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UNIVERSITY OF THE WITWATERSRAND, JOHANNESBURG
DEPARTMENT OF MEDICINE
MEDICINE COURSE FOR GEMP 3 STUDENTS - 2015
AIMS AND OBJECTIVES
Medicine in third year GEMP is a formal qualifying course. Students who fail this block will have to repeat the block immediately. This will mean that students who fail a block will graduate later than their peers.
o ATTENDANCE OF 90% OF WARD AND HOSPITAL ACTIVITIES AND THE SUBMISSION OF TWO CASES REPORTS ARE DP REQUIREMENTS. STUDENTS WHO DO NOT FULFIL ATTENDANCE AND LOGBOOK REQUIREMENTS WILL NOT BE PERMITTED TO WRITE THE EXAM.
o STUDENTS ARE REQUIRED TO BE IN THE WARDS ON THE MONDAY, TUESDAY, THURSDAY AND FRIDAY OF THE FINAL WEEK OF THEIR BLOCK.
o AT THE END OF THE FIFTH WEEK OF THE BLOCK,UNIT HEADS WILL ADVISE THE ADMINISTRATION OFFICE IF A STUDENT HAS NOT FULFILLED THE DP REQUIREMENTS AND SHOULD NOT BE PERMITTED TO WRITE THE EXAMINATION.
Table of Contents1 INTRODUCTION.........................................................................................................22 OBJECTIVES AND CASE COMPETENCIES....................................................................23 A TYPICAL GEMP 3 WEEK IN THE WARDS..................................................................34 WEDNESDAY INTRODUCTION AND TUTORIALS........................................................55 STUDY AND CLERKING TIME: BEDSIDE TUTORIALS...................................................66 PROBLEM BASED LEARNING (PBL) SESSIONS...........................................................67 THEME SESSIONS.....................................................................................................88 SEMINARS.................................................................................................................89 NEUROLOGY, DERMATOLOGY AND RADIOLOGY.......................................................810 CASE REPORTS.........................................................................................................911 PERFORMANCE ASSESSMENT...................................................................................912 CLINICAL REASONING.............................................................................................1213 FORMULATING A CLINICAL ASSESSMENT (or Total Diagnosis)................................1314 7 KEY QUESTIONS...................................................................................................1615 CASE CLERKING NOTES..........................................................................................16
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1 INTRODUCTION
Each hospital will have an orientation talk for their GEMP III students on the first Monday morning of the block. There will be an introductory talk for each GEMP III group on the first Wednesday of each block at 1:00pm in the Seminar Room, Dept of Internal Medicine, Area 553, Charlotte Maxeke Academic Johannesburg Hospital
The object of the GEMP 3 six-week block in Internal Medicine is to teach medical students the fundamental skills of clinical medicine. GEMP 3 students should be familiar with the normal – this will be a chance to speak to and examine patients with real medical conditions and to become familiar with clinical diagnostic reasoning and investigation. The emphasis will be on learning medicine at the bed-side. The skills include communication with patients and the art of obtaining a concise, goal-directed medical history. The basic techniques of eliciting a history and the physical signs of diseases will be demonstrated and practised throughout the course. The students will also be introduced to the concept of maintaining a problem oriented medical record (POMR) and will be expected to keep such a record on individual patients. The primary goals of the course will be to develop history taking and examination skills and to learn how to formulate a concise Clinical Assessment. The formulation of a good Clinical Assessment is one of the most important skills in Medicine and is closely linked to the understanding of Clinical Reasoning techniques. Internal Medicine has been allocated a nine-week block in GEMP 4 where greater emphasis will be placed on clinical management.
2 OBJECTIVES AND CASE COMPETENCIES
The list of clinical topics covers a wide variety of conditions encountered in Internal Medicine. Each of these topics has been allocated a level of competence which the student should attain before graduation. Objectives have been written for each of these topics and they should be considered to be core knowledge for both written and clinical assessments. To maintain awareness of the level of competence required a list of topics sorted by discipline and the associated levels will be available to both students and staff in the medical wards. The objectives are available on the CHSE website. Students must be familiar with the core curriculum which appears on the web.
It is unlikely that students will be able to see all of the conditions listed during their GEMP 3 block. However, students who make full use of the wards and of the vast numbers of patients available to them should have little difficulty in seeing patients with most of these conditions. It is up to the students to seek out patients who cover systems that they have not already seen in the wards. They should cover as many of the conditions assigned “2” in the list of competencies. This list is available on the web (http://gemp.health.wits.ac.za) and on the departmental notice board. Students should also use their logbooks intelligently in order to cover the objectives. Good interpersonal relationships with the resident staff will make these tasks a lot easier.
2.1 Explanation of levels of competence.
1 = Be able to recognize or place:The student is not expected to be able to deal with this clinical picture, but he is expected to have some knowledge of it. This means that, when confronted with it in a patient or in the literature, he can place this clinical picture and knows how and where to acquire more information. This level indicates an overview of the condition.
2 = Be able to cope with clinically: The student must be able to cope with this clinical picture in practice. This means, that in an actual situation he must be able to consider this clinical picture as a diagnosis. This assumes knowledge of the clinical picture. The extent of this knowledge varies according to the clinical picture, but contains at least knowledge
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of the presentations and complaints, and knowledge of diagnostic and therapeutic possibilities.
2 D = Able to diagnose : For level 2 able to diagnose means that the diagnosis must be made personally by means of physical examination, simple aids or additional investigation requested by the doctor himself (simple laboratory or x-ray investigation).
2T = Able to treat : For level 2 able to treat means that the therapy must be carried out by the doctor personally, referring to the most common therapy for an uncomplicated illness.
2E = Emergency management : means that the student should be able to cope with the emergency situation at least. The student should be able to make the appropriate referral for more specialist care. The common emergencies in Medicine are covered in a booklet “A Guide to the Management of Common Medical Emergencies in Adults” which will be given to students with the GEMP III handout for Internal Medicine when they register at the beginning of the year. The cost of the book has been included in the fees of GEMP III students in 2011. Students should ensure that they keep the handout so that they have it available when they do their Internal Medicine block.
Levels of competence are intended only as a guide. Students must not feel restricted by the level as even the rarest condition will illustrate the basic principles of Clinical Medicine and may be used in a clinical examination for this purpose. For example, the signs of an upper motor neurone lesion are as valid in amyotrophic lateral sclerosis (level 1) as in a cerebrovascular accident (cerebral infarction level 2D).
3 A TYPICAL GEMP 3 WEEK IN THE WARDS
The time table below is intended as a guide. The actual time table in use in each of the wards will differ depending on the availability of staff and facilities.
The general principles are as follows: STUDENTS ARE EXPECTED TO SPEND THE WHOLE DAY, EXCEPT ON
MEDICAL SCHOOL DAY, IN THE HOSPITAL AND IN THE WARDS. The wards are available to students at all times, including evenings and at week-
ends. Bedside teaching will largely take place in the mornings and will be based on ward
allocations (4 to 8 students per group). Afternoons will be used for Hospital based activities. Students allocated to the
wards will form a single group for these activities (6 to 18 students). Attendance at INTAKE is compulsory including on Medical School Day. Students should follow up on their patients because they can learn a lot by doing
this. Students are expected to wear white coats in the wards and their name tags at all
times. They should also be familiar with the Faculty Dress Code regulations (available on the GEMP website).
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A typical week in a Medical Ward in GEMP 3
THIS IS INTENDED ONLY AS A GUIDE. EACH HOSPITAL WILL DETERMINE ITS OWN TIME-TABLE WITHIN THESE PARAMETERS AND WILL GIVE THE TIMETABLE TO THE STUDENTS AT THE BEGINNING OF THE BLOCK .
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
08:0008:30 Bed-side
tutorialBed-side tutorial
Medical School Day
Bed-side tutorial
Clerking time
Ward access time if required
Ward access time if required
09:00
09:30 Study & Clerking time
Study & Clerking time
Study & Clerking time
Bed-side tutorial10:00
10:30 Study & Clerking time
11:00 Bed-side tutorial
Neuro-logy tutorial
11:3012:00 Study &
Clerking time
Bed-side tutorial12:30 Bed-side
tutorial13:00
Study & Clerking time
13:30 Study & Clerking time
Clerking time
Lunch time14:00
14:30 Seminar Dermatology OPD (PM if possible)
PBL 2 15:00 Radiolo
gy Tutorial
15:30 PBL 1 + Themes
16:00 Study & Clerking
Seminar16:3017:00 Medical
intake Ward access time if required Medical
intake
17:3018:0018:3019:0019:3020:0020:3021:00
Study and clerking
3 2 3 4 12
Bed side Tuts
2 1 2 2 7
Neuro tuts 0 2 0 0 2PBL time 1.5 0 0 1.5 3Seminar Time
1 0 1 0 2
Radiology 0 2 0 0 2Dermatology 0 0 1.5 0 1.5Intake time 4 0 0 4 8Totals 11.5 7 7.5 11.5 37.5Lunch 1 1 1 1 4
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4 WEDNESDAY INTRODUCTION AND TUTORIALS
GEMP 3 - 2015VENUE - CONFERENCE ROOM, DEPARTMENT OF MEDICINE, AREA 553,JOHANNESBURG HOSPITAL
ROTATION INTRODUCTION BY:-
PROF PARBHOO
DERMATOLOGYTUT
HAEMATOLOGYTUT
DERMATOLOGYTUT
1ST 07 JANUARY1.00 – 2.00PM
14 JANUARY7.30 – 8.30AM
21 JANUARY7.30 – 8.30AM
04 FEBRUARY7.30AM – 8.30AM
2015/02/16 - 2015/02/20 Forensic Medicine Week
2ND 25 FEBRUARY1.00 – 2.00PM
04 MARCH7.30 – 8.30AM
11 MARCH7.30 – 8.30AM
25 MARCH7.30AM – 8.30AM7.30AM – 8.30AM
3RD 08 APRIL1.00 – 2.00PM
15 APRIL7.30 – 8.30AM
22 APRIL7.30 – 8.30AM
06 MAY 7.30 – 8.30AM
4TH 20 MAY1.00 – 2.00PM
27 MAY7.30 – 8.30AM
03 JUNE7.30 – 8.30AM
17 JUNE7.30 – 8.30AM
2015/06/29 - 2015/07/10 VACATION
5TH 15 JULY1.00 – 2.00PM
22 JULY7.30 – 8.30AM
29 JULY7.30 – 8.30AM
12 AUGUST7.30 – 8.30AM
6TH 26 AUGUST1.00 – 2.00PM
02 SEPTEMBER7.30 – 8.30AM
09 SEPTEMBER7.30 – 8.30AM
16 SEPTEMBER7.30 – 8.30AM
7TH 07 OCTOBER1.00 – 2.00PM
14 OCTOBER7.30 – 8.30am
21 OCTOBER7.30 – 8.30AM
04 NOVEMBER7.30 - 8.30AM
Dates changed due to public and religious holidays
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5 STUDY AND CLERKING TIME: BEDSIDE TUTORIALS
The major emphasis will be on bed-side learning. Students will be expected to take histories from, and to examine patients with a range of diseases. These patients will be discussed with tutors at daily bedside teaching rounds. While learning clinical skills will dominate tutorials, students must develop the ability to formulate a clinical assessment (See Formulating a Clinical Assessment below). Since the course relies on the availability of clinical material, students cannot expect a systematic exposure to each of the organ systems. THE STUDENTS THEMSELVES WILL BE RESPONSIBLE FOR SEEKING OUT PATIENTS WHO EXHIBIT FEATURES OF DIFFERENT DISEASES, THEREBY ENSURING THAT EVERY STUDENT SEES THE FULL SPECTRUM OF PATHOLOGY. To facilitate this, each student will be required to keep a LOG BOOK recording the details of each patient clerked and presented as well as procedures witnessed during the block. Full details on how to use the LOG BOOK appear on the first page of the book.
6 PROBLEM BASED LEARNING (PBL) SESSIONS
PBLs will be based on real problems identified in the wards and will work as follows:
1. The PBLs will be run by facilitators in each of the three hospitals. 2. Each week of the block is devoted to a different sub-specialty (Division) and this
will be the same for each hospital. 3. On the Monday, the facilitator will choose a topic from the list provided by the
Division. (See time table on page 6). Part of this session must incorporate a theme session the content of which will be available in a pack provided by theme coordinators (see Theme sessions below).
4. The choice of topic will depend on which patients are available in the hospital at that time.
5. The PBL must be based on the problem or problems presented by a real patient who is at present in the hospital. The patient should be clerked and seen by all the students (see 4 above)
6. The group of students must be divided up and each sub-group given a different task (eg If the topic is the myeloproliferative disorders and the patient has CML, the patient must be clerked and his problems identified. Then one group could look at the epidemiology, another at the molecular changes and their implications, another at the spectrum of presentation, another at the treatment options, another at ethical issues in transplantation etc).
7. The GEMP themes (viz Community-Doctor, Patient-Doctor, Personal and Professional Development and Basic Clinical Sciences) must be incorporated.
8. The students then have the week to see the patient and to research each of their topics.
9. The session at the end of the week will be devoted to the students presenting their findings to the facilitator. Other members of the hospital staff should be encouraged to participate.
10. Student attendance and performance at PBL sessions will be recorded in the student’s Logbook.
6.1 PROBLEM BASED LEARNING (PBL) & SEMINAR TOPICS - 2015
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7 THEME SESSIONS The first PBL session of four of the six weeks will incorporate discussion on the
GEMP themes (Confidentiality and Truth Telling, End-of-Life Decision Making, Patient Adherence to Medication).
Problem Based Learning - Topics Seminar Topics
Week 1Block 1: 05 - 09 JanBlock 2: 23 – 27 Feb Block 3: 06 – 10 April Block 4: 18 - 22 MayBlock 5: 13 -17 JulyBlock 6: 24 – 28 AugBlock 7: 05 - 09 Oct Pu
lmon
olog
y 1. Asthma2. Pulmonary embolic disease3. Pleural effusion4. Lung cancer5. Occupational lung disease6. Respiratory emergencies (e.g.
haemoptysis, pneumothorax etc.)7. Community acquired pneumonia
1. Chronic obstructive pulmonary disease (COPD)
2. Respiratory infection in HIV-seropositive patients
Week 2Block 1 : 12 - 16 JanBlock 2 : 02 – 06 March Block 3: 13 – 17 April Block 4: 25 - 29 MayBlock 5: 21 - 25 JulyBlock 6: 31 Aug – 04 SeptBlock 7: 12 – 16 Oct Ca
rdio
logy
1. Chronic Rheumatic heart disease2. Infective endocarditis3. Risk Factors for Atherosclerosis4. Pulmonary Embolism5. Hypertension6. Pericardial disease (Pericardial
effusion, tamponade)7. Cardiomyopathy (Alcohol,
Peripartum, Idiopathic)
1. Management of heart failure
2. Acute coronary syndromes
Week 3Block 1: 19 – 23 JanBlock 2: 10 - 14 March Block 3: 21 - 25 April Block 4: 01 – 05 JuneBlock 5: 28 July – 01 Aug Block 6: 07 - 11 SeptBlock 7: 19 - 23 Oct H
aem
atol
ogy 1. Acute Leukaemias
2. Myeloproliferative disorders 3. Non Hodgkin’s Lymphoma/
Hodgkin’s Lymphoma4. Multiple Myeloma & Chronic
Lymphocytic Leukaemia5. Bleeding disorders6. Thrombotic disorders
1. General approach to Anaemias
2. HIV & Haematology
Week 4Block 1: 26 – 30 Jan Block 2: 17 – 21 March Block 3: 28 April – 02 May Block 4: 08 - 12 JuneBlock 5: 04 - 08 Aug Block 6: 14 - 18 SeptBlock 7: 26 – 30 Oct En
docr
inol
ogy 1. Diabetes and its complications
2. Thyroid disorders3. Hypoglycaemia4. Disorders of mineral metabolism
(hypercalcaemia, osteoporosis etc)
5. Adrenal disorders6. Pituitary disorders
1. Diabetes (type I and type II)
2. Thyroid disorders (hyperthyroidism & hypothyroidism)
Week 5Block 1: 02 Feb – 06 Feb Block 2: 24 - 28 March Block 3: 05 – 09 May Block 4: 15 - 19 June Block 5: 11 - 15 Aug Block 6: 21 – 25 SeptBlock 7: 02 - 06 Nov Rh
eum
atol
ogy 1. Systemic Lupus Erythematosus
2. Gout3. Approach to lower back ache4. HIV & Rheumatic disease5. Rheumatoid Arthritis6. Osteoarthritis7. Steroid induced osteoporosis
1. Approach to Polyarthritis
2. Approach to monoarthritis
Week 6Block 1: 10 - 14 FebBlock 2: 31 Mar - 04 April Block 3: 12 - 16 May Block 4: 22 - 26 JuneBlock 5: 18 - 22 Aug Block 6: 28 Sept – 02 Oct Block 7: 09 - 13 Nov
Neu
rolo
gy
1. Anterior circulation stroke2. Meningitis3. Neuropathy4. Myelopathy
1. Epilepsy
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Lists of the topics to be covered and resource material will be available to students and facilitators on the GEMP III website (http://gemp.health.wits.ac.za).
Facilitators will be drawn from the ward staff. More details on Themes can be found in the booklet GEMP Themes, obtainable
from the CHSE.
8 SEMINARS
Seminars will work as follows:1. There will be two seminars per week. 2. Each week of the 6-week block will be devoted to a particular sub-specialty (eg
Pulmonology, cardiology etc. - see time table above) 3. Topics will be presented by tutors at each hospital (Students at each hospital will
group together for the seminars). 4. The topics will be of the “approach to” type and will be the same at each hospital
(see time table above)
Charlotte Maxeke Johannesburg Academic Hospital Seminars and PBLs:- Mondays and Thursdays at 2:00pm in the Seminar Room, Department of Internal Medicine, Area 553;
Chris Hani Baragwanath Hospital Seminars and PBLs:- Mondays and Thursdays at 1:30pm in the Wits Learning Centre
Helen Joseph Hospital Seminars and PBLs:- Mondays and Thursdays at 2:00pm in the Learning Centre, 4th Floor, Helen Joseph.
9 NEUROLOGY, DERMATOLOGY AND RADIOLOGY
Neurology will be taught as part of Internal Medicine. Special time will be set aside in the mornings in each ward to teach at the bedside. This does NOT mean that patients with neurological conditions should be excluded from general teaching rounds. See individual ward time tables. In addition, a clinical tutorial will be given once a week. For further details please phone 011-488-4432 for further information.
Dermatology will be taught as a hospital activity (ie One group of students made up of those assigned to Medical wards).
o Ward time table. Students should attend the outpatient clinics at the three teaching hospitals as follows: (See individual ward time tables.) Contact Mrs Mgijima for further information. 011 488 3644 or [email protected]
o GEMP 3 students will be expected to be familiar with the ABC of Dermatology. This would include knowing the primary lesions of dermatological conditions which forms the basis of understanding the language of the discipline.
o Students will be exposed to the vast spectrum of Dermatological diseases at the out –patient clinics as well as ward patients at the various teaching Hospitals. The diseases dealt with will range from simple infections such as impetigo to complex diseases such Mycosis Fungoides. Students will be expected to be able to recognize various conditions and be familiar with the basic pathology and management of each condition.
o Teaching will take place at the clinics. In depth knowledge of dermatologic conditions and drug management is NOT expected.
o Notes covering the syllabus for GEMP 3 will be provided and text books will be recommended. Students should become familiar with the approach to handling a patient with a skin condition which will be taught using the various diagnostic methods and tools which lead to a confirmed diagnosis.
o As dermatology is a clinically oriented discipline, students will be tested at the end of the block OSCE with a clinical scenario, most likely in the form of photographs of patients with the skin signs of disease.
Radiology will be taught as a hospital activity (ie One group of students made up of those assigned to Medical wards).
o Hospital time table (Venue: Radiology Department at each Hospital).
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Chris Hani Baragwanath Hospital: Tuesdays 13:00 to 14:00 Helen Joseph Hospital: Tuesdays 14:00 to 15:00 Charlotte Maxeke Jhb Hospital: Tuesdays 13:30 to 14:30
o Radiology stations will form part of the end of block OSCE.
10 CASE REPORTS
During the 6 weeks that GEMP 3 students spend in the medical wards, they are required to keep case notes on the patients allocated to them. These notes should document, in an orderly fashion, the major points relating to the patient's history, examination, treatment and progress. A suggested layout is shown in the section entitled CASE CLERKING NOTES. The format follows a problem orientated approach. The records should be on A4 paper and should be collected together in some form of file. The Department of Medicine would prefer to see actual case notes rather than those prepared on a word processor the night before submission. Case notes on TWO patients must be handed to the head of your Medical Unit.
• The first case report must be handed in at the end of the third week of the block. The second case report must be submitted at the end of the fifth week of the block. The tutors assigned to mark the case reports must do so BEFORE THE LAST THURSDAY OF THE BLOCK when they will be discussed together with the ward report. (See Performance Assessment)
• It is a DP requirement for each student to complete and submit two case reports.
• Please see the rubric for marking of Case Histories (Page 28)
11 PERFORMANCE ASSESSMENT
11.1 MID-BLOCK ASSSESSMENT
Students will undergo a mid-block assessment at the end of the third week of the block. The purpose of this assessment will be to identify weaknesses and create a plan to correct problems before the end of block assessment and OSCE. The mark obtained at the mid-block assessment will not contribute to the students' final mark but will merely act as a gauge of performance and a mark which students should strive to improve before the end of the block.
11.2 WARD REPORTS AND LOGBOOK
Evaluation of student performance in the medical wards will be made on the last Tuesday of the block at a meeting of consultants, registrars and intern staff. The evaluation form is at the back of the Logbook which will be evaluated at the same time. Students should pay particular attention to the section titled “Meets Expectations” to gauge what is expected of them. A satisfactory score is 30 or above. STUDENTS WILL ALSO BE EVALUATED ON THEIR PROFESSIONALISM AND THEIR ATTITUDE TOWARDS PATIENTS.
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11.3 TUTORIAL ASSESSMENT
You are expected to present cases that have been clerked by you in the ward. The assessment will be used to assess you as well as to encourage the structure of the tutorial. Please use the template to direct the interaction with your tutor as well as to focus your case presentation. A minimum of six assessments will form part of your DP requirement. Please also pay attention to the management and investigations as well as pharmacology, that may be relevant to the case.
The onus is on the presenting student to give the booklet to the tutor and to make sure it is completed. The booklet should be handed in at the end of week three and the end of week six to your unit head. Your unit head will review all the forms in the first three weeks to see if there are any areas of concern or to encourage those that are doing well. Please make sure forms are filled in correctly and completely.
11.4 EXAMINATIONS
STUDENTS ARE NOT PERMITTED INTO THE WARDS TO CHECK CASES THE DAY BEFORE THE CLINICAL EXAM.
STUDENTS WHO DO NOT HAVE THEIR STUDENT CARDS AT WRITTEN AND CLINICAL EXAMINATIONS, WILL NOT BE PERMITTED TO PROCEED WITH THE EXAMINATIONS.
IT IS FORBIDDEN FOR STUDENTS TO HAVE BOOKS, STUDY MATERIALS OR CELL PHONES WITH THEM IN AN EXAM. ANY STUDENT FOUND WITH THESE ITEMS INAN EXAM WILL BE SUBJECT TO DISCIPLINARY ACTION.
11.4.1 O BJECTIVE S TRUCTURED C LINICAL E XAMINATION (OSCE) There will be no Medical School Day on the last Wednesday of every block. An OSCE will be held in the morning of the last Wednesday of each six-week Medicine block. The examination will start at 08:00 and students will go to a different unit and possibly a different hospital from that in which they have been for the six-week Medicine block. A notice advising students of the venue will be displayed on the Monday before the OSCE on the GEMP website.
STRUCTURE OF THE OSCE
The examination will consist of twelve stations through which each student will pass. At six of the stations the student will be expected to demonstrate his or her ability to elicit clinical signs or symptoms in the presence of an examiner. The objective of the OSCE is to test the acquisition of clinical skills and not theoretical knowledge.
Stations (Total 12) 2 x Radiology (X-rays with questions requiring short written answers. No examiner
present) 2 x Diagnostic stations (various modalities ranging from ECGs, lab results, flow
volume loops etc, in the form of MEQs, i.e. short written answers. No examiner present).
2 x Dermatology stations (photographs with questions requiring short written answers. No examiner present).
6 x Clinical stations (Real patients, common conditions covering major systems. Emphasis should be on clinical skills and the interpretation of signs although some diagnostic reasoning should be included. Examiner present).
These stations will be the same for all venues.
11.4.2 MULTIPLE CHOICE EXAMINATION (MCQ)
The MCQ examination will be held in Room 3A01B, Medical School) at 13:00 on the last Wednesday of the block, following the OSCE. There will be a total of 55 questions and these will include:
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X-type questionso Focus on Clinical Methods and factual information such as applied
pathology, physiology and pharmacology. A-type questions
o Focus on diagnostic reasoning skills and formulation of a clinical assessment rather than therapeutics. GEMP themes will be included here.
R-type questionso Focus on both Clinical reasoning and Pathophysiology.
Questions will be drawn from the Department of Internal Medicine and the National MCQ Data Bank. Question papers may not be kept by students after the examinations.
11.4.3 EXAMINATION TIME TABLE: 2015
Written Examinations
Venue: 3A01(B), Level 3, Medical School Time: 01:00pm - 03:00pm Dates:
Block 1 - 11 February 2015Block 2 - 01 April 2015Block 3 - 13 May 2015Block 4 - 24 June 2015Block 5 - 19 August 2015Block 6 - 30 September 2015Block 7 - 12 November 2015
OSCE
Venue: A notice will be displayed on the Monday before the OSCETime: 08:00amDates:
Block 1 - 11 February 2015Block 2 - 01 April 2015Block 3 - 13 May 2015Block 4 - 24 June 2015Block 5 - 19 August 2015Block 6 - 30 September 2015Block 7 - 12 November 2015
11.5 ALLOCATION OF MARKS
The final Medicine mark will consist of:
OSCE 60%*MCQ 25%Ward Mark 7%Logbook 3%**Case Histories 5%Total 100%
*60% for clinical stations; 40% for non clinical stations**Logbook is DP requirement.
o Students are required to pass the clinical component of the examination in order to proceed.
11.6 PASS/FAIL REQUIREMENTS
o A student with an overall Fail mark – Fails.o A student who fails the clinical component of the OSCE, irrespective of his overall
final mark – Fails.o A student who fails more than two clinical cases in the OSCE, irrespective of his
overall OSCE clinical and overall final mark – Fails.
12 CLINICAL REASONING
Reaching a diagnosis is a skill which takes many years of practice to perfect. The diagram below represents two methods of Clinical Reasoning. Both rely on pattern recognition.
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The INDUCTIVE method involves the systematic collection of data followed by a search for a recognisable pattern of disease within the data.
o Using this method is an important step in developing clinical reasoning skills since it teaches the student lists of questions to ask in taking a history and a systematic approach to examination.
o Experienced physicians still use this method when the other method has let them down.
The HYPTHETICO-DEDUCTIVE method is an active form of pattern recognition in which a constellation of symptoms and / or signs suggests a disease pattern or hypothesis. The physician then asks questions, looks for signs or does investigations which are aimed at completing any missing pieces of the pattern of disease suggested by his hypothesis.
o This is not wild guessing but a systematic and rapid way of recognising and confirming a disease pattern.
o The more disease patterns a physician has in his knowledge base the better he is able to recognise them when confronted by what may seem to be unconnected signs and symptoms.
13 FORMULATING A CLINICAL ASSESSMENT (or Total Diagnosis) The following diagram is a useful guide to formulating a clinical assessment
All clinical assessments can be expressed in a few sentences in terms of these six headings.
EXAMPLES
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(3) TIME SCALEAcute,
Chronic, etc
(4) CAUSE /RISK FACTORS
InfectiveMetabolic
etc.
(1) Patient’s identityName , age , sex, occupation etc.
(5) SEVERITYAdvancedDisease
(2) PROBLEM NAMEDiagnosis or Syndrome
ANATOMICALPATHOLOGICALPHYSIOLOGICAL
(6) COMPLICATIONSProblems in their
own right
1. Miss Lucy Nkosi is a 28 year old unemployed Black Woman.(1)
She has chronic rheumatic heart disease with tight mobile mitral stenosis (3) (4) (5) (2)
complicated by atrial fibrillation. (6)
2. Mr Pieter Botha, aged 50, has a history of heavy smoking.(1 & 4)
He has two major problems.Firstly severe chronic obstructive pulmonary disease with cor pulmomale
(5) (3) (2) (5)caused by smoking.
(4)This is complicated by congestive cardiac failure.
(6)Secondly, he has a right apical mass, probably a carcinoma, not visible on his old
chest x-ray, (2) (3)with features of a Pancoast's syndrome on the right.
(6)Smoking is also a likely aetiological factor. (4)
The art of formulating a good Clinical Assessment is difficult. It takes practice and becomes easier once the student has become familiar with “Clinical Language”. The student should take every opportunity to practice presenting a Clinical Assessment particularly on post-intake rounds and at bed-side tutorials. It should be noted that the formulation of a clinical assessment closely follows the hypothetico-deductive method of clinical reasoning described above. The “problem name” represents the initial hypothesis (now established) while the other components represent the process used to confirm and enlarge upon the selected disease pattern.
Each of the components of a Clinical Assessment has its own peculiarities which will become more evident as the student tries to use the system.
1. Patient’s identity
Anything which serves to identify the patient and his/her position in life can be used here.
A chronic illness, such as diabetes, becomes so much part of a patient’s life that it becomes part of his identity and may “set the scene” in terms of his problems. Similarly, an occupation, such as mining, may have medical implications.
Obviously age, gender and psychosocial factors need to be included here.
2. Problem name
The choice of a problem name can be likened to a triangle. At the apex is the ideal, complete diagnosis. However, clinically and particularly at the bed-side, it is not always possible to reach the apex and one has to settle for a less complete diagnosis or syndrome or even just the organ system involved
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Nodular sclerosing Hodgkin’s Disease Stage 3B
Lymphoma
Lymphadenopathy
Complete Diagnosis
Syndrome
Signs / symptoms
Differential Diagnosis
Nodular sclerosing Hodgkin’s Disease Stage 3B
Lymphoma
Lymphadenopathy
Complete Diagnosis
Syndrome
Signs / symptoms
Differential Diagnosis
in the pathology. Thus “Hodgkin’s Disease”, “Lymphoma” and “lymphadenopathy” are all reasonable “problem names” which could apply to the same patient. The choice will depend on how much information is available – “Hodgkin’s Disease” implies that the result of a biopsy is available; “Lymphomas” are sometimes recognisable clinically while “lymphadenopathy” is clearly clinically recognisable but could have a number of causes. Thus moving down the triangle tends to increase the differential diagnosis or the possible causes (see 3).
As more information becomes available, so the “problem name” will approach the complete diagnosis at the apex of the triangle. When presenting a Clinical Assessment the student should choose a problem name which matches the information that he has at that particular time.
Problem names are easy to identify. They are always a mixture of anatomical, pathological and, sometimes, physiological terms. Eg Mitral (anatomical) stenosis (pathological).
3. Cause
Cause is used here in the broadest sense and could include the actual aetiology, idiopathic or risk factors. For example it would be appropriate to include here the risk factors identified if the “problem name” was myocardial infarction.
4. Time
Terms such as “chronic”, “acute” or “exacerbation” of a chronic condition are all acceptable words which can be used to describe the “tempo” of an illness.
Often, particularly in hospital, the patient is seen during only a brief window of time in the course of his illness. It is often important to note where the patient is on this time scale. (eg Terminal heart failure).
5. Severity
Severity is often time related which is why they are together in the diagram above.
Terms such as mild, moderate and severe are all acceptable here. Sometimes the word “severe” has a particular defined meaning. For
example, “severe mitral regurgitation” could refer to a patient with pulmonary hypertension, enlarged left atrium, fixed splitting of the second sound, soft S1, an S3 and a loud pansystolic murmur who may well be in cardiac failure.
Other terms may relate to a specific problem name such as “malignant” to describe hypertension or “tight” to describe a stenosed valve.
6. Complications
The distinction between severity and complications may be blurred. Severe conditions are often complicated and the presence of complications implies severity. This is why they are on the same side of the diagram above and can, in some cases, be merged together.
The best way to think of a complication is a condition which requires management in its own right. For example a pulmonary embolus complicating a deep vein thrombosis.
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7. Other considerations
It should be noted that items under cause, problem name and complications may be interchangeable. For example, consider a patient who has a DVT complicated by pulmonary embolus who is now in cardiac failure. If pulmonary embolus is the problem name then the DVT is the cause and the cardiac failure a complication. Equally, the DVT could be the problem name, then both pulmonary embolus and cardiac failure are complications.
When more than one problem is present, each problem should be presented separately, that is using two sets of the diagram above. Such problems may be entirely separate or they could be interrelated. For example, a man with a heavy smoking history may have COPD and a bronchogenic carcinoma.
14 7 KEY QUESTIONS
Students will be encouraged to take a holistic view of patient care. The diagrams below serves to remind students of the key areas which should be borne in mind for every patient they see.
7 key questions
for the consultation
ongoing care ?
communicating with my patient ?
levels of health care ?
quality and evidence ?
causation and prevention ?
the health care team ?
resources ?How would I manage in a setting with few
resources? (diagnostic, therapeutic, referral)
Who else could help me to provide optimal care, and how? (health team members, family, organisations)
How would the different levels of health care handle this patient? When would I refer from primary care? When can s/he go home? What would be the role of a GP in ongoing care?
By what standards can I judge whether this patient is getting high quality care? Are management decisions based on the best evidence? Are there clinical guidelines that could help me to achieve best evidence care?
What is the prognosis? How should I plan ongoing care (e.g. after discharge)?
What causes this disease/ disorder, and who tends to get it? What could have prevented it and how?
Which beliefs influence my patient’s perception of his/her illness, and how should I respond to these? What 4 key messages do I want to communicate to her/him?
15 CASE CLERKING NOTES
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Case clerking is an essential part of undergraduate training which has the following specific goals:
To record the histories, physical findings and prognosis of patients in a logical and orderly fashion.
To interpret the patient's symptoms and physical signs at various stages in the evolution of the illness.
To develop a diagnostic approach and the formulation of a logical clinical assessment.
To understand the indications and interpretation of special investigations.
To develop a knowledge of therapeutics.
While GEMP 3 students will have ample opportunity to clerk patients in preparation for presentation at the bed-side, the purpose of producing two written case reports is to examine these goals in detail and to develop a culture of keeping good written medical records. In assessing these reports cognisance will be taken of the fact that this is the student’s first effort and that his/her experience is limited.
The following guidelines should be remembered when preparing the case notes:
1. The case report should follow the format given in the example included in these notes.
2. The case notes should be written at the bedside (time should not be wasted rewriting notes neatly).
3. Frequent discussion with the ward staff as the patient's problem(s) evolve is essential and the outcome of these discussions should be summarized in the notes.
4. The patient's story must be given, not the interpretation e.g. a description of the chest pain and not the patient “presented with angina".
5. Standard abbreviations are difficult to avoid but novel, self-made abbreviations should not be used.
6. A differential diagnosis of the likely conditions (not a long list) should be given after the history and modified if necessary after the examination.
7. The reason for any investigation should be indicated. The result must be expressed in the appropriate units and its significance described.
8. Daily follow-up notes are not required but events indicating progress of the illness should be described.
9. The notes should be up to the date of the report or the date of discharge. 10. Treatment should be detailed, including the dosage of the drugs used, their
indications and major adverse effects. 11. A detailed discussion of the disease is not required.12. A discharge summary is essential. If the patient has not actually been discharged,
the summary should be sufficiently comprehensive for another doctor to take over management of the patient.
13. No references are required.
15.1 RECOMMENDED HEADINGS FOR ROUTINE CASE NOTES
NAME OF PATIENT AGE SEX M S W D WARD AND BED NUMBER OCCUPATION STUDENT'S NAME DATE ALLOCATED --------------------_____ DATE COMPLETED MAIN (OR PRESENTING) COMPLAINT(S)
Short and to the point and including duration. Usually a symptom and not a diagnosis (eg chest pain not angina)
HISTORY OF PRESENT ILLNESS (OR OF THE MAIN COMPLAINT)16
This is the most important part of the history and should be goal directed (towards making a diagnosis). If the main complaint is respiratory in nature, all aspects of a respiratory history should be explored at this point. It is simply not logical to delay taking a respiratory history until you reach “Respiratory” under the heading “systematic history”.
HABITS, SOCIAL CONDITIONS, PLACES OF RESIDENCE (if relevant), PAST ILLNESS, FAMILY HISTORY.SYSTEMATIC HISTORY
This should be viewed as a ”net” to catch information which may not have been revealed under the headings above. This is not the place to take a history about the main complaint.
SUMMARY OF PROBLEMS PRESENTEDAt this stage make a list of the problems presented by the history since they may necessitate especially detailed examination of a certain system or systems. In relation to each problem enumerate, briefly, important positive or negative physical findings to be looked for (i.e. findings which will help to define more clearly the nature of the disturbance in physiology).
EXAMINATION(a) General(b) Systems. In practice it is easier to record findings under regional headings (eg Head and Neck) while some findings are best recorded by system (eg CNS). A sensible mixture is acceptable.
WARD SIDE-ROOM INVESTIGATIONS
PROBLEM LIST
At this stage make a list of the patient's problems. The problems should be numbered and listed in order of importance and urgency. Individual problems should be stated clearly and simply and at the level of your understanding the problem. The 'problem' may therefore merely be one of the patient's complaints, i.e. a symptom; it may be a physical sign; it may be a cluster of signs and symptoms which together indicate a single deviation from normal physiological function; it may be a syndrome or rarely it may be an actual diagnosis which can be made fairly firmly at a clinical level, or which the patient has volunteered. Clearly as your knowledge increases, the problem list will become shorter since apparently separate symptoms or physical findings often indicate the same physiological derangement.
It is important that the problem list should contain only factual information and no diagnostic guesses. It is also important that it should contain all the problems of the patient as a whole person, i.e. his physical as well as his psychiatric and social problems.
INITIAL ASSESSMENT
Once you have listed the patient's problems it is advisable to make a very brief summary of the pertinent symptoms and signs which fall under that problem. Each problem should then have the following format -
Problem (1) Name it.
S. Subjective findings i.e. the symptoms, past illnesses, habits and family history applicable to his particular problem, set out in single words or short phrases.
O. Objective findings i.e. the signs you found on clinical examination and the results of side-room or special investigations applicable to this particular problem; again set out in single words or short phrases.
A. Assessment of the problem. This is vital and should be your understanding of the problem at this stage in the light of the findings on history and examination. It
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may take the form of a pathophysiological state, a different diagnosis or a definitive diagnosis and should include an assessment of the severity and/or complications. For example: tight mitral stenosis complicated by atrial fibrillation. Guidelines on formulating a clinical assessment can be found at the end of these notes.
P. Plan of management. This must be directed towards solving this particular problem. Generally the following aspects of management should be considered -
a. Diagnostic approach (further investigations required, etc)b. Therapeutic measuresc. Monitoring (eg 6 hourly blood pressure measurements)d. Patient education (and prognostic aspects)
However, in any particular problem only one or two aspects may be relevant, depending upon the level of understanding of the problem and/or the necessity to restore disturbed physiological function toward normal urgently (perhaps before a definite diagnosis is made).
PROGRESS NOTES
The progress notes should form as important a part of the clinical case clerking notes as the initial record. The same code of numbering and format (i.e. S O A P) should again be used and each problem discussed as frequently as necessary. Problems which are evolving quickly, either because of the acute course of the disorder or because additional information has become available (from special investigations etc), should be mentioned daily. Problems which have become stable (either in terms of therapy or in terms of diagnostic aids available) need be discussed less frequently.
It is here that investigations performed (with dates) and treatment given should be detailed. You should also mention (and discuss with the staff) investigations which you consider would be useful and have perhaps not been performed.
It is important to realize that faulty understanding of the patient's problems and the making of defective decisions may be unavoidable at the outset. A careful record of the evolution of your understanding of the patient's illness during his stay in hospital is therefore essential.
New problems may occur during a patient's stay in hospital. If these are complications of an existing problem they should be discussed under the appropriate numbered heading. If not, they should be assigned a new number and discussed separately, again using the SOAP format.
Finally, flow sheets or graphs may sometimes be useful in following alterations in important diagnostic parameters especially in patients with complicated ill-understood problems.
DISCHARGE SUMMARY
The summary should follow the Problem Orientated Medical Record described above. Information should be summarized concisely (this should not be a second record of the patient's illness). More space should be devoted to problems which are ongoing than to those which have been resolved. Mention should also be made of future management and of the overall prognosis. Special mention should be made of complications which might arise as the result of the patient's illness in the future. If preventive measures can be taken to avoid these they should be outlined in detail. When writing the summary, put yourself in the place of a busy doctor who is taking over the management of your patient.
15.2 SPECIMEN CASE CLERKING NOTES FOR GEMP 3 STUDENTS
NAME OF PATIENT: Mr J S
AGE: 60 years Gender : Male M S W D: Married18
WARDS AND BED NO: Ward 2, Bed 1 OCCUPATION : Retired (previously worked as clerk in business)
DATE ALLOCATED : 1 October, 2005DATE COMPLETED : 3 November, 2005
COMPLAINTS: 1. Cough for 3 months.2. Recent weight loss.
HISTORY OF PRESENT ILLNESS
Chronic cough. Present for many years especially in the morning. Worse over the past three months. Productive of white sometimes yellow sputum but has never seen blood in his sputum. No episodes of chest pain and no pain on coughing. Never felt feverish. No sweating. Smokes 40 cigarettes per day since a young man and ascribed coughing to this.Leads a very sedentary life and his activity is not limited by shortness of breath; however, he can climb only one flight of stairs before having to stop because of shortness of breath. No orthopnoea. No paroxysmal nocturnal dyspnoea. No history of asthma or wheezing. Frequent bronchitis especially during the winter months. No TB exposure.Occupation - many changes, always clerical. No exposure to industrial dusts.Weight loss:- was 77Kg now 70 Kg. Clothes now too big for him. Appetite normal; no GIT symptoms.
SYSTEMATIC HISTORY
1. Cardiovascular system. No history of cardiac disease or rheumatic fever. No chest pain. No palpitations. No swelling of the ankles.
2. Respiratory system - see above.3. Gastrointestinal system. Weight loss mentioned above. Appetite has not
changed recently. Diet normal. No abdominal pain. Stools are well formed, brown in colour. They do not float on water and change in appearance.
4. Genito-urinary system. No symptoms.5. Central nervous system. No symptoms.6. Musculo-skeletal system. No symptoms.7. Endocrine system. prefers warm weather. No constipation. No family
history of Diabetes Mellitus.
HABITS
Smokes 40 cigarettes per day. Drinks occasional beer - no spirits. He takes no drugs or medicine regularly.
SOCIAL CONDITIONS
The patient lives in a flat with his wife who is severely crippled by chronic rheumatoid arthritis. Mr J S cares for her himself. He cannot afford private nursing care. Their children are both married. The son lives in Durban and the daughter in East London. He has arranged for a close family friend to take care of his wife for a few days while he is in hospital and is therefore anxious to leave hospital as soon as possible.
PAST ILLNESSES
No serious illness. Frequent attacks of bronchitis, especially in winter, for many years. These have sometimes kept him from work. No operations.
FAMILY HISTORY
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Father died of Cancer of lung age 57 years. Mother died of cancer of the breast at the age of 50 years. No brothers or sisters. Children aged 28 and 26 years, both alive and well. No grandchildren.
SUMMARY OF PROBLEMS PRESENTED BY HISTORYNo 1. Persistent non-productive cough.
Indicates chronic irritation of tracheal or bronchial mucosa. More likely causes in this patient -
1. Chronic inflammation - careful examination of the lungs important.
2. Tumours of, or compressing, the trachea or bronchi. Increased mediastinal dullness, lymphadenopathy, atelectasis to be sought.
3. Pharyngeal disease or sinusitis.
No 2. Weight Loss
This has occurred in the case of an apparently adequate food intake. Possible groups of cause are -
1. Malabsorption - other evidence would be useful. Skin, nail lesions, abnormal appearance of the tongue, pallor (anaemia). Examine stool - steatorrhoea, undigested food?
2. Conditions causing metabolic wastage - Diabetes - examine urine for glucose.
3. Hypermetabolic states - Hyperthyroidism - Goitre, tremor, warm sweaty hands, lid lag.
4. Malignant tumours - especially upper gastrointestinal tract and, in this patient, lung (note smoking and family history).
No 3. Social Problem
The need to return home to care for his wife.
EXAMINATION
Weight 66kg. Obvious evidence of weight loss. Plethoric. Mildly cyanosed. No jaundice. Skin and finger nails look normal. No sweating. Hands feel cold.
Head and neck. Marked temporal wasting. No tenderness over the sinuses. No lymphadenopathy. No supraclavicular lymphadenopathy. Mouth and pharynx normal. Thyroid gland not palpable. Trachea deviated to left.
Thorax. No axillary lymphadenopathy.
Lungs. Increased antero-posterior diameter of the thoracic cage. Adequate movement.
Upper edge of liver dullness - 7th interspace right mid-clavicular line. Decreased cardiac dullness. Air entry poor throughout. Prolonged expiratory phase. Persistent rhonchus not cleared by coughing, left upper lobe. Sputum white mucoid with flecks of blood.
Heart. B P 130/86. Pulse rate 84/mm regular. No evidence of cardiac failure. No cardiomegaly. 1st and 2nd heart sounds normal. No clinical evidence of pulmonary hypertension.
Abdomen. Soft liver edge 2cm below the costal margin in the right mid-clavicular line. Spleen not palpable. No other masses palpable. No free fluid. Normal bowel sounds on auscultation. No inguinal lymphadenopathy. Genitalia normal. PR normal with normal stool.
Extremities. Normal.20
Central nervous system. Normal. No tremor. Eyes normal.
WARD SIDE-ROOM INVESTIGATIONS
Urine. Dipstix - normal.
PROBLEMS
No 1. Persistent non-productive cough.
Subjective. Heavy smoker. Worsening cough. No infection or pain.
Objective. Hyperexpanded (see 3). Persistent rhonchus left upper lobe. Deviated trachea. No evidence of infection. Mild haemoptysis.
Assessment. ? Bronchial obstruction (? left upper lobe) - probable tumour with smoking background
Plans.1. Diagnostic. Chest x-ray. Sputum - bacterial culture, TB
microscopy and culture, cytological examination for malignant cells. Bronchoscopy, if indicated by results of above.
2. Therapy. Nil at present - suppression of cough may interfere with sputum collection.
3. Education. Reassure patient that investigations will be completed quickly (see 4).
No 2. Weight loss.
Subjective. 11kg loss. Adequate diet no gastrointestinal symptoms. Malaise.
Objective. Evidence of weight loss.
Assessment. Possible malignant tumour - lung (see 1). No evidence for other causes - malabsorption, diabetes mellitus, hyperthyroidism.
Plan. Await outcome of investigation or Problem 1.
No 3. Chronic Obstructive Pulmonary Disease (C O P D)
Subjective. Heavy smoker, chronic cough, frequent bronchitis. Dyspnoea on climbing one flight of stairs (grade 3).
Objective. Mild cyanosis, plethora. Chest hyperexpanded, liver pushed down. Poor air entry, prolonged expiration. White mucoid sputum. Heart normal.
Assessment. C O P D. Chronic bronchitis with cyanosis and bronchospasm. No evidence of pulmonary hypertension, cor-pulmonale or infection (see 1).
Plans.1. Diagnostic. See 1. Lung function tests - Pre & Post bronchodilator
spirometry should be performed. Arterial saturation.
2. Therapy. Depends on outcome of tests. Bronchodilators - oral Venesection if haemoglobin greater than 18g%.
No 4. Social problem
Subjective. Wife ill - patient needs to care for her.21
Plan. Speed up investigations. Daughter may be able to come to Johannesburg.
PROGRESS NOTES
2 October, 2001. Problem 1. Cough: Now Small Cell Carcinoma
S. Still coughing but comfortable.O. Clinically no change. Rhonchus still present. Chest x-ray left hilar shadow with
collapse of L upper lobe. Deviation of trachea. Evidence of C O P D. Sputum cytology (Lab No TJ66354/01) malignant cells compatible with small cell carcinoma of bronchus. Medical oncology consulted - Refer to medical oncology outpatients with results of cytology and staging - see plan
A. Small cell carcinoma of L upper lobe bronchus complicated by collapse of L upper lobe, weight loss and mild haemoptysis.
P. Discharge to Medical Oncology Outpatients.Book CT Scan brain and sonar liver as outpatient
Problem 3. C O P D
S. Feels more comfortable. Not moving about much.
O. Still cyanosed. No change. Haemoglobin 17,4g%, P C V 56%. White cell count 6 000, platelet count 220 000. p02 6,2, pH 7,4. X-ray chest hyperinflated normal
heart. Spirometry; FVC - Pre 2.78 l (67% pred), Post 2.84 l (69% pred) FEV1 - Pre 1.40 l (43% pred), Post 1.51 l (46% pred) FEV1/FVC ratio - Pre 50%, Post 53%
A. Polycythemia secondary to hypoxia due to Stage 3 (severe) COPD with no evidence of reversibility. Subjectively better on bronchodilator.
P. No change. Venesection not indicated.
DISCHARGE SUMMARY
Problem 1. Small cell carcinoma of bronchus.
S. Presented with persistent cough and weight loss. Heavy smoker.O. Persistent rhonchus left upper lobe. Obstruction of left main bronchus on CXR.A. Small cell carcinoma of left main bronchus (Limited disease) complicated by
collapse of L upper lobe bronchus and marked weight loss. Histology (Lab No TJ66354/04). No clinical evidence of metastatic spread.
P. To return to Oncology OPD on 9 October for chemotherapy. CT Scan and liver sonar booked (7 October).
Problem 2. Chronic obstructive pulmonary disease.
S. Heavy smoker, chronic cough, reduced effort tolerance. Grade 3 dyspnoea.O. Cyanosed hyperinflation, mild bronchospasm. Heart normal. p02 6,5, Kp, pC02
6,2, Kp, Peak Flow 250 L/min.A. Chronic obstructive pulmonary disease (mainly chronic bronchitis) complicated by
hypoxia and secondary polycythemia.P. Discharged on Ventolin inhaler (2 puffs 8 hourly).
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GEMP III CASE REPORT GRADING RUBRIC
The purpose of the case report is to allow the student to follow a patient from admission to discharge; to gain an understanding of medical record keeping by properly gathering and interpreting findings from the history, physical examination and diagnostic tests.
The complete guide to writing a case report is included in the GEMP III handout. All examiners are required to familiarise themselves with this document (available from the Medicine secretary). The pass mark is 60%.
A. PRESENTATION 5- acceptable format- logical sequence- neatness- concise
B. HISTORY 20 - complete- relevant detail- interpretation of history
and logical differential diagnosis
C. EXAMINATION 20- complete- relevant system(s) details with
regards complaint(s)
D. ASSESSMENT - list of primary and secondary problems 15- list of likely differential diagnoses
(not extensive)
E. MANAGEMENT PLAN 15I. Investigations
- reason for investigation(s)- interpretation
II. TherapyIII. MonitoringIV. Patient education
F. PROGRESS NOTES 10- relevant to illness- new problems
G. DISCHARGE SUMMARY 15 - assessment - pertinent and supportive findings - relevant results & management plan - TTO, follow-up
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