MEDICAL SCHOOL
MB ChB
YEAR 3
MEDICINE AND SURGERY
HANDBOOK FOR STUDENTS AND
TEACHERS
2003-2004
YEAR 3 MEDICINE AND SURGERY
TABLE OF CONTENTS
Introduction .................................................................................................... 3
Objectives ....................................................................................................... 3
Core clinical problems ................................................................................... 3
Resources for learning .................................................................................... 5
Patients ............................................................................................... 5
Teachers ............................................................................................. 5
Self-directed learning ......................................................................... 6
i.
Recommended books ....................................................... 6
ii.
Videos, web-based materials etc ...................................... 6
iii.
Your suggestions .............................................................. 6
iv.
Student selected components ........................................... 7
Formal teaching .................................................................................. 8
i.
Tutorials and skills lab sessions........................................ 8
ii.
General Practice Attachments .......................................... 8
iii.
Lectures ............................................................................ 9
iv.
Diabetes teaching .............................................................. 9
Assessments ................................................................................................. 10
Unit Assessment .............................................................................. 10
i.
Professional Behaviour .................................................... 10
ii.
Clinical assessment .......................................................... 10
iii.
Written assessments ........................................................ 11
a. Case reports ............................................................. 11
b. Student selected components .................................. 11
c. Multiple choice exam ............................................... 11
Formative assessment ................................................................................... 12
Tutorial support ............................................................................................ 12
Professional Indemnity ................................................................................. 12
Firm Leaders ................................................................................................ 12
Quality assurance ......................................................................................... 12
Contacts ........................................................................................................ 13
Student support ............................................................................................. 13
Student Health and Safety ............................................................................ 14
Claiming Travelling Expenses ..................................................................... 14
Appendix 1: Core curriculum and standards ................................................ 15
Medicine and Surgery A ................................................................. 16
Medicine and Surgery B .................................................................. 21
Appendix 2: Examples of possible SSC topics ............................................ 26
Appendix 3: SSC marking criteria ............................................................... 29
Appendix 4: Additional Medicine and Surgery B Assessments Information.. 30
Appendix 5: How to clerk a patient ............................................................. 32
2
Introduction
The primary purpose of the Medicine and Surgery Units in Year 3 is to build on the clinical
skills you have acquired in the Basic Clinical Skills Unit in Year 2 so that you are able to:
a) make an assessment of a patient presenting with a common problem and come to a
working diagnosis,
b) choose and interpret appropriate investigations to refine that diagnosis, and
c) outline a plan of management.
During the year you will complete two units in medicine and surgery – Medicine and Surgery
A (introduction to the diseases of the cardiovascular and respiratory systems, vascular
surgery, diseases of the ear, nose, throat and oral cavity) and Medicine and Surgery B
(introduction to diseases of the gastroenterological, endocrine, renal and nervous system).
The units have their major focus on different systems, but this is simply to ensure that you are
exposed to most specialities. They have the same objectives, and you can’t forget the heart or
abdomen just because it is in the other unit! You will be introduced to the common
conditions affecting many systems of the body that will provide the foundation for the
subjects you will cover in Years 4 and 5.
Objectives
By the end of the attachment you should be able to
 Take record and present a relevant history
 Examine a patient and elicit, demonstrate and interpret common physical signs
 Integrate the history and physical findings to construct a working diagnosis
 Formulate plans for investigation and treatment of the core clinical problems in the light
of the available evidence base
 Demonstrate a professional attitude, including the need to
- Treat patients with courtesy and consideration
- Respect the dignity and privacy of patients and confidentiality of information
- Work efficiently and professionally with other colleagues within the team to maximise
the interests of the patient
Core clinical problems
To guide you, we have drawn up a list of common problems. By the end of the two medicine
and surgery attachments you should expect to feel competent in assessing a patient presenting
with any of these problems, and in planning investigations and treatment.
1.
Cardiovascular disease (cardiology and vascular surgery)
a)
I have chest pain
b)
I have high blood pressure
c)
I get palpitations
d)
I have a heart murmur
e)
I am short of breath
f)
My legs hurt when I walk
g)
My fingers and toes hurt
h)
I have an aortic aneurysm
i)
I suffer from strokes
j)
My leg is cold and painful
2.
Respiratory disease
3
a)
b)
c)
I have coughed up blood
I am wheezy
I am coughing up coloured sputum
3.
Diseases of the ear nose and throat
a)
I am dizzy
b)
My voice has changed
c)
My child can’t hear
d)
I am deaf
e)
My nose is blocked
f)
I have a lump in my neck
g)
I have mouth ulcers
4.
Gastrointestinal and breast disease
a)
I have pain in my abdomen
b)
I have pain or difficulty in swallowing/I have been vomiting
c)
I have vomited blood or have blood in my stools
d)
I have gone yellow
e)
I have noticed a change in my bowel habit
f)
There is a lump in my abdomen
g)
I have a breast lump
5.
Neurological disease
a)
I have a headache
b)
I have had a blackout
c)
I have a weak arm
d)
I am dizzy/unsteady
e)
I have weak legs
6.
Endocrinology and diabetes
a)
I am thirsty
b)
I have lost weight
c)
There is glucose in my urine
7.
Urology and renal medicine
a)
I have passed blood in my urine/ there is protein in my urine
b)
I have stopped passing urine
c)
I pass a lot of urine/ have to pass urine at night
d)
I keep getting cystitis
e)
I have lump in my testicle
f)
I have pain in my loin
Core Curriculum
The curriculum you received in Year 2 has been extended to cover the material you need to
cover in the Year 3 Medicine and Surgery Units (Appendix 1). These are the basic skills you
need to acquire and on which you may be tested. Remember that you are expected to have
retained the skills you acquired in your first clinical attachment – irrespective of the system to
which they relate - and that you may also be tested on these.
4
Resources for learning
1. Patients
These provide by far the most important resource for your learning. You will be allocated to
medicine and surgery firms during the attachment, and should ensure that all patients under
the care of the firm are allocated for clerking. You should aim to follow them throughout the
course of their admission and learn from them and their experiences. In the modern NHS,
patients are often admitted under one team but have their care transferred to another team
during the admission. You will learn by far the most from the patients you have seen all the
way through from admission to discharge. You will have to use your initiative to achieve this.
In addition, the patients you see during your general practice attachments will give you the
chance to learn more about chronic problems and the wider impact of illness on the lives of
patients and their families
In medicine and surgery, the patients admitted as an emergency offer the greatest learning
opportunities. Make sure that you take advantage of this by clerking and presenting as many
patients as possible when you are on take. This is also an opportunity for you to see and learn
about many of the investigations and practical procedures that form part of the objectives.
Acute takes
You will be required to attend four medical and four general takes during your attachment to
Medicine and Surgery B, including weekends. Attendance will include staying until late
evening or overnight (see below) and presenting cases on post-take rounds. A consultant
signature will be required on each occasion to confirm satisfactory attendance. Any problems
with fulfilling this requirement must be discussed in full with the unit tutor, and will be
included in the report on your performance.
The following attendance is expected of a student on take:
Monday-Thursday:
Friday:
Saturday-Sunday:
Join take team at 5 pm, or earlier if no other teaching commitments,
and stay until at least 12 midnight. Attend post-take round the
following morning
Join take team as soon as day-time teaching commitments completed,
stay until the end of the evening post-take round.
Join take team at 12 noon, stay until the end of the evening post-take
round.
You are reminded of the contents of the Code of Conduct agreement relating to access to
patients and clinical work which you signed at the beginning of the Clinical course. You must
adhere to this at all times. To refresh your memory, the major points are reiterated in the
Year 3 Handbook.
2. Teachers
The consultant and trainee staff on your firm are ready to help you achieve the objectives of
the course. Some of your learning will come from timetabled teaching sessions, but much
more will be informal. You will also have the chance to attend clinics and operations in which
teaching is much more opportunistic.
Patient care is a team effort and many people are involved. You will learn a lot from all team
members – health care professionals and others. People are often very busy but you will find
that, if you demonstrate an enthusiasm for learning, they generally like to teach when they
can. Going down to the radiology department or other investigations with your patient will
5
teach you much more than a book, and seeing what physiotherapy or dietary assessment
actually involves is much more informative than hearing it referred to it in a lecture.
3. Self-directed learning
Expect to have to supplement your learning by reading books and papers. Read around a
clinical problem at the same time as you see a person with the condition. This way knowledge
is much easier to retain. You should become well acquainted with at least one general
textbook for medicine, and for surgery. The clinical skills books recommended in year 2 will
be useful for revision of the basics.
RECOMMENDED BOOKS
General

Kumar P, Clarke M. Clinical Medicine

Souhami RL, Moxham J. Textbook of Medicine

Burkitt RG, Quick CRG, Deakin PJ. Essential surgery: problems, diagnosis and
management

Garden OJ, Bradbury AW, Forsythe JLR. The principles and practice of surgery
Other recommended books (All available in the Medical School Library)

C.O'Callaghan and B.M.Brenner. The kidney at a glance. Blackwell Science Ltd

Brewer S, Cranston D, Nobel J, Reynard J. Urology: a handbook for medical students

J Pickup and G Williams. Textbook of Diabetes. Blackwell

A Levy and S Lightman. Endocrinology. Oxford Core Texts.

J Hampton. The ECG made easy. Churchill Livingstone

R. Corbridge, Modern ENT practice: an essential guide. Arnold

M.S. McCormick, W.J. Primrose, I.J. Mackenzie. A new short textbook of
otolaryngology. Arnold
VIDEOS, WEB-BASED MATERIALS ETC.
In some topics you will be allocated a session for watching surgical videos and self-directed
learning on the computers in the student IT room. Useful websites will be bookmarked but
please feel free to add to these if you find a site you feel might benefit other students.
The cardiology, neurology and urology departments have written Web based tutorials
covering the knowledge-based curriculum for their subjects. The urology tutorials can be
found at http://www.bui.ac.uk/ and include self-assessment exercises. The neurology tutorials
can be found on Blackboard and include tutorials, a neurology examination ‘crib sheet’ that
you can print out and use, clinically based self assessment questions and also a message board
for you to post questions about neurology that you find puzzling or difficult. The cardiology
tutorials are also available on blackboard. We would appreciate constructive feedback about
these sites and how they can be improved.
YOUR SUGGESTIONS
We would like to establish a database of the useful learning resources you have identified.
This will be of great value to colleagues in your year and in future years. If you find a useful
website, book or review article please enter it on to the database on the Medicine and Surgery
unit teaching sites accessed by logging on to Blackboard.
6
STUDENT SELECTED COMPONENTS
Introduction
Student selected components form a very important part of the learning opportunities on this
unit and are allocated 20% of the time you are attached to the unit and 15% of the overall unit
mark. The marking criteria for SSCs are given in Appendix 3. They are intended to allow you
a) to attain transferable skills that will help you to continue the learning process that will be
required throughout your career and b) to learn about something that is not absolutely core
knowledge but is of interest to you.
The sort of thing you may consider would be:
a) To obtain and report on experience in a speciality or technique you may not encounter in
the basic curriculum (e.g. cardiac surgery, renal dialysis etc.)
b) To undertake a literature or web-based study of a particular topic or treatment, perhaps
leading to proposals for further research or management guidelines
c) To develop educational materials or information resources (computer or paper-based) for
patients, relatives, medical students or health care professionals on a particular topic
d) To undertake a survey or audit on some aspect of health care delivery. This might be from
the perspective of the consumers or the deliverers
e) To combine these to produce a detailed case report on one or two patients including the
patients’ and/or families perspective of their illness or management, with a full discussion
of the literature on the condition and/or its management.
This list is only intended to give you some guidance. We hope that many of you will come up
with other ideas. Try and vary the type of SSMs you do through the year and not simply do a
library based SSC each time.
You have to undertake an SSC in each of the year 3 units, with a further period of SSC time at
the end of the year. The SSC report you produce at the end of each unit must ‘stand-alone’,
but you may wish to design for yourself a programme of SSCs that are loosely linked to allow
you to cover an area in more detail. The end of year SSC period is a good opportunity to build
on the work undertaken in one of your unit SSC. You might, for example, use one of the unit
SSCs to undertake a literature review in a topic and make preparations (e.g. develop study
design, apply for ethical approval) for a piece of research that you complete in the summer. If
you are considering making a video, CD or creating a website as your project please ensure
that your supervisor has the appropriate equipment as we cannot provide any funding for
SSCs.
Practicalities of the SSC within Medicine and Surgery A and B:
1. You need an idea – a list of suggested SSCs is available in Appendix 2 and on the
Medicine and Surgery A and B Unit sites on Blackboard, though we would encourage
you to think up your own idea.
2. You need a supervisor. If you are planning to choose a title from our list of suggestions,
supervisors have already been identified. If you have an idea of your own, you also need
to identify someone to supervise the project for you in which case you must get them to
sign a Supervisor Acceptance Form that can be found on Blackboard or from the unit SSC
administrator. Many supervisors are very happy to help and advise you with your project.
It is therefore worth considering how easy or otherwise it would be for you to visit your
supervisor to make use of their support when making your selection.
3. You need to register your SSC with the SSC administrator (For Medicine and Surgery A
with Sylvia Finch (Sylvia.finch@bristol.ac.uk), and for Medicine and Surgery B with
7
4.
5.
6.
7.
8.
Sharon Byrne (Sharon.byrne@bristol.ac.uk)). You must e-mail the appropriate unit SSC
administrator with a list of four projects in which you are interested indicating your order
of preference by the end of the first week of the block. If someone else has already
registered for your first preference, you will be allocated to your second preference etc.
Only one student can do each project in each block and allocation will be strictly on a
first-come first-served basis. You will be notified by e-mail of the name and contact
details of your supervisor.
You need to define exactly what you think what you are going to get out of the project,
and to draw up a plan. You should make an early appointment with your supervisor to
discuss your plans.
You need to spend the equivalent of one day per week on your SSC. How this is
timetabled will depend on your teachers, but you should try to make sure that you get to
work on this project within the first two weeks of the unit
If you are encountering problems, seek help from your supervisor in the first instance.
Otherwise contact the relevant unit SSC administrator who will direct you to the most
appropriate person.
The completed report must be submitted to the unit SSC administrator 1 week before
the end of unit assessment. If you have not done so, you will fail the unit. It is entirely
up to you to make sure this happens – no one will chase you. You should send your
SSC to the unit SSC administrator electronically. If, for any reason, this is not possible
please send two copies to Sylvia Finch) at the Radiology Dept, Bristol General Hospital
Guinea St. Bristol BS1 6SY(for Medicine and Surgery A) or to Sharon Byrne at the
Department of Neurology, Frenchay Hospital, Bristol, BS16 1LE (for Medicine and
Surgery B). You will receive an e-mail from the unit SSC administrator confirming that
she has received your project. You must print out this receipt and keep it as proof that
you have submitted your SSC.
It is wise to start thinking about the subject of your external SSC as soon as possible. If
you want do to a research or audit project you will need to get approval from the relevant
committee and this can take many months.
Summary of SSC dates:
Dates
Block 1
Block 2
Block 3
Block 4
1st September 2003
to
31st October 2003
3rd November 2003
to
23rd January 2004
26th January 2004
to
26th March 2004
29th March 2004
to
4th June 2004
SSC Registration deadline
SSC Completion deadline
5th September 2003
24th October 2003
7th November 2003
16th January 2004
30th January 2004
19th March 2004
2nd April 2004
28th May 2004
4. Formal teaching
TUTORIALS AND SKILLS LAB SESSIONS
Some core problems and clinical skills will be covered in tutorials. The course organisers at
the trust will arrange these where you are based. They will include student-led sessions are
likely to require preparatory work on your part.
8
GENERAL PRACTICE ATTACHMENTS
During this unit you will have two half-day sessions with your year 3 GP. The purpose of
these sessions is to provide further teaching and experience in the way that the core clinical
problems for this unit present and are managed in primary care settings. For example most
people with abdominal pain present initially to a GP and only a small proportion of them ever
reach a hospital. How do GPs take a history and examine patients to work out how to treat
them, and to determine which patients need hospital referral?
In primary care, the problems are often more recent and less serious. It is particularly
important to consider ‘the whole person’ and how factors in the patient’s personality, family,
past history and social environment affect the presentation of the problem and how best to
manage it.
The objectives of the GP attachments are therefore to:
 to see clinical cases in a relaxed environment including patients’ own homes
 to experience the selective use of history and examination and hypothesis testing
 to see less well differentiated illness
 to see the emotional and physical response to illness
 to see the interaction of social and psychological factors with physical illness
 to appreciate the interaction between primary and secondary care
Attendance is very important.
At each teaching session the GP will have cancelled their normal surgery and will have
invited 2 – 4 patients for you to interview and examine. It is important that you do not let
them down, or the GPs who have dedicated time to teach you. Your GP will have sent you
dates for your teaching sessions in each block. If one of these dates clashes with an important
teaching session at the hospital, please contact the GP to re-arrrange it, giving him or her at
least 2 weeks notice.
You will be able to practice and improve your skills in history taking, examination, diagnosis,
and patient management in this small group environment.
If you have any administrative problems with the GP attachments please contact the GP
teaching administrator, Sally Sterland, on 954 6639. For any other problems please contact Dr
Salisbury by e-mail on c.salisbury@bristol.ac.uk .
LECTURES
During the unit you will have two days of integrated system teaching on the Monday of week
1 and the Friday of week 9. These core topics will be included in the end of year examination.
DIABETES TEACHING
The last week of your first Medicine and Surgery unit (week 9) will be dedicated to teaching
diabetes. This week will comprise a mixture of lectures, and small group teaching, and will be
delivered centrally.
First Block:
Diabetes course: Report to Level 9 Lecture theatre, BRI on Monday
October 27th 2003, at.10.00 am
Second Block:
Diabetes course: Report to Level 9 Lecture theatre, BRI on Monday
January 19th 2004, at.10.00 am
9
This teaching is delivered to students doing both Medicine and Surgery A and B. Full
timetables will be issued at the start of the course.
CONTACTS:
Dr Polly Bingley
(Diabetes Course Organiser)
Diabetes and Metabolism, Medical School Unit, Southmead
Tel
0117 959 5337
Polly.bingley@bristol.ac.uk
Miss Bethan Sait
(Diabetes Secretary)
Diabetes and Metabolism, Medical School Unit, Southmead
Tel
0117 959 5337
Bethan.sait@bristol.ac.uk
Assessments
Your progress on the unit and your attainment of the aims and objectives of the course will be
assessed in a number of ways. You will have both summative and formative assessments. To
pass the unit you need to pass all three parts of the summative assessment. Merits and
distinctions will be awarded on the basis of a composite mark for the clinical examination,
SSC (project plus case reports) and the multiple choice question examination.
Summative assessments
1.
PROFESSIONAL BEHAVIOUR
In preparing students to qualify as doctors, the University has the responsibility to ensure not
only that your clinical skills and knowledge are adequate but also that you display appropriate
behaviour towards patients, staff and society in general. Skills and factual knowledge can be
objectively assessed by the formal examinations that take place at the end of most clinical
attachments.
The Faculty relies upon the clinical teachers who closely supervise your work to report
behaviour which displays an inappropriate attitude. Following consultation with their
colleagues, teachers will assess you as satisfactory or not in the following categories:
appearance, attendance and punctuality, attitude and behaviour.
Your teachers should point out anything which they perceive as unsatisfactory to you during
your teaching so that you have an opportunity to address the issue. Teachers will be asked to
provide positive feedback on your attitude/behaviour. However, if a problem remains then it
will be reported to the Clinical Dean and you will be asked to discuss the issue with him.
The Clinical Dean will seek a resolution of any problems highlighted.
This assessment is relatively new to the Medical School. Its implementation has been agreed
jointly between staff and student representatives. Further information is available through
the Clinical Dean’s website.
2.
CLINICAL ASSESSMENT (50% of overall unit assessment)
The summative OSCEs for both Medicine and Surgery A and B will take place in the 9th
week of your second Medicine and Surgery attachment and each will consist of a mixture of
stations which will test clinical skills, communication skills, practical procedures,
10
interpretation of common investigations and understanding of some treatment of the core
problems as outlined in the core curriculum in Appendix 1. The marks for each unit will be
considered separately, and you will be required to pass both. Further details about the OSCE
are included in Appendix 4 at the back of this book and additional explanatory notes and
advice are available on the Galenicals web-site
(http://www.medici.bris.ac.uk/galenicals/unihome.htm ).
3.
WRITTEN ASSESSMENTS (50% of overall unit assessment)
i.
STUDENT SELECTED COMPONENT (15% overall)
Your Student selected component report contributes 15% of your overall unit assessment
mark (see above). The completed SSC report must be handed in one week before the end of
the unit. If you have not done so, you will fail the unit. The marking criteria are given in
Appendix 3.
ii.
CASE REPORT (5% overall)
You are required to write up or present one patient case history. This patients should illustrate
a core problem from one of the groupings related to your current attachment (i.e. cardiology,
respiratory medicine, ENT, vascular surgery or radiology for Medicine and Surgery A, and
gastrointestinal and breast disease, neurological disease, endocrinology and diabetes, or
urology and renal medicine for Medicine and Surgery B). This case report should include the
key points of the history, examination and investigations with your conclusions about the
diagnosis. This should be followed by a section on the management and progress up to
discharge. The case history should therefore cover the whole admission and discussion of the
underlying condition and management options as well as the initial clerking. In Medicine and
Surgery A and B, you will be required make a formal presentation of this case to your
teachers and colleagues towards the end of the unit, and to answer their questions on it. Your
mark for this case will be assigned on the basis of their comments
iii. MULTIPLE CHOICE EXAM (30% overall)
Your knowledge will be assessed in a multiple choice question exam held in June 2004. The
paper will include questions covering Medicine and Surgery A and B (including Diabetes
Week), IST Teaching and GP Attachments and may include questions of the extendedmatching format. The marks for each unit will however be considered separately, and you will
be required to pass both. You will be expected to have acquired at least the amount of
knowledge relating to the core problems consistent with having read the relevant chapters of
basic medicine and surgical textbooks, as well having attended the lecture teaching.
Full details of the summative assessments in Year 3 and the requirements for progression into
Year 4 are given in the Year 3 Handbook. Failure in these examinations will require re-takes
in July 2003 and will usually result in the loss of opportunity to carry out the end of year Post
examination SSC.
11
Formative assessments
These assessments will be performed towards the end of your first Medicine and Surgery
attachment and will provide you with feedback on how your are progressing so that you are
made aware of any areas on which you particularly need to focus in your second attachment.
The assessment does not contribute to your overall unit mark
The formative assessment in both units will be an OSLER (objective structured long
examination record). In this assessment you will be watched by an examiner while you take a
history from a patient and examine them (in about 45 minutes, including recording your
findings) and will then be asked to discuss the case. The examiner will be assessing your
ability to take a history, examine a patient, record the information, make a reasonable
diagnosis or differential diagnosis and outline a management plan – i.e. how well you
progressing towards achieving the objectives of the Year 3 Medicine and Surgery units. This
is an excellent way to judge how a student is getting on, and it is currently part of the final
MB BCh exam. An aide memoire to the ‘full clerking’ is included in Appendix 5. We think
that, even if you are not particularly polished at this stage, the OSLER will provide you with
very useful feedback.
Tutorial support
You will be allocated a tutor who will meet with you regularly throughout your attachment to
the unit. The purpose of these meetings is to make sure that your are clear about the aims and
objectives of the unit and that you are achieving these, and that you making satisfactory
progress with your self-directed learning. Your tutor may also be able to help if there are
problems with the delivery of teaching that is timetabled for you.
Professional Indemnity
Students are reminded that they are expected to become members of one of the medical
defence organisations – either MPS or MDU. This costs nothing and ensures that you have
indemnity for professional activities in non-NHS-owned establishments such as hospices and
GP surgeries. You should protect yourselves against this risk.
Firm Leaders
Each firm of students should appoint a firm leader (or clerk) whose responsibilities are to
provide liaison with the Lead Clinician, General Practitioner and Clinical Sub-Dean or
Clinical Dean. He/she should also ensure that rotas are set up so that each student has an
equal share of outpatient clinic attendance, on-take experience and patients with a spectrum of
conditions to see independently.
Quality assurance
This will be assessed by questionnaires which will be distributed at the end of the course.
12
Contacts:
Medicine and Surgery A
Unit Organiser:
Professor Michael Rees (Dept of Radiology, Bristol General Hospital)
(m.rees@bristol.ac.uk)
Unit Administator and SSC administrator:
Sylvia Finch (Dept of Radiology, Bristol General Hospital)
(sylvia.finch@bristol.ac.uk)
Examinations Lead:
Mr Desmond Nunez (Dept of ENT, Southmead Hospital)
Tel: 928 2731
Fax: 928 2319
Tel: 928 2731
Fax: 928 2319
Tel: 959 6222
(d.a.nunez@bristol.ac.uk)
Medicine and Surgery B
Unit Organisers:
Dr Polly Bingley (Division of Medicine, Southmead Hospital)
Tel: 959 5337
(polly.Bingley@bristol.ac.uk)
Miss Jane Blazeby (Division of Surgery, Level 7, BRI)
Tel: 928 2336
(j.m.blazeby@bristol.ac.uk)
Curriculum translator
Miss Rachel English (Division of Surgery, Level 7, BRI)
Tel: 928 2336
(Rachel.English@bristol.ac.uk)
SSC administrator
Mrs Sharon Byrne (Neurology, Frenchay Hospital; am only)
Tel: 970 1212 Ext 2979
(Sharon.byrne@bristol.ac.uk).
Student support
If you are experiencing problems of an academic or personal nature, advice should be sought
from the appropriate Undergraduate Teaching Co-ordinator or the Clinical Dean.
Undergraduate teaching co-ordinators
BATH
Dr W N Hubbard
Consultant Physician
Education Centre
Royal United Hospital
Bath BA1 3NG
Tel
01225 825479
Fax
01225 825479
maureen.jacobs@ruh-bath.swest.nhs.uk
BRI
Mr N Rawlinson
Consultant, A&E
Dolphin House
Bristol Royal Infirmary
Marlborough St
Bristol BS2 8HW
Tel
0117 928 3912
Fax
0117 928 2151
Nigel.Rawlinson@bristol.ac.uk
13
FRENCHAY
Dr D Smith
Consultant Physician
Academic Centre
Frenchay Hospital
Bristol BS16 1LE
Tel
0117 918 6764
Fax
0117 970 1691
David.Smith38@virgin.net
SOUTHMEAD
Mr J Morgan
Consultant Surgeon
Southmead Hospital
Westbury on Trym
Bristol BS10 5NB
Tel
0117 959 2435
morgan_jdt@southmead.swest.nhs.uk
WESTON
Dr D Paterson
Consultant Pathologist
Weston General Hospital
Grange Road
Weston Super Mare BS23 4TQ
Tel
01934 636363 x 3315/3321
David.Patterson@waht.swest.nhs.uk
CLINICAL DEAN
Dr Clive Roberts
Centre for Medical Education
39-41 St Michael’s Hill
Tel
0117 954 6518
Mob 07850 908760
C.J.C.Roberts@bristol.ac.uk
Student Health and Safety:
Statement by the University’s Health and Safety Committee dated 25 January 1999:
“Students are reminded of their duties to other members of the University, including visitors,
referred to in the Faculty Introduction in the undergraduate prospectus.
It is foreseeable, based on national statistics for workers in this discipline, that some members
of this course may experience allergic reactions to the exposure to animals/chemical agents.
It is essential that, as soon as it is known, any student who has an existing or who develops
any medical condition that may affect their ability to participate fully in the course of study
should inform their supervisor. This will enable the student and the University to discuss and
agree appropriate health and safety procedures to facilitate continued study.”
Claiming Travelling Expenses
Students may claim the usual return bus fare to the university from Trust where they are in
residence to attend teaching delivered centrally.
Claim forms are available from the Clinical Dean’s Office, Medical Education Centre.
Completed forms should be submitted to the office within a month of the end of the
attachment
PLEASE CHECK YOUR EMAIL, THE CLINICAL DEAN’S OFFICE WEBSITE, HOSPITAL
NOTICEBOARDS AND THE YEAR 3 NOTICEBOARDS IN THE MEDICAL SCHOOL AND THE
CLINICAL DEAN'S OFFICE, 39-41 ST MICHAEL'S HILL REGULARLY. INFORMATION
PERTINENT TO YOUR STUDIES IS OFTEN POSTED VIA THESE MEANS.
14
APPENDIX 1
YEAR 3 MEDICINE AND SURGERY
Core curriculum and standards
Underlying principles:
1. These are the core curriculum and standards for the a student completing Year 3 Medicine
and Surgery units, not the end of the MB ChB course
2. They build on the curriculum of the Year 2 Clinical Attachment and those of the Medicine
and Surgery A and B units are complementary
3. They reflect that the majority of teaching on these courses is done by generalists
(physicians, surgeons and general practitioners) rather than specialists teaching about their
area of expertise
4. The emphasis in the Year 2 clinical attachment is on history taking and clinical
examination of the different body systems. This is extended in the 3rd year so that students
can assess common clinical problems in a sensible, analytical and problem-solving way.
5. They are minimum standards, i.e. all students should be at this level by the end of the
Medicine and Surgery A and B unit
6. These standards should be used for the OSCE exams at the end of the Medicine and
Surgery A and B units
7. They acknowledge the need to develop clinical skills to recognise both the normal and the
clearly abnormal
15
APPENDIX 1
Core curriculum for Medicine and Surgery A
(introduction to diseases of the cardiovascular and respiratory systems, vascular surgery,
diseases of the ear, nose, throat and oral cavity)
A. CARDIAC SYSTEM
1. Common symptoms of cardiovascular disease
Chest pain
Explore basic characteristics including site, radiation, precipitating,
relieving and associated factors
Identify specific history and assoc features of angina and myocardial
infarction pain, and distinguish from other causes of chest pain
Assess severity (nil, ordinary exertion, severe exertion, rest)
Breathlessness
See Respiratory Curriculum
Identify specific history of Shortness of Breath on Exertion, Orthopnoea
and Paroxysmal Nocturnal Dyspnoea
Identify assoc symptoms of cardiac failure
Palpitations
Identify history of frequency and rhythm of heart beat and associated
symptoms
Dizziness/blackouts
Identify history of sudden faintness, with or without ensuing loss of
consciousness, which may be cardiovascular in origin
Leg pain
Identify specific history and assoc features of intermittent claudication,
acute ischaemia of leg and deep vein thrombosis
2. Examination of the cardiovascular system
General examination
Recognise clear pallor, central and peripheral cyanosis
Identify the constellation of signs of cardiac failure
Pulse
Ability to measure radial pulse, rate and rhythm
Compare radial and apex pulses
Examine radial, brachial, femoral, popliteal, posterior tibial and dorsalis
pedis pulses and classify correctly as normal, weak or absent.
Identify clear deep vein thrombosis in calf and thigh
Blood pressure
Demonstrate correct method of measuring blood pressure, including
applying cuff, inflating and deflating at right rate, and identifying
Korotkov sounds
Identify clearly raised level of blood pressure
JVP
Demonstrate correct method of measuring JVP
Identify clearly elevated JVP
Murmurs
Detect clear cardiac murmur and classify as systolic or diastolic
Lungs
See Respiratory Curriculum
Recognise clear basal crackles
Oedema
Identify ankle and sacral oedema
3. Diagnostic tests/medication of cardiovascular system
Chest X-ray and other
Ability to measure cardio thoracic ratio, and recognise cardiomegaly
imaging
Recognise clear pulmonary oedema..Awareness of the use of MRIand
CT and nuclear medicine in the diagnosis of cardiovascular anatomy
and pathology
ECG
Recognise features of a normal ECG, rate and rhythm
Identify cardiac arrhythmias: AF, ectopic beats
Identify clear myocardial infarction
Use of GTN
Describe use as diagnostic test, technique, side effects
4. Equipment
Cardiac pacing
Cardiac catheterisation +/- angioplasty
Electro physiology studies
Exercise testing
Echocardiography
Have observed. Broadly know indications and risks.
Have observed. Broadly know indications and risks.
Awareness of use of these studies
Have observed. Broadly know indications and risks
Awareness of the use of these studies and
recognition of examples
16
APPENDIX 1
B. RESPIRATORY SYSTEM
1. History and evaluation of symptoms
Breathlessness
Explore precipitants, relieving factors, speed of onset and progression
of breathlessness, and associated symptoms.
Associate type of breathlessness and assoc symptoms with common
causes: asthma, COPD, pneumonia, pulmonary embolism, lung cancer
Assess severity (nil, ordinary exertion, severe exertion, rest)
Chest pain
See cardiovascular curriculum
Identify specific features of pleuritic chest pain
Cough
Explore nature of cough (dry, productive) precipitants, relieving
factors, speed of onset and progression, and associated symptoms
Sputum/Haemoptysis
Explore nature of sputum (mucoid, purulent, haemoptysis) and
associated symptoms
Wheeze /Stridor
Identify clear description of wheeze and stridor and associate with
common causes
2. Examination of respiratory system
General examination
Identify noisy breathing, clubbing, cyanosis, cervical
lymphadenopathy, signs of smoking, recent weight loss
Shape of chest wall
Identify barrel, pigeon and funnel chests and clear thoracic scoliosis
Respiratory movements
Assess respiratory frequency and depth.
Identify clear tachypnoea, intercostal recession and hyperventilation
Percussion
Identify dullness and resonance over different lung areas
Identify clear pleural effusion and pneumothorax
Breath sounds
Voice sounds
Identify normal breath sounds. Identify clear cases of localised and
generalised wheezes (rhonchi) and pitch (high medium, low), crackles
(crepitations) and pleural rub, and associate with common causes.
Identify localised or generalised reduced breath sounds
Identify normal, and clearly increased and decreased voice sounds
3. Diagnostic tests/medication of respiratory system
Chest X-ray and other
Recognise clear cases of pneumonia, pneumothorax, pleural effusion,
diagnostic tests
lung mass and fractured ribs
Appreciate absence of radiological signs in some serious conditions –
asthma, pulmonary embolus. Awareness of the use of other diagnostic
methods ie. CT and nuclear medine in the diagnosis of respiratory
disease and pulmonary embolus
Use of bronchodilator
Demonstrate correct technique for use of bronchodilator MDI and adult
spacer device
4. Equipment
Peak Flow Meter
Respiratory Function tests
Demonstrate correct technique for measurement of Peak Flow
Observe and know basics of referral criteria
C. OTORHINOLARYNGOLOGY
1. History and evaluation of symptoms
Deafness
Dizzy
Ringing in ears
Establish onset, progression and severity of
deafness. Assess level of handicap. Identify
associated symptoms including earache, discharge,
tinnitus and vertigo. Risk factors including previous
infection, noise exposure and family history
Establish nature, frequency, and duration of
episodes of dizziness. Identify associated
symptoms including tinnitus, deafness, nausea and
vomiting. Identify aggravating factors such as head
position and hyperventilation.
Determine characteristics of tinnitus, aggravating
17
APPENDIX 1
Hoarseness
Difficulty swallowing
Neck lump
Blocked nose
2. Examination of ear, nose and throat
Ear
Nose
Throat
Neck
3. Diagnostic tests
Audiogram
Tympanometry
FNA
4.
factors and level of distress. Assess associated
symptoms including deafness, discharge, earache
and vertigo. Identify risk factors including noise
exposure.
Assess duration and severity of voice problems.
Identify associated symptoms including stridor,
dysphagia, sore throat and risk factors including
smoking and vocal abuse
Establish onset, progression and degree of difficulty
with swallowing and whether with fluids and/or
solids. Associated symptoms such as weight loss,
hoarseness, stridor and indigestion.
Explore symptoms related to the lump: pain,
duration, and change in size. Identify associated
symptoms including hoarseness, dysphagia, sore
throat, and weight loss. Assess risk factors
including smoking and excess alcohol.
Assess severity, duration, onset and side(s) affected.
Explore associated relevant symptoms including
rhinorrhoea, postnasal drip, sneezing, itching and
facial pain and pressure. Identify history of atopy
and associated diseases including asthma, hay fever
and eczema.
Assess hearing loss with Weber and Rinnes tuning
fork tests. Inspection of pinna and external auditory
meatus. Otoscopic examination of ear and
recognition of features of tympanic membrane.
Inspection of external nose and anterior nares.
Knowledge of techniques of examination of the
nasal cavity and postnasal space, including anterior
rhinoscopy and rigid nasendoscopy.
Assessment for dysphonia and stridor. Inspection of
oral cavity and oropharynx. Awareness of methods
of examination of the larynx and hypopharynx,
including indirect laryngoscopy and flexible
laryngoscopy.
Inspection and systematic palpation of the neck with
assessment of size, shape, position, mobility and
consistency of the neck lump. Assessment of
transillumination of lump and presence of bruits.
Understand the principles of pure tone audiometry
and be able to interpret findings in common causes
of deafness
Understand the principles of tympanometry
Understand the role and process of FNA of neck
lumps
Equipment
Tuning Fork (512 or 256Hz)
Otoscope
Familiar with correct use
Familiar with correct use
18
APPENDIX 1
D. MAXILLOFACIAL SURGERY
1. History and evaluation of symptoms
Mouth ulcer
Odontalgia
Temporomandibular pain
Facial deformity
Facial fracture
2. Examination
Mouth ulcer
Leukoplakia / erythroplakia
Jaw mass
Facial deformity
Facial fracture
Stomatitis/Glossitis
3. Diagnostic tests
Radiology
Blood tests
Assess duration, associated symptoms, relevant
predisposing factors
Location, duration, severity, radiation, associated
symptoms
Location, duration, severity. Association with toothgrinding, malocclusion, psychosomatic factors
Awareness of congenital versus acquired.
Functional effect on speech, breathing, etc.
Psychological effect.
Awareness of symptoms arising from facial
fractures ie pain, swelling, diplopia, malocclusion,
symptoms of intracranial or cervical trauma
Size, shape, number, location
Size, shape, degree, location, induration, ulceration
Examination and assessment
Examination for deformity and disability: cranial
nerves, occlusion, airway obstruction
Appearance, localised/generalised
Awarenes of the value of plain radiology and other
imaging techniques x-rays
Relationship of anaemia and other systemic diseases
with oral ulceration, stomatitis and glossitis
E. VASCULAR SURGERY
1. History and evaluation of symptoms
Claudication pain
Ischaemic rest pain
Symptoms of leaking/ruptured aortic aneurysm
Numbness and paraesthesiae of periphery
Varicose veins
Peripheral vasospasm
Amaurosis fugax
Transient ischaemic attacks
2. Examination
Carotid bruit
Aortic aneurysm
Peripheral pulses
Peripheral skin/nails/hair changes
Varicose veins
The diabetic foot
Assess distance and severity. Duration.
Severity, duration
Differentiating symptoms from other causes of back
pain. Shock.
Duration, extent, associated symptoms
Duration, extent, associated pain, and other
symptoms
Constellation of symptoms
Typical presentation
Typical presentation, and relation of symptom
complexes to arterial site of origin
Auscultation
Palpation technique and size assessment. Surface
mark the aortic bifurcation.
Palpation technique
Types, degree, significance
Basic anatomy of deep and superficial venous
drainage of the leg. Recognition of a varicose vein.
Assess feet for signs of diabetic foot disease,
including typical deformity and distribution of
ulcers. Screen for peripheral neuropathy and
peripheral vascular disease.
19
APPENDIX 1
The vasospastic hand/foot
3. Diagnostic tests
ABPI
Duplex ultrasound
Arteriography
Treadmill testing
Diagnosis of diabetes
Plain abdominal film
CT and MRI
Appearance of transient and established vasospastic
changes
Value, meaning and unreliability in diabetes
Indications and meaning of result
Indications, complications and meaning of result
Indications and meaning of result
Interpret plasma glucose results using the WHO
criteria for diagnosis of diabetes mellitus
Usefulness and limitations in aortic tree disease
Awareness of the usefulness of these tests in the
diagnosis of vascular disease.
20
APPENDIX 1
Core Curriculum for Medicine and Surgery B: (Introduction to diseases of the
gastroenterological, endocrine, renal and nervous systems)
A. ABDOMINAL SYSTEM
1. History and evaluation of symptoms
Pain
Explore basic characteristics – site, radiation, and nature of pain.
Identify foregut, mid gut and hind gut pain
Identify biliary pain, pain of peritonitis, intestinal colic and obstruction
Weight loss
Amount, duration, anorexia
Dysphagia
Duration, grading, nature
Reflux
Identify constellation of symptoms associated with reflux
Vomiting/nausea
Explore amount, precipitating factors, colour, content, frequency
Jaundice
Identify constellation of symptoms and history associated with
obstructive jaundice and distinguish from other causes of jaundice
Bowel habit
Assess nature (diarrhoea/constipation), frequency, consistency, colour,
associated symptoms
Rectal bleeding
Explore amount, colour, frequency, associated symptoms, description
of stool including meleana and symptoms of anaemia
Ascites
Identify history of ascites distinguish from other causes of abdominal
swelling
Abdominal/groin swellings
Explore history, onset, associated bowel symptoms – distinguish simple
hernia history from impending obstruction/strangulation
Perianal symptoms
Explore pain, itching, discharge, anal lumps
2. Examination
General
Hands
Face/mouth
Lymph nodes
Abdominal inspection
Abdominal examination
Abdominal auscultation
Hernias
Rectal examination
3. Diagnostic tests
Full blood count
Assess overall appearance. Identify nutritional problems, state of
hydration, features of shock
Identify clubbing, palmar erythema, Duputren’s contracture, flap
Examination for signs of anaemia, jaundice, mouth ulcers, spider naevi
Examine the neck/axillae/groin for lymphadenopathy
Scars, masses, distension, discolouration
Superficial and deep examination. Examination of the liver, spleen,
kidneys, abdominal masses and ascites.
Identify normal pattern and obstructive bowel sounds
Examination of groin hernia.
Discuss inspection and examination of the perianal area and per rectum
examination
Plain CXR/AXR
Urine
Ultrasound/contrast studies
Understand iron deficiency anaemia, inflammatory markers and
abdominal disease
Interpretation of results
Interpretation of obstructive jaundice and differentiation from other
forms of jaundice
Identify free intra peritoneal air, obstruction of the GI tract
See renal/urology system
Understand the main role of these in abdominal investigations
4. Equipment
Proctoscope/sigmoidoscope
Identify and appreciate their role
Amylase
Liver function tests
21
APPENDIX 1
B. BREAST
1. History and evaluation of symptoms
Lump
Explore symptoms related to the lump: pain, duration, and change in
size. Relevant past history and history of risk factors
Nipple discharge
2. Examination
Lumps
Duration, amount, nature of discharge and related factors
Assess overall appearance of breasts, describe the lump: size, shape,
site, position, mobility, and consistency.
Lymph nodes
Examination of supraclavicular, axillary and groin nodes
3. Diagnostic tests
FNA
Understand the role and process of FNA
Mammogram
Identify the investigation and understand its role in diagnosis and
screening
C. ENDOCRINE SYSTEM
1. Diabetes Mellitus
History and evaluation of symptoms
Diabetes
Identify characteristic symptoms associated with diabetes and
symptoms suggesting urgent need for insulin. Be aware of common
presentations of type 1 and type 2 diabetes
Hypoglycaemia
Identify typical symptoms of hypoglycaemia and be aware of the
range of hypoglycaemic warning experienced by patients
Be aware of the social and psychological implications of this
chronic condition on the life of a person with diabetes
Examination for acute and chronic complication of diabetes
Assessment of the severely ill
Identify signs of diabetic ketoacidosis and hyperosmolar non-ketotic
or comatose patient
state, and assess the severity of dehydration and coma. Distinguish
between the clinical pictures of hyper- and hypoglycaemic coma
Eyes
Test visual acuity using a Snellen chart
Perform direct ophthalmoscopy, and identify lesions of diabetic
retinopathy and cataract on a photograph
Feet
Assess feet for signs of diabetic foot disease. Screen for peripheral
neuropathy and peripheral vascular disease.
Diagnostic tests / therapeutic interventions in diabetes mellitus
Diagnostic criteria
Interpret plasma glucose results using the WHO criteria for diagnosis
of diabetes mellitus
Urinalysis
Identify glycosuria, ketonuria, proteinuria and haematuria, on urine
stick testing and describe their significance
Capillary blood glucose
Perform capillary blood glucose measurement and use the results to
measurement
guide treatment adjustment
Education
Describe the likely requirements of a person with diabetes for
information, education and support, and the options for delivery of this
Diet and lifestyle changes
Describe the principles of dietary and lifestyle advice in insulin-treated
and non-insulin treated diabetes mellitus
Oral hypoglycaemic agents
Describe indications, side effects and contraindications for metformin,
sulphonylureas and other agents
22
APPENDIX 1
Insulin
Hypoglycaemia
Describe indications, technique of administration, principles of dose
adjustment and side effects
Treat hypoglycaemia in conscious and unconscious patients
2. Thyroid Disease
Common symptoms of abnormal thyroid function
Thyrotoxicosis and
Identify constellation of symptoms associated with (i)
hypothryoidism
thyrotoxicosis, and distinguish from anxiety (ii) hypothyroidism,
and distinguish from other causes of tiredness
Examination of the thyroid
Thyrotoxicosis and
hypothyroisism
Thyroid gland
Identify characteristic signs of (i) thyrotoxicosis including tremor,
sweating, eye signs, and distinguish from anxiety (ii)
hypothyroidism including slowness, hoarse voice, thin hair, dry
skin, slow reflexes
Examine the neck to identify the thyroid gland. Assess its overall
size and consistency and describe any palpable masses
3. Hypothalamo-pituitary-adrenal axis
Most common presentations of pituitary and adrenal disease
Adrenal overactivity and
Identify constellation of symptoms and signs associated with (i)
insufficiency
corticosteroid excess and (ii) primary and secondary
hypoadrenalism
Pituitary hormone excess and
Be aware of the constellation of symptoms and signs associated with
deficiency
(i) excess of prolactin/ACTH or growth hormone and (ii) deficiency
of ACTH/gonadotrophins/TSH
Compression of structures
Examine visual fields and identify obvious bitemporal hemianopia
related to the pituitary
4. Calcium metabolism
Hypercalcaemia an
hypocalcaemia
Identify constellation of symptoms associated with (i)
hypercalcaemia, and ask appropriate questions to formulate a
differential diagnosis aend (ii) hypocalcaemia
Diagnostic tests / medications in endocrinology
Thyroid function tests
Interpret TSH and free thyroid hormone results
Cortisol replacement and long
term steroid use
Describe use and side effects of corticosteroid therapy
D. RENAL/UROLOGICAL
1. History and evaluations of symptoms
Abdominal pain
Describe the symptoms and signs of renal & ureteric colic
Urinary volume
Identify clearly abnormal urinary frequency and distinguish from
polyuria. Identify oliguria/anuria. Aware of the significance of
polyuria, nocturia and frequency
Urine characteristics
Identify blood in the urine. Recognise that it may be the only
manifestation of serious urinary tract disease. Be aware of the
significance that frothy urine may indicate proteinuria.
Urinary stream
Describe lower urinary tract symptoms including frequency, urgency,
nocturia, dysuria, hesitancy, poor stream.
Urinary incontinence
Distinguish urge and stress incontinence
23
APPENDIX 1
Uraemia
Identify the non-specific symptoms of uraemia: lethargy, pruritus,
pigmentation, and loss of sensation
2. Examination of renal/urology system
Blood pressure
Be competent in correct measurement technique of blood pressure,
and aware of importance of cuff size and Korotkov sounds. Familiar
with automated methods of measurement and aware of role of
ambulatory measurements
Circulatory volume
Make use of examination of tissue turgor, jugular venous pressure and
postural blood pressure measurements in clinical assessment of
circulatory volume
Kidneys
Be aware of techniques for kidney palpation and clinical
characteristics of renal masses.
Bladder
Percuss and palpate the bladder
Prostate
To perform rectal examination under supervision and assess prostatic
size, outline and texture.
Scrotum
Identify normal and clearly abnormal testicles by palpation. Identify
scrotal swelling, and distinguish testicular and epididymal swelling
and hydrocoele, varicocoele. Distinguish from inguinal hernia.
Demonstrate transillumination of hydrocoele.
(See lumps and bumps curriculum)
Oedema
Identify constellation of symptoms and signs associated with nephrotic
syndrome, and distinguish from cardiac failure, venous insufficiency
and hypoalbuminaemia of other cause
3. Diagnostic tests of renal/urology system
Midstream urine sample
Technique for collection of clean samples. Interpretation of urine
culture results
Urine testing
Identify haematuria, proteinuria, glycosuria and ketonuria on urine
stick testing. Be aware of the sensitivity of urinary dipsticks and the
importance of thorough investigation of abnormalities
Blood tests
Imaging
Urodynamics
Invasive investigations
Potassium: significance of abnormal results and the effect of
haemolysis.
Creatinine: strengths and weaknesses as a measurement of renal
function.
PSA: significance and role in screening
Blood gases: interpretation of pH, bicarbonate and “base excess”
Awareness of imaging techniques commonly used in investigation of
renal and urinary tract disease (ultrasound, plain abdominal X ray
“KUB”, IVU/other contrast techniques, CT/MRI) and of the
indications for choosing each of these. Able to identify major organs
on normal CT abdomen. Able to interpret common signs on the IVU
Aware of free urinary flow trace patterns and the significance of post
void residual bladder volume.
Awareness of techniques of cystoscopy, and renal biopsy and of
indications for these.
24
APPENDIX 1
E. NEUROLOGICAL SYSTEM
1. Common symptoms of neurological disease
Headache
Able to elicit accurate history of headache and distinguish between
benign headaches (tension headache, migraine) and serious headaches
(meningitis, subarachnoid, haemorrhage, temporal arteritis).
Weakness/immobility
Identify history of weakness, its pattern and mode of onset. Identify
acute onset of stroke and TIA and be aware of the risk factors.
Dizziness / unsteadiness
Identify clear history of vertigo. Awareness of other common causes of
dizziness. Elicit a history of ataxia.
. Identify clear history of generalised epileptic seizure and distinguish
from vasovagal event. Aware of the principles of management of
common epileptic conditions.
Blackouts
2. Examination of nervous system
General examination
Identify signs of meningeal irritation and the skin rash associated with
meningococcal septicaemia. Identify muscle wasting..
Cranial nerves
Tone
Power
Reflexes
Tremor and co-ordination
Gait
Speech
Sensation
Demonstrate ability to examine all the cranial nerves particularly eye
movements, pupil reactions, facial sensation, facial weakness
(distinguish between an upper and lower motor neurone lesion),
dysarthria, tongue weakness and wasting.
Identify clearly increased and decreased muscle tone in upper and lower
limbs.
Examine power in limbs. Distinguish constellation of signs of upper
and lower motor neurone lesion.
Examine the biceps, triceps, supinator, knee and ankle and plantar
reflexes. Identify clearly increased and decreased/absent tendon
reflexes. Awareness of the value of reinforcement.
Recognise the tremor of Parkinson’s Disease and distinguish from
hyperthyroidism/anxiety/ benign essential tremor. Able to examine coordination in the upper and lower limbs
Examine patient’s gait, and identify clear neurological abnormality due
to major hemiplegic stroke, cerebellar disease and Parkinson’s Disease
Recognise clear speech abnormality. Able to distinguish between
dysphasia and dysarthria.
Examine limbs and trunk for fine touch, proprioception, vibration and
pain sensation. Identify clearly reduced / altered sensation and pattern.
3. Diagnostic tests of nervous system
CT scan of head
Recognise clear cerebral haemorrhage and infarct.
25
APPENDIX 2
EXAMPLES OF POSSIBLE SSC TOPICS
(Further suggestions are available on the Medicine and Surgery Unit Blackboard sites):
Surgery
 The patients journey through a major resection for hepatic or pancreatic cancer.
 Enteral nutrition in patients undergoing GI surgery.
 The problems facing patients undergoing elective surgery for colorectal cancer requiring a stoma
 Discuss advances in imaging of colorectal cancer.
 Radiotherapy for rectal cancer.
 Discuss the influence of patients groups in the treatment and management of breast cancer
 Reconstruction after mastectomy.
 Literature study of breast infections
 Multiple endocrine neoplasia type 1

Scoring systems in acute pancreatitis

Blunt abdominal trauma – how is it best investigated

Discuss the falling mortality in acute appendicitis in the UK
Gastroenterology

Examine the evidence for a link between MMR and inflammatory bowel disease

What is it like to have coeliac disease

GI endoscopy past, present and future

Review the web-based resources for patients in gastroenterology

Do any treatments work for irritable bowel syndrome?

How does H.pylori cause ulcers?

Can the mortality from GI bleeding be reduced?

Are there alternatives to liver transplantation?

How does alcohol damage the liver?

Discuss the ethical issues surrounding tube feeding in neurological disease

The impact of malnutrition in hospital patients

Modern techniques for nutritional support

Why do patients with dyspepsia present to their General Practitioner? How should these patients
be managed in Primary Care?
Renal

Visit a dialysis centre, assess patient perceptions etc

Follow a kidney transplant, pre-op, op and post-op

Acute renal failure (literature based): why mortality still so high? how can it be improved? what
are recent advances in management?

What is the future of organ transplantation (literature based) animal organs, cloning, organ culture
etc, also widening use of living unrelated kidney donors.
Neurology
 Follow a patient who has had a stroke from admission to discharge and comment constructively on
their management whilst in hospital, drawing on published evidence where possible.
 Design a patient information sheet for people with migraine
 Discuss the psychological and social impact of epilepsy









Alcohol poisons nerve – how and why?
Epilepsy surgery – the way forward
Respiratory support for people with motor neurone disease – ethical or criminal
Examination of the lower / upper limbs- on CD-rom (group project)
Beta interferon – what the patients’ think
Complex disability - how it impacts on the family
Investigation of the young stroke
MS- future research prospects
Neurological consequences of HIV and AIDS
26
APPENDIX 2
Diabetes, endocrinology and metabolism

Write an information leaflet for patients on tablet treatment/ diabetic retinopathy and how to
prevent it/ benefits of exercise/starting insulin etc.

A review for websites useful for a newly diagnosed patient or a patient with a newly diagnosed
complication

Islet transplantation – the current status

Should screening for diabetes be introduced?

How could length of in-patient stay of people with diabetes be reduced?

Impotence in diabetes – aetiology and management

Insulin infusion pumps - who should get them?
 Non-invasive glucose monitors – what is available and what works?
 What advice can we give patients on the use of ACE inhibitors in diabetes?
 Is MacDonald’s bad for health?
 Design a national plan for reducing the future incidence of type 2 diabetes
 Why are people with diabetes more likely to have heart attacks?
 Should we operate on obesity?
 Graves disease – review the possible treatment options
 Ghrelin – Review of a recently identified hormone
 Discuss risks and benefits of various treatment options for postmenopausal osteoporosis
 Acromegaly: Meet with and write a case study of a patient with acromegaly with particular regard
long term medical and social consequences
 Atrial fibrillation in thyrotoxicosis - is it a bad thing?
 Accompany a patient having radioactive iodine therapy for hyperthyroidism. Describe the
experience from the patient’s perspective.
Radiology
 Websites for users of radiology services
 Analysing radiologists reporting errors
 Computer aided analysis of radiological images (lung)
Cardiology
 How would you explain to a patient the benefits and risks of taking medication for high blood
pressure
 Discuss the benefits of screening of patients for coronary disease
 An audit: the use of stress testing in ischaemic heart disease
 A case study: a patient suffering from a MI focusing on management of his condition
 Acute coronary syndrome – definition and patient information
 Cardiac amyloid disease
 Cardiovascular complications of cocaine
 Chelation therapy for heart diseases, is there any evidence?
 Drug therapy & plaque stability
 High altitude pulmonary oedema
 Identification and treatment of coronary risk factors in patients who have had a myocardial
infarction
 Long QT Syndrome pathology & treatment
 Percutaneous transluminal coronary angioplasty v. coronary artery bypass grafting as a treatment
for ischaemic heart disease
 Nitrates in cardiology
 Student approach to the interpretation of ECGs
 The effects of steroid abuse on the cardiovascular system
 The pathophysiology & management of valvular heart disease
 The use of betablockers in Marfan syndrome
27
APPENDIX 2
Respiratory medicine
 The investigation and management of suspected venous thromboembolism
 Assessment of school policy on asthma
 Cryptogenetic fibrosing alviolitis: A forgotten disease
 Discuss various smoking cessation strategies and their relative success
 Lung transplantation
 Management of cystic fibrosis
 How society copes with new diseases, using sleep apnoea as a model
 The epidemiology of TB in the UK. Looking into the likely causes for the recent resurgence of TB
in the UK
 The pathophysiology & current management of ARDS
 The use of bronchoscopy as a medical imaging technique
 Pleural mesothelioma audit
 Pathology of malignant lung cancer
ENT
 The treatment of recurrent laryngeal nerve palsy
Vascular Surgery
 A Rough Guide to the abdominal aortic aneurysm
 Amputation through the ages
 Atherosclerosis and smoking
 Clinical management of acute limb ischaemia
 Compare & contrast interventional methods for repairing aortic aneurysms
 The causes, effects and treatment of venous leg ulceration
 Lower limb amputation
 The management of intermittent claudication
 Who gets peripheral vascular disease and how does it affect their lives?
28
APPENDIX 3
MARKING STRATEGY FOR SSMS
There will obviously be some diversity in the SSC projects and the students’ approach to them. In order to
consider more than just factual content, please give a mark for the SSC in each of the following areas. Please
remember that student has been allocated eight days for this SSC and the quality of the work should reflect this.
ORIGINALITY
1
2
3
4
5
Fail. No original contribution from student in terms of idea or interpretation of subject matter
Poor. Pedestrian approach to subject
Average. Unoriginal idea but personalised approach by student
Good. Original idea / interpreted supervisor’s idea in novel manner.
Excellent. Student’s own idea. Showed outstanding imagination and originality.
CONTENT
1 Fail. Misinterpretation of the topic. Frequent factual errors. Inadequate coverage.
2 Poor. Minimal coverage and understanding of the topic. Muddled and confused thinking.
3 Average. Adequate but lacking depth
4 Good. Thorough, clear, concise and relevant account of subject
5 Excellent. Publication standard.
PRESENTATION
1 Fail. Very poor. Organisation confusing. No diagrams / inappropriate diagrams.
2 Poor. Poor structure/ organisation of the material. Extremely long /too short. Diagrams poor quality.
3 Average. Reasonable structure / organisation. Appropriate use of diagrams.
4 Good. Good structure with good use of text and diagrams.
5 Excellent. Textbook or publication standard presentation. Clearly labelled relevant diagrams.
REFERENCES and SOURCE MATERIAL
1 Fail. Very few, out of date references. Key facts in text not referenced. Not listed in appropriate format. No
evidence that references actually read. Source material not quoted.
2 Poor. Limited references / source material. Inadequate literature search. Some key references missing.
3 Average. Adequately referenced / researched. Listed appropriately
4 Good. Good range of references/ sources with up to date material. Listed appropriately. Evidence of
thorough background research.
5 Excellent. All key references included with clear evidence they have been read and critically analysed. Wide
range of sources referenced (Web based material, newspapers). Appropriately listed.
INDEPENDENT WORK
1
2
3
4
5
Fail. Required a lot of staff effort and guidance / failed to recognise that some guidance required.
Poor. Needed frequent prompting. Dependent on supervisor for guidance.
Average. Reasonable level of independent work. Some prompting required. Aware of own limitations
Good. Worked independently. Appropriate liaison with supervisor
Excellent. Worked independently. Demonstrated high degree of initiative.
STUDENT NAME:
SUPERVISOR:
SSC TITLE:
ORIGINALITY
CONTENT
PRESENTATION
Comments:
29
REFERENCES
INDEPENDENT
WORK
TOTAL
MARK
APPENDIX 4
ADDITIONAL MEDICINE AND SURGERY B ASSESSMENTS INFORMATION
The unit assessment consists of :
‘Must pass’ components:
Professional Behaviour assessment
Handing in an SSC and making a formal presentation of a case report
Written assessment
Clinical assessment
The final unit mark consists of :
Clinical assessment (50%): OSCE
Written assessment (50%):
- MCQ exam (30%)
- SSC (15%)
- Case report (5%)
Merits and distinctions will be based on your combined marks from clinical and written
assessments for Medicine and Surgery B.
1.
The Objective Structure Clinical Examination (OSCE)
The OSCE will be held on the morning of the last Thursday of your second Medicine and Surgery
attachment, (25th March 2004 or 3rd June 2004 ) between 08.30 and 17.30 hrs. Your OSCE in
Medicine and Surgery A will be on the previous day. The exam will take place in the Academic
Centre, Frenchay Hospital. Students will be divided into five groups with different start times.
You will receive notification of the time to arrive by e-mail, and are expected to turn up in good
time for the start.
Students are expected to be presentable and wear clean white coats, as patients will be present. ID
badges must also be worn. You will need a pen, a watch and a stethoscope.
Content
You will rotate through 12 stations and the exam will last approximately 1½ hours
For more detailed descriptions of the type of stations, please refer ‘The Second Clinical
Attachment OSCE: what to expect’ on the Galenicals web-site
(http://www.medici.bris.ac.uk/galenicals/osce.htm).
In outline the stations will include:
Two 10-minute stations:

A clinical station (history): you will be asked to take a history from an actor playing the
part of a patient complaining of one of the core clinical problems listed in the handbook.
 A clinical station (examination): you will be asked to examine a particular system and tell
the examiner what you have found. The examiner will tell you
Ten 5-minute stations:
 Three or four short clinical examination stations covering neurology, nephrology, urology,
breast disease, and endocrinology if not covered in longer stations: Some examples would
be. a) partial neurological examination - previous stations have included sensory or motor
examination of upper or lower limbs, cerebellar signs, particular cranial nerves etc. b)
rectal examination on a mannequin, c) breast examination, d) examination of the thyroid,
e) eye examination as relevant to general physical examination (e.g. ophthalmoscopy,
visual acuity testing, visual fields etc), f) taking blood pressure properly!
 Communication skills: explaining something to a patient
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APPENDIX 4




Two stations involving testing urine or interpretation of laboratory results, charts etc.
relating to core problems and suggesting potential causes and follow-up investigations and
management
X ray interpretation: you will be given an X ray (see handbook for the types of things to
expect) with an accompanying scenario and asked some questions related to diagnosis,
aetiology, clinical presentation etc.
Procedures: you will be asked to perform one of the procedures (on a mannequin if
appropriate) listed in the handbook. These are things we expect you to have become
familiar with while you are on the wards or in theatre or perhaps in a clinical skills session
(e.g. taking blood, setting up an IV infusion (not inserting cannulae yet), aseptic technique
etc. )
Miscellaneous: This is a catch-all category that could include a) any aspect of the general
examination which you should have brought with from your time in the first clinical
attachment, and which you should have used during your clerking of patients on this unit
e.g. part of the basic examination of the heart and lungs b) videos of patient histories c)
photographs d) identification of commonly used instruments or special investigations as
listed in the handbook e) duplication of one of the possibilities listed above.
This list is only meant to give you some guidance as to what to expect. It is not intended to be
a complete syllabus or curriculum. Other stations might be included in your exam.
Each station will have either an examiner, someone to instruct you what to do or clear written
instructions, depending on content. There will be ‘marshals’ to tell where to go and make sure that
everything is clear. There will not be any chance of you getting lost or going the wrong way.
The OSCE will draw its contents from the syllabus in the back of your course handbook. Other
useful sources of information are i) the Galenicals’ website pages on the Second Clinical
Attachment OSCE. The principals of this exam are the same though the content will be more
focused on the AERON subjects, ii) the OSCE tutorial on the Galenicals’ website, iii) Appendix 4
of your Medicine and Surgery B handbook.
2.
Student selected component (SSC)
This must be handed in before the end of the unit, and, at your end of unit assessment with your
tutor, you will be required to produce a copy of the e-mail you will receive from Sharon Byrne
confirming receipt of the project. You must print this off and keep it. Your SSC must be handed in
on time. This is non-negotiable. If your SSC is handed in late without prior agreement with the
unit lead due to exceptional circumstances, you will fail
3.
Case reports
You are required to write up or present one patient case history. This patients should illustrate a
core problem from one of the groupings related to your current attachment (i.e gastrointestinal
and breast disease, neurological disease, endocrinology and diabetes, or urology and renal
medicine for Medicine and Surgery B). This case report should include the key points of the
history, examination and investigations with your conclusions about the diagnosis. This should be
followed by a section on the management and progress up to discharge. The case history should
therefore cover the whole admission and discussion of the underlying condition and management
options as well as the initial clerking. In Medicine and Surgery B, you will be required make a
formal presentation of this case to your teachers and colleagues at the end of the unit, and to
answer their questions on it. The suggested format is a 10-minute presentation with
overheads/powerpoint with 5 minutes for questions. Your mark for this case will be assigned on
the basis of their comments
PJB/11.08.03
31
APPENDIX 5
How to clerk a patient
32
APPENDIX 5
33