12.3, PTT 22, INR 1.0
Platelet count 238
Na 140, BUN 20, K 3.6, Creatinine 0.7, Cl 110, Bicarb 25, Glucose 135 mg/dl
Problem #1: Bleeding per rectum
Assessment: The patient has experienced several episodes of bloody stools in the past three
days. In addition, there is evidence that this patient has had substantial blood loss including:
(1) A decrease in hemoglobin from 12.2 to 9.8 in two days with normal MCV, which suggest
an acute bleed;
(2) Orthostatic changes (increase in HR of >20, decrease in Systolic BP > 15mmHg)
suggest that the patient has lost >1 liter of a blood.
The differential diagnosis of lower GI bleed include: Diverticulosis, colon cancer or
polyps, ulcerative colitis, angiodysplasia, and hemorrhoids.
Diverticulosis is likely as it most (Why?)
Brisk upper GI bleed is also possible
Plan: Continue monitoring patient in HDU with careful monitoring of vital signs.
Diagnostic:
 Place NG tube to assess for gastric bleeding
 Consult a gastroenterologist for upper endoscopy and colonoscopy
 Treatment:
 Type and crossmatch. Transfuse 2 units packed red blood cells to replace blood
loss, since she is at risk to cntinue bleeding
 No food or drink in preparation for endoscopy according to gastroenterologist
instructions
 Further treatment dependent on endoscopic findings. Consider initiate gastric
acid blocking regimen prophylactically
Patient education:
 Inform patient of the possible diagnoses and the need for careful monitoring and
testing
 Inform patient of endoscopic procedures, explain risks and benefits, obtain
informed consent
 Inform patient of need for transfusion, explain risks and benefits, obtain informed
consent
Problem #2: Anemia
Assessment: The patient has developed an acute anemia. Her hemoglobin had dropped
2.4 G/dL (from 12.2 to 9.8).
Plan:
Diagnostic:
 Monitor blood count every twice daily for continued bleeding and decrease in
hemoglobin
Treatment:
 Place adequate intravenous access (2 large bore peripheral catheters)
 Group and cross-match. Transfuse 1 unit packed red cells now.
 Intravenous fluids: normal saline at 100cc/hour
 Transfuse packed red cells to keep hemoglobin > 10 G/dL
Patient education:
 Inform patient of need for transfusion, explain risks and benefits, obtain informed
consent
 Inform patient of signs and symptoms of worsening anemia that she should be
aware of, such as worsening orthostatic hypotension, weakness, faintness, pallor,
tachycardia.
-------------------------------------------------------------------------------------Resources:
Departmental handbook
Signed: Chizaso Makolija
10. COM / KCH DEPARTMENT OF MEDICINE LEAVE REQUEST
LEAVE REQUEST
Student’s Name______________________________________________________
Student’s Signature___________________________________________________
Total # of hours requested: ___________ Total # of days requested: ___________
Time period of leave: ______/______/______ through ______/______/______
Return to Clerkship: ______/______/______
Reason: ___________________________________________________________
_________________________________________________________________________
SIGNATURE AND AUTHORIZATION
________________________
Attending’s Signature
________________________
Clerkship Director’s Signature
________________________
Date
________________________
Date
________________________
Department Chair’s Signature
________________________
Date
REPORT OF ILLNESS OR INJURY
Student’s Name _____________________________________________________
Absent dates: ______/______/______ through ______/______/______
Return to Clerkship: ______/______/______
Briefly explain nature of illness or injury: __________________________________
__________________________________________________________________
Administrative Coordinator ____________________________ Date____________
(PLACE IN STUDENT’S FILE)
Draft
11. LEARNING OBJECTIVES
a) Broad
1. To take an accurate and systematic history, gathering all appropriate
information.
2. To perform a thorough and systematic physical examination, eliciting the clinical
signs which are present.
3. To make a differential diagnosis in appropriate order taking account of common
conditions and serious conditions using a surgical sieve to do this.
4. To develop professional standards and communication skills when dealing with
patients and colleagues.
More specifically these objectives entail:
1) Clinical Skills
a. History and physical examination.
Student will be able to describe and define:
● The significant attributes of a symptom including location, radiation,
intensity, quality, temporal sequence, alleviating and aggravating factors,
setting, associated symptoms, and functional impairment.
● The four methods of physical examination (inspection, palpation,
percussion, and auscultation), including where and when to use them, their
purpose, and the findings they elicit
● Obtain a history and physical examination in a logical, organized, and
thorough manner covering the identifying information, chief complaint (in
patient’s words), present illness, past medical history, family history, social
history, review of systems, and physical examination.
b. Oral case presentation.
Student will be able to:
● Give a concise, 5 minute or less, summary of a case with emphasis on the
presenting symptom(s), pertinent past medical history, family history,
social history, review of systems and pertinent positives and negatives in
the physical examination.
c. Problem list and differential diagnosis.
Student will be able to:
● Formulate a problem list and differential diagnosis based on findings in the
history and physical examination and develop appropriate diagnostic,
therapeutic, and patient education plans for each problem identified.
d. Interpretation of laboratory and X-ray data.
Student will be able to:
● Order and interpret results of various diagnostic studies indicated by
clinical findings.
e. Use of the medical literature.
Student will be able to:
● Search and critically analyze the medical literature
2) Professionalism
The student will exhibit appropriate attitudes and behavior befitting a general
internist caring for the whole patient with colleagues, consultants and the health
care team in the areas of:
● Respect
● Responsibility and accountability
● Caring, compassion and communication
b) Specific
1. MBBS 3 learning objectives - Cardiology
History taking
Being able to take a full and detailed cardiovascular history.
Physical examination
Being able to do a full cardiovascular examination.
General impression
Peripheral signs of heart disease
Heart sounds, murmurs
Jugular venous pressure
Capillary refill time
Blood pressure
Pulse palpation
Electrocardiography
Understanding the electrophysiological bases of ECG.
Being able to do an ECG.
Being able to read an ECG, with focus on
Identifing axis, sinus rhythm, atrial fibrillation, features of ischemic heart disease,
left ventricular hypertrophy
Congestive cardiac failure
Definitions and relations between
Acute and chronic heart failure
Left sided and right sided heart failure
Diastolic and systolic heart failure
Aetiologies
Treatment
Prevention
Ischaemic heart disease
Pathophyisology
Atherosclerosis and the concept of plaque rupture
Risk factors
Epidemiology
Definition, treatment and investigations in
Stable angina
Unstable angina
Myocardial infarction
Valvular heart disease
Mitral stenosis, Mitral regurgitation, Aortic valve stenosis, Aortic valve regurgitation
to know the commonest cause
to list the clinical consequences
to understand the physical signs
to list drugs that might be used
to know how the valve lesion might be treated surgically
Rheumatic fever
to understand the pathophysiology of rheumatic fever
to list the clinical features of rheumatic fever and know the major and minor
criteria (Duckett Jones)
to list the treatment options for acute rheumatic fever
to understand the importance of antibiotic prophylaxis for patients who have had
rheumatic fever
to understand the relationship between rheumatic fever, rheumatic valvular heart
disease and infective endocarditis
2. MBBS 3 Learning objectives - Respiratory Medicine
1. To be able to take relevant history and do complete respiratory examination
2. To understand and explain the anatomical and physiological basis for both the normal
physical exam and pathological physical signs
3. To name respiratory causes of finger clubbing
4. To understand and point out the following important aspects on pneumonia
a. causes of pneumonia (community acquired or hospital acquired, nneumocystis)
b. clinical presentation of pneumonia (symptoms and signs:consolidation/pleural effusion
and how consolidation and effusion appear on CXR)
c. CURB-score
d. Relevant investigations
e. drugs used to treat pneumonia and reasoning behind the choice of antibiotics
5. To know the following respiratory manifestations of tuberculosis
a. symptoms and signs
b. radiological appearances on CXR
c. relevant investigations
d. name of drugs used for TB treatment
6. To know the following important aspects of pleural effusion
a.causes (infective and non-infective)
b.tests that can be done on pleural fluid
c. how to distinguish transudate from exudates pleural effusion using total protein, LDH
and ratios.
7. To understand the following on asthma
a. pathophysiology and triggering factors
b. different drugs used and how they act (based on pathophysiology of the disease)
c. different routes of drug administration (oral, nebulisation, IV, inhaler, MDI)
d. common side effects of the drugs
e. to be able to explain the use of an asthma inhaler to a patient.
8. To understand COPD (definition, epidemiology, clinical features, investigations and
treatment)
9. To understand what is meant by cor pulmonale, the pathophysiology of cor pulmonale and
which respiratory conditions are likely to give rise to it.
10. To understand lung malignancy (different types, risk factors, clinical features,
investigations and possible treatments in general).
11. To know risk factors/clinical features/diagnosis of pulmonary embolism.
12. To know how to systematically present CXR findings and how consolidation, a cavity, lung
abscess, bullae, reticulonodular infiltrates, pneumothorax, effusion, pulmonary
edema,cardiomegaly appear on CXR.
PROCEDURES AND PRACTICALS
To know the principles of
a. chest drain insertion, indications and complications
b. pulse oximeter and blood gas interpretation
c. nebulisation (drugs/indications) and inhaler technique
d. O2 therapy
3. MBBS 3 Medicine Learning objectives - Gastroenterology
Oesophagus and stomach
To know the differential diagnosis of upper GI bleeding
To list the risk factors for peptic ulcer disease
To understand how the history and examination may help you differentiate between different
causes of upper GI bleeding
To know the “red flags” on history, examination that may indicate gastric cancer
Describe the acute management of Upper Gastrointestinal Bleeding
To define the terms dysphagia and odynophagia
To understand the difference between “neurological” and “anatomical” dysphagia
To list common causes of dysphagia
Understand and be able to describe Diagnostic Procedures used in the investigation of the
oesophagus, stomach and small bowel.
Pancreas
Describe the signs and symptoms of Acute and Chronic Pancreatitis
To know the severity score for acute pancreatitis
To list common causes of acute and chronic pancreatitis
Jaundice
To be able to classify jaundice
To know the common causes of each type of Jaundice
To know how the types of jaundice may be differentiated by history, examination, blood tests,
urine dipstick tests and imaging
Liver
Be able to describe the signs and symptoms of Chronic Liver Disease.
To list the causes of Cirrhosis
Describe the risk factors, presentation, investigation and management of liver tumours
including HCC.
Describe the complications of liver failure including clotting derangement, hepatic
encephalopathy and hepatorenal syndrome
To be aware of the causes of PHTN and the clinical differences between patients with
cirrhosis and hepatic fibrosis due to schistosomiasis
Ascites
To be able to classify ascites
To list 3 causes for transudative ascites and 3 causes for exudative ascites
To know how to investigate ascites including interpretation of findings on ascitic tap
Diarrhoea
To understand the different clinical types of diarrhea and how the characteristics of the
diarrhea and associated symptoms may indicate the underlying cause
To know the common infections causing acute and chronic diarrhea
Understand the situations where antibiotic treatment is appropriate for infective diarrhea
See LOs: Drugs and Diarrhoea
To be aware of “red flags” which may indicate that a patient has colon cancer
To have a brief understanding of inflammatory causes of diarrhoea including Inflammatory
Bowel Disease
Nutrition
To know how to assess nutritional status in an adult
To know the criteria for prescribing nutritional supplements in an adult
PROCEDURES
Ascitic Tap and interpretation
Ascitic Drain
NG tube insertion
Urine Dipstick and interpretation
Urinary catheterisation.
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4. MBBS 3 Medicine Learning objectives - Renal Medicine
To know the classification of uraemia
To give 2 examples of causes of uraemia that fit into each category
To know how GFR can be estimated in the clinical setting
To know the importance of proteinuria in the assessment of renal disease
To be able to define the terms nephrotic syndrome and nephritic syndrome
To know at least 2 causes each of nephrotic syndrome and nephritic syndrome
To know the clinical features of acute renal failure
To know the clinical features of chronic renal failure
To know the biochemical and haematological abnormalities associated with CRF
To know what investigations are relevant for a patient with suspected renal impairment
To know how chronic renal failure might be treated
To know the different presentations of renal tract infection
To know the common bacterial causes of renal tract infection
To know how a patient with suspected urinary infection might be investigated
To know the approach to a patient with vasculitis
5. MBBS 3 Medicine Learning objectives - Neurology
1. The main learning objective is to be able to take relevant history and do complete
neurological examination:
a. To understand the anatomical and physiological basis for both the normal
physical exam and pathological physical signs. To localize pathology to the
appropriate location within the nervous system
b. To be able to differentiate between neurological, functional and psychiatric
symptoms by history taking, examining and relevant investigations.
2. To be able to localise different neurological symptoms and signs:
a. Upper motor neuron versus lower motor neuron lesions.
b. Cerebral Hemispheric lateralization
c. Brainstem lesions
d. Cerebellar lesions
e. Lesions in the basal ganglia
f. Spinal lesions
g. Peripheral nerve
h. Lesions in the neuromuscular junction
i.
Muscular diseases
3. Understanding paraparesis and hemiparesis and importance of being able to localise
their cause.
4. To recognise the danger signs of a headache and to know the most common benign
headache types (migraine, tension neck, etc)
5. To be able to differentiate causes of disequilibrium and dizziness
6. To take an appropriate mental status exam and differentiate focal versus global forms
of cognitive impairment
7. To recognise symptoms and signs and be able to make appropriate differential
diagnoses for at least the following conditions:
a. Epilepsy and other conditions causing collapse.
b. Stroke
c. Space occupying lesion in CNS (other than stroke). Common infections and
tumours, especially HIV-related conditions.
d. Peripheral neuropathy, polyradiculitis
e. Acute confusional state (delirium) coma and dementia
6. MBBS 3 Medicine Learning objectives - Endocrinology
(1) Thyroid
▪ Hyperthyroidism
causes
clinical features
investigation
management
▪ Hypothyroidism
causes
clinical features
investigation
management
▪ Thyroid enlargement
causes
investigation
complications
(2) Pituitary
To know the clinically relevant hormones produced by the pituitary gland
To list the common pituitary tumours
To understand the consequences of pituitary tumours
To describe the clinical syndrome of prolactinoma
To describe the clinical syndrome of acromegaly
To list 3 causes of pituitary failure
To recognise the clinical features of acute pituitary failure (apoplexy)
(3) Adrenal Gland
To revise the physiology of the adrenal gland
To list the common conditions associated with the adrenal gland
To describe the clinical features of Cushing’s syndrome
To know 3 causes Cushing’s syndrome
To recognise the clinical features of adrenal insufficiency
To know 3 causes of adrenal insufficiency
To describe the features of phaeochromocytoma