1

UNIVERSITI KUALA LUMPUR

ROYAL COLLEGE OF MEDICINE PERAK








YEAR 3 MODULE HANDBOOK

(MEDICINE)

2014-2015
















2

GENERAL MEDICAL ATTACHMENT LOG BOOK

Aims

The aims of this attachment relate both to the development of clinical skills
and to gain experience in general medicine.

1. Clinical Skills

Students will have developed a range of clinical skills during the Introductory
Clinical Course. This attachment will provide the opportunity for students to
further refine their basic skills of history taking and physical examination.

These skills are best learned through practice and observation. You will
receive teaching from a number of different tutors and medical staff of all
grades of seniority. You should be willing to present your case histories and
physical findings and thereby learn through feedback from your teachers.

You should also observe and take part in the everyday activities of the ward
and the ward doctors. You should attend ward rounds, theatre sessions, and
clinics and be present on emergency admission days.

Students should seek a broad experience predominantly in medicine through
clerking patients and following them through their stay in hospital and in
observing in the out-patient clinic and other departments of the hospital
.Patients transferred to surgical wards should continue to be followed
throughout their stay.

For each patient you see you should document and keep a record of the
history and examination findings. This will form subject matter for some of
the clinical teaching sessions with your tutors. Each student should be make
at least 3 formal case presentation to their tutor. You should also whenever
possible continue to follow your patients throughout their stay in hospital
and accompany them if they have detailed radiological or endoscopic
investigations or other procedures. You should compare your notes with
those in the case records to observe points of similarity and difference.

Student should gain experience in the following areas of medical practice :

Acute medical emergencies, ably on an admissions ward
Investigations (particularly through radiological and endoscopic
procedures) of patients with a range of conditions.

3
Rehabilitation of patients prior to discharge from hospital as
exemplified by patient with stroke illness.
Discharge planning and the multi-disciplinary approach to patient
care
Infection diseases- with particular reference to malaria, typhoid and
typhus fever, dengue fever, leptospirosis, opportunistic infections and
infections in the immunocompromised patient
Poisoning and snake bites


Learning Objectives

At the end of the module you should have:

Refined and improved your basic clinical skills
An understanding of your level of ability to elicit physical findings and
where improvement is required.
An ability to assimilate and combine skills in order to elicit histories
and examine patients from the perspective of individuals body systems
(cardiovascular, respiratory, abdomen , musculosekeletal, endocrine ,
nervous system )
An ability to assess an elderly person, including medical history, drug
therapy, physical and social functioning and mental state
An ability to intergrate theoretical knowledge and clinical skills to
enable the formulation of differential diagnoses.
Experience in the investigation and management of a range of common
medical conditions







4
APPENDIX

Basic Clinical Skills to be attained by the end of the module

An understanding of the role of history taking in making a diagnosis

An understanding of the relevance and importance of the different
modes of communication which may occur in the doctor/patient
interactions

An understanding of ways in which you can improve your
communication skills

Knowledge of the components of a full clinical history and the
relevance of each

An ability to present histories from patients with a variety of medical
complaints

A knowledge of how to detect and be able to describe the clinical
relevance of the following physical signs :

- Anaemia
- Cyanosis
- Jaundice
- Clubbing
- Peripheral oedema
- Goitre
- Iymphadenopathy

Elicit the rate and rhythm of the pulse and palpate the peripheral
arterial pulses

Measure the systemic arterial blood pressure

Detect the jugular venous pulse

Auscultate for vascular bruits

Auscultate the heart to distinguish the first and second heart sounds
and thereby distinguish systolic and diastolic murmurs


5
Determine the position of the trachea in the suprasternal notch

Assess movements of the chest wall

Percuss the chest wall

Auscultate the lungs

Detect abdnormalities in vocal resonance and tactile vocal fremitus

Palpate the abdomen to detect sites of tenderness

Detect and characterise abnormal masses in the abdomen

Detect enlargement of the liver, spleen and kidneys

Examine the abdomen for the presence of ascites

Perform a digital rectal examination

Examine the higher mental functions of language, memory and
concentration

Examine the cranial nerves ( including the optic fundi with an
opthalmoscope)

Detect wasting and weakness in the limb musculature

Elicit changes in muscles tone

Elicit the tendon reflexes and plantar responses

Detect abnormalities of peripheral sensation

Perform and interpret tests of co-ordination in the limbs

Examine the gait





6
Rheumatology

Location : Raja Permaisuri Bainun Hospital

Aim:
To gain a level of skills, knowledge and attitudes of the assessment of patients with
rheumatic diseases appropriate for newly qualified doctors.
Objectives:

1) to observe the clinical assessment of patients in rheumatology clinics
2) to be able to recognise abnormal function of the musculoskeletal system
3) to become familiar with the clinical features of common rheumatological conditions
4) to understand the principles of the management of common rheumatological
conditions
5) to understand the criteria for referral to a rheumatological clinic

Further Information

Core musculoskeletal examination skills

Set out below is a summary of the skills to be acquired during the medical course, together
with their purpose and some examples of clinical features you should learn to recognise.

Systemic enquiry:

To elucidate further the history volunteered by the patient, enquire about:

Pain (nature, site(s) & radiation), stiffness, weakness, swelling, wasting.
Onset & pattern of symptoms (periodicity, rate of change). Appearance.
Systemic fatigue, stiffness, weakness, fever, anxiety, depression

Reading List
All students should be familiar with Basic Clinical Skills material, including:

1) The GALS video: This is available in the Library
2) Recommended reading
Clinical Examination in Rheumatology - Doherty M & Pattrick M (Wolfe 1992)
An Atlas of Rheumatology - Shipley M - (Wolfe Atlas series 1992)
Rheumatology in Practice - Dieppe P et al - (Mosby)
ABC of Rheumatology 2
nd
Edition (BMJ Books 1999)

For more advanced reading:-
Rheumatology - Klippel J & Dieppe P (Mosby 2nd Edition 1998)
Oxford Textbook of Rheumatology - Maddison P et al (OUP, 2nd Edition 1998)





7
Cardiology

Year 3 Clinical Skills with particular reference to Cardiology

AIMS

You should be able to take a history with particular reference to cardiovascular symptoms and
perform a full clinical examination of the cardiovascular system.

Learning Outcomes

Below are the basic areas within each subject and should be viewed as the minimum required
understanding in each section. You should understand the features of the history and
examination which will help you make a differential diagnosis. The clinical exams will test
these issues and therefore they can be viewed as a minimum curriculum.

1. Take a clinical history in patients with cardiovascular disease.

Specifically you should be able to identify the underlying cause of the problem in patients
presenting with breathlessness and chest pain. This will require you to be able to differentiate
on the basis of history and examination a number of conditions some of which are outlined
below.

Particular reference to identifying the causes of chest pain. Identifying myocardial
infarction, angina and non-cardiac pain.

Identifying heart failure as a cause of breathlessness.

Identifying the probable causes of syncope, collapse and dizziness.

Know the causes of haemoptysis and differentiate between these on the history

Identifying the risk factors for cardiovascular disease.

8
2. Examination of the cardiovascular system.

You should be fully competent to undertake a complete examination of the heart and
arteries with particular attention to being able to identify the conditions below:

Left heart failure

Congestive failure

Aortic stenosis and regurgitation

Mitral stenosis and regurgitation

Tricuspid regurgitation

3. Be conversant with the following practical procedures.

Be competent to perform an ECG

Be capable of reporting an ECG to determine:

Rhythm - Sinus, atrial fibrillation, heart block and differentiation of
broad complex from narrow complex tachycardia

Identify left ventricular hypertrophy

Identify myocardial infarction and localise to inferior or anterior
regions of the heart.

Interpret a CXR to be able to diagnose heart failure

Interpret a CXR to be able to diagnose lung cancer

4. Have observed the following procedures and understand the indications for them and
the major complications of these.

Have seen an echocardiogram and understand what information this type

investigation can give

Investigation and Therapeutics.





9

5. Understand the investigation and basic treatment including pharmacology of the main
drugs used for the following:

Atrial fibrillation

Myocardial infarction

Stable angina pectoris

Acute left ventricular failure

Congestive cardiac failure

Infective endocarditis

6. You should be familiar with basic cardiac and thoracic anatomy (this should be
revision!)

Helpful notes for the Cardiology and Cardiothoracic Surgery attachments

History & Examination Cardiovascular patients.

History taking.

All histories from patients should be taken and recorded along the basic lines:

Presenting Complaint
History of presenting complaint
Past Medical History
Systems review
Family History
Drug History
Social History

Examining patients with cardiovascular disease.

A general examination is essential including examination of the hands (clubbing) and head
and neck (central cyanosis). In particular care should be taken with the following:

Radial Pulse: Regular / irregular - change with exercise

Blood Pressure: Measure SBP and DBP at Korotkov V (silence)

JVP: Note wave form (No a wave in atrial fibrillation). Measure height as vertical
from angle of Louise.

Carotid: Visible neck pulsation (Corrigans sign), Quality of the upstroke- slow rising in
aortic stenosis, bisfiriens in mixed aortic valve disease.

LV apex beat: Position, quality.

Parasternal heave: RV volume overload and hypertrophy, Left atrial enlargement


10

Auscultation: Apex, left sternal edge, aortic and pulmonary areas
Radiation (to the neck, axilla, the back)
Effect of position (role on left - mitral murmurs; sit forward - aortic
regurgitation)

Examine the peripheral pulses
Examine both sides
Listen for vascular bruits
Examine the abdomen for aneurysm.

Listen to the lung bases for inspiratory basal crackles suggesting left heart failure.


ECGs.

For your own experience it would be a good idea for you to collect two abnormal ECGs.

Photocopy and report two abnormal ECGs

Try to report as follows:

Rate, Rhythm, and QRS axis.
Describe the PR interval and the QRS duration. (Put the normal range in brackets after each)
(One mm square = 40 msecs)
Describe the abnormalities of the QRS complexes on the ECG.

Exercises.

These may help your basic understanding of some aspects of cardiology. If you know these the
subject area will be much clearer to you.

11
Neurology


Teaching Location: Raja Permaisuri Bainun Hospital
Aims
To understand the nature and importance of neurological medicine
To acquire the core skills and knowledge required for the practice of neurology
To understand the need to integrate these skills and knowledge into the wider
practice of medicine

Objectives

To become competent in taking a history and performing an appropriate
examination in patients with neurological diseases
To be able to diagnose the common neurological diseases
To know about the common neurological conditions
To appreciate the role of multidisciplinary team working in neurological practice
To be aware of the current and emerging therapeutic options in neurological
diseases
To understand and witness the extent of specialisation within neurological
medicine
Assessment

This will be formative in nature

Suggested Reading

Basic:
Harrisons Clinical Methods (Neurology section)
Neurological Differential Diagnosis John Patten 2
nd
Edition Springer

Advanced:
Brains Diseases of the Nervous System 9
th
Edition
Neurology in Clinical Practice 3
rd
Edition Bradley, Daroft, Fenichel and Marsden
Butterworth-Heinemann










12
The Neurosciences

The Neurosciences encompass Neurology and Neurosurgery together with the imaging
and Neurophysiological practices which are untilised in the investigation of patients with
disorders of the Nervous System.
The teaching is provided principally by Prof. Dato Dr. Gurdeep Perkash Singh (Physician)

Your Responsibilities
If you are told something, you may not remember it. If you learn it yourself, you will
remember.

Specific skills to be acquired :-
History and Recognition of clinical pattern of neurological disorder :

You should be able to take a relevant neurological disorder :

1. Appreciate the various causes of headache . List the causes you have seen and keep
notes on the characteristics of different sorts of headache and facial pain .
2. Understand the significance of different patterns of weakness and the urgency of
evolving paraplegia, understand what is meant by an upper and a lower motor
nuerone lesion and list causes you have seen.
3. Distinguish between peripheral neuropathy and isolated median, ulnar and lateral
popliteal nerve lesions and know the signs of a C5/6 and L5/S1 root lesion. List
what you have seen.
Neurological Examination

You should be able to assess and understand the significance of :-

1. Optic nerve function including
1.1. measurement of visual acuity
1.2. identification of visual field abnormalities seen in optic nerve compression , a
pituitary tumour and a lesion in the topic radiation
1.3. fundoscopy : using the direct ophthalmoscope
1.4. pupillary abnormalities

2. Eye movements : the different between
2.1. Conjugate and dysconjugate gaze disorders
2.2. internuclear ophthalmoplegia
2.3. III, IV and VI nerve palsies
3. Lower cranial nerve examination, including V, VIII, X, XI and XII nerves


4. Motor examination including :-
4.1. Appearance

13
4.2. Upper and lower limb tone, including the rigidity of Parkinsonis
disease
4.3. Power in two muscles at each joint
4.4. intrinsic muscles of the hand to distinguish between a median and
ulnar nerve lesion
4.5. Tendon stretch reflexes

Perform simple tests of coordination


5. Perform simple test of sensation to indentify and understand the significant of
5.1. A sensory level in spina cord disease
5.2. Glove and stocking sensory loss in a peripheral neuropathy


Dissociated sensory loss in syringomyelia


Knowledge :-

You should understand the basis of investigation and treatment of the following :

1. Epilepsy
2. Stroke including the clinical symptoms and signs of cerebral hemisphere and
brainstem pathology and subarachnoid haemorrhage.
3. Parkinsons disease
4. Migraine
5. Multiple sclerosis
6. Brain tumour including an understanding of cerebral localisation
7. Spinal cord compression
8. Papilloedema
Record them as you encounter them and make a point of seeking patients with
those you have not yet seen.

Procedures:

You should observe the following and understand their benefits and risks :

LP. (You should arrange with the ward staff to observe this procedure)
CT Scan and MRI
Spinal Operation


Recommended Materials:

You can revise the video on Clinical Examination which you saw during the introductory
clinical course. This is available in the Library.

Reading :

- Essemtial Neurology : Wilkinson TMS, Blackwells
- (Practical Neurology by WB Matthews)

14


Infectious Diseases

2. Infections Disease

Infection diseases with particular reference to malaria, typhoid and typhus fever,
dengue fever, leptospirosis, opportunistic infection and infections in the
immunocompromised patient and understand the pathophysiology. Investigation
and management of these.
A knowledge of the emergency management of snake bite and poisoning
Tutors and students should acknowledge that while each of these objectives can
and should be met by all students (irrespective of what stage they have reached in
Year 3) the degree of expertise of successive groups through the year would clearly
increase.





Conass Marks

Case write-up = 30 %
mini-CEX = 20 %
Case presentation = 30 %
Log book = 20 %

Total = 100 %
















15


Year 3 Medicine MBBS UniKL Formative Mini-Clinical Evaluation (mini-CEX)

(modified from the Royal Australasian College of Physicians)


Trainees name: . Date: .

Assessors name: . . Group:

Hospital: ..

Setting: In-patient Out-patient Emergency Others: ...

Patient problem / Diagnosis: . History taking: 10 minutes

Patient age: yrs. Gender: Male Female Physical Exam: 10 minutes

Problem / Case Complexity: Low Medium High Discussion: 5 minutes

*Please rate the trainee against what you would expect of a trainee in Year 3

poor unsatisfactory satisfactory good excellent not observed

Total
% % % % %

1. Medical interviewing skills 0, 1, 2, 3,4, 5,6 7,8 9,10 n/o
(15%)


2. Physical examination skills 0, 1, 2, 3, 4, 5,6 7,8 9,10 n/o
(15%)


3. Discussion including investigations 0, 1, 2, 3, 4, 5,6 7,8 9,10 n/o
(10%)


4. Overall clinical performance Total












Time taken for observation: mins Time taken for feedback: mins

Assessors satisfaction with mini-CEX: low 5 10 15 20 25 30 35 40 high

Trainees satisfaction with mini-CEX: low 5 10 15 20 25 30 35 40 high


Assessor signature: .. Trainees signature:

Strengths: Suggestions for development: