Internal Medicine Junior Clerkship

MBBS III HANDBOOK

THE DEPARTMENT OF MEDICINE Kamuzu Central Hospital Lilongwe Campus, College of Medicine 2013/14

Name: ______

DEPARTMENT OF MEDICINE

Department of Medicine; Kamuzu Central Hospital POB 149, Lilongwe 3

Department of Medicine, College of Medicine University of Malawi Private Bag 360, Chichiri; Blantyre 3

Academic Lead, Campus Lilongwe Department of Medicine, Kamuzu Central Hospital Dr. med. Clara Schlaich, MPH e-mail: [email protected] phone: 0996265576

Head of Department Dpt of Medicine, Kamuzu Central Hospital Dr. Jonathan Ngoma TABLE OF CONTENTS

1. INTRODUCTION 3

2. OUTLINE OF MBBS III MEDICAL ATTACHMENT 5

3. KCH DEPARTMENT OF MEDICINE WEEKLY ORGANIZATION...... 9

4. WARDS AND OUTPATIENT CLINICS...... 10

5. POSTEXPOSURE PROPHYLAXIS (PEP) to PREVENT HIV INFECTION...... 11 . 6. REQUIREMENTS OF MBBS III MEDICAL ATTACHMENT 12

7. ASSESSMENT...... 13

8. ORIENTATION TO COLLABORATING INSTITUTIONS 14

9. EXAMPLE OF A CASE WRITE UP 15

10. STUDENT LEAVE REQUEST FORM ...... 20

11. LEARNING OBJECTIVES 21

13. STUDENT ADMISSION FORM of KCH DPT of MEDICINE (Case write up) ...... 29

2 INTRODUCTION

In October 2012 the Lilongwe Campus of the College of Medicine was established. Starting with the academic year 2012/2013 teaching of MBBS 3 in Community Health, Medicine, Pediatrics, Surgery and Pediatrics is conducted within the clinical Dept´s at Kamuzu Central Hospital and in the new Lilongwe Campus facilities

Welcome to the Department of Medicine at Kamuzu Central Hospital!

Your 3rd year Medicine Attachment is a 7 week rotation based in the Department of Medicine at Kamuzu Central Hospital. The Light House Trust, Partners in Hope Hospital and University of North Carolina Project are additional teaching sites and will contribute to your teaching experience. Faculty from the Queen Elizabeth Central Hospital will come to Lilongwe for your teaching.

The Medical Department at Kamuzu Central Hospital is organized in 4 Teams: A, B, C and D. Each team is consisting of a Head of Firm (usually a Medical Specialists and Lecturer), consultants, Registrars, Interns and you – the Students! You will be assigned to one of the teams and follow their routine. Each team has one day out of 4 when it admits patients in the Short Stay Unit and follows these patients on the wards until they are discharged from the wards. You will also see patients in the in- and outpatient clinics, in the High Dependency Unit.

It is our hope that your medicine rotation will be complimentary in terms of its educational value with what you learnt during preclinical years and with what you will learn in other departments.

The philosophy of modern medical education is to provide learning opportunities to students, and it is the responsibility of the student to make the most of those opportunities. Therefore there has been a move from teacher-centered education to learner-centered education which more closely reflects the responsibility you will need to take for your own ongoing education throughout your medical career.

Basic Professional Expectations of Third-year Students

1. Ensure that patient welfare is your first priority when dealing with all patients. Always inform your clinician if you have any concern while clerking a patient. 2. Follow through on all tasks assigned to you by members of your medical team. If you are unable to do this inform your team. Be honest: Faking signatures or giving wrong excuses for not attending or preparing is not acceptable. 3. Attend all activities on time. If you must be absent, get permission in advance. 4. Dress professionally. The way you dress makes a statement about your school, hospital, and the medical profession; it may influence the way you are perceived by your patients. If you have any question about what constitutes professional dress, consult the coordinator. 5. Protect yourself from infection and injury: Wear appropriate protective equipment (such as gloves, sturdy shoes, face masks). Rest before you come to work, never drink alcohol before work. If you feel sick, report to your team member, if you don´t feel comfortable to do a procedure in a patient, talk to your consultant. 6. Treat every member of the health care team, and every patient with respect. 7. Make sure your handwriting is legible and ensure every note includes your name (also in BLOCK LETTERS) and role. 8. Preserve confidentiality, do not discuss patients in public places and destroy all papers with patient specific information that are not part of the medical record. Do not look in the chart (paper or electronic) of any patient for whom you are not caring. 9. If there are any circumstances that that do not allow you to follow these rules talk to the 3rd year coordinator as soon as possible.

Top 5 Ways to Excel during your Internal Medicine attachment

1. Be actively involved in the care of your patients to the greatest extent possible. Go the extra mile for your patients. You will benefit as much as they will. The more you put in, the more you will gain.

2. Read consistently and deeply about the problems your patients face. Read about topics before your tutorials. Raise what you learn in your discussions with your team and in your notes. Educate your team members about what you learn whenever possible.

3. Learn to do clear and concise presentations as early as possible. This will make you more effective in patient care and gain the confidence of your supervisors to allow you more involvement in patient care.

4. Be enthusiastic, ask questions and be willing to speak up – share your thoughts in teaching sessions, share your opinions about your patients’ care, constructively discuss how to improve the education you are receiving and the systems around you.

5. Actively seek feedback and reflect on your experiences.

Any concerns?

If there are any concerns or problems, academically or in your private life if they influence your academic performance –speak to the third year academic head. She will keep this information private unless discussed with you otherwise. The aim will be to find individual solutions and support to keep you in the program.

4 2. OUTLINE OF YOUR MEDICAL ATTACHMENT

STRUCTURE OF THE ATTACHMENT: You will be joining the medical department for 7 weeks. The teaching is organized in theme weeks, a theme being an important field of medicine. Theme-weeks are (the order may change):

 Introduction  Respiratory Medicine  Cardiology  Gastroenterology  Neurology  Renal Medcine & Endocrinology  Haematology & Oncology/ Exam Week

This is to give you an overview how your weekly timetable is roughly going to be structured. It may vary slightly from week to week. Please consult your updated timetable for current details.

OUTLINE MEDICAL ATTACHMENT MBBS III

SCHEDU SATURDAY/ MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY LE SUNDAY Departmental Case Departmental Case Departmental Hand-over presentation Hand-over presentation Hand-over

8:00-9:30 Case Students only Pharmacology Students only with x-rays presentations at UNC lecture students At Partners in Hope Admitting Clinics GMC Clinics team to cover and/or Short-Stay Short Stay Short Stay Unit, High Unit* Unit* Short Stay Unit* Teaching 10:00- Teaching Dependency Ward 12:00 Ward Unit, Ward* and/or and/or and/or Rounds Rounds Ward Work Ward Work Ward Work

Office Hour 12:00- academic Lunch break 14:00 lead 13:00- 14:00

Core Case PBL 1 Seminars Seminars Seminars 14:00- 18:00 Practical Practical Skills Seminars Seminars PBL 2 Skills

* Students join their team on call (A,B,C,D) for Short Stay Unit

COMMON HANDOVERS The Department has a common handover in the morning and a shorter handover in the afternoon. You are required to join the common departmental morning handover, every Monday, Wednesday, Friday at 8 a.m. (sharp!). It takes place in the handover room in Ward 2, Renal Unit (CW2).

CASE PRESENTATIONS “Student´s only” case presentations (4 students each session) take place on Tuesdays and Thursdays with one faculty member to give you feedback. Venues are the Campus, the UNC lecture hall and the Partner’s in Hospital (shuttle bus will leave 7:30 sharp from Campus). The session include four student presentations each, whereby you will be presenting an interesting case of a patient that you have clerked on the wards.

On Mondays (starting in the 2nd week of your assignment) there will be four 3rd year students presenting a case each in the departmental handover. Patient presentations should be Power Point presentations (max 5-8 slides). Please make sure that the computer/projector is set up and running well before the meeting starts to not cause any delay to the meeting.

If there is any insecurity in choosing an appropriate case, please contact the Academic lead.The Case presentations will not be graded. However you will be getting a verbal and written feedback, with a statement “fail”, pass”, “credit”. If you “failed” you will have to repeat the case presentation.

How to do a successful case presentation: -Clerk the patient thoroughly - Discuss the case with your clinician -follow the rules for a good power point presentation -Use the structure given in the “blue book” -avoid typing errors - practice your presentation, do not read from the slides - read up on the topics - speak slowly and with confidence, raise your voice!

PROBLEM BASED LEARNING (PBL) PBL sessions have a part 1 and part 2. You will work together with a tutor. In the session on Friday, the tutor will confront you with a case which you then will discuss within the group. You are to identify problems which you shall try to solve within the group (elect a student preceptor!) on the basis of the knowledge that some of the group members may already have. Open questions and unresolved problems will be investigated by every student. By the end of the session your tutor will also hand in some learning objectives to make sure your group is not missing any important topics. The case will be rediscussed on the basis of your newly gained knowledge in the session on Thursday the following week. The tutor will only try to guide your discussion, but is not supposed to lecture.

SEMINARS/ SPECIALITY TEACHING

6 These are seminars of 45 mins duration which will cover learning contents that you would have formerly encountered during fourth year and which due to the curriculum changes will now have to be covered in 3rd year. We try to fit the contents of the speciality teaching into the respective theme week, but there are some fields of medicine which do not have a theme week of their own, hence you will find some specialty teaching which does not fit thematically into the week. Not all the content of the learning objectives will be covered by the formal classroom lectures. You are expected to cover all topics named in chapter 10 by self study. Remember: you will benefit most from the classroom teaching if you read the topic up before you come to the class!!! Some guidance for reading you will find in the CMS.

CLINICS You are supposed to attend two out of the following clinics ONCE: General Medicine Clinic, Diabetes Clinic, in –patient HIV clinic or Light House ART clinic, Oncology Clinic, Partners in Hope private clinic. Your attendance shall be signed by off the respective clinician at the END of the session (don´t ask for multiple signatures at the end of assignment!! You won´t get them).

ON-CALLS SHORT STAY UNIT You will spend two afternoons on-call with your team in the Short Stay Unit. During the week, this will be from 2-8 p.m, on weekends from 8 a.m. to 2 p.m. You are free to choose any appropriate day for you, either weekends or weekdays. You are welcome to do additional days. The Short Stay Unit offers fantastic opportunities to clerk and present lots of interesting and acutely ill patients, and to perform lots of procedures. Please bring your logbook and get your signatures!

PRACTICAL PROCEDURES You are expected to perform a minimum number of certain practical procedures. These are listed in your logbook. Whenever you have performed a practical procedure, have it signed in your logbook by the tutor who witnessed it (asking for multiple signatures at the end of assignment will not be accepted!!).

The “typical nursing procedures –nasogastric tubes, urinary catheters, s.c. and i.m. injections and blood-glucose testing- can be signed by the nurse in charge.

PATIENT WORK-UPS You are required to work up a minimum of 18 patients during your medicine attachment. A work-up may be on an inpatient or outpatient, in the Short Stay or High Dependency Unit and should include the following:

1) A written history and physical examination. 2) A problem list with differential diagnosis, a diagnostic plan, a therapeutic plan, and a patient education plan for each problem. 3) A concise case presentation to the attending or supervising physician.

An example of a written up case is given at the end of the handbook You may wish to use the departmental admission forms as template for your clerkship. If you thoroughly fill that form, this counts as a patient You will find them on the wards. But you may use any form you wish or type your write-up by computer as long as the standard format is followed:

 IDENTIFYING  INFORMATION  SOCIAL HISTORY  PRESENTING COMPLAINT  REVIEW OF SYSTEMS  HISTORY OF PRESENT  PHYSICAL EXAMINATION ILLNESS  LABORATORY STUDIES  PAST MEDICAL HISTORY  ASSESSMENT  FAMILY MEDICAL HISTORY  PLAN Students are encouraged to do in-depth reading about their cases in any standard medical textbook. The case presentation should be a concise, 5 minute or less, summary focusing on the information and findings PERTINENT to the present illness. What is pertinent will depend entirely on the problem(s) for which the patient is seen. These cases will form part of your continuous assessment. Students should record these cases in the student log book for evaluation at the end of rotation.

PROBLEM ORIENTED MEDICAL RECORDS Students should make daily rounds on their hospital patients and gain experience writing progress notes in the SOAP format i.e. SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN. If a patient from your firm is admitted to the High Dependency Unit or the Intensive Care Unit you will find it interesting to follow the patient´s clinical course in these settings. However you are not required to write notes in these units.

RECOMMENDED TEXTBOOK Textbook chosen for history taking and physical examination is the departmental “Blue Book” edited by EE Zijlstra. You receive personal copies of the Malawi National Treatment guidelines and Tb and HIV guidelines. Use them for your reference. However it is essential that you supplement with other books e.g. Hutchison’s Clinical methods by Michael Swash. You will find additional textbook in the “student pantry” at the telemedicine unit. Also you receive soft copies of the WHO x-ray book and “neurology in Africa”. You must read these books till the end of your rotation.

CONSULTANT EVALUATIONS Each student will have two formal feedback evaluations during the clerkship. One feedback will be done midway through attachment and another one at the end. Feedback sessions are meant to be mutual, and the student is more than welcome to give his/her feedback to the Department.

ABSENCES The Medicine Department has adopted the following policy on absenteeism: Students may have up to two days of excused absences during the clerkship. If the student is absent for three or more days, they have to be made up. All requests for leave must be approved by the year coordinator in the department.

8 3. DEPARTMENT OF MEDICINE WEEKLY ORGANIZATION-INPATIENT AND OUTPATIENT SERVICES

SATURDAY/ SCHEDULE MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SUNDAY 8:00-9:30 Hand-over Outreach - Hand-over Hand-over O H Hand-over Optional: District Health u a Case Clinics/ Tb Case Pharmacology t n X-ray talk Join admitting team to cover Short-Stay Unit, High presentati Ward presentation talk r d- 9:00-10:00 Dependency Unit, Wards. ons interns/registr. e o (2nd / 4th students a v week) Join Ward rounds of teams c er h 7: 30

G - ra

n D d i R s o t u r n i d c 8: t 00 - 9: H 00 e (1s t / a 3r l d t we ek) h Senior W Staff Ward ar meeting Rounds d Ward Rounds OPD ART (1st / 3rd Ward Rounds R 9:00-12:30 Cancer week) Diabetes Clinic GMC C o Hematology Clinic Hematology l u Clinic Bweila Tb Ward /FNA Clinic i n Ward Rounds n ds round i ART 12:30-13:00 c clinic* Journal Club 14:30-15:30 Cancer Clinic* GMC 13:00- ART Clinic* s Cance or Postgraduat Diabetes Clinic from ART clinic* 15:30 r Morbidity and e teaching from 11:00 11:00 Clinic Mortality * statistics 15:45- Afternoon Afternoon Afternoon Hand-over Afternoon Hand-over Afternoon Hand-over 16:30 Hand-over Hand-over Monday –Friday Telemedicine lectures between 10:00-17:00; see monthly schedule Daily: Cover of Short Stay and Consultations to other Dpts: AdmittingTeam A, B, C or D, after hours: Interns on call Ward Rounds (4A, 4B): Daily by teams A,B,C,D. HDU and Dialysis: Daily rounds by assigned consultant (monthly) intern/registrar (weekly) * ART Inpatient and Cancer Clinic by UNC, Light House and KCH 4. WARDS AND OUTPATIENT CLINICS

 Ward 4A: Female Medical Ward

 Ward 4B: Male Medical Ward

 HDU: High Dependency Unit (in ward 4A)

 Ward 2: Hemodialysis Unit (in renovation)

 Short Stay Unit: Admitting and Short-stay ward (8 beds)

 Diabetic Clinic: Medical Specialist Clinic OPD II Tuesdays from 11:00

 General Medicine Clinic: Medical Specialist Clinic OPD II Wed from 11:00

 Light House Trust ART Clinic: Tuesdays and Wednedsays 8:00

 In-patient HIV clinic: Medical Specialist Clinic Monday, Wednesday and Thursdays from 13:00 in OPD 1

 Partner’s in Hope Clinic: Outpatient private clinic every morning

 Oncology /Hematology Clinic: Medical Specialist Clinic Tuesday, Thursday Ward 2 UNC room from 9:00 a.m.

 Bweila Hospital Tb Ward: Specialist Ward rounds Tuesday or Friday from 9:00-11:00

5. POSTEXPOSURE PROPHYLAXIS (PEP) to PREVENT HIV INFECTION FOR MEDICAL STUDENTS AT KAMUZU CENTRAL HOSPITAL

If you had a needle prick or spilled blood or body fluid on eye, mouth or damaged skin there is a risk of becoming infected with HIV:

PEP should be considered. It is available to you at Kamuzu Central Hospital with no costs at all times! What to do?

- Report to your senior clinician immediately

- Do not delay, best prevention of HIV infection, if PEP medication is started within 2 hours of injury. You may start PEP even if you have not done an HIV test. But you must do the test ASAP. Best is: Know your status before you have an injury!

- Remember to clean area of injury thouroughly first with water and soap or in case of the the eyes, plenty of water

Wash your hands after procedures and clinical examination, wear gloves

Use hand lotion to prevent eczema, dryness of skin, Cover cuts and abrasions of skin

Make sure you are immunized against Hepatitis B before you start your clinical assignement, Know your HIV status

Rest well before work, no alcohol

Sound knowledge of procedures, prepare your work space, take your time

As a 3rd year Medical Student you must have a clinician supervising any invasive procedure; do not do any procedures in non-cooperative patients

6. REQUIREMENTS OF THE MEDICAL ATTACHMENT

1) You will complete at least 18 history and physical exams during the clerkship and have the write-up and problems list evaluated by your intern, registrar or consultant, as well as orally presented the cases to a senior doctor. 2) You will have three dedicated patients on the ward who you have to manage on a daily basis under the supervision of your senior team members.

3) You will present two cases of patients you have clerked during one of the morning handovers, one of which shall be a common departmental handover.

4) You will attend a minimum of two different of the following clinics at least once: Diabetic and General Medical Clinic, ART clinic (Light House), in-patient HIV clinic, Cancer/Oncology clinic.

5) You will perform a required minimum set of practical procedures as listed in your logbook. If you do extra procedures/activities they will be merited in the continuous assessment.

NB: All formal requirements must be signed by a clinician (intern, registrar, consultant) on the same day. Signatures cannot be given on retrospect. Nursing procedures (NGT, Foly cath, im,s.c.injections MRDT, BG can be signed by nurse in charge). 7. ASSESSMENT Continuous assessment To pass this you will need to: 1. Conduct yourself in a professional manner at all times during the attachment as laid out in the professional expectations listed above. 2. Satisfy the senior doctors you work with that you have adequately meet the objectives of this attachment 3. Adequate completion of your logbook including: . Clerking of at least 18 patients including write up and presentation of the cases to a medical intern, registrar or consultant. . Participate in weekly presentations during the morning handovers . Attend at least two in- or outpatient clinics during your rotation 4. Have not been absent for more than 2 days or made up time of longer absenteeism

Clinical Skills: the grade of the OSCE´s and Long Case are averaged up (60/40) Objective Structured clinical examination; OSCE This clinical exam will focus on your ability to perform a systematic physical examination. You will be expected to elicit the abnormal findings and interpret your findings to be able to come up with a list of causes for these. Additionally you will have to interpret an y-ray and a n ECG. Long case This clinical exam will focus on your ability to perform a complete history and physical examination on one patient, to present your findings clearly and concisely, and to be able to come up with a problem list and differential diagnosis in an appropriate order. This exam will be done at a time convenient to you and your examining consultant at some stage during the final two weeks of your attachment. It is your responsibility to arrange a time for this.

Written exam The written exam consists of short answer and multiple choice questions that refer to learning objectives. This exam will focus on your ability to come up with a differential diagnosis and determine which aspects of the history and physical examination would be most helpful in narrowing the diagnosis.

Grading scheme

This clinical rotation will be graded as passed or failed only. The pass mark is 50% To pass you must receive a pass, credit or distinction in any of the above mentioned three components. Each component will receive a grade, but the final grade is pass/fail only.

Grades: 75—100 = distinction 65—74 = credit 50— 64 = pass 45- 49 = marginal fail 0-44 = undoubted fail The student must pass each component independently during the rotation to be deemed to have passed the rotation successfully!! 8. COLLABORATING INSTITUTIONS

THE LIGHT HOUSE TRUST

Lighthouse Trust, a Public Trust and recognized Center of Excellence for integrated HIV prevention, treatment, care and support in Malawi, works in close coordination with the Ministry of Health (MOH), Kamuzu Central Hospital and Lilongwe District Health Office (DHO) to operate two large integrated HIV testing, treatment and care clinics in Lilongwe, Malawi: one on the campus of Kamuzu Central Hospital (KCH) and another at Bwaila Hospital, the Martin Preuss Centre (MPC). Currently, combining both Lighthouse and MPC clients, Lighthouse is the largest single provider of ART in Malawi with over 18, 000 adults and children alive on ART by June 2012. Lighthouse provides HIV Testing and Counseling to over 3, 500 clients per month, cares for over 180 bed ridden patients under Home Based care and over 5, 000 patients under the psychosocial and treatment adherence program call Ndife Amodzi. Lighthouse is a Training Centre for HTC, integrated ART/PMTCT and Palliative care.

University of North Carolina University Project /Tidiziwe Clinic

The University of North Carolina Project-Malawi (UNC Project) is a collaboration between the University of North Carolina at Chapel Hill and the Malawi Ministry of Health. It is based on the campus of Kamuzu Central Hospital in Malawi's capital, Lilongwe.

The mission of UNC Project-Malawi is to identify innovative, culturally acceptable, and affordable methods to improve the health of the people of Malawi, through research, health systems strengthening, prevention, training, and care.

UNC Project; Tidziwe Centre

Private Bag A-104; Lilongwe; MALAWI

Partners in Hope Clinic, Lilongwe, Malawi 9. EXAMPLE OF A COMPREHENSIVE CASE WRITE-UP A “comprehensive write-up” will be a complete history and physical examination in standard Problem-Oriented Medical Record form or a problem-focused ambulatory note (see following example) and will include: 1.a) A complete Problem List, with problems designated as "active" or "inactive/resolved" with dates 1.b) A comprehensive Assessment with differential diagnoses of undiagnosed problems (including rationale for including/ excluding diagnoses) or discussion of diagnosed problems 1.c) Plans, divided into diagnostic, therapeutic and educational plans 1.d) Literature References 1.e) the student's name, printed and signed 1.f) Abbreviations: Since medical records are communication devices, abbreviations should NOT be used because their meaning is not universal among all readers of the medical records. Specifically, students should NOT use error-prone abbreviations, symbols and dose designations (see Appendix D). USING THE STABDARD STUDENT ADMISSION FORM OF THE KCH DPT OF MEDICINE WILL SATISFY THESE REQUIREMENTS. YOU CAN USE THIS FORM OR USE THE FORMAT BELOW. EXAMPLE of In-patient History and Physical Examination PROBLEM LIST Problem Date Onset ACTIVE Problems Date Resolved Inactive/resolved No. Problems

1. 1990s Allergic reaction to sulfa (rash, peeling skin)

2. 2000 2000s Hx of cervical cancer

3. 2001 Hypertension

4. 29 Oct-09 GI bleed

5 I Nov-09 Anemia

Date of Admission: 30 January 2010 Date of Exam: 1/Feb/10 ID: 55 –year old woman who is a school teacher History from: Patient and her daughter, who gave good history. Not all medical records not available RE: Admission to HDU Presenting Complaint: "Bloody stools" for 3 days

History of Present Illness: The patient is a 55-year old married woman with history of hypertension since the year 2001. She has been in good health over the past one and half years until October 29, 2002, when she began passing bright red blood per rectum along with "dark black clots" and "black stools". The patient says she has had more than 10 bowel movements of this kind within the last 3 days. She has been feeling weak for the last one day and half and has had some "near-fainting" episode after which she found herself drenched with sweat, as if "someone dumped a bucket of water over my head". The patient's daughter says that the patient may have experienced a brief loss of consciousness (less than 30 seconds.) during this "near-fainting" episode, as she stopped talking for a short period of time. On the morning of October 30, 2002, the patient was brought to the QECH. At this time the bleeding had ceased and her only complaint was weakness. She was described as being stable, and her admission hemoglobin was 12.2 g/dl. She was observed in 4B with the hope of discharging her the following day. During the night of the admission, the patient again began to pass bright red blood per rectum, but without black clots. She says she passed 3 bloody bowel movements during that nights.

The patient says she has never had any prior episodes of rectal bleeding. She had experienced some constipation the week before, and had used glycerol suppositories, which had given relief. She has no fever, nausea, vomiting, diarrhea, sick contacts, chest pain, shortness of breath, recent weight changes or changes in appetite. She also says she has had occasional abdominal pain for a few months, but no history of previously diagnosed GERD or peptic ulcer disease.

Past Medical History Adult illnesses: Cervical cancer – in 2000 Hypertension- first aware of diagnosis in 2001 Childhood illnesses not asked The patient has no history of bleeding disorder, liver disease, diabetes mellitus, myocardial infarction or renal disease.

Hospitalizations/Surgeries: 1980, 1983, at QECH- birth of her children 2000 at QECH- Hysterectomy, reason for CIN. Transfusions: During surgery for carcinoma of uterine cervix

HIV History: HIV test done during this admission is negative

Current medications: Atenolol 100mg once a day, Hydrochlorothiazide 25 mg once/day Aspirin- dosage unknown, last dose taken 10 days ago

Allergies: Penicillin ® reaction unknown; told by doctor not to take penicillin Sulfa ® acute onset of "red rash and skin peeling in sheets" (1990s) Cortisone ® face swelling

Family History: Patient's father died in his 40s from “liver cancer." Mother died in her 70s of a "stroke, and had diabetes mellitus. The patient has numerous siblings, some of whom are step-siblings. One sister has diabetes. Two of the step-siblings have died, causes unknown. Health status of the other siblings are unknown. There is no family history of bleeding disorders. Personal Profile/Social History: The patient is a married school teacher. She does not smoke and has never smoked, does not take alcohol or illicit drugs. Her diet consists mostly of maize meal. She doesn't each much fruit or vegetables. Review of Systems: Skin: Has no rash, itching, bruising. Eyes: Reports no blurry vision, other visual disturbances. Ears: Reports no hearing loss, tinnitus, pain, discharge, vertigo. Nose: Has "allergies” which cause runny nose, sneezing, cough. Mouth: Has no gingivitis, sore tongue, taste changes, dental problems Throat: Reports no pain, voice changes Pulmonary: Reports no chest pain, pneumonia, SOB, DOE, wheezing, sputum, hemoptysis Circulatory system: Has no chest pain, palpitations, dyspnea, PND, orthopnea, edema, syncope GU: Reports no frequency, nocturia, polyuria, urgency, dysuria, hematuria, hesitancy, urinary flow changes, retention, incontinence; has no history of kidney problems Gynaecological history: See PMH. Breast: Not asked Sexual Hx: Not asked Musculoskeletal system: repots no problems. Nervous system: Has no history of head trauma, headaches, numbness, paralysis, convulsions, seizures, tremor, gait disturbances, coordination changes Mood: Not asked. PE:  General Appearance: Patient appears well-nourished, appearing her stated age. She is lying comfortably in bed, in no evident distress. She is alert, oriented and cooperative.  Vital Signs: Temp 96.0; Respirations 14; Oxygen sat 99% on Room Air; Supine- HR 89, BP 147/64; Standing- HR 110, BP 131/54  Skin: Warm, dry, pale  Head: Non tender over scalp  Eyes: Acuity not tested. PERRLA. Extraocular muscles function intact. Fundi normal  Mouth: Mucosa pink, moist, slightly pale. No lesions or bleeding. No tonsillar erythema or exudates.  Neck: Supple. Thyroid gland not enlarged, No enlarged lymph nodes, No jugular venous distention; no carotid bruits.  Pulmonary: Lungs examination normal (percursion and auscultation)  Cardiac: No thrills, lifts or heaves. PMI palpated in left 5th ICS at the midclavicular line, non-bounding. Rate and rhythm are regular, normal S1 and S2. No murmurs, extra heart sounds heard.  Abdomen: Soft, non-tender, non-distended. Normal bowel sounds. Spleen and liver not enlarged and no other palpable organs  Rectal (done by Registrar- reported as showing no masses but Bright red blood on glove.  Extremities: Full motion in all extremities. No clubbing, cyanosis, edema. Patient was slow to stand due to dizziness.  Neuro: Alert and oriented in person, time and place. Cranial Nerves: II - XII grossly intact. Normal speech. Sensation normal to light touch, Normal power in all extremities (examined biceps, triceps, knees and ankles) Babinski response down going. Admission lab results: CBC: WBC 7.9, differential: Bands 7, Segs 50, Lymphs 37, Monocytes 5, Eos O, Baso 1 Hgb 9.8 (was noted to have been 12.2, 2 days PTA), Hct 28. MCV 93.9, PT 12.3, PTT 22, INR 1.0 Platelet count 238 Na 140, BUN 20, K 3.6, Creatinine 0.7, Cl 110, Bicarb 25, Glucose 135 mg/dl

Problem #1: Bleeding per rectum Assessment: The patient has experienced several episodes of bloody stools in the past three days. In addition, there is evidence that this patient has had substantial blood loss including: (1) A decrease in hemoglobin from 12.2 to 9.8 in two days with normal MCV, which suggest an acute bleed; (2) Orthostatic changes (increase in HR of >20, decrease in Systolic BP > 15mmHg) suggest that the patient has lost >1 liter of a blood. The differential diagnosis of lower GI bleed include: Diverticulosis, colon cancer or polyps, ulcerative colitis, angiodysplasia, and hemorrhoids. Diverticulosis is likely as it most (Why?) Brisk upper GI bleed is also possible Plan: Continue monitoring patient in HDU with careful monitoring of vital signs.

Diagnostic:  Place NG tube to assess for gastric bleeding  Consult a gastroenterologist for upper endoscopy and colonoscopy  Treatment:  Type and crossmatch. Transfuse 2 units packed red blood cells to replace blood loss, since she is at risk to cntinue bleeding  No food or drink in preparation for endoscopy according to gastroenterologist instructions  Further treatment dependent on endoscopic findings. Consider initiate gastric acid blocking regimen prophylactically

Patient education:  Inform patient of the possible diagnoses and the need for careful monitoring and testing  Inform patient of endoscopic procedures, explain risks and benefits, obtain informed consent  Inform patient of need for transfusion, explain risks and benefits, obtain informed consent

Problem #2: Anemia Assessment: The patient has developed an acute anemia. Her hemoglobin had dropped 2.4 G/dL (from 12.2 to 9.8). Plan: Diagnostic:  Monitor blood count every twice daily for continued bleeding and decrease in hemoglobin Treatment:  Place adequate intravenous access (2 large bore peripheral catheters)  Group and cross-match. Transfuse 1 unit packed red cells now.  Intravenous fluids: normal saline at 100cc/hour  Transfuse packed red cells to keep hemoglobin > 10 G/dL

Patient education:  Inform patient of need for transfusion, explain risks and benefits, obtain informed consent  Inform patient of signs and symptoms of worsening anemia that she should be aware of, such as worsening orthostatic hypotension, weakness, faintness, pallor, tachycardia.

------Resources: Departmental handbook

Signed: Chizaso Makolija

10. COM / KCH DEPARTMENT OF MEDICINE LEAVE REQUEST

LEAVE REQUEST Student’s Name______

Student’s Signature______

Total # of hours requested: ______Total # of days requested: ______

Time period of leave: ______/______/______through ______/______/______

Return to Clerkship: ______/______/______

Reason: ______

______

SIGNATURE AND AUTHORIZATION

______Attending’s Signature Clerkship Director’s Signature Department Chair’s Signature

______Date Date Date REPORT OF ILLNESS OR INJURY

Student’s Name ______

Absent dates: ______/______/______through ______/______/______Return to Clerkship: ______/______/______

Briefly explain nature of illness or injury: ______

______

Administrative Coordinator ______Date______

(PLACE IN STUDENT’S FILE) Draft

11. LEARNING OBJECTIVES a) Broad

1. To take an accurate and systematic history, gathering all appropriate information.

2. To perform a thorough and systematic physical examination, eliciting the clinical signs which are present.

3. To make a differential diagnosis in appropriate order taking account of common conditions and serious conditions using a surgical sieve to do this.

4. To develop professional standards and communication skills when dealing with patients and colleagues.

More specifically these objectives entail:

1) Clinical Skills

a. History and physical examination. Student will be able to describe and define: ● The significant attributes of a symptom including location, radiation, intensity, quality, temporal sequence, alleviating and aggravating factors, setting, associated symptoms, and functional impairment. ● The four methods of physical examination (inspection, palpation, percussion, and auscultation), including where and when to use them, their purpose, and the findings they elicit ● Obtain a history and physical examination in a logical, organized, and thorough manner covering the identifying information, chief complaint (in patient’s words), present illness, past medical history, family history, social history, review of systems, and physical examination. b. Oral case presentation. Student will be able to: ● Give a concise, 5 minute or less, summary of a case with emphasis on the presenting symptom(s), pertinent past medical history, family history, social history, review of systems and pertinent positives and negatives in the physical examination.

c. Problem list and differential diagnosis. Student will be able to: ● Formulate a problem list and differential diagnosis based on findings in the history and physical examination and develop appropriate diagnostic, therapeutic, and patient education plans for each problem identified.

d. Interpretation of laboratory and X-ray data. Student will be able to: ● Order and interpret results of various diagnostic studies indicated by clinical findings.

e. Use of the medical literature. Student will be able to: ● Search and critically analyze the medical literature

2) Professionalism

The student will exhibit appropriate attitudes and behavior befitting a general internist caring for the whole patient with colleagues, consultants and the health care team in the areas of:

● Respect ● Responsibility and accountability ● Caring, compassion and communication b) Specific

1. MBBS 3 learning objectives - Cardiology

History taking Being able to take a full and detailed cardiovascular history.

Physical examination Being able to do a full cardiovascular examination. General impression Peripheral signs of heart disease Heart sounds, murmurs Jugular venous pressure Capillary refill time Blood pressure Pulse palpation Electrocardiography Understanding the electrophysiological bases of ECG. Being able to do an ECG. Being able to read an ECG, with focus on Identifing axis, sinus rhythm, atrial fibrillation, features of ischemic heart disease, left ventricular hypertrophy

Congestive cardiac failure Definitions and relations between Acute and chronic heart failure Left sided and right sided heart failure Diastolic and systolic heart failure Aetiologies Treatment Prevention

Ischaemic heart disease Pathophyisology Atherosclerosis and the concept of plaque rupture Risk factors Epidemiology Definition, treatment and investigations in Stable angina Unstable angina Myocardial infarction

Valvular heart disease

Mitral stenosis, Mitral regurgitation, Aortic valve stenosis, Aortic valve regurgitation

to know the commonest cause to list the clinical consequences to understand the physical signs to list drugs that might be used to know how the valve lesion might be treated surgically

Rheumatic fever to understand the pathophysiology of rheumatic fever to list the clinical features of rheumatic fever and know the major and minor criteria (Duckett Jones) to list the treatment options for acute rheumatic fever to understand the importance of antibiotic prophylaxis for patients who have had rheumatic fever to understand the relationship between rheumatic fever, rheumatic valvular heart disease and infective endocarditis

2. MBBS 3 Learning objectives - Respiratory Medicine

1. To be able to take relevant history and do complete respiratory examination 2. To understand and explain the anatomical and physiological basis for both the normal physical exam and pathological physical signs 3. To name respiratory causes of finger clubbing 4. To understand and point out the following important aspects on pneumonia a. causes of pneumonia (community acquired or hospital acquired, nneumocystis) b. clinical presentation of pneumonia (symptoms and signs:consolidation/pleural effusion and how consolidation and effusion appear on CXR) c. CURB-score d. Relevant investigations e. drugs used to treat pneumonia and reasoning behind the choice of antibiotics

5. To know the following respiratory manifestations of tuberculosis a. symptoms and signs b. radiological appearances on CXR c. relevant investigations d. name of drugs used for TB treatment

6. To know the following important aspects of pleural effusion a.causes (infective and non-infective) b.tests that can be done on pleural fluid c. how to distinguish transudate from exudates pleural effusion using total protein, LDH and ratios. 7. To understand the following on asthma a. pathophysiology and triggering factors b. different drugs used and how they act (based on pathophysiology of the disease) c. different routes of drug administration (oral, nebulisation, IV, inhaler, MDI) d. common side effects of the drugs e. to be able to explain the use of an asthma inhaler to a patient.

8. To understand COPD (definition, epidemiology, clinical features, investigations and treatment)

9. To understand what is meant by cor pulmonale, the pathophysiology of cor pulmonale and which respiratory conditions are likely to give rise to it. 10. To understand lung malignancy (different types, risk factors, clinical features, investigations and possible treatments in general).

11. To know risk factors/clinical features/diagnosis of pulmonary embolism.

12. To know how to systematically present CXR findings and how consolidation, a cavity, lung abscess, bullae, reticulonodular infiltrates, pneumothorax, effusion, pulmonary edema,cardiomegaly appear on CXR.

PROCEDURES AND PRACTICALS To know the principles of a. chest drain insertion, indications and complications b. pulse oximeter and blood gas interpretation c. nebulisation (drugs/indications) and inhaler technique

d. O2 therapy

3. MBBS 3 Medicine Learning objectives - Gastroenterology Oesophagus and stomach To know the differential diagnosis of upper GI bleeding To list the risk factors for peptic ulcer disease To understand how the history and examination may help you differentiate between different causes of upper GI bleeding To know the “red flags” on history, examination that may indicate gastric cancer Describe the acute management of Upper Gastrointestinal Bleeding To define the terms dysphagia and odynophagia To understand the difference between “neurological” and “anatomical” dysphagia To list common causes of dysphagia Understand and be able to describe Diagnostic Procedures used in the investigation of the oesophagus, stomach and small bowel.

Pancreas Describe the signs and symptoms of Acute and Chronic Pancreatitis To know the severity score for acute pancreatitis To list common causes of acute and chronic pancreatitis Jaundice To be able to classify jaundice To know the common causes of each type of Jaundice To know how the types of jaundice may be differentiated by history, examination, blood tests, urine dipstick tests and imaging

Liver Be able to describe the signs and symptoms of Chronic Liver Disease. To list the causes of Cirrhosis Describe the risk factors, presentation, investigation and management of liver tumours including HCC. Describe the complications of liver failure including clotting derangement, hepatic encephalopathy and hepatorenal syndrome To be aware of the causes of PHTN and the clinical differences between patients with cirrhosis and hepatic fibrosis due to schistosomiasis

Ascites To be able to classify ascites To list 3 causes for transudative ascites and 3 causes for exudative ascites To know how to investigate ascites including interpretation of findings on ascitic tap

Diarrhoea To understand the different clinical types of diarrhea and how the characteristics of the diarrhea and associated symptoms may indicate the underlying cause To know the common infections causing acute and chronic diarrhea Understand the situations where antibiotic treatment is appropriate for infective diarrhea See LOs: Drugs and Diarrhoea To be aware of “red flags” which may indicate that a patient has colon cancer To have a brief understanding of inflammatory causes of diarrhoea including Inflammatory Bowel Disease

Nutrition To know how to assess nutritional status in an adult To know the criteria for prescribing nutritional supplements in an adult

PROCEDURES Ascitic Tap and interpretation Ascitic Drain NG tube insertion Urine Dipstick and interpretation Urinary catheterisation. . 4. MBBS 3 Medicine Learning objectives - Renal Medicine To know the classification of uraemia To give 2 examples of causes of uraemia that fit into each category To know how GFR can be estimated in the clinical setting To know the importance of proteinuria in the assessment of renal disease To be able to define the terms nephrotic syndrome and nephritic syndrome To know at least 2 causes each of nephrotic syndrome and nephritic syndrome To know the clinical features of acute renal failure To know the clinical features of chronic renal failure To know the biochemical and haematological abnormalities associated with CRF To know what investigations are relevant for a patient with suspected renal impairment To know how chronic renal failure might be treated To know the different presentations of renal tract infection To know the common bacterial causes of renal tract infection To know how a patient with suspected urinary infection might be investigated To know the approach to a patient with vasculitis

5. MBBS 3 Medicine Learning objectives - Neurology 1. The main learning objective is to be able to take relevant history and do complete neurological examination:

a. To understand the anatomical and physiological basis for both the normal physical exam and pathological physical signs. To localize pathology to the appropriate location within the nervous system

b. To be able to differentiate between neurological, functional and psychiatric symptoms by history taking, examining and relevant investigations.

2. To be able to localise different neurological symptoms and signs:

a. Upper motor neuron versus lower motor neuron lesions.

b. Cerebral Hemispheric lateralization

c. Brainstem lesions

d. Cerebellar lesions

e. Lesions in the basal ganglia

f. Spinal lesions

g. Peripheral nerve h. Lesions in the neuromuscular junction

i. Muscular diseases

3. Understanding paraparesis and hemiparesis and importance of being able to localise their cause.

4. To recognise the danger signs of a headache and to know the most common benign headache types (migraine, tension neck, etc)

5. To be able to differentiate causes of disequilibrium and dizziness

6. To take an appropriate mental status exam and differentiate focal versus global forms of cognitive impairment

7. To recognise symptoms and signs and be able to make appropriate differential diagnoses for at least the following conditions:

a. Epilepsy and other conditions causing collapse.

b. Stroke

c. Space occupying lesion in CNS (other than stroke). Common infections and tumours, especially HIV-related conditions.

d. Peripheral neuropathy, polyradiculitis

e. Acute confusional state (delirium) coma and dementia

6. MBBS 3 Medicine Learning objectives - Endocrinology

(1) Thyroid ▪ Hyperthyroidism causes clinical features investigation management

▪ Hypothyroidism causes clinical features investigation management

▪ Thyroid enlargement causes investigation complications

(2) Pituitary To know the clinically relevant hormones produced by the pituitary gland To list the common pituitary tumours To understand the consequences of pituitary tumours To describe the clinical syndrome of prolactinoma To describe the clinical syndrome of acromegaly

To list 3 causes of pituitary failure To recognise the clinical features of acute pituitary failure (apoplexy)

(3) Adrenal Gland To revise the physiology of the adrenal gland To list the common conditions associated with the adrenal gland To describe the clinical features of Cushing’s syndrome To know 3 causes Cushing’s syndrome To recognise the clinical features of adrenal insufficiency To know 3 causes of adrenal insufficiency To describe the features of phaeochromocytoma