Warwick
Medical School
MB ChB Phase I
Essentials of Clinical
Medicine
Essentials of Clinical Medicine Module
1
Essentials of Clinical Medicine
Module Leader
Module Leader
Dr Alex Conner – Assistant Professor
A.C.Conner@warwick.ac.uk
Warwick Medical School
Co- Module Lead – Dr David Tweedie - Clinical Tutor for WMS
david@tweedie.info
Contact details for all the lecturers in this module are contained at the top of their
session pages.
2
Essentials of Clinical Medicine
Introduction
The module Essentials of Clinical Medicine is designed to underpin the MBChB
course by providing an introduction to major topics that feature in the integrated
curriculum that occur in Phase I, such as, the nervous system and neurobiology,
musculoskeletal system, infection and immunity, the respiratory and
cardiovascular systems. This module will also introduce generic subjects such as
anatomical terminology, medical imaging, histology, metabolism (nutrition), early
embryonic development, and pathology. It will also provide the essential basic
understanding to support student’s knowledge base as they move through Phase I
modules.
Aim
The aims of the module are to enable students to

Provide an understanding of major topics that will feature in the integrated
curriculum undertaken in Phase I.

Address the essential components of basic body system ‘ultra’ and ‘gross’
structure in order to be able to evaluate and understand the complexities
arising across subsequent modules.

Promote a conceptual and information based understanding of body systems
and pathology.

Broaden students knowledge base of basic principles and skills relevant to
the core modules in Phase I
Pre-requisites
Before each lecture and group work, students should read the relevant section of
the handbook and web pages, download any necessary handouts from the web
and examine any appropriate text to support their understanding of the topic(s) to
be addressed.
Summary of Intended Learning Outcomes

It should be noted specific detailed learning outcomes will also be addressed
within the specific topics. Overall on completion of this module, students
should be able to:

Use and understand appropriate basic terminology across body systems
(Gastrointestinal tract, cardiovascular system, Nervous System, Respiratory)
in the description of both normal and pathological conditions

Describe and understand the fundamentals of normal function of cellular
systems and pathogenic consequences
Essentials of Clinical Medicine
3

Understand basic medical terminology for use in anatomy, medical imaging,
histology and immunity and infection.

Explain the fundamentals of the organisation of organ systems in health
(Cardiovascular system, Nervous System, Respiratory system). This would
include an ability to describe the basic histology of epithelia, connective
tissue and mucosa.

Outline the basic pathology of organ damage

Describe mechanisms responsible
homeostasis in health and disease.

Explain the medical basis of pathological conditions and influences on health
to identify better models of patient care and clinical perspectives.

Describe normal neo-natal development and metabolism and evaluate the
consequences for pre-term nutrition

Understand the fundamentals of drug interaction and the consequences for
prescribing
for
intracellular
regulation
and
Sessional Structure & Teaching Methods
Sessions will contain a mixture of lectures and group-work based sessions. A
typical session will comprise of a lecture followed by group work. The lecturing
staff will provide the relevant case histories or associated questions related to the
specific sessions, with students expected to act as discussants. Teaching staff will
guide and moderate subsequent discussion as and when deemed appropriate to
the session.
Assessment
Material from this module will be included in the End of Semester (ESA) written
assessments and Objective Structured Clinical Examinations (OSCE) and may be
included in all subsequent assessments in Phase I.
Suggested Reading
Clinical Medicine
By P Kumar, M Clark, and W.B Saunders
Edition: 6 illustrated, Published by Elsevier Saunders UK, 2006
ISBN: 0702027634
Clinically Oriented Anatomy: Student CD-ROM [CD-ROM].
By K.L. Moore, A.F Dalley, A.M.R Agur.
Edition: 5, illustrated.
Published by Lippincott Williams & Wilkins UK, 2006
ISBN 0781736390, 9780781736398
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Essentials of Clinical Medicine
Illustrated Clinical Anatomy.
By P Abrahams, J. Craven and J Lumley
Edition: 1, illustrated
Published by Hodder Arnold UK, 2005.
ISBN 0340807431
Human Physiology: The Basis of Medicine,
By G Pocock and C.D Richards,
Edition: 3, illustrated.
Published by: Oxford University Press UK, 2006
ISBN 0198568789
Introduction to Clinical Examination
By M.J Ford, I Hennessy, A Japp
Elsevier 2005
Pathophysiology of Heart Disease
By L.S Lily
Edition: 4
Published by Lippincott, Williams & Wilkins UK, 2006
ISBN 0781763215
Pathology.
By A. Stevens and J Lowe
Edition: 2
Publisher: Mosby UK, 2000
ISBN 0-723432007
Essentials of Clinical Medicine
5
Sessions during Induction Week
All sessions will take place in the MTC Lecture Theatre
DATE
7 September
8 September
9 September
10 September
6
SESSSION
TITLE
LECTURER
1
Introduction to Essentials of
Clinical Medicine
1.45 – 2.15pm
Dr Alex Conner and
Dr David Tweedie
2
Introduction to the
Terminology of Medicine
2.15 – 5.00pm
Professor Peter
Abrahams
3
Embryology
9.00am – 12.15pm
Dr Carolyn Rodgers
4
Introduction to Molecules
1.45 – 4.00pm
Dr Sinclair Steele
5
Introduction to Pathology
9.00am – 12.15pm
Dr Paul Matthews
6
Histology, chemical
pathology, haematology and
microbiology
1.45 – 5.00pm
Dr Paul Matthews
7
Introduction to Clinical Skills: Dr Linda Maxwell
What is a sign – The
Physical Examination
9.00am – 12.15pm
8
Integrated Learning Session
– Putting the week together
1.45 – 5.00pm
The Clinical
Education Fellows
Essentials of Clinical Medicine
Semester 1 Timetable
All sessions are on Tuesday afternoons in the MTC LT 1.45 – 5.00pm
DATE
SESSION
TITLE
LECTURER
14 September
9
Introduction to Clinical
Scenarios and Evidence
Based Medicine
Dr Jeremy
Shearman
21 September
10
Introduction to Physiology
Dr David Tweedie
and Dr Barney Ward
28 September
11
Introduction to Molecules
Dr Sinclair Steele
5 October
12
Respiratory &
Cardiovascular Anatomy
Dr David Tweedie
12 October
13
Cell Physiology
Dr Alex Conner
19 October
14
Introduction to
Neurobiology
Dr Dawn Collins
26 October
15
Introduction to Imaging
Techniques
Dr Fraser Millard
2 November
16
Molecules in the Human
Body
Dr Graham Ladds
9 November
17
Homoestatis
Professor Peter
Stanfield
16 November
18
Integrated Session*
Clinical Education
Fellows
23 November
19
Clinical Skills 1
MedLine Training
Samantha Johnson
30 November
20
Clinical Skills 1
Evidence Based Medicine
Training
Samantha Johnson
 Students to meet in LT at 1.45pm for briefing by CEFS. Break into groups
and go with an identified CEF to work on an area covered by EoCM.
Students to have e-mailed in advance if they want a particular area
covered.
Essentials of Clinical Medicine
7
Session 1
Date: 7 September 2010
Introduction to the module
Module Leaders:
Dr Alex Conner – Assistant Professor
Dr David Tweedie – Clinical Tutor WMS
Email:
A.C.Conner@warwick.ac.uk
david@tweedie.info
Overview
This module was started in 2008 and is undergoing constant
development. It has been changed in the light of comments from both
students and staff involved in the 2009 cohort running. Your feedback
throughout the running of the module is important and you do not have
to wait until the end to let us know what is working really well and
those areas that you feel require further attention/revision
Aims
To explain the rationale behind the planning of the module including
the different educational backgrounds of students in your cohort.
To encourage students with limited scientific background to
understand very basic concepts.
To encourage students with more substantial scientific backgrounds to
help their colleagues in group work.
To stress the clinical importance of this knowledge.
Intended Learning Outcomes
After this session you should:
 Appreciate the principles underlying the module
 Appreciate the relevance of the material to clinical medicine
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Essentials of Clinical Medicine
Session 2
Date: 7 September 2010
Introduction to the Terminology of Anatomy and Anatomy Group
Work
Session Leader:
Email:
Professor Peter Abrahams
p.h.abrahams@warwick.ac.uk
Overview
A lecture will introduce about 100 common anatomical terms which form the basis
of medicine. During the next three years most of you will DOUBLE your
vocabulary and in this first week will use about 300 new terms. These terms are
the very basis of medical practice and knowing about their origins will make it
easier to work out the meaning in years to come. A special section on imaging and
radiological terminology will also been provided at a future session.
Teaching Aims
To gain insight into the use of medical / anatomical terminology as used
throughout your future medical practice.
Intended Learning Outcomes
By the end of the session or at least by the end of the first two weeks you should
be able to:
1.
“Translate” half a dozen typical case histories from medical terminology into
common language.
2.
Be able to write a description of a person in a certain position or injury so that
a fellow student could make themselves into that stance.
3.
Be aware of the range of new terms especially prefix and suffixes that often
give clues to meaning.
Structure of the Session:
1.
Lectures with video clips etc. to illustrate the many terms used.
2.
Group work based on “Chinese Whispers”. Pictures of anatomical odd
patients which you will have to describe and pass to the next group who will
then enact the position you have written down . They will do the same for you
from a different set of pictures.
3.
Plenary session translating the written word into actions and making
“statues”.
Essentials of Clinical Medicine
9
Cross-Modular Themes
Every new term used in these sessions will be used constantly over the next 30
years of your medical career.
Suggested Reading
Any anatomy text book - the first chapter or two on terminology.
Illustrated Clinical Anatomy, ISBN 0 340 80743 1 by Abrahams Craven Lumley
Hodders. This also has a website with 1000 downloadable jpeg files of anatomy
and clinical medicine.
Another similar short book recommended is Essential Clinical Anatomy by Moore
and Agur Williams Wilkins. An atlas is a very good way of seeing and learning
anatomy and there are many on the market- some have lots of clinical cases and
pictures on DVDs.
Terminology used in Anatomy is the foundation language and cornerstone of all
medical practice, it is the language that one doctor uses to describe accurately a
clinical situation to another person in the team.. Most average people have a
normal English vocabulary of around 5000 words. Your new medical vocabulary
will have doubled that figure in the next few years - so the sooner you start
learning it the easier all medical subjects will seem. Learning precision in clinical
medicine starts today with the anatomical words, their origins and definitions. By
the end of just your first afternoon you will have gained approximately 300-400
new terms and be able to use them in a correct context. Learning this new medical
language will make reading and lectures so much more comprehensible day by
day so that in future you will be able to work out new terms from first principles.
Many of you will feel overloaded with new facts at the end of these sessions but
do not worry- it does get easier as time passes- believe me!
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Essentials of Clinical Medicine
Group Work in Tutorial rooms
Each group of students will be given one photo with two different numbered
anatomical everyday poses on it.
You will then WRITE a description of that person’s position in anatomical /
medical terminology (5-10 minutes) and then pass on the written text and number
to the group next door.
They will then swap with you their written descriptions of their numbered positions.
You will then take their description and work out the position of their photos (5-10
minutes). With these two positions you will then send members of your group to
act out in the lecture theatre at the plenary session for all to see how accurate your
interpretations are.
It is like Chinese Whispers with Medical Terminology
Essentials of Clinical Medicine
11
PREFIXES
PREFIX
MEANING
EXAMPLE
a-,abad, ac-, af-, alambiantebi, bin-, biscircumco-, col-, com-, con,corcontradedis-, dif-, diex-, e-, efextra-
away from
to, towards, near
both, double
before, in front
two, double, both
around
together, with, very,
thoroughly
against, opposed
away from, down, absent
apart, away
out of, away from
(on the) outside, beyond,
outward
Not, in, into, very,
thoroughly
below, beneath
between
inside, within
into, inward
not
after, behind
under
above, excess
across, through
abduction
Afferent nerve fibres
ambidextrous
antebrachium
biceps
circumflexion
Contraction
in-, il-, im-, irinfrainterintraintrononpostsub-, suf-, supsuper-, supratrans-
Contraceptive
Depression
Dissect
Emission
Extracranial
indigestible, immersion,
intoxicate
Infracostal
Intercostals
Intrauterine
Introflexion
non-toxic
post-traumatic
Subcutaneous
Suprapubic
Transvenous
SUFFIXES
SUFFIX
MEANING
-al
-an
-ar, -ary
-ation
pertaining to
pertaining to
pertaining to
condition, state
-ion
-ive
-ous
-or
act of
pertaining to
pertaining to
agent, person,
instrument
MATCH THESE
12
FUNCTION
FORMS/INDICATES
adjectives
adjectives
adjectives
nouns (indicates
process or action)
nouns
adjectives
adjectives
nouns
EXAMPLE
Facial
Median
fibrillar, fibrillary
Ossification
Contraction
Antitussive
Pyogenous
Respirator
Essentials of Clinical Medicine
LIST A
1.
abduction
2.
adduct
3.
adrenal
4.
antero-inferior
5.
anterolateral
6.
bilateral
7.
dextrad
8.
dorsiduction
9.
extracystic
10. extroversion
11. interdental
12. intero-inferior
13. interrenal
14. intra-articular
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
intracardiac
intracerebral
intra-oral
intra-osseous
intravenous
intravesical
mediolateral
postbrachial
postero-anterior
posterolateral
sinistrad
subcutaneous
sublingual
superoposterior
suprarenal
transvesical
Essentials of Clinical Medicine
LIST B
a. concerning the area beneath the tongue
b. outside or unrelated to the bladder
c. within the urinary bladder
d. pertaining to an inward and downward position
e. between adjacent teeth
f. to the left
g. inside the heart
h. indicating movement from back to front
i. near the kidney
j. within a joint
k. inside the mouth
l. draw toward the main axis of the body
m. turning inside out
n. lateral movement of the limbs away from the
median plane of the body
o. pertaining to two sides
p. located behind and at the side of a part
q. pertaining to posterior portion of the upper arm
r. located above the kidney
s. across or through the bladder
t. between the kidneys
u. concerning the middle and side of a structure
v. within the main portion of the brain
w. above and behind
x. to the right
y. drawing backwards
z. in front and below
aa. beneath the skin
bb. in front and to one side
cc. within the bone substance
dd. within a vein
13
1.
A 50-year-old man was admitted to hospital. He was is hypovolaemic
(Latin: volumen: volume) shock. Haematemesis and bleeding per rectum
were conditions reported by the paramedic.
On admission his haemoglobin count was found to be low, and
thrombocytopenia as well as deranged clotting of blood was noticed.
In spite of being resuscitated with packed red blood cells and frozen plasma,
haemorrhage and deterioration in his coagulopathy occurred (coagulation:
clumping together of blood cells; clotting) the following day. An upper
gastrointestinal endoscopy was performed. This revealed a large quantity
of blood in the patient’s stomach and oesophagus, as well as oesophageal
varices. The patient’s condition deteriorated further and he died.
A post-mortem was held. The pathologist noted in his report the body of a
middle-aged man, deeply jaundiced with gynaecomastia, the abdomen
markedly distended and moderate oedema. A large quantity of straw
coloured fluid was present in the peritoneal cavity and numerous varices
were found in the distal end of the oesophagus. Hepatic cirrhosis and
splenomegaly were noticeable. Blood was found in all parts of the intestinal
tract. Histology of oesophageal tissues indicated large-scale submucosal
venous dilatation while the liver showed micronodular cirrhosis (cirrhosis;
end-stage liver disease characterised by nodular regeneration).
2.
A 70-year-old man visited his physician complaining of dysphagia and
dyspnoea. He also referred to a swelling in his neck, suspecting a goitre.
After physical examination, a needle biopsy and an ultrasound scan the
physician diagnosed thyroid cancer.
He recommended an immediate thyroidectomy and a dissection of the
neck to search for and remove enlarged lymph nodes.
3.
A 36-year-old woman visited her physician complaining about pain in the
right side of her thorax and some apnoea. During the physical examination
the physician observed tachypnoea and evidence of shock. He also noted
varicose veins, especially in her right thigh and calf and on questioning she
told him that she had had painful varicose veins in her lower limbs for some
time. On cardiac examination he detected tachycardia and arrhythmia. The
physician performed an ECG and also requested a pulmonary angiogram
and fluoroscopy. Fluoroscopy of the patient’s lungs revealed poor or absent
pulsations in the descending branch of the right pulmonary artery and relative
anaemia of the right lung.
Diagnosis: a thrombus from a varicose vein in the lower limb caused
pulmonary thromboembolism.
4.
A markedly obese woman visited the physician for a right-sided abdominal
pain. The pain dated from two years ago when, at first, intermittent episodes
of epigastic pain lasting two to four hours occurred. At the time
cholecystitis with cholelithiasis was diagnosed and a cholecystectomy
was performed. Five large gallstones were found. Since then everything had
gone well until about four months ago when right-sided pain taking a
crescendo pattern started again. It did not cause nausea or emesis and
there was no urge to defaecate. Apart from the cholecystectomy mentioned,
her past medical history was only marked by an appendicectomy a
tonsillectomy and an arthroplasty. A physical examination confirmed her
14
Essentials of Clinical Medicine
obesity. She was, anicteric. Her neck revealed no lymphadenopathy or
thyromegaly. No hepato-or splenomegaly could be observed and a
haemo-negative stool was registered.
No oedema was apparent.
Laboratory tests indicated no gastrointestinal abnormalities and the kidneys
showed no signs of hydronephrosis
Diagnosis: As physical examination and laboratory tests did not suggest
specific abnormalities or deviations, an occult nephrolithiasis could be
diagnosed.
5.
Mrs Fairburn (59) was admitted to hospital complaining of severe pain in the
upper right part of the abdomen. She was anorexic, febrile and nauseous.
She also complained of intermittent emesis. Although her sclerae (outer
layer of eyeballs) were yellow she was not particularly jaundiced.
Tenderness and guarding were present in the upper quadrant of the anterior
abdominal wall.
Radiological and laboratory tests were performed and cholecystits resulting
from calculi in the gallbladder was diagnosed. A cholecystectomy was
performed by laparoscopy and a gallstone was removed from the bile duct
after choledocholithotomy
6.
A 40-year-old heavy smoker visited the pulmonologist and complained
about persistent tussis, thoracalgia and haemoptysis. Bronchoscopy
and thoracography were requested.
A congenital lesion was revealed and after a biopsy a bronchogenic
carcinoma was found in the in the apex of the lung.
7.
A young woman, married to a medical student, woke up one morning not
feeling well. Apart from being anorexic and lethargic, she experienced
severe abdominal pain. As it was time for her menstrual period, her husband
suspected probable dysmenorrhoea or even an ectopic pregnancy since
she missed her last menstrual period. After she had also begun to feel
febrile and nauseous, followed by emesis, so her husband took her to
hospital.
During investigation the physician detected a localised myospasm in the left
lower quadrant of the abdomen. A blood count indicated leukocytosis. The
physician eventually diagnosed appendicitis and gave instructions for the
patient to be prepared for an appendicectomy.
8.
A post mortem was performed on the body of an 80-year-old woman. The
patient had been admitted to hospital with severe melaena (black, tarry
faeces) She required a blood transfusion. A hemicolectomy was performed
but complications led to ischaemia of the colon and a colostomy also had
to be established.
A week after surgery the anastomosis broke down. The patient was readmitted with severe sepsis and faecal peritonitis. The bowel had to be
reanastomosed by further surgery. A few days later, however, the patient
died.
At necroscopy the lungs were found to be congested and
oedematous. The bowel anastomosis was still in place. Pus was found in
the subphrenic spaces. Histology indicated the presence of colonic
diverticula and diaphragmatic inflammation. Severe hepatic congestion
was also observed.
Essentials of Clinical Medicine
15
Session 3
Date: 8 September 2010
Embryology
Session Leader: Dr Carolyn Rodgers
E-mail: C.J.Rodgers@warwick.ac.uk
Overview:
An introduction to basic embryology and the events of the first three weeks of
human life.
Aim:
Begin your study of embryology
Outline the early major developmental events and anatomical landmarks of a
human embryo
Understand and be able to use the terminology of early human development
Act as an introduction to the systems embryology you will encounter in the phase
one modules
Begin to identify relevance of embryology to clinical practice
Learning Outcomes:
Describe simply the processes from fertilisation to implantation
Describe simply the second week of human development
Describe simply the early stages of placental development
Describe simply the development of three germ layers
Describe simply the establishment of body axes
Be able to connect some clinical problems to aberrations in the development of an
early human embryo
Recommended Reading:
Langman’s Medical Embryology, by T.W.Sadler, PhD 11TH Edition 2010.
Lippincott Williams and Wilkins
Embryology Colouring Book. Matsumara and England
16
Essentials of Clinical Medicine
Session 4
Date: 8 September 2010
Introduction to Molecules
Session Leader:
Email:
Dr Sinclair Steele
sinclair.steele@ntlworld.com
Overview
A review of the structure and function of key biological molecules. An overview of
membrane components and functions. The key principles behind signal
transduction.
Teaching Aims
To introduce the basic structure and function relationships of the major biologically
important molecules. To indicate the clinical significance.
To summarize the principles behind membrane function and signal transduction.
Intended Learning Outcomes
At the end of this session it is expected that you will be able to:

Briefly describe the functions of the major cellular organelles.

Understand the fragility of the human cell and be able to list injurious stimuli.

Appreciate the importance of medical genetics.

Define key genetic terminology – transcription, replication and translation.

Recognize chromosomal structure.

Have achieved an understanding of protein structure and the effects of
disruption of this structure for the whole body.

Have achieved a critical understanding of the importance of the ionic balance
across the cell membrane.

Appreciate the range of functions of a biological membrane.

To understand the principles of signal transduction without having memorized
any one complete pathway.
Essentials of Clinical Medicine
17
Sessions 5 and 6
Date: 9 September 2010
Introduction to Pathology Day
Session Leader:
Title:
Email:
Tel:
Dr Paul Matthews
Consultant Histopathologist UHCW and Honorary Associate
Professor/Phase II Co-ordinator Warwick Medical School
paul.matthews@uhcw.nhs.uk
024 7696 5437
Overview:
What is pathology?
What are its branches?
How do those branches interact and provide results that drive clinical
diagnosis?
Teaching Aims:
The session aims to introduce the main branches of pathology, namely;
1. Histopathology
2. Haematology
3. Clinical Biochemistry
4. Microbiology
Intended Learning Outcomes:
By the end of the day the student will understand the importance of clinical
pathology to patient management.
Structure of the Day:
The day begins with a short introduction. There are four specialty based
sessions (lecture and group work). These will be followed by a plenary
session where a clinical case will be used to illustrate the importance of
interaction between the specialties and ward based clinicians.
Cross-Modular Themes:
See individual session outlines.
Assessment:
Material from this module will be included in the End of Semester (ESA) written
assessments and Objective Structured Clinical Examinations (OSCE) and may be
included in all subsequent assessments in Phase I.
18
Essentials of Clinical Medicine
Timetable
Time
0900
Topic
Introduction
Type
Talk
Tutor in charge
Paul Matthews
0915
Histology
Lecture
Paul Matthews
0945
Histology
Group Work
Paul Matthews
1100
Haematology Lecture
Beth Harrison
1130
Haematology Group Work
Beth Harrison
1345
Biochemistry Lecture
Steve Smith
1415
Biochemistry Group Work
Steve Smith
1515
Microbiology
Lecture
Peter Munthali
1545
Microbiology
Group Work
Peter Munthali
1630
Plenary
Discussion
Paul Matthews
Beth Harrison
Steve Smith
Peter Munthali
Essentials of Clinical Medicine
19
Session Title:
Introduction to Histopathology
Session Date:
9 September 2010, 0915-1030
Session Leader:
Title:
Dr Paul Matthews
Consultant Histopathologist UHCW and Honorary Associate
Professor/Phase II Co-ordinator Warwick Medical School
paul.matthews@uhcw.nhs.uk
024 7696 5437
Email:
Tel:
Overview:
This session is intended as an introduction to those aspects of general
pathology/histopathology that will help in your understanding of other
Semester 1 modules. Semester 2 includes the Mechanisms of Disease
Module which will look at general pathology in more detail.
Teaching Aims:
The session aims to introduce the concepts of;
5. How does a histopathologist make a diagnosis?
6. Inflammation and Healing
7. Thrombosis and Embolism
8. Atheroma
9. Neoplasia
Intended Learning Outcomes:
By the end of the session the student will be able to understand the very
basics of;
1. How a pathologist makes a diagnosis from tissue.
2. Acute Inflammation including the relevance of Latin i.e. Tumor, rubor, calor,
dolor, role of vessels and neutrophils
3. Chronic Inflammation including causes, typical cells and granulomas.
4. Granulation tissue and its role in healing.
5. Thrombosis and embolism.
6. Atheroma including the atheromatous plaque and clinical results.
7. Defining the “-plasias”
a. Hyperplasia
b. Metaplasia
c. Dysplasia
8. Defining the “-trophies”
a. Hypertrophy
b. Atrophy
9. Terminology of Tumours
a. Benign and Malignant
b. Invasion and Metastasis
c. Clinical Effects
Structure of the Session:
The session begins with a lecture. The themes will be explored further in
the group work.
20
Essentials of Clinical Medicine
Cross-Modular Themes:
Gastrointestinal Module; Acute and chronic inflammation of various GI
organs including stomach, liver and colon. Neoplasia of GI tract.
Health in the Community; Work of other healthcare professionals.
Molecules; various mediators of inflammation, molecules important in cell
cycle control and cellular growth which are also important in adaptation and
neoplasia.
Handouts and other relevant Information:
Available on-line prior to the lecture.
Required and Recommended Reading:
This is an introductory talk and there is no required prior reading. However
the basics of general pathology are well covered in;
General and Systematic Pathology (3rd Edition), Underwood, Churchill
Livingstone
Core Pathology, Stevens and Lowe, Mosby.
These texts will be useful help in your understanding of this brief overview
and
One of them is essential for the Semester 2 Mechanisms of Disease
module. Have a look and choose your favourite.
Assessment:
Material from this module will be included in the End of Semester (ESA) written
assessments and Objective Structured Clinical Examinations (OSCE) and may be
included in all subsequent assessments in Phase I.
Essentials of Clinical Medicine
21
Group Work (Cellular Pathology)
1. Having been fascinated by the workings of the pathology department (as
revealed in the Essentials of Medicine Module) you take a holiday job as a Medical
Laboratory Assistant in the pathology department of your local hospital. Due to a
delivery error, the samples for all the different branches of pathology have become
mixed up. You are given the job of sorting out which samples need to go to which
branch of pathology. E.g. a wound swab with the clinical information - (?infection)
would need to go to the microbiology department. Just match up the samples to
the correct branch of pathology.
The branches to choose from are;
1. Histopathology/Cytopathology (Cellular pathology)
2. Haematology
3. Microbiology
4. Clinical Biochemistry/Chemical Pathology.
The Samples:
Branch of Pathology.
Bone Marrow Aspirate (Anaemia ?cause)
Blood for Troponin T (?myocardial infarct)
Blood Cultures (?septicaemia)
Colon Biopsy (diarrhoea ?cause)
Blood Film (?leukaemia)
Blood for Liver Function Tests (LFT) (?hepatitis)
Duodenal Biopsy (?coeliac disease)
Faeces (?ova/cysts/parasites)
Full Blood Count (FBC) (?anaemia)
Mid Stream Urine (MSU) ?urinary tract infection (UTI)
Swabs for Methicillin Resistant Staph.Aureus (MRSA) Screen (?carrier)
Faeces for C.Difficile Toxin (?pseudomembranous colitis)
Blood for Urea and Electolytes (U and Es) (?renal failure)
Blood for Amylase (?pancreatitis)
Lymph Node Biopsy (?tuberculosis)
22
Essentials of Clinical Medicine
2. Pick a Pathological Process
Here are some common clinical scenarios. Use your previous knowledge and any
information from the lecture to identify the broad category of pathological process
that is occurring.
e.g. Bernard is a 16 year old who presented to the emergency department with a
12 hour history of vague abdominal pain which has since become localised to the
right lower side of his abdomen. He undergoes an operation to remove his
appendix. The appendix looks red, swollen and is covered in yellow pus.
Pathological Process: This is a case of acute appendicitis and an example of
acute inflammation.
Choose the pathological process in the following cases from this list.
a. Cell death
b. Acute inflammation.
c. Chronic inflammation
d. Healing and repair
e. Embolism
f. Atheroma
g. Benign Tumour
h. Malignant Tumour
Case 1
Jessie is a 32 year old with a 6 month history of diarrhoea and passing blood in
the stools. She has lost weight. On examination the anus is very sore with
ulceration. She has a test to look into the colon (colonoscopy). This shows ulcers
in the lining of the bowel and there are narrow areas.
Pathological Process:
Case 2
Archie is 60, has had raised blood pressure for 20 years and has smoked since he
was 12. Last night he felt a pain in his chest which he initially laughed off as
indigestion. However the pain worsened, spread to involve his left arm and he
became very sweaty. He went to casualty where the F2 doctor carried out an
electrocardiogram (ECG) and sent blood for a Troponin-T level (which was raised).
Pathological Process:
Essentials of Clinical Medicine
23
Case 3
Matilda is 90 and has had an ulcer on the inner aspect of her left ankle for many
months. In the past she suffered from varicous veins. The ulcer is covered by
yellow dead material. A surgeon removes the dead material (debridement) and
underneath is revealed red tissue which bleeds very easily.
Pathological Process:
Case 4.
Brenda found a lump in the breast. Her GP sent her to the specialist who
examined her breasts and found the lump. The specialist also found a lump in the
adjacent armpit and noticed tenderness over the spine when light pressure was
applied.
Pathological Process:
Case 5.
Susie has just stepped off the plane from Australia. In the arrivals lounge she felt
severe chest pain and became breathless.
Pathological Process:
Case 6.
Stan is 25 and has had a cough for 3 days. He is coughing up bright yellow
sputum. He has felt unwell and has had a fever. He also has some sharp chest
pain which is worse when he breaths in.
Pathological Process:
3. The Virtual Autopsy
Archie (whom you first met in case 2 above) does not survive the night despite all
that the power of modern medicine has to offer. The relatives give permission for
an autopsy to be performed. You are shown pictures of the main organs relevant
to the cause of death.
For each of the photographs;
a. Describe the appearance and
b. Try to decide on what is wrong.
If you had to certify the cause of death what would you give as;
a. The immediate cause of death
b. The underlying diseases that gave rise to a)?
24
Essentials of Clinical Medicine
Heart
Description?
Problem?
Coronary Artery
Description?
Problem?
Essentials of Clinical Medicine
25
Kidney
Description?
Problem?
Cause of Death
a) …………………………………….(immediate cause)
b)……………………………………..(underling cause leading to a)
c)……………………………………..(underling cause leading to b)
d)……………………………………..(underling cause leading to c)
26
Essentials of Clinical Medicine
Session Title:
An Introduction to Haematology
Date: 9 September 2010, 1100-1215
Session Leader:
Email:
Dr Beth Harrison
Consultant Haematologist
University Hospital Coventry and Warwickshire
beth.harrison@uhcw.nhs.uk
Overview
This session aims to introduce you to some general aspects
of haematology related to red blood cells and blood
coagulation and will help you in your understanding of some
Semester 1 modules including respiratory and cardiovascular
physiology.
Teaching Aims:
To understand what blood parameters can be
measured in a Haematology Laboratory
To understand how we decide what is normal and
abnormal in a blood count
To understand the work of a blood transfusion
laboratory
To understand Virchow’s Triad
Intended Learning Outcomes:
By the end of the session the student will be able to
understand;
What do red blood cells do?
What is anaemia?
What is the ABO blood group system?
Why does blood clot (principles)?
Structure of the Session:
The session begins with a lecture. The themes will be
explored further in the group work.
Required and Recommended Reading
This is an introductory talk and there is no required reading.
Essentials of Clinical Medicine
27
Group Work (Haematology)
Exercise 1
This is the full blood count on a young woman with longstanding tiredness. What
abnormalities can you see in the results? (You have been given the reference
ranges.)
Test Name
WBC
Rbc
Hb
Hct
MCV
MCHC
Plt
Neut
Lymp
Mono
Eos
Baso
NRC
Comments
Result
7.59
3.30
6.3
0.220
67.6
28.3
571
6.45
0.91
0.23
0.00
0.00
0.00
Blood Film. Microcytosis.
Hypochromasia.
Unit
x10^9/l
x10^12/l
g/dl
l/l
fl
g/dl
x10^9/l
x10^9/l
x10^9/l
x10^9/l
x10^9/l
x10^9/l
x10^9/l
Reference Range
4.00-11.00
4.10-5.10
12.0-15.0
0.360-0.460
80.0-100.0
31.5-34.5
140-400
2.00-7.00
1.00-3.00
0.20-1.00
0.02-0.50
0.01-0.10
Hb=Haemoglobin; WBC=White Blood Cell Count; Rbc=Red Cell Count; MCV=Mean Cell Volume;
Plt=Platelet count
Please list the abnormalities:
Can you think of anything that might be causing these abnormalities?
You may not know the names of the tests but what other pieces of information
would you like to find out?
28
Essentials of Clinical Medicine
Exercise 2
A 40 year old woman has just presented to you with a swollen leg after a 10 hour
coach journey down from Edinburgh to see her sister. She is on the combined oral
contraceptive pill and is a life long smoker. Her BMI is 41. She had an arthroscopy
on her knee 4 weeks ago to investigate pain following a twisting injury. She is
concerned because her mother died following a pulmonary embolism aged 38.
List her risk factors for a venous thrombosis under the different elements of
Virchow’s triad
Blood
Vessel
Flow
If you don’t do something about the blood clot in her leg what might happen to
her?
Essentials of Clinical Medicine
29
Exercise 3
Blood Group antigens and antibodies:
Blood Group O: Red cells do not express Blood Group A or Blood Group B on
their cell surfaces. Plasma contains antibodies against Blood Group A and Blood
Group B (“Anti-A” and “Anti-B”). “Anti-A” and “Anti-B” lyse red cells of Blood Group
A and B respectively.
Which blood (red cells) can patients of the following groups receive?
Patient is
Blood Group A
Blood Group AB
Blood Group B
Blood Group O
Can receive blood of group(s)
Individuals of Blood Group ______ are known as universal donors because their
blood can be given safely to patients of all blood groups.
Individuals of Blood Group ______ are known as universal recipients.
Some one of Blood Group AB can receive plasma from donors of which Blood
Group and why?
30
A______________________________________________
Essentials of Clinical Medicine
Session Title: Introduction to Clinical Biochemistry
Date: 9 September 2010, 1345-1500
Session Leader:
Email:
Dr Steve Smith
Consultant Clinical Biochemist
University Hospitals of Coventry & Warwickshire
steve.smith@uhcw.nhs.uk
Overview:
This session is intended as an introduction to Clinical
Biochemistry, its scope and terminology.
Teaching Aims:
Introduction to interpretation in Clinical Biochemistry and the
use of Clinical Biochemistry tests in patient diagnosis and
management.
Intended Learning Outcomes: At the end of the session you will:
1. Understand some of the terminology
2. Be able to describe the role of Clinical Biochemistry in the
diagnosis and management of electrolyte disorders
3. Be able to describe the role of Clinical Biochemistry in the
diagnosis of diabetes
4. Understand how Clinical Biochemistry supports the diagnosis
a. and management of renal disease
5. Understand how Clinical Biochemistry links with the other
a. Pathology disciplines
Required and Recommended Reading
This is an introductory session and there is no required prior
reading. However the basics of Clinical Biochemistry are well
covered in;
Clinical Biochemistry: An illustrated Colour Text, 4th Ed.
A. Gaw, MJ Murphy, RA Cowan, DStJ O’Reilly, MJ Stewart, J.
Shepherd. Churchill Livingstone.
Essentials of Clinical Medicine
31
Group Work (Clinical Biochemistry)
Case 1
A 50 year old man turns up at his General Practitioner’s complaining of tiredness.
The GP hasn’t seen the patient for many years and decides to do a check-up as
he is significantly overweight and a known smoker?
What checks would you do and why?
(The findings will be provided on the day)
What might have happened if these had not been done for a few years longer?
The GP after reviewing the findings decided to arrange for the patient to have a
Glucose Tolerance Test (GTT).
What is a glucose tolerance test and what is it used for?
What preparation does the patient need to do and what should they not do during
the test?
The results of the patient’s GTT were as follows:
0 min Glucose
= 5.8 mmol/L
120 min Glucose
= 12.6 mmol/L
What do these results indicate?
32
Essentials of Clinical Medicine
Case 2.
65 year old male, known Type 2 diabetic attends for his annual check having had
a blood test a week earlier.
What are these tests designed to indicate?
What conclusions did the GP draw from these results?
Weight
BP
Sodium
Potassium
Urea
Creatinine
eGFR
95kg
150/95
140 mmol/L (135-143)
3.2 mmol/L (3.7-5.0)
7.5 mmol/l (2.6-6.6)
105 μmol/L (59-104)
65 ml/min/1.73m2 (<60)
Full Blood Count: No abnormalities
Urine Albumin 50mg/mmol Creatinine (<2.5)
HbA1C
8.0% (DCCT ) (6.5% -7.5%)
TSH
6.5 mIU/L (0.34 – 4.0)
Glucose (Non fasting) 6.0 mmol/L (<7.8)
What would the GP’s suggestions to the patient be in the light of these results?
Case 3
A 19 year old male was involved in a road traffic accident. Both femurs were
fractured and his spleen was ruptured. Two days after surgery and transfusion of
16 units of blood the following results were found:
Sodium 136 mmol/L (135-143)
Potassium 6.1 mmol/L (3.7-5.0)
Urea 20.9 mmol/L (2.6-6.6)
Creatinine 190 μmol/l (59-104)
Adjusted Calcium 2.40 mmol/L (2.222.58)
Phosphate 2.8 mmol/l (0.75-1.40)
Bicarbonate 17 mmol/L (22-29)
The patient was producing only 10 ml urine per hour and a spot urine sodium was
8mmol/L
What diagnosis pulls all this information together?
Essentials of Clinical Medicine
33
Why is no eGFR quoted?
What is an ‘adjusted’ calcium? What is it adjusted for?
What follow-up tests should be performed and how frequently?
What are the three phases of acute renal failure?
34
Essentials of Clinical Medicine
Session Title:
Introduction to Microbiology
Session Date:
9 September 2010
1515 – 1630
Session Leader:
Title:
Department:
Email:
Tel:
Dr Peter Gayo Munthali
Consultant Microbiologist and Honorary Associate Professor
Microbiology, UHCW
peter.munthali@uhcw.nhs.uk
024 7692 5472
Overview:
This session is intended as an introduction to the microbiology
component of the infection and immunity module. Most of the
themes introduced will be covered in more detail during the
immunity and infection module.
Teaching Aims:
The session aims to familiarise you with the concepts of;
1.What
is
Microbiology?
What
does
a
microbiologist/Virologist do?
2. Bacteria, anatomy and classification
3. Viruses and classification
4. Common themes in bacterial and viral infections
5. Mycology and disease
6. Infection control
7. Antibiotics and other anti-infectives
clinical
Intended Learning Outcomes:
By the end of the session the student will be able to;
1. Describe the role of a clinical microbiologist/virologist in
patient care
2. Describe the difference between bacteria and viruses.
3. Distinguish between gram-positive and gram-negative
bacteria
4. Describe bacteria by their shape as either cocci or rods
5. Describe the relationship between viruses and cells in viral
multiplication
6. Name some common bacterial and viral diseases linked to
their causative organisms
7. Describe in broad terms, how antibiotics work on bacteria
8. Describe the importance of infection control in health care
Essentials of Clinical Medicine
35
Structure of the Session:
This is a lecture and group work in which the themes raised in the lecture
will be further explored.
Cross-Modular Themes:
Infection & the Immune System: Immunology module; The anatomical
organisation of the immune system and how it is adapted to resist infection,
the main effector mechanisms of the immune response and how they are
generated and function and the control of immune response to limit self
damage.
Pathology module; understanding the function of the neutrophil and chronic
inflammation including Granulomatous inflammation
Introduction to Molecules module; functions of the major cellular organelles,
transcription, replication and translation and functions of a biological
membrane
Handouts and other relevant Information:
Available on-line prior to the lecture
Required and Recommended Reading:
This is an introductory talk and prior reading is not mandatory. However
those who would like prior reading, and especially those without prior
biology knowledge, can read the following;
Clinical Microbiology by J. Keith Struthers;
Chapter 1 and parts of Chapters 2-4
Medical Microbiology by Morag C. Timbury;
Chapter 2, Bacteria-structure, growth, nutrition and genetics
Chapter 20, Viruses: general properties, host response and replication
These will act as a brief introduction to basic microbiology on which you will be
able to build on during the immunity and infection module and throughout your
medical school training.
Assessment:
Material from this session which acts as an introduction to the subject prior to the
immune and infection module may be directly or indirectly included in the End of
Semester (ESA) written assessments and Objective Structured Clinical
Examinations (OSCE) and may be included in all subsequent assessments in
Phase I.
36
Essentials of Clinical Medicine
Group Work (Microbiology)
Case 1
1a.
A 43 year old man presents with this condition, what is the diagnosis?
1b.
A swab was taken from the lesion, describe what process is seen on the
agar plate (choose one).
a.
b.
c.
Gamma haemolysis
Alpha haemolysis
Beta haemolysis
1c.
Describe the microscopic appearance of the organism
1d.
What do you think is the name of the organism? (Choose one)
a.
b.
c.
d.
e.
f.
Staphylococci
Beta haemolytic Staphylococci
Alpha haemolytic streptococci
Beta haemolytic streptococci
Gamma haemolytic streptococci
Beta haemolytic staphylococci
1e.
To which antibiotics is the organism resistant?
1f.
Which antibiotics would you use to treat this infection? (You can choose
more than one
a.
b.
c.
d.
e.
f.
g.
Co-trimoxazole
Penicillin
Clarithromycin
Clindamycin
Linezolid
Erythromycin
Tetracycline
Case 2
2a.
Loveness Wariki, a 70 year old alcoholic woman presents with shortness of
breath, “the worst headache of my life” and pain when looking at lights
(photophobia). A chest X-ray was done and a lumbar puncture performed.
A few hours later her shortness of breath worsened and required intubation
for ventilation in Intensive Care Unit. She was started on benzylpenicillin 2.4
g 4 hourly.
Describe the CXR. (Choose one)
a.
b.
c.
d.
e.
f.
g.
Right lower zone consolidation
Bilateral consolidation
Left upper zone consolidation
Right upper zone consolidation
Right middle lobe consolidation
Left lower zone consolidation
Normal chest X-ray
Essentials of Clinical Medicine
37
2b.
A blood culture and cerebral spinal fluid (CSF) grew this organism.
Describe its cultural appearances. (Choose one)
a.
b.
c.
2c.
Which term best describes the organism on microscopy. (Choose one)
a.
b.
c.
d.
e.
2d.
Gram-positive cocci
Gram-negative cocci
Gram-negative cocci
Gram-positive diplococci
Gram-negative diplococci
Choose the most likely name for this organism
a.
b.
c.
d.
e.
2e.
Gamma haemolytic colonies
Alpha haemolytic colonies
Beta haemolytic colonies
Staphylococcus aureus
Beta haemolytic Streptococci
Streptococcus pneumoniae
Neisseria meningitides
Methicillin resistant Staphylococcus aureus (MRSA)
What is the most appropriate diagnoses for Loveness? (You can choose
more than one)
a.
b.
c.
d.
e.
f.
g.
h.
Atypical pneumonia
Community acquired pneumonia
Pneumococcal pneumonia
Staphylococcus pneumonia
Bacterial meningitis
Meningitis due to Neisseria meningitides
Pneumococcal meningitis
Staphylococcus meningitis
Case 3
3a.
This is a back of Endless Mavalas, a 13 year old girl who has been sent
back from school because she is unwell. Several other pupils have this
condition.
What is the most likely diagnosis?
a.
b.
c.
d.
e.
f.
g.
3b.
38
Measles
Urticaria
Herpes simplex
Chicken pox
Small pox
Rubella
Shingles
Mr Hopeful Lejend had a similar condition at 10 years of age.
He is complaining of burning pain from this lesion.
What is the diagnosis?
Essentials of Clinical Medicine
Group Work (Microbiology) Cases Pictures
Case 1
1a
1b
1c
1e
Essentials of Clinical Medicine
39
Antibiotic Sensitivity Plate
21.5mm
23mm
10mm
11mm
30mm
Key for 1e
S-Sensitive, R-Resistant
Antibiotic
Co-trimoxazole
Penicillin
Clarithromycin
Clindamycin
Linezolid
Erythromycin
Tetracycline
Code
A
B
C
D
E
F
G
Zone Sizes
Sensitive
≥ 20mm
≥ 20mm
≥ 22mm
≥ 17mm
≥ 20mm
≥ 22mm
≥ 20mm
Status
Resistant
≤ 16mm
≤ 19mm
≤ 19mm
≤ 16mm
≤ 19mm
≤ 19mm
≤ 19mm
R
S
R
R
S
R
S
Case 2
40
Essentials of Clinical Medicine
2a
Loveness Wariki CXR on Admission
2b
2c
Essentials of Clinical Medicine
41
Case 3
3a
Endless Mavalas’s Spots
42
Essentials of Clinical Medicine
3b
Mr. Hopeful Lejend’s Face
Essentials of Clinical Medicine
43
Session 7
Date: 10 September 2010
Introduction to Clinical Skills II: What is a sign – The Physical
Examination
Session Leader:
Email:
Dr Linda Maxwell
Hillcrestmm@aol.com
Overview
Physical examination is a different but no less exacting skill than history taking. It
is art but also science. Long hours of practice, study and experience are required
to learn this new art, which calls into play visual, auditory, olfactory, tactile and
muscular senses.
The ability to observe is one of the marks of a fine clinician. This session will start
the long process of developing your observational skills necessary for good clinical
practice. It will also introduce the all important vital signs.
Objectives
After the session the student should be able to:

Define a sign

Recognise the needs, sensitivity and rights of the patient

Recognise that visual, auditory, olfactory, tactile and muscular senses are all
used when examining the patient

Differentiate between the need for a comprehensive examination and a
focused examination

Understand the importance of a good preparation and organisation before
examining a patient

Understand the importance of observation of the whole patient first, then the
detail.

Conducet a general survey of the patient

List and recognise some common signs found on general examination.

Understand the importance of and list the vital signs

Define normal temperature range and
thermometers used to take a temperature

Attempt to palpate a pulse and measure a blood pressure

Count respiratory rate and assess the rhythm, depth and effort of breathing

Read and enter data onto an observation chart

Describe your findings with respect to the general survey and vital signs
44
discuss
different
types
of
Essentials of Clinical Medicine
Structure of the Session
There will be two lectures and one small group session.
Lecture 1
General aspects of physical examination and common signs
Lecture 2
Vital signs
Small Group Vital signs and Observation charts
Required and Recommended Reading
1.
Introduction to Clinical Examination (essential to read for CSc1)
M J Ford, I Hennessy, A Japp, Elsevier 2005
2.
Clinical Skills
NLT Cox and T A Roper
Oxford Core Texts, Oxford University Press, 0192628747, 2005
3.
Clinical Examination: A Systematic Guide to Physical Diagnosis
N J Talley and S O’Connor (CD and e-text)
Elsevier 2006
4.
Lecture Notes on Clinical Skills
Chris Hatton and Roger Blackwood
4th Edition, Blackwell, 0632065117
5.
Pocket to Guide to Clinical Examination
Owen Epstein, G David Perkin, John Cookson, David P de Bono
3rd Edition, Mosby, 0723425760
6.
Clinical Medicine
Praveen Kumar and Michael Clark
Latest Edition, W B Saunders, 0702025798
Reference book:
Color atlas of physical signs in general medicine
Zatouroff M Mosley
Essentials of Clinical Medicine
45
Session 8
Date: 10 September 2010
Integrated Learning Sessions - Putting the week together!
Session Leaders: The Clinical Education Fellows (The CEFs)
Overview
Interactive session with the Clinical Education Fellows to aid understanding of how
all of the concepts include in the past week can be integrated and examined.
Teaching Aims
Review of the week
Introduction to Short Answer Question format
Revision session
Intended Learning Outcomes
To allow students to clarify issues arising from the first week of the Essentials of
Clinical Medicine course.
To introduce students to the integrated nature of the majority of examination
questions.
To emphasise the importance of group work and team working in the Medical
School and NHS
46
Essentials of Clinical Medicine
Session 9
Date: 14 September 2010
Introduction to Clinical Scenarios and Evidence Based Medicine
Session Leader:
Email:
Dr Jeremy Shearman
Consultant Gastroenterologist
South Warwickshire Foundation Trust
jeremy.shearman@swft.nhs.uk
Overview
A practical introduction to clinical case scenarios with some worked examples of
clinical problem solving.
Teaching Aims
To illustrate some fundamental principles of history taking, physical examination
and the use of investigations.
To demonstrate how technical aspects of clinical investigation are much easier if
one applies basic patho-physiological principles to the history the patient has
given.
To prompt a realisation that the key to clinical medicine is the ability to ask good
questions.
Intended Learning Outcomes
After this session you should:
 Be able to understand why you might want to be a doctor
 Be keen to embark on a career in clinical medicine
 Be able to view the “pre-clinical” lectures in the context of the clinical course
Recommended Reading
Level one – for everyone
Evidence based medicine: what it is and what it isn’t
Sackett et al BMJ 1996; 312: 71-72
Level two – for further reading for those who are interested
Evidence based medicine: How to practice and teach EBM
Straus et al 2005 Elsevier
ISBN-10: 0-443-07444-5
Level three – for the “boffs”
Clinical epidemiology – how to do clinical practice research 3rd Ed
Haynes et al 2006 Lippencott Williams and Wilkins
ISBN-10: 0781745241
Essentials of Clinical Medicine
47
Group Work for Session 9
Introduction to clinical scenarios and evidence based medicine (EBM)
In groups of three or four students the following case scenarios should be
considered and discussed for no more than10mins. The groups should then
discuss their responses with the other groups.
Case 2
A 32 year-old plumber attends the clinic with his wife following a recent episode of
rectal bleeding. He describes the blood as bright red and present predominantly
on the toilet paper. His grandfather died at the age of 88 with bowel cancer.

What does the patient think is the cause of the problem?

Why has his wife come with him?

What is the most likely cause of the problem?

What other information would do need from the patient (i.e. what other
questions should you ask)?

What sort of investigation would be most worthwhile?
Case 3
A 72 year-old man is referred to the clinic because of iron deficiency anaemia. He
has no symptoms. He takes blood pressure medication, aspirin and clopidogrel
since a coronary stent was placed 6 months ago.

What do you suspect might explain his test results?

Might there be other explanations?

What sort of investigations might the patient need?

Will those investigations seem logical to a patient with no symptoms?

How might you explain your concerns?
Case 4
A 22 year-old drug user presents to the A+E department with a swollen left leg.
Despite being on methadone he continues to inject heroin and the A+E
department tell you that he has already attended their department 3 times that
week.
48

Why might the patient have attended hospital?

What is the most likely cause of the swollen leg?

What sort of investigations might be useful?

What are your thoughts on treatment?
Essentials of Clinical Medicine
Case 5
As a junior doctor you are called to a cardiac arrest.
An 85 year-old man has collapsed. He had been admitted to hospital five days
previously after a blackout. He is a retired public health doctor. He now lives on his
own since the death of his wife 2 years previously. On admission his neighbours
expressed concern about his memory. He has prostate cancer and is on hormonal
therapy.
By the time you arrive on the ward the nursing staff have initiated advanced life
support and his ECG shows asystole (no electrical activity).

What do you think is the likely outcome?

What do you see as your priority?

To whom do you have a responsibility and why?
Essentials of Clinical Medicine
49
Session 10
Date: 21 September 2010
Introduction to Physiology
Session Leader:
Email:
Dr David Tweedie
david@tweedie.info
Overview
The session consists of two lectures and group work. The intention is to introduce
some general concepts in physics and physiology.
Teaching Aims
To introduce and give insight into some general principles that will be needed in
later modules.will be dealt with in greater Learning Outcomes and Reading
needed
To refresh students knowledge on some basic physical principles underpinning
human physiology
Intended learning outcomes
To understand some basic physical principles, and their importance in clinical
practice
To understand of some of the processes in physiology and their importance in
clinical practice
To prompt students to understand that physiology underpins the practice of
medicine
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Group work for session 10
Pressure
Take each other’s blood pressure - the facilitators will show you how - and then
answer the questions.
1. “You have found that the blood pressure is about ***mm Hg [mm of
mercury].
2.
How high would the column be if the manometer contained water?” [Hint:
SG of mercury is 13.6 times that of water. Or - unscientifically, it is 13.6
times as heavy]
3. You are measuring CVP with a water manometer. You find that the
pressure is 5 cm of water when the zero of the manometer is level with the
heart. If someone lowers the patients bed by 10 cm without adjusting the
zero, what will the new reading be?
4.
When might this happen and does it matter?
Nerve, muscle & reflexes
Use the tendon hammer provided to try eliciting the knee jerk and ankle jerk
reflexes.
Try the reflex with the joint as straight as possible, and at 90 degrees.
1. Which position gives a better ‘twitch’
2. Why do you think this is? (there must be tension in the muscle or tendon for
demonstration of reflex)
3. Think about what this means for some of the other joint reflexes we regularly
examine. (eg. for biceps reflex you may need to stretch the tendon with your finger
before you can elicit reflex)
4. Try eliciting the same reflexes with your subject clenching their teeth hard.
5. Can you convince yourself of a difference? Why does this difference occur?
You will notice that it can be very difficult to be sure that a failure to elicit a reflex
jerk is definitely due to decreased tone, and not operator technique! It is good
technique always to compare sides but the only way to be sure is a lot of practice.
Fluid compartments
As a doctor in A&E you have to resuscitate a patient who has
lost a lot of fluid. What fluid would you use – and why - if the fluid lost was
a] blood because of trauma?
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51
b] water because of e.g. severe diarrhoea?
If you had no blood what fluid would you use?
Acid / Base
Look at the following blood gas results and consider the questions below.
Normal results are given below as a help.
Normal values:
7.35 – 7.45 (lower = acidosis, higher = alkalosis)
PO2 10 – 13 kPa
PCO2 4 – 4.5 (high CO2 = resp. acidosis, low CO2 = resp alkalosis)
BE
-2 - +2 (negative = metab. acidosis, positive = met. Alkalosis)
pH
1. This patient is complaining of a 12 hour history of abdominal pain.
pH
pO2
pCO2
BE
7.2
13
4.0
-8.0
On 21% oxygen.
1.
2.
3.
4.
Does the pH show an overall acidosis or an alkalosis?
Is the problem respiratory or metabolic?
What might be happening in the body tissues to cause this problem?
What could the body do to compensate?
2. This patient is on a ventilator in the ITU
pH
pO2
pCO2
BE
7.8
15
2.5
-1.0
On 30% oxygen.
1.
2.
3.
4.
Does the pH show an overall acidosis or an alkalosis?
Is the problem respiratory or metabolic?
What do you think is causing the problem?
What would the body do if it had control of respiration at this time?
3. This patient is on home oxygen 24% for long standing COPD.
pH
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7.35
Essentials of Clinical Medicine
pO2 9.1
pCO2 7.0
BE
+6.4
1. The pH appears normal, but what are the respiratory and metabolic
components doing?
2. Which do you think is the underlying problem, and which is compensating?
3. How long does it take for this ‘balance’ to happen?
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Session 11
Date: 28 September 2010
Introduction to Molecules
Session Leader:
Email:
Dr Graham Ladds
graham.ladds@warwick.ac.uk
Overview
This session is aim at refreshing some of the session cover in the first five weeks
of the molecules module. We will cover general principles of Genetics, Membrane
structure, transport of ions, receptors and cellular signalling and protein structure.
A brief question and answer session will enable any problems students have had
on the molecules module to be discussed.
Teaching Aims
(1)
To help with any difficulties that students are having with the material
covered in Molecules in the human body to date. Please let me know any
topics or concepts that you want covered.
(2)
Introduce a fully integrated ESA-style question, so students can see how the
material from different modules fits together, and have practice doing a
question.
Intended Learning Outcomes
To be able to access support for Molecules in the human body.
To gain understanding of how learning from modules is integrated within the ESA
questions and practice doing a question.
Structure of the Session:
1:45 to 4:00 Revision of Molecules in the human body – Key/Difficult Issues
Lecture
4:00 to 4:30 Questions using ESA format
4:30 to 5:00 Questions from students
Required and Recommended Reading
None.
However, please let us know any topics or concepts that you want covered by
emailing Graham Ladds on graham.ladds@warwick.ac.uk.
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Essentials of Clinical Medicine
Session 12
Date: 5 October 2010
Respiratory and Cardiovascular Anatomy
Session Leader:
Email:
Dr David Tweedie
david@tweedie.info
Teaching Aims
To introduce students to the anatomy of cardiovascular and respiratory systems.
Objectives Intended Learning Outcomes
After the session students should have a basic understanding of:




Basic cardiovascular physiology; to help understanding of pulsatile, one-way
flow and the double circulation of blood
Structure and function of blood vessels
Structure of heart
Overview of vascular tree





Basic respiratory physiology; to help understanding of tidal flow of respiration
Overview of respiratory system
Structure of thorax
Structure of airways
Structure of lungs




Surface anatomy
Bony landmarks; sternum, spine, ribs
Heart
Lungs
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Session 13
Date: 12 October 2010
Session Leader:
Email:
Dr Alex Conner
a.c.conner@warwick.ac.uk
Overview
All of the body’s functions are carried out by collections of cells all working
together. Just like with normal physiology (understanding the parts and how they
work), this session will describe the average cell and how they can specialise.
There will be an emphasis on the normal functions of the cell allowing most of the
body’s processes to occur. The disruption of these processes and the relevance
for medicine will be discussed.
Teaching Aims
This session will describe the fundamental cell biology needed to understand how
the body works at a cellular level.
The core functions of cells will be described. This will include the production of
proteins from DNA, the movement of proteins around the cell and the relevance of
ions for cellular function. This is key to understanding all of the processes involved
in
Knowing the effects of treatments on cellular components will allow a more
complete understanding of therapeutic intervention.
Intended Learning Outcomes
1. To have a broad understanding of cell biology including the names, function and
clinical relevance of the cell’s main constituents.
2. To understand the general physiology of cellular actions with an emphasis on
cellular trafficking and signalling, neuronal transmission and muscle contraction.
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Essentials of Clinical Medicine
Group Work:
Cell Physiology
Using the model and list of terms given below correctly label the typical eukaryotic
cell:
List of Terms
Ribosomes
Mitochondria
Chromatin
Nucleolus
Golgi complex
Vacuole
Nuclear pore
Lysosome
Cytoplasm
Nuclear envelope
Rough ER
Microfilaments
Plasma Membrane
Microtubule
Smooth ER
Centriole
Questions:
1. Describe the contents and function of the nucleus.
2. Describe the functions of the ER
3. Outline the physiological importance of the cell membrane
4. Describe the structure and function of the mitochondria.
“The Central Dogma” is the requirement of a cell to convert DNA to mRNA
to protein. The DNA is held in the nucleus and transcribed to mRNA. The
mRNA is translated into protein in the cytoplasmic via the rough
endoplasmic reticulum. This process is all held in place by the membrane
and is provided with energy by the mitochondria.
5. Can you think of ways in which the organelles/features outlined in questions
1-4, may be involved in the onset or treatment of diseases?
i Nucleus
ii ER
iii Cell Membrane
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57
iv Mitochondria.
6. Label the cells a-f
a
58
b
c
d
e
f
Essentials of Clinical Medicine
Session 14
Date: 19 October 2010
Session Leaders: Dr Dawn Collins
Emails:
dawn.collins@warwick.ac.uk
Overview
This session will highlight the gross structure and functions of the most fascinating
system in the body. A thorough understanding of the structure and function of the
nervous system is vital for understanding how the body works as the nervous
system forms the hub that controls all bodily functions, from thinking and feeling to
eating and reproducing. By understanding how the nervous system works and how
changes in the activity within this system impacts on the other systems, you can
figure out how changes and deficiencies may cause the symptoms that you
associate with different diseases and disorders.
Teaching Aims
In the previous session, the cellular composition of the nervous system was
discussed. This session will expand on this and discuss the gross anatomy and
functioning of the nervous system and how you can relate this to the functioning of
the whole body. A good understanding of how a normally functioning nervous
system works will allow you to predict the outcomes and symptoms that you might
observe in clinical situations when a patient has suffered damage to their nervous
system.
The nervous system has been divided into many components according to
structure and function. These components and how they interact to link brain to
body will be discussed. The main classification of the nervous system into central
and peripheral components and the relationship between the two will be
discussed. A review of the gross anatomy of the central nervous system will be
provided and give insight into how different areas control different functions and
how this can be applied in clinical cases. The link between central and peripheral
nervous system will be reviewed and the control of somatic and visceral
functioning elucidated.
Intended Learning Outcomes
At the end of the session and the prescribed reading the student will be able to:





Understand the basic arrangement of the nervous system into, for example:
central and peripheral, somatic and visceral components and the structures
that comprise and are involved in the control of these elements
Describe the structure and functional component parts of the brain
Describe the structure and function of the spinal cord
State the component parts of the peripheral nervous system and understand
the signals that peripheral nerves carry
Understand how the function of the nervous system can be tested in the
clinic
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59
Structure of the Session
The structure of the session will be confirmed on the website closer to the date,
but will consist of a lecture session followed by group work and/or self-directed
study.
Cross-Modular Themes
No human function can be understood thoroughly without an understanding of how
the nervous system operates as it is central to the control of every aspect of the
body. The information discussed in this session will be utilised in every other
biological module you study. Testing of the nervous system is a vital component
that you will learn in Clinical Skills in semester 1; the anatomy will support your
understanding of clinical conditions and the effects of lesions occurring in different
regions of the CNS and will become more relevant as you move through the
semesters.
Handouts and other relevant Information
The lectures will be placed on the Medical School Intranet and various materials
will be handed out for the small group sessions.
Required and Recommended Reading
We recommend that you have access to a basic physiology book that details the
basic anatomy and functioning of the nervous system for revision purposes, this
knowledge can be expanded on as you work through Phase 1 and give you a
good grounding for the Neurobiology module in Semester 3.
For lighter reading, any books by Oliver Sacks (e.g. The Man who Mistook his
Wife for a Hat; An Anthropologist on Mars; Islands of the Colour Blind), will give
you a fascinating insight into the life of a neurologist and the inspiring cases that
you may encounter.
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Essentials of Clinical Medicine
Group Work Questions
Q1. Indicate the cerebral regions of the following lobes and note which major
function they control.
Frontal
Parietal
Temporal
Occipital
Q2. On the same figure, show the position of the central sulcus, lateral sulcus and
cerebellum.
Q3. What is the precentral gyrus mainly involved in?
Q4. And the postcentral gyrus?
Q5. Regions of the brain can also be defined according to their cerebral structure,
these areas have been given numbers. What are the numbers known as?
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61
Q6. On the diagram of the brain below, indicate the areas involved with
Vision
Hearing
Motor function
Sensation
Taste
Speech
Q7. What would the effect of losing the blood supply to the areas labelled 17?
Q8. Areas 41 & 42 are also know by what name (clue: involved in language)?
Q9. Label the follow diagram (and add any other areas you know). In what plane is
the figure made?
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Essentials of Clinical Medicine
Q10. Label the following figure of the spinal cord
Q11. Label the following external view of the base of the skull
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63
Q12. Label the following internal view of the base of the skull
Q13. Which lobe of the brain sits in the anterior fossa of the skull?
Q14. Which lobe of the brain sits in the middle cranial fossa of the skull?
Q15. Which lobe of the brain sits in the posterior cranial fossa of the skull?
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Essentials of Clinical Medicine
Q17. Label the spinal and vertebral levels. Note how the offset between levels
changes as you go down the vertebral column.
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65
Session 15
Date: 26 October 2010
Introduction to Imaging Techniques
Session Leader: Dr Fraser Millard
Email: Fraser.Millard@swh.nhs.uk
Overview:
What do you think is the most important scientific invention? To celebrate its
centenary in 2009, the Science Museum conducted a poll to answer this question.
The winner was the x-ray machine.
X-rays were discovered in 1895 by Wilhelm Röntgen who received the first Nobel
Prize in Physics in 1901. Further imaging techniques are now widely available,
Ultrasound, Computed Tomography (Allan Cormack and Godfrey Hounsfield, the
Nobel Prize in Medicine 1979), Magnetic Resonance Imaging (Paul Lauterbur and
Sir Peter Mansfield, the Nobel Prize in Medicine 2003), and Nuclear Medicine.
These techniques are used to show anatomy, pathology and more recently the
function of the human body in both health and disease. Technological advances
have also led to the development of fine instruments and devices which may be
introduced into the body to obtain images and perform interventions to treat
patients. The development of the microchip and modern computing have
revolutionised the amount of information obtained by these imaging techniques
and how this information is stored and shared between providers of healthcare. As
a result there has been a huge expansion in the role of imaging in the investigation
and treatment of patients. However, as well as these benefits, imaging also has
risks from the exposure to ionising radiation and magnetic fields, and
complications from contrast agents such as allergic reactions and renal failure,
interventional procedures, and over diagnosis and over treatment.
When you qualify as Doctors in less than four years time, these techniques will
become available for you to request in your practice. How may imaging help you to
manage your patients? Which is the best imaging technique to request and how
will it affect your patients? How will you interpret and use the information
generated? By the end of the afternoon I hope you will have tasted a flavour of this
topic and whetted your appetites to find out more.
Teaching Aims and Intended Learning Outcomes:






66
An understanding of the role of imaging in patient management
The principles of interpretation of basic radiological studies
A basic understanding of the imaging techniques available and their
advantages and disadvantages
An introduction to radiation protection of the patient
An understanding of what the patient will experience when undergoing
investigations in the radiology department
The role of the imaging department
Essentials of Clinical Medicine
Preparation for the Session:
To read the Introduction to Weir J, Abrahams P, Spratt J, Salkowski L.. Imaging
Atlas of Human Anatomy. Mosby Elsevier 2010 Fourth Edition.
See WMS library or intranet.
Recommended Reading:
Weir J, Abrahams P, Spratt J, Salkowski L. Imaging Atlas of Human Anatomy.
Mosby Elsevier, 2010 Fourth Edition.
See WMS library or intranet.
Patel P. Lecture Notes: Radiology. Blackwell Publishing, 2010 Third Edition.
The Royal College of Radiologists. Making the best use of clinical radiology
services: referral guidelines. London: The Royal College of Radiologists, 2007.
Additional Information
Imaging Techniques - their basic principles - usages and relevance to
anatomical studies and clinical medicine are only too self evident as modern
medicine relies so much on exact diagnosis often confirmed by imaging. This
session will introduce you to the anatomical terminology of various views and
techniques of imaging. It will also show you why certain methodologies are best for
certain clinical situations and how the anatomy is shown in different ways by
different modalities ie ultrasound looks like a snowstorm at first but is the most
reliable method to diagnose someone with abdominal pain, whereas an MR
(magnetic Resonace ) imaging is the best way to see if an intervertebral disc is
prolapsed and yet a crush fracture of the adjacent vertebra may be best visualised
by a CT (Computerised Tomogram) scan. We will also see examples of most
common modern imaging techniques and how the terminology of anatomy is used
in their description of the normal and pathological conditions. All modules and all
clinicians use imaging so it is important to learn the normal anatomy of most
structures so as to be able to recognise pathology in a clinical setting
"ALL YOU NEED TO KNOW ABOUT
DARED TO ASK"
MODERN
IMAGING BUT NEVER
DIAGNOSTIC X-RAY
X-rays are a form of electromagnetic radiation given off as electrons change their
orbits around a nucleus; they have a wavelength and energy between low energy
visible light and high energy cosmic radiation. The use of X-rays derives from their
energy. The body is almost completely opaque to low energy visible light and
completely transparent to high energy cosmic rays, whereas X-rays are
differentially absorbed by body constituents. X-rays pass easily through air or fatty
tissues (RADIO-TRANSPARENT) but substances such as bone, calcium stones or
heavy metals absorb most of the X-rays (RADIO-OPAQUE).
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67
A patient standing between an X-ray source and a photographic plate will cast a
varying shadow on the plate - an X-ray photograph of the body constituents. X-ray
negatives are used. This means the less dense a material, the more X-rays will
pass through onto the plate, producing a darker image.
The X-rays which do not pass on the plate release their energy inside the body,
damaging the molecules they collide with. This is the mechanism by which X-rays
are harmful - the effect is particularly seen on rapidly dividing cells, e.g. skin, gut,
the fetus or gonadal cells.
An X-ray can be taken as a single exposure of an area of the body, i.e. a PLAIN XRAY, but several other techniques are used.
The direction that the beam passes through the subject determines the name of
the view, i.e. a postero-anterior chest X-ray is taken with the subject's back
towards the beam and chest on the "cold" X-ray plate. This view is ideal for
judging heart size and lungs whereas the antero-posterior chest X-ray is much
better for viewing the vertebral bodies. Can you think why?
CONTRAST STUDIES
Body cavities, the lumen of vessels (e.g. arteries, veins, ureters) or viscera (e.g.
bowel) can be further delineated by the use of suspensions of heavy metals or
halogens.
These contrast media can be introduced in a variety of ways:
1)
2)
3)
by direct introduction (barium enema)
by injection (arteriograms)
via injection or ingestion into the bloodstream and then concentration by
specific organs [e.g. intravenous urogram (kidneys), oral cholecystogram
(gall bladder)].
X-ray pictures are taken before and after introduction of the contrast media and
one shot converted into a positive print. When the two are superimposed any
unchanging bone and soft tissue shadows will almost vanish - SUBTRACTION
TECHNIQUE. This may also been performed via a computer as in DIGITAL
SUBTRACTION ANGIOGRAPHY (DSA).
ANGIOGRAPHY
Access to the arterial system to produce an arteriogram (angiogram) is usually
obtained by puncture and catheterisation of a femoral artery under local
anaesthetic. Radiographic contrast medium is then injected into the vessel in the
area under examination. If for some reason access via the femoral artery is not
possible (eg. iliac occlusive disease or the presence of a graft) alternative sites
such as the brachial or axillary artery can be used. Translumbar aortography
(TLA), a method of arteriography involving direct percutaneous puncture of the
aorta, is now less commonly employed as it does not allow selective catherisation
of aortic branches and hence percutaneous interventional vascular procedures
cannot be performed. The development of new technology has meant that the
aorta and main upper and lower limb arteries can be visualised from an
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Essentials of Clinical Medicine
intravenous injection of contrast medium (into the brachial vein, superior vena
cava or right atrium). obviating the need for arterial puncture in some patients.
This technique employs DIGITAL SUBTRACTION ANGIOGRAPHY (DSA)
whereby unwanted background information is 'subtracted' leaving only an image of
the blood vessels. Images of arteries obtained by injection into a vein are referred
to an intravenous DSA examination (IV DSA). DSA images of arteries can, of
course, be obtained by direct intra-arterial injection (IA DSA).
Manual photographic subtraction of background information can also be performed
with conventional (non digital) arteriography. Subtraction, either photographic or
digital, is used in cases where fine vascular detail is required and can be simply
recognised by the fact that the arteries appear black as opposed to white as on an
unsubtracted film. The veins may be visualised in the same way as arteries, e.g.
by direct puncture and catheterisation (via the femoral vein in most instances).
The veins of the upper and lower limbs are imaged by injecting contrast medium
via an 18G or 20G needle placed in a peripheral vein e.g. the dorsum of the foot or
hand or the cubital fossa. Alternatively if imaging from an arterial injection over a
prolonged period of time, the arterial, capillary and venous phases can be
recorded and venous anatomy visualised. This is a particularly useful way of
imaging the portal venous system without necessitating direct trans-splenic or
trans-hepatic puncture.
NUCLEAR MEDICINE - RADIONUCLIDES
Nuclear Medicine is a medical speciality concerned with the application of
radionuclides to patients. Most of these applications remain within the field of
diagnosis, whilst some applications of radionuclides are made for therapeutic
purposes. Examples of the latter include the administration of iodine-131 for the
treatment of patients suffering from hyperthyroidism or thyroid cancer, the
administration of P-32 as treatment of POLYCYTHAEMIA VERA (disease of too
many red cells), the intra-cavity administration of therapeutic doses of
radionuclides for the treatment of malignant effusions, the intra-articular
administration of radionuclides for the treatment of benign chronic arthritic
effusions, and so on.
In most of the diagnostic procedures in nuclear medicine, trace amounts of
suitable radionuclides linked to suitable compounds (radio-pharmaceuticals) are
administered to patients in order to investigate organ or tissue function and
metabolism. Indirectly, information concerning size, shape and displacement or
organs can be recorded. With suitable radiation detectors (gamma cameras and
scanners), often associated with computer processed information, the arrival,
distribution and disappearance of a radiopharmaceutical can be monitored over a
region of interest or a particular organ.
Time activity curves and/or images are often displayed in order to analyse and
investigate the patient's condition.
Time activity curves are used in the
measurement of cerebral, hepatic or renal blood flow, whilst numerical data
analysis can be applied to the investigation of myocardial perfusion, glomerular
filtration, and a variety of other indices of organ physiology. The images recorded
(often called scans) are frequently used to investigate the presence of primary or
secondary cancer in a variety of organ systems. Tumours or metastases can be
detected either as areas with increased activity ('hot spots') or as areas of reduced
Essentials of Clinical Medicine
69
activity ('cold' spots). 'Hot' spot detection is used in the brain and in bone, whilst
'cold' spot detection is often used in the liver, lungs and kidneys.
The most commonly used radionuclide (99M-Technetium) is linked (labelled) to
compounds such as phosphates for bone scanning, chelates for brain and kidney
scanning, or colloids for liver, spleen and bone marrow scanning, or to red cells for
blood pool imaging.
Radiopharmaceuticals act as "magic bullets" for the localisation and lateralisation
of disease. The relevant merits of these diagnostic procedures include the
absence of mortality and even morbidity in all its studies, the low radiation doses
delivered to patients when compared with conventional radiological techniques,
the absence of side-effects or discomfort to patients and the overall economy of
these investigations. Radionuclide bone scans have replaced X-ray skeletal
surveys in the search for skeletal metastases – “hot spots” (frequently
encountered in patients suffering from carcinoma of the breast, prostate, lungs,
thyroid and kidney). Scans have considerably reduced the need for invasive
angiography in the detection of embolic lung disease and reduce the need for
invasive catheterisation procedures of the heart in the evaluation and follow-up of
patients suffering from myocardial ischaemia. These scans can also replace
contrast IVU studies in the assessment of renal function, and eliminate the need
for elaborate 24 hour urine collection in measurements such as creatinine
clearance. Radionuclide treatment of hyperthyroidism is today a commonly used
and most effective method of controlling this disease.
COMPUTED TOMOGRAPHY
The limitation of all plain radiographic techniques is the two dimensional
representation of a three dimensional structure. The linear attenuation coefficients
of all the tissues in the X-ray beam form the image.
Computed tomography (CT) obtains a series of different angular X-ray projections
which are processed by a computer to give a section of specified thickness. The
CT image comprises a regular matrix of picture elements (pixels). All the tissues
contained within the pixel attenuate the X-ray projections and result in a mean
attenuation value for the pixel. This value is compared with the attenuation value
of water and is displayed on a scale (the Hounsfield scale). Water is defined as 0
Hounsfield units (HU) and the scale is 2000HU wide. Air typically has a HU
number of -1000; fat is approximately -100 HU; soft tissues are in the range +20 to
+70 HU, and bone is greater than +400 HU.
The CT machine consists of a rigid metal frame with an X-ray tube sited opposite
to a set of detectors. In early designs the tube and detectors scanned across the
patient and then rotated to a different position ("translate-rotate"). Current third
generation CT machines have a wider detector array and an X-ray fan beam which
encompasses the whole patient. All the views per slice can be collected
simultaneously so that the tube and detectors only rotate around the patient.
Routine acquisition times are 2-4 seconds, though a variant of the design utilises a
constantly rotating tube/detector system which permits sub-second scan times.
All CT machines, of whatever generation, share similar components. The
detectors are either gas ionisation chambers, or scintillation crystals linked to
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Essentials of Clinical Medicine
photomultiplier tubes. The signal is digitised by an analogue-to-digital converter in
the gantry. The digitised signal is transferred to the image processing computer
and subsequently displayed on the operators console. Images are usually
photographed on medical recording film (hard copy) using optical or laser
cameras. For long term storage the data is transferred to magnetic media (tape or
disc) or to optical disc. These discs can then be stored in an imaging "Juke Box".
No specific preparation is required for examinations of the brain, spine,
musculoskeletal system and chest. Studies of the abdomen and pelvis almost
always require opacification of the gastrointestinal tract using a solution of dilute
contrast medium (either water soluble or a barium compound). Generally 7501000 ml is given orally 30-60 minutes prior to imaging, with the final 300 ml taken
as the patient enters the examination room. The large bowel may also be
opacified by a solution of contrast medium administered rectally, either in a
preparation room or on the CT table. Examinations of the female pelvis are often
performed after the insertion of a vaginal tampon to facilitate interpretation.
Identification of vascular structures may be made on the basis of anatomy alone
but may require the intravenous injection of water soluble contrast medium.
Techniques vary accordingly to the individual case but the most common method
is to inject a bolus of 50 ml followed by a rapid infusion of 50 ml using contrast
medium of 300-370 mg iodine/ml. In the last few years the new generation 64 slice
scans with 3D ROTATIONS have added a new dimension to anatomy learning you will see me use these in future modules.
ULTRASOUND
In comparison with all the other images ultrasound images do not depend on the
use of electromagnetic wave forms. It is the properties of high frequency sound
waves (longitudinal waves) and their interaction with biological tissues that go to
form these 'echograms'.
A sound wave of appropriate frequency (diagnostic range 3.5 - 10 MegaHertz) is
produced by piezo-electric principles. The size and shape of the emitting crystal
and its resonant frequency are important factors in determining the course of the
sound beam within the tissues to be examined.
As the beam passes through tissues, two important effects determine image
production:
(i)
Attenuation: This is the loss of energy from the system and is a
consequence of absorption and reflection, refraction and beam divergence
out of the range of the receiver.
(ii)
Reflection within the range of the receiver: It is the reflected sound waves
(echoes) that combine to produce the image and the image texture is
dependent upon differences in acoustic impedance between different tissues.
Ultrasound imaging systems are sensitive to the very small changes in
acoustic impedance within soft tissue structure/ranges.
In modern ultrasound imaging practice, by applying these principles, sophisticated
hardware has been developed that converts the pulse-echo system, briefly
described above, into a real-time tomographic image. Addition of the facility to
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71
measure movement (principally cardiac valves and flowing blood) by ultrasound
using the Doppler principle has lead to the development and wide availability of
Duplex Scanners.
It is the effects of shadowing and enhancement within an ultrasound image that
are of paramount importance. Systems are designed assuming an average
attenuation through a depth of tissue and balanced to give an even signal intensity
for deep and superficial tissues. Tissues causing shadowing are: fibrous, calcific
or gaseous. Tissues causing enhancement are fluids.
The advantages of an ultrasound imaging system in clinical practice are: Nonionising radiation is used. The safety of ultrasound at diagnostic power levels has
been well proven over a long time now. Main worries were of thermal effects to
local tissues and cavitation. Soft tissue images are obtained without the need for
contrast agents. Equipment is relatively cheap and mobile. Ultrasound machines
can be taken to the patient's bedside if necessary. Multiplanar and non-organ
specific imaging is possible. Real time images allow immediate operator-patient
interation to maximise the diagnostic potential of the examination and have lead to
their use in guiding -interventional procedures (biopsy and drainage). Patients find
the system very acceptable as it required only light pressure on the skin.
The limitations of an ultrasound imaging system are:
(i)
The quality and diagnostic potential of the examination are dependent on the
skill and expertise of the OPERATOR.
(ii)
Ultrasound systems are unable to image tissue - gas and tissue-bone
interfaces. Gas and bone containing structure cannot be imaged, and their
presence obscures deeper lying tissues.
By having available a selection of different ultrasound transducers of varying
frequencies and focusings, shapes and sizes, the range of imaging has been
maximised:
Ultrasound imaging is a real-time, interactive process and the quality of the images
is NOT best appreciated from hard-copy. (Printed format).So these are best seen
on VIDEO / CDRom.
MAGNETIC RESONANCE IMAGING
MRI combines a strong magnetic field and radiofrequency energy to study the
distribution and behaviour of hydrogen protons in fat and water.
The spinning proton of the hydrogen nucleus can be thought of as a tiny bar
magnet, with a north and south pole. In the absence of an external magnetic field,
the magnetic moments of all the protons in the body are randomly arranged.
However when the patient is placed in a strong magnetic field these magnetic
moments align either with or against the field lines of the magnet. There is a small
excess of magnetic moments which align with the field so a net magnetic vector is
established.
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Radiofrequency energy is used to generate a second magnetic field, perpendicular
to the static magnetic field of the machine.
The result of this second magnetic field is to rotate or "flip" the protons away from
the static magnetic field; the amount of rotation depends on the quantity of RF
energy absorbed. Once the RF field is switched off, the protons experience only
the effects of the static magnetic field and flip back to their original position. This
return to the equilibrium state is called "relaxation" and during it protons emit the
RF energy which they had acquired. This energy is detected by the antenna in the
MRI machine, digitised, amplified, and finally spatially encoded by the array
processor. The resulting images are displayed on the operator's console and can
be recorded on hard copy, for viewing, or transferred to magnetic tape or optical
disc, for storage.
MRI systems are graded according to the strength of the magnetic field they
produce. High field systems are those capable of producing a magnetic field
strength of 1-2-4-8 Tesla (10,000-20,000 Gauss), mid-field systems operate at
0.35-0.5 T and low field systems produce a field strength of less than 0.2 T. Mid
and high field systems use superconducting magnets in which the coils of copper
wire are kept in a superconducting state (-269°C) by being immersed in an
insulated helium bath. Electromagnets are fitted in resistive systems and are
limited by heating factors to 0.35 T. The third type use permanently magnetised
metal cores and are of low field strength owing to the massive weight. MRI does
not cause any recognised biologic hazard. Patients who have any form of
pacemaker or implanted electroinductive device must NOT be examined. Other
prohibited items include ferromagnetic intracranial aneurysm clips, certain types of
cardiac valve replacement, and intraocular metallic foreign bodies. Generally it is
safe to examine patients who have extracranial vascular clips and orthopaedic
prostheses, but these may cause local artefacts. Loose metal items must be
excluded from the examination room and beware of your credit cards!
The preparation for an MRI examination is simple.
clothes and must answer a strict safety questionnaire.
Patients wear metal free
MRI images may be obtained in ANY plane, but axial, coronal and sagittal views
are the most common presented. An intravenous injection of contrast medium (a
gadolinium complex) may be given to enhance tumours, inflammatory and
vascular abnormalities.The next decade will see the increased use clinically of MR
ANGIOGRAPHY (MRA) - where the flow of blood in vessels is picked up by the
detectors without the use of contrast medium or any interventional procedure- now
commonly used in assessing brain vasculature.
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Session 16
Date: 2 November 2010
Molecules in the Human Body
Session Leader:
Email:
Dr Graham Ladds
graham.ladds@warwick.ac.uk
Overview
This session is aim at refreshing some of the session cover in the first five weeks
of the molecules module. We will cover general principles of Genetics, Membrane
structure, transport of ions, receptors and cellular signalling and protein structure.
A brief question and answer session will enable any problems students have had
on the molecules module to be discussed.
Teaching Aims
(3)
To help with any difficulties that students are having with the material
covered in Molecules in the human body to date. Please let me know any
topics or concepts that you want covered.
(4)
Introduce a fully integrated ESA-style question, so students can see how the
material from different modules fits together, and have practice doing a
question.
Intended Learning Outcomes
To be able to access support for Molecules in the human body.
To gain understanding of how learning from modules is integrated within the ESA
questions and practice doing a question.
Structure of the Session:
1:45 to 4:00 Revision of Molecules in the human body – Key/Difficult Issues
Lecture
4:00 to 4:30 Questions using ESA format
4:30 to 5:00 Questions from students
Required and Recommended Reading
None.
However, please let us know any topics or concepts that you want covered by
emailing Graham Ladds on graham.ladds@warwick.ac.uk.
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Essentials of Clinical Medicine
Session 17
Date: 9 November 2010
Homeostasis
Session Leader:
Email:
Professor Peter Stanfield
p.r.stanfield@warwick.ac.uk
Overview
Claude Bernard (1878) wrote that: ‘The constancy of the internal environment is
the condition for a free and independent life’. Homeostasis is the term now used
to describe this constancy and the study of the physiological mechanisms that
regulate the internal environment. Both nervous and endocrine systems provide
the feedback systems that perform such regulation.
Teaching Aims
The session aims to introduce the concept of homeostasis as central to thinking
physiologically about human function. Body fluid balance will be used as exemplar
to illustrate the principles.
Intended learning outcomes
At the end of the session, it is intended that learners have had the opportunity to:
 understand the concept of homeostasis;
 understand the concept of balance in body water and sodium content;
 understand the compartmentalisation of the fluid compartments of the body and
the equilibria that exist between them;
 understand in general how water intake and loss are regulated;
 understand the concepts of osmolality and volume as important regulated
quantities; and
 understand in outline the roles of the nervous system and of hormones in the
regulatory processes.
Structure of the session
13.45 – 14.45
Fluid balance and the equilibria between compartments of the
body fluids (Lecture Theatre)
15.00 – 16.00
Group work (Seminar Rooms)
16.00 – 17.00
Homeostatic mechanisms and the regulation of body water
and extracellular fluid volume (Lecture Theatre)
Cross Modular Themes
Homeostatic mechanisms are central to understanding systemic, integrated
function of the human body and these mechanisms are upset in many disease
states. Body fluid regulation will be studied in more detail in the module on the
urinary tract in semester 3. But the principles have relevance to many of the
modules of phase I, and body fluid regulation is particularly important to the normal
function of the cardiovascular system. For example, as clinicians, helping a
patient manage their heart failure, you will reduce the amount of work the failing
heart has to do by giving drugs – diuretics and inhibitors of aldosterone production
or action - that will reduce the extracellular fluid volume.
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75
Other relevant information
Before the session, lectures and the group work problems will be made available
by way of the medical school intranet.
Recommended reading
Human Physiology: The Basis of Medicine by G Pocock & CD Richards. 3rd edition
OUP 2006. Section 1.3: Homeostasis; Chapter 28: The regulation of body
fluid volume.
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Essentials of Clinical Medicine
Session 18
Date: 16 November 2010
Integrated Session
Session Leader:
Email:
Dr Alex Conner/Dr David Tweedie
a.c.conner@warwick.ac.uk
david@tweedie.info
Overview
Interactive session with the Clinical Education Fellows and group leaders to aid
understanding of previous sessions and to clarify any problems that have arisen.
Teaching Aims
Revision session
Intended Learning Outcomes
To allow students to clarify issues arising from the Essentials of Clinical Medicine
course. To ensure that the correct teaching is provided for these sessions, it is
essential that students email the module leads in the week before this session.
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