School of Medicine
Year 3
Clinical Log Book
2009/10
NAME:
.......................................................................................
Evelyn Rouse
(Years 3 and 5 Curriculum Assistant)
Undergraduate Medicine Office
Charing Cross Campus
Imperial College London
Room 138, The Reynolds Building
St Dunstan’s Road
London W6 8RP
Tel:
020 7594 1616
Fax:
020 7594 9315
https://education.med.imperial.ac.uk
Clinical Log Book 2009-10
Why use a clinical log book?
The clinical part of the medical course is less structured and calls for more selfdirection and initiative than earlier parts. This means that you must take
responsibility for directing your own learning in the hospital and general practice
environment. This clinical log book is intended to help you with this and we hope
you will find it useful. It will:

show you what you should be observing, doing and practising when you are
in the wards, clinics, theatres and in general practice;

help identify any gaps in your learning and guide you in remedying them;

prepare you for the Objective Structured Clinical Examination (OSCE), at
which you will be assessed on your performance of the skills described in
this book.

On the Year 3 page of the Intranet we have given some suggestions about
time points for learning. These are for guidance only but we hope that it will
help you plan and monitor your learning.
1
Clinical Log Book 2009-10
Contents
Section
Page
1
Getting the most out of your firm
3
2
History and examination skills
4
3
Clinical skills and procedures
11
4
Communication skills
18
5
Patient Safety
25
6
Learning about patient care: Clinical Experience
27
7
Anaesthetics and critical care-learning outcomes
38
8
Formulary of drugs
40
9
Attainments in Pathology
51
2
Section 1
GETTING THE MOST OUT OF YOUR
CLINICAL ATTACHMENTS

During your clinical course you will be attached to firms and working on the
wards. This type of attachment is very different from any learning which you
have experienced in the past. You will be expected to plan much of your own
learning, including finding and seeing patients for yourself and taking histories
from and examining patients.

Meet fellow students as a group once or twice a week to share experiences,
present cases to each other, look at X-rays and investigation results and
learn from each other.

The more you do/participate the more you will gain from your clinical
experience. There is no substitute for participation!

Set yourself objectives for each firm.

Your firm leaders will also emphasise this: it is vital that you attend “takes”
when your firm is on call (construct a rota for yourselves if necessary). You
should all attend the post-take ward-round with the consultant early the next
morning. This provides a vast amount of experience in acute medicine and
surgery

Some suggestions to think about:
1.
Talk to patients about what their experience in hospital has been like and how
it has affected them and their families.
2.
Whenever possible go with patients who are having special investigations
and ask if you can watch. This is particularly important with patients you have
clerked yourself.
3.
Ask if you can observe the physiotherapist, radiographer, cardiology
technician, dietician or occupational therapist on the ward or in their
department when they are caring for patients allocated to you. Where
practicable, offer to help (e.g. taking blood, doing ECGs). Offer to do a blood
pressure or TPR round with/for the nurses and do the charting. Ask if you
can sit in on a nursing report session.
4.
Spend time on the ward after 5 pm when there are less people around and
the house officer might appreciate some help with routine tasks and will have
more time to talk about your patients.
3
Section 2
HISTORY AND EXAMINATION SKILLS
A good history is the most powerful investigative tool we have in getting to
understand the patient’s clinical problem. It is a skill which is difficult to
acquire and you can only become good at it if you take every opportunity to
practise history-taking again, again and again. In taking a history you should:
1.
Introduce yourself to the patient and obtain his/her agreement to undertake a
clinical assessment. The great majority will be happy to speak to you but
some will not and you have to accept that. Try to establish a good rapport
and listen sympathetically to the patient.
2.
The next and crucial stage of history-taking is a detailed and careful
questioning of the patient. Establish the patient’s main complaint or
complaints (i.e. the presenting complaint) – in the patient’s own words.
3.
Obtain a clear picture of all the important symptoms (the history of the
presenting complaint); in particular clarify the chronology and characteristics
of each major symptom (this is often best done by having a list of questions
ready). Try to avoid medical terms and do not accept ‘diagnostic terms’ from
the patient. Instead, get a detailed description of the actual symptoms – in the
patient’s own words. Try not to lead the patient, but allow them to
communicate their problem in their own way.
4.
Having elucidated the clinical problem, go on to the rest of the history:

systems review - you should have a set of standard questions to ask about
every system but you have to use your judgment about leaving some out if
appropriate;
past medical history
family history – parents, siblings, other close relatives, children
personal and social history - including accommodation, work, with whom they
are living (tactfully!), smoking and drinking habits (likewise)
drug history, including any allergies – and also including non-prescribed
drugs such as food supplements and herbal preparations, and recreational
drugs other than alcohol and nicotine.




See the Communication Skills section for a more detailed description.
5.
At the end of this process you should have a good idea what the problem is
and you should summarise the history, before going on to the clinical
examination of the patient (which is dealt with further on in your log book).
6.
The final stage of the history and examination is to construct a differential
diagnosis. This is a list of possible pathologies which could explain the
features shown by the patient. Try to do this when you write your notes,
putting the most likely causes first. You may form a reasonably clear picture
of the problem quite early in this process and this will increasingly influence
the rest of what you say and do as you gain experience.
4
The main aim of Year 3 is to develop and practise the basic clinical skills of
history-taking and examination. Use the log book principally as an aid to
help you to do this systematically.
Attaining Competence
It is suggested that you work with a colleague to provide mutual feedback on your
development of clinical competencies. When you feel that you have attained
competence in a particular skill, ask a member of your firm, (a consultant, registrar
or SHO) a senior nurse or GP, to observe you performing this skill, and if they are
satisfied with the standard of your performance. Your firm leaders will want to see
you do this as part of their assessment of your overall clinical competence.
Ability to conduct a general physical examination
Use a Clinical Skills textbook to help you (e.g. “Macleod’s Clinical Examination”),
though these may contain more detail than you need. This log book is not in any
sense a substitute. Seek the help of ward doctors and work in pairs to prompt
each other. You are less likely to leave out important items, especially when you
have had relatively little practice.
Examined:-
Date
Date
lymph nodes
-
axillary
-
cervical
-
inguinal
skin
hair and nails
breast
thyroid
lump/mass(any
site)
Basic ears and
throat
examination
5
Date
Date
Examination of the cardiovascular system
Examined and
presented*:-
Date
Date
Date
Date
cyanosis/clubbing
peripheral and
carotid pulses
measurement of
blood pressure
jugular venous
pressure
palpation of
precordium
auscultation:
normal heart
sounds
auscultation:
murmurs
auscultation:
lung bases
oedemaassessment
ophthalmoscopy
examination of
varicose veins
*: in this and succeeding sections regard this as a minimum number!
6
Examination of the respiratory system
Examined and
presented:-
Date
Date
respiratory rate
clubbing/cyanosis
shape, expansion
of chest
position of
trachea
palpation and
percussion of
chest
auscultation of
chest: normal
breath sounds
auscultation of
chest: added
sounds
7
Date
Date
Examination of the alimentary and abdomen system
Examined and
presented:-
Date
Date
Date
jaundice/stigmata
of liver disease
mouth/hands
inspection/general
palpation of
abdomen
palpation of liver
and spleen
palpation of kidneys
palpation of
masses
auscultation of
abdomen
hernial
orifices/femoral
pulses
tests for ascites
rectal examination*
external genitalia*
* would not normally be performed on patients during Year 3
8
Date
Neurological and mental state examination **
Examined and
presented;
Date
Date
Date
Date
mental functioning
including mini
mental state
exams
speech and
language
balance
gait
arm drift and
pronation
cranial nerves
(general) incl
tuning fork tests
power and tone of
limbs
co-ordination
reflexes
plantar responses
sensation (touch,
pin prick, joint
position)
cerebellar signs
extrapyramidal
signs
upper v lower
motor neurone
lesion
**: remember that there will be a specialised Neurology and Psychiatry
attachment in Year 5, and an Ophthalmology attachment in Year 6.
9
Examination of the locomotor system***
Examined and
presented:
Date
Date
Date
Date
joints: inspection
and palpation
joints: normal and
abnormal
movement
spine: inspection
and palpation
spinal movement
examination of
limbs
gait
GALS screen
***: remember that there will be a specialised rheumatology and orthopaedic
surgery attachment in Year 5.
For Year 3, you should focus on the GALS screen.
10
Section 3
CLINICAL SKILLS AND PROCEDURES
The following skills and procedures may be taught in GP practices, the Clinical
Skills Laboratory or on the ward. Your level of confidence and skill will increase
only through practice with patients or in the lab.
Whilst on all your introductory firms you need to acquire some basic skills; some
you will witness, others perform. Because it is important that you obtain regular
practice, you should date each time you practice or witness a procedure. We do
not feel that being signed off is particularly helpful for either students or teachers
but remember that if you do not do or see these procedures only you will lose out.
Levels Criteria for Clinical Skills
On the following pages you will find a list of skills which should be described or
performed during your Year 3 clinical course.
The minimum skills level you should attain is shown and the levels have the
following meaning:
Level 1 – Student can describe
Level 2 – Student can perform on a model
Level 3 – Student can perform (on patient) with supervision
Level 4 – Student can perform without supervision, or can explain or interpret
Depending on the learning opportunities available students may have the chance
to outperform the minimum levels.
11
Skills to be Described or Performed
Skill
To
Level (1)
Date
Date
Instruments
Use the following instruments:
Stethoscope
4
Ophthalmoscope
4
Otoscope
4
Tendon Hammer
4
Diagnostic skills
Take and record:
Blood pressure
4
Temperature
4
Pulse
4
Respiratory rate
4
Further Diagnostic skills
Spirometry and respiratory function tests
3
Perform and report ECG
4
Identify normal and some simple abnormalities in ECG
4
Measure and record peak flow rate
4
Record blood glucose measurement
4
Use Glasgow coma scale
4
Check pulse oximetry
4
Test urine (stick)
4
Observe arterial puncture and cannulation
1
Charts
Read and record:
TPR temperature, pulse, respiratory and blood
pressure.
4
Vital signs (temperature,
pressure, height and weight).
4
respiratory,
blood
Fluid balance
4
Treatment drug charts
4
The recommended minimum level is shown here. Level 1 – Student can describe, 2 – can perform on
model, 3 – can perform (on patient) with supervision, 4 – can perform without supervision. Depending on the
learning opportunities students may have the chance outperform the recommended levels.
[1]
12
Skill
To
Level
Procedural Skills
Perform the following:
Basic life support procedures
2
Scrubbing
4
Administer a metered-dose inhaler and demonstrate an
awareness of the different types of inhalers.
4
Administer oxygen at defined concentrations
3
Prescribe and administer a nebuliser
3
Venepuncture
3
Cannulation
3
Male/female catheterisation
3
Suturing
3
Prepare and administer a nebuliser
4
Give injections (intramuscular and subcutaneous).
2
Wound care and dressing
3
Hand washing and infection control
4
Setting up an aseptic trolley
4
Gloving
4
Setting up an infusion
3
Taking a blood culture
3
Taking swabs and specimens for culture
3
Inserting a nasogastric tube
1
Investigations and Scans
Interpret arterial blood gases (femoral/radial artery)
4
Interpret simple pathological reports
4
Interpret simple laboratory data
haematology and microbiology.
from
biochemistry,
1
Explain the procedure and understand the interpreted
results from:
1
Imaging
X Ray
Chest – identify simple abnormalities
4
Abdomen – identify simple abnormalities
4
Skeletal - identify simple abnormalities
4
13
Date
Date
Skill
To
Level
IVU
4
Explain the procedure and understand the interpreted
results from:
4
Scans
Ultrasound Scan, CT and MRI
4
Isotope
Bone, lung and thyroid
4
Understand the interpreted results from:
Bronchoscopy
4
Upper GI endoscopy
4
Colonoscopy
4
Sigmoidoscopy
4
Biochemistry
4
U and E
4
Liver Function tests
4
Thyroid Function tests
4
Haematology
4
FBC
4
Clotting tests
4
14
Date
Date
Procedures to be observed only
Skills to be observed (only)
Date
Blood transfusion
Insertion of a CVP line
Tracheal intubation
Invasive arterial and CVP monitoring
Artificial ventilation
Pleural aspiration of effusion and pneumothorax
Abdominal paracentesis
15
Date
Date
Other Procedures
Procedure
Date
16
Date
Date
Follow patients through the following procedures and be able to explain them
simply, avoiding medical jargon.
Practice giving explanations to a colleague.


endoscopy

bronchoscopy

upper GI endoscopy

colonoscopy

sigmoidoscopy
radiographic imaging

chest x-ray

contrast enema

contrast meal

IVU

CT scan

ultrasound examination

imaging of abdomen and pelvis

echocardiography

use of Doppler to measure blood flow

MRI scan

isotope scan

bone

lung

thyroid
Please note that there is an opportunity to detail “significant and untoward"
operations and procedures observed in the Portfolio of Clinical Experience.
17
Section 4
COMMUNICATION SKILLS
You will have many opportunities to develop your communication skills. As well as
being able to practice and reflect on how you take a history (gather information)
you will also be able to observe and practice both the sharing of information with
patients and written communication.
To help you in the development of the appropriate skills we have included the lists
of the skills associated with effective gathering and sharing of information with
patients which you will be familiar with from Years 1 and 2.
When practising these skills remember that it is not the practice in itself that is
useful but the opportunity to reflect on what you did and to receive feedback. It is
the three-tiered approach of practice, reflection and feedback that enables
identification of areas of both strength and those that need further work.
History taking (gathering information)
Take the opportunity to record in the box below 10 consultations which you believe
went either very well or very badly and record why you think that was the case.
Consultation
(record some details of
content that will help you
recall the consultation)
What went
well?
18
What could be done differently?
Consultation
(record some details of
content that will help
you recall the
consultation)
What went
well?
19
What could be done differently?
Sharing information
You should aim to observe health professionals performing tasks related to sharing
information. Tick the appropriate box when you have seen a task performed.
You are then expected to attempt and become competent at certain tasks during
Year 3 and the log book should record when you attempted them
Date
Date
Date
Date
Date
Explain a procedure
Explain a treatment
regime
Use the telephone to
give information
Written communication
You will now have the opportunity to write up your own notes. Before doing so
read the medical records of some of your patients and reflect on how effective the
written documentaries are. Refresh your memory on the skills associated with
effective written communication from your notes from Year 2 and bear these in
mind when writing and recording histories, examinations and any findings.
Tick and date the appropriate box to indicate what you have done.
Date
Date
Date
Date
Date
Record a history and
examination
Record examination
findings
Maintain patients'
records neatly and
accurately
By the end of Year 3 you are expected to be competent in the above tasks.
20
In addition there are some tasks to be conducted in MOCK situations only.
DO NOT PERFORM THEM IN REAL SITUATIONS AS UNDERGRADUATES.
You should aim to observe these as frequently as possible and note in the box
below each time you observe such a procedure.
Procedure
Dates observed
Explaining test results
Breaking bad news
Gaining informed consent
for a procedure
Writing a discharge letter
Writing a clinic letter to a
GP
Completing a death
certificate
Writing a clear (and legal)
prescription
21
Date(s) practised in
mock situation
Skills associated with patient-centred interviews
Stage 1: Commencing the interview
A
Preparation



Attend to self-comfort
Minimise distraction
Focus attention on next consultation
B










Start to establish a relationship
Greet the patient
Introduce yourself (full name)
Clarify your role in health care team
Clarify patient’s name
Attend to patient’s comfort
State purpose of interview
Mention note taking
Clarify time available
Assess patient’s ability to communicate
Demonstrate interest and respect
Stage 2: Gathering information






















Use open questions initially
Allow patient to complete initial sentence
Ask patient if s/he has any questions
Demonstrate Active listening
 Verbal
 non-verbal
Facilitative responses
Pick up verbal and non-verbal cues
Wait time
Survey for problems
Set agenda
Clarify patient's use of terms
Avoid unexplained jargon
Summarise
Use signposting/transition statements
Use silence appropriately
Use open-to-closed ended cone
Avoid leading questions
Avoid multiple questions
Probes sensitively
Show warmth
Make empathic statements
Identify patient's feelings
Acknowledge feeling
22
Stage 3: Closing the interview



Provide an end summary
Discuss action plan
Carry out a final check
 further information
 questions
 worries and concerns

Thank patient and say goodbye
Content (PC = Presenting Complaint)
Students should be able to obtain information on the following:
1
Patient's major concerns
2
Patients' understanding of the cause of the presenting complaint
3
The effect of the PC on the patient's life
4
History of the PC
5
Previous episodes of the PC
6
Patient's knowledge of treatment to date
7
Patient's knowledge of investigations to date
8
Past medical history
 previous illnesses
 at least 5 from list for screening
 previous hospitalisations/operations
 medication (PC)
 medication (other)
 allergies
9
Family history
 Parents’ health
 siblings’ health
 other family members (e.g. children/partner)
10
Social History
 age
 who lives in household
 work (nature and satisfaction)
 housing
11
Lifestyle
 smoking
 alcohol
 recreational drugs
 diet
 exercise
 sleep
23
12
Function enquiry (systems to be covered)
 General
 Cardio-respiratory
 Gut
 Genito-urinary
 Neurological
 Musculo-skeletal
 Thyroid
Skills associated with giving information












Explain purpose of interview
Check what patient already knows
Determine amount of information patient wants
Use short words and phrases
Avoid use of jargon
Use explicit categorisation
Summarise
Use specific advice statements
Check understanding
Clarify if patient has any questions
Clarify if patient has any concerns
Use active listening techniques
Remember that patients recall best what they are told first and last.
Information a patient may wish to know about any given procedure










When the procedure will take place
Where
What preparation is necessary
How long it will last
How painful it will be
Who else will be present
What are possible side/after effects
When the result will be available
Who will give the result
Offer to inform relatives
There is no single correct approach. Requirement is for flexibility, sensitivity to
individual needs and ability to take the initiative to empathise and communicate
with the individual. Good practice is rooted in values, primarily the value of the
person – adult or child and respect for both the individual and their family or close
friends/carer.
24
Section 5
PATIENT SAFETY IN THE 3rd YEAR CURRICULUM
Background
In order to enhance patient safety a number of strategies and interventions are
necessary but it is critical that learning about patient safety and human error
should start at an early stage in order to inculcate a culture of safety amongst
tomorrow’s doctors.
This program represents the formal integration of Patient Safety into the
undergraduate curriculum and builds on similar efforts already undertaken within
Imperial.
The learning objectives of this teaching programme are:
 To gain an understanding of human error.
 To appreciate concepts in error theories.
 To acknowledge that all of us have limitations of knowledge and skill and
might need to seek help sometimes.
 To be able to recognize conditions and situations that predispose to error
and to take measures to control them.
Teaching format
There will be one lecture given to all third year students that will cover all the
learning objectives described above. This will be supplemented by two e-learning
modules that highlight errors that have occurred in real practice and use these to
illustrate key concepts in patient safety theory. All third year students will be
expected to access and complete these two modules.
Assessment
Patient safety principles will be integrated into two OSCE stations during the third
year OSCEs and students will be assessed for observed behaviours that reflect
safe practice.
25
26
Section 6
Learning about Patient Care
CLINICAL EXPERIENCE
Introduction
27
Where you will learn
28
Learning Outcomes
28
Learning Methods
29
Inter-professional Learning
30
Checklists

Clinical Presentations
31

Syndromes and diseases
34
Anaesthetics, Critical Care and Emergencies are covered in Section 7
Introduction
At qualification all doctors, whatever their eventual career path, should have a
common core of clinical knowledge and experience. As you move through this year
you will proceed from learning basic clinical examination and history taking skills to
more complex clinical investigation and management. By the end of the year you
will be well on your way towards acquiring the general clinical knowledge and
experience necessary to satisfy the medical school and the GMC. In Year 5 you
will build on this clinical basis to study some subjects in more depth for example
neurology and rheumatology. Remember though that this is a life-long process
and, as a very eminent physician once said: “You never know enough”!
This section is a companion to your logbook of clinical skills and should be used in
a similar way.
27
Where you will learn
As you know from this course guide the year includes 4 clinical attachments; one
of 4 weeks (completed during Year 2), the next of 8 weeks and the last two of 10
weeks each. It is intended that the first two attachments will be at the same site
and that you spend at least one-third of the year at one of central sites (Charing
Cross, Chelsea and Westminster or St Mary’s).
During the year you will be expected to see emergencies on the ward and in the
A and E department and being on emergency take with your firm is a vital part
of clinical experience. You will also gain other clinical experience on the wards, in
outpatients and in the last 3 attachments in general practice, where you will spend
half a day a week for 18 weeks with a general practitioner whose teaching will
focus on clinical skills. As you move through the firms you should therefore have
the opportunity to meet patients with the common symptoms, syndromes and
diseases and you should try to meet patients with less common conditions on the
list. Your experience will be paralleled by the Systems and Topics e-Lecture
course which will be delivered predominantly as online learning via Blackboard and
via up to 10 live lectures during the clinical attachments, and of course you must
supplement this with private study using, books, journals and the Internet. PBL will
very largely be based on actual patients rather than paper scenarios.
Clinical teaching takes place at a large number of hospital sites and it follows that
your experience will differ at each location. Teaching will be organised differently to
fit in with the clinical service needs of each hospital and with the local availability of
particular expertise. The learning objectives however are the same everywhere
and the learning programmes will be based on that principle. At or before the
beginning of each of your 10-week attachments you will be given a detailed
scheme of the learning opportunities for the whole of your stay which will almost
always include teaching outside your own firm.
Learning outcomes
Clinical examination

By the end of the year you should know how to examine the normal
cardiovascular system, respiratory system etc and be able to recognise
common abnormalities of each system.
Interviewing patients

You should be able to take a history relevant to the symptoms, syndromes
and diseases on the list
Clinical Knowledge

By the end of Year 3 you should know the common causes of the list of
general and specific symptoms.

You should be able to describe and understand the basic features
(presentation, pathophysiology and aspects of pathology), investigations and
the principles of clinical management for the common syndromes.
28
Clinical experience
You will see a rather formidable list of clinical presentations and even more of
syndromes and conditions. Some of these are relatively uncommon and you may
see only one or two examples during the year, or even none. But we believe that it
is important for you to be aware of the basic facts about even these disorders-we
have not included anything really rare or “small print”. Equally, if you are on take
and someone with a truly unusual syndrome comes in, do not feel that you should
overlook it just because it is not on the list. All clinical experience is valuable.
It is also essential to remember at all times, as no doubt you have in the first two
years, that:
1.
All meetings and interactions with patients are dependent on their consent.
Whatever the setting this cannot be taken for granted.
2.
Within the limits of what you can and should do you should always take
opportunities to be actively helpful in the care of patients, not only as
observers.
3.
In several of the situations listed here you will appreciate that the patient can
take the role of teacher.
Learning methods
As already mentioned, these will comprise:

Lectures

Intranet / Blackboard material

Tutorials

Ward rounds

Bedside teaching

PBL (mainly patient based)

Textbooks

Internet sites

Journals
29
Interprofessional learning
As a doctor you will be part of a team looking after patients. It is therefore
important for you to know how other members of the team approach their patients
and what skills they bring which will complement your own.
Most of your time is spent learning from doctors, but during your attachments in
Year 3, to help you with understanding the approach of other team members you
will be having some sessions with students of other health care professions.
The form that these sessions will take will vary according to the resources of the
particular trust: you may be learning alongside other students or from other
professionals or both, most often in the context of a Multidisciplinary Team.
You will be learning about them but just as importantly they will be learning about
your approach as doctors and the impression that you make on them may affect
their future attitudes towards doctors.
In the OSCE you will be assessed on
1.
Promoting effective and appropriate communication between health
professionals with the aim of improving the patient pathway.
2.
Demonstrating an understanding and respect for the role of others by
participating in interprofessional working practices.
3.
Demonstrating sound clinical judgement across a range of differing
professional and care delivery contexts.
Please note that there is an opportunity to detail case studies, where you have
observed multi-disciplinary teamworking, in the Portfolio of Clinical Experience.
Questions to consider:
1.
When taking a history, what questions do other professionals ask that might
be useful to you?
2.
How do they approach their patient? Is the patient relaxed?
How do patients react to their approach of other professionals?
3.
How is the information that they gather useful to you?
4.
How is it shared with you and others?
5.
Do you understand the notes made by other professionals?
6.
When would you normally meet other professionals to discuss a patient?
30
Clinical presentations
For convenience these are listed under systems headings. As you already realise
this may not necessarily fit into predictable categories: for instance, chest pain
sometimes has gastro-oesophageal origins. Medical and surgical diagnoses are
not separated. It is expected that at the end of the year students will have
knowledge of the common differential diagnoses for these symptoms and
presentations and a basic scheme of investigation.
Since the 3rd and 4th attachments occupy an almost unbroken period of 20 weeks it
might be helpful to have some landmarks, bearing in mind that half of you will be
doing your medical attachment first and half the surgical. In this section therefore
we have marked each presentation or condition as M which is medical or S as
surgical. In some circumstances this is rather artificial, but the main purpose is to
help you in pacing your learning. You will see that medical conditions predominate
and this does reflect clinical practice on an everyday basis. Therefore we suggest:

That you familiarise yourself with all items marked S during your surgical
attachment, whether you do that first or second.
That the items marked M will mainly form part of your medical attachment but
that you can take opportunities for learning about them during the surgical firm
if it does not interfere with your main learning objectives during that period
General
Weight loss–also endocrine
M
Fever
M
Night sweats
M
Tiredness - also endocrine, haematology etc
M
Lumps in neck and groin – also haematology
S
Rashes – as markers of systemic disease
M
Cellulitis
M
Alcohol abuse (may be gastrointestinal, neurological, psychiatric)
M
Collapse +/- loss of consciousness
(may be cardiovascular, neurological)
M
Cardiovascular
Chest pain
M
Shortness of breath (acute and chronic) – also respiratory
M
Palpitations
M
Oedema-also GI, renal
M
Claudication – also neurological
S
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Stroke –also neurological
M
Respiratory
all M
As above
Cough
Haemoptysis
Wheeze
Gastrointestinal
all S
Acute abdominal pain
Chronic abdominal pain
Nausea and vomiting – also infections, cardiovascular, neurology etc
Haematemesis
Diarrhoea
Constipation
Melaena and rectal bleeding
Endocrine
all M
Weight loss
Weight gain
Polyuria and polydipsia
Goitre
Haematology
all M
Lymph node enlargement
Pallor
Fatigue
Easy bruising/bleeding
Renal/urology
Loin pain
S
Haematuria
S
Oedema
M
Uraemia
M
Urinary retention
S
Urinary frequency
S
Incontinence
S
Scrotal swelling
S
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Neurology (Year 5 attachment but important general medical presentations)
As under cardiovascular, also:
all M
Acute headache, including meningism
Chronic recurrent headache
Collapse
Seizures
Focal weakness
Focal sensory disturbance
Cognitive deficit/decline
Acute confusion/delirium
Rheumatology (also a Year 5 attachment but important general medical
presentations)
Joint pain
all M
Joint swelling
Backache
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Clinical situations, syndromes and diseases
Our intention is that you will become acquainted with main presentations, and the
principles of investigation and management of these conditions. You should make
every effort to gain first-hand clinical experience of as many as possible. For some
rare conditions this may be difficult or impossible but form the majority it should be
possible during one of the four attachments in the year, even if, as already
mentioned, students have to go outside their own firm. Again, the subdivision is
largely by systems, but remember the note in the previous section.
Cardiovascular
all M unless indicated
Myocardial infarction
Other acute coronary syndromes
Stable angina
Acute heart failure
Chronic heart failure
Atrial fibrillation (see also emergencies)
Valve disease including endocarditis
Hypertension
Aortic aneurysm
Cerebrovascular accident (stroke)
Lower limb vascular disease
S
Deep vein thrombosis
Pulmonary embolism
Varicose veins
S
Respiratory
all M
Asthma
Chronic obstructive pulmonary disease
Pneumonias
Tuberculosis
Carcinoma of the bronchus
Pneumothorax
Fibrosing lung disease (especially occupational)
Bronchiectasis
Gastrointestinal
Peptic ulcer disease (see also emergencies, acute abdomen)
M
Gastro-oesophageal reflux and hiatus hernia
M
Inflammatory bowel disease
M
Inguinal and femoral hernias
S
Hepatitis (acute and chronic)
M
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Cirrhosis and portal hypertension
M
Cholecystitis and gall stones
S
Appendicitis
S
Peritonitis
S
Pancreatitis
M
Diarrhoea due to infection or infestation
M
Haemorrhoids
S
Anal fissures and fistulas
S
Diverticular disease
S
Carcinoma of the large bowel
S
Carcinoma of the pancreas
S
Carcinoma of the stomach
S
Carcinoma of the oesophagus
S
Endocrine and metabolic
all M
Diabetes mellitus
“Metabolic syndrome”
Hypothyroidism
Hyperthyroidism
Osteoporosis
Osteomalacia
Diabetes insipidus
Hypopituitarism and pituitary tumours
Acromegaly
Cushing’s syndrome
Adrenal insufficiency
Hypercalcaemia (including hyperparathyroidism)
Hypocalcaemia
Haematology
all M
Anaemias (iron/folate/B12 deficiencies)
Leukaemias (acute/chronic)
these will be covered in detail
Lymphomas
in the Year 5 Pathology Course
Myeloma
but may present in general medicine
Clotting disorders (genetic/acquired)
Sickle cell disease
35
Renal/urology
M/S respectively
Acute renal failure (see also emergencies)
Chronic renal failure and its complications
Glomerulonephritis
Use of dialysis (haemo- and peritoneal)
Urinary tract infections
Renal/ureteric stones
Prostatic hypertrophy
Carcinoma of the prostate
Carcinoma of the kidney
Carcinoma of the bladder
Congenital abnormalities of renal tract
Neurology (predominantly Year 5, but may present in general medical setting)
Migraine
all M
Transient ischaemic episodes
Meningitis
Peripheral neuropathy
Paraparesis / Paraplegia
Subarachnoid haemorrhage
Parkinson’s disease
Epilepsy
Dementias
Rheumatology (predominantly Year 5, comment as for neurology)
Recognition of osteoarthritis and rheumatoid arthritis
all M
Recognition of multisystem diseases (systemic lupus, sarcoid)
Polymyalgia rheumatica
Acute arthropathy
Oncology
mixed M and S unless indicated
Malignancies already mentioned under specific systems
Concepts of screening
Carcinoma of the breast (and non-malignant breast lumps)
Principles of radiotherapy and chemotherapy
Palliative care including pain management
36
S
Medicine for the elderly
all M
Although most of the conditions affecting the elderly have already been listed (with
the very important exception of dementia), students need to be aware of the
principles of:
Differential epidemiology of disease
Variation in disease presentation in the elderly
Modifications in management in the elderly
Clinical Pharmacology and Therapeutics
all M
Most of the formal teaching of therapeutics takes place in the final year but the
following are part of learning for Year 3:
Principles of pharmacokinetics and drug metabolism
Types of adverse drug reaction
Adverse drug interactions
Special considerations in prescribing for the elderly, children and in pregnancy
and lactation (these are particularly relevant for Year 5)
Principles of new drug development
Students should also be aware of the main types of drugs used in the above
conditions and their main uses and problems but detailed descriptions of
management will not be expected at this point, except for the emergencies listed in
the next section.
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Section 7
ANAESTHETICS AND CRITICAL CARE
Learning objectives
 Understanding the application of basic physiology to the cardiovascular,
respiratory and metabolic events, normal and abnormal, occurring during
anaesthesia
 Awareness of the common medical conditions likely to increase perioperative risk
and the principles of their management
 Ability to recognise critical events perioperatively
 Ability to identify the critically ill patient, in particular the importance of sepsis and
the systemic inflammatory response syndrome following major surgery
 Understanding principles of management of these patients, with particular
emphasis on oxygen therapy and fluid balance
 Understanding approaches to the management of acute pain, particularly postoperatively, and of chronic pain, emphasising the multidisciplinary nature of the
pain team
 Acquisition of practical skills including management of the airway (not intubation),
managing delivery of oxygen by different devices, IV cannulation, and setting up
IV infusions with additives.
Emergencies
all M unless indicated
This includes most of the important medical and surgical emergencies. If at all
possible students should see these on the wards and particularly in A and E
departments. It may not be possible to obtain first-hand experience for all of these
but awareness of how to recognise them is essential as is knowledge of the
principles of management.
all M unless indicated
Cardiac arrest
Anaphylaxis
Severe sepsis
Meningitis
Hypovolaemic shock secondary to haemorrhage
Acute arrhythmias (supraventricular and ventricular)
Complete heart block
Acute left ventricular failure
Malignant hypertension
Acute arterial occlusion
Status asthmaticus
Tension pneumothorax
Respiratory failure
Haematemesis
38
Variceal haemorrhage
Perforated ulcer
S
Acute obstruction
S
Acute liver failure/encephalopathy
Hypoglycaemia
Diabetic ketoacidosis
Non-ketotic hyperosmolar coma
Lactic acidosis
Acute adrenal insufficiency
Severe hypercalcaemia (esp. in malignancies)
Hypo- and hypernatraemia
Poisoning
salicylates, paracetamol, opiates, tricyclics, methanol,
lithium, digoxin
Head injury
Chest and abdominal trauma
Severe burns
Status epilepticus
Acute paraparesis/paraplegia
Acute renal failure
Malaria
39
Section 8
FORMULARY OF DRUGS
Drug
Indication
Pharmacological
class
Comments
Please use the following table as a basis for a personal list of drugs and look up all
the new drugs you come across in the BNF and standard recommended books.
Comments may include patient response, possible side-effects, potential
interactions with other drugs.
40
41
Drug
Indication
Pharmacological
class
Comments
42
Drug
Indication
Pharmacological
class
Comments
43
Drug
Indication
Pharmacological
class
Comments
44
Drug
Indication
Pharmacological
class
Comments
45
Drug
Indication
Pharmacological
class
Comments
46
Drug
Indication
Pharmacological
class
Comments
47
Drug
Indication
Pharmacological
class
Comments
48
Drug
Indication
Pharmacological
class
Comments
49
Drug
Indication
Pharmacological
class
Comments
50
Drug
Indication
Pharmacological
class
Comments
Section 9
ATTAINMENTS IN PATHOLOGY
During clinical attachments in Years 3 and 5, you should undertake the following
tasks in pathology practice. The list is not exhaustive, merely representative of the
pathology skills and knowledge applicable to the practice of medicine.
You may be examined in some aspects of these as part of general medicine,
pathology, or in an OSCE or PACES, since pathology is key to the study of
medicine. These skills are all part of everyday medical and surgical practice and
should therefore form part of following through a patient in hospital.
The following may be examined in YEAR 3 are marked with an asterisk in the right
hand margin.
*
As you make these observations, or gain these skills, you might wish to tick them
off on this list.
Cellular Pathology
1 Observe a cervical smear sample being taken and be able to discuss the
possible results.
2 Observe a frozen section from an operation being cut and reported by the
attendant pathologist
3 Attend a multi-disciplinary team meeting (any of the specialities) at which a
pathologist is present.
4 During your surgical attachment follow a surgically-excised specimen from
formalin-fixation to diagnosis in the pathology department.
5 Observe a fine needle aspiration of any site, for example lymph node,
breast or thyroid and be able to discuss the advantages and disadvantages
of this procedure.
Some of these will be done in outpatients.
Chemical Pathology/Clinical Chemistry
1 Observe, follow-up and interpret blood gas results from a patient from ITU
*
2 Observe, follow-up and interpret a low serum sodium from a
post-operative patient
*
3 Meet a patient with type II diabetes and discuss with the patient the
possible complications of this disease
*
4 Look at an abnormal liver function test from a patient and attempt to
interpret the results
*
5 Look at the case notes of a patient with high serum calcium and note the
symptoms caused by high calcium levels
*
6 Observe and interpret urine dipstick testing for pH, glucose, ketones,
bilirubin, blood and protein.
*
51
Haematology
1 Observe how a patient is identified and a blood sample is taken for blood
grouping/cross-matching
*
2 Observe how patient identity and details of blood for transfusion are
checked and how a blood transfusion is monitored
*
3 Meet a patient with sickle cell disease and be able to describe the clinical
features of a painful crisis
*
4 Attend an anticoagulant clinic and observe how therapy is monitored and
doses are adjusted
*
5 Observe a patient receiving either prophylactic or therapeutic heparin and
be able to explain how the dose is decided and whether or not therapy
requires monitoring
*
Immunology
1 Know how to send a blood sample for cryoglobulins to the laboratory
2 Know how patients with systemic lupus erythematosus are monitored
3 Know how self-injectable adrenaline is administered
4 Meet a patient with an autoimmune disease or transplant and discuss the
immunosuppressive drugs they take and the requirement for monitoring for
drug toxicity
Microbiology
1 Observe how blood culture is taken aseptically after thorough disinfection
of skin
2 Observe how a sample of cerebrospinal fluid is taken aseptically after
thorough disinfection of skin
3 Observe how a "Dipstick" is used to test a sample of urine and how the
result is interpreted
*
4 Know how to instruct a patient to collect a mid-stream specimen of urine
*
5 Observe how to collect wound swabs from deeply-infected sites, without
skin contamination
52