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Internal Medicine Clerkship MDCN 504 UNDERGRADUATE MEDICAL EDUCATION CORE DOCUMENT (Year 3) Class of 2017 2016-2017 Academic Year © 2014
Internal Medicine Clerkship
MDCN 504
UNDERGRADUATE MEDICAL EDUCATION CORE DOCUMENT (Year 3) Class of 2017 2016-2017 Academic Year
© 2014
INTERNAL MEDICINE CLERKSHIP
CLERKSHIP DIRECTOR Dr. Rahim Kachra
Health Sciences Centre Telephone: 403-220-4506
Fax: 403-283-6151 E-mail: [email protected]
EVALUATION COORDINATOR Dr. Michael Slawnych South Health Campus
Telephone: 403-956-3899 Fax: 403-956-1482
Email: [email protected]
BEDSIDE TEACHING COORDINATOR Dr. Michaela Walter
Peter Lougheed Centre Telephone: 403-943-4555
Pager: 09382 E-mail: [email protected]
MEDICAL TEACHING UNIT DIRECTORS
Dr. David Sam Foothills Hospital
Telephone: 403-220-3865 E-mail: [email protected]
Dr. Oliver Haw For Chin Rockyview General Hospital
Pager: 06285 Email: [email protected]
Dr. Paul Le Blanc
Peter Lougheed Centre Telephone: 284-0777 Fax: 403-284-0711
E-mail: [email protected]
Dr. Paul Davis South Health Campus
Telephone:403-956-2401 Fax: 403-956-2995
Pager: 12530 Email : [email protected]
Program Coordinator: Kelsey O’Donnell Tel: 403-210-7539
Email: [email protected]
Each of these key people is very approachable and concerned about individual students having a positive experience during their medicine clerkship rotation. If problems arise during the rotation, please contact the appropriate person listed above as soon as possible.
Table of Contents OVERVIEW OF THE MEDICAL CLERKSHIP ........................................................................................ 1 TERMINAL OBJECTIVE ........................................................................................................................ 1 ORGANIZATION OF THE CLERKSHIP................................................................................................. 1 Clinical Experiences ............................................................................................................................. 1
Medical Teaching Units (4 weeks) ................................................................................................................... 1 Inpatient and/or Outpatient Subspecialty Care (6 weeks) ............................................................................. 2 Formal Learning Sessions ................................................................................................................................ 2
ATTITUDINAL OBJECTIVES: Professionalism ................................................................................... 3 ABSENCES, TIME AWAY AND MAKE-UP TIME (including CaRMS) ................................................. 3
Absenteeism ...................................................................................................................................................... 3 Time Away & Make-up Time ............................................................................................................................. 3
EVALUATION AND PROMOTION ......................................................................................................... 4 EVALUATION TOOLS ........................................................................................................................................ 5
In-training Evaluation Report (ITER) – Student Performance Report Form ................................... 5 Written Examination – Summative .................................................................................................. 6
Formative Evaluations ...................................................................................................................................... 6 OSCE - Objective Structured Clinical Examination ........................................................................ 6 Formative Online Examination ........................................................................................................ 6
Exam Deferrals ..................................................................................................................................... 6 Patient Logbook & History and Physical Exam Passport .................................................................. 7 Abuse of Students by Residents and/or Faculty ................................................................................ 7 APPENDIX I – Suggested Format for Writing Up Histories and Physical Exams ............................. 9 APPENDIX II – Emergency and On Call Duties ................................................................................. 11
Pregnancy and Call ......................................................................................................................................... 11 Clerk on-call responsibilities .......................................................................................................................... 11 “On Call” Rooms for the MTU rotation (FMC, PLC, RGH, SHC): ................................................................ 12 GUIDELINES FOR USE of the (RGH) Sleep Rooms ..................................................................................... 13 SOUTH HEALTH CAMPUS - UNASSIGNED CALL ROOM USAGE GUIDELINES ...................................... 14
APPENDIX IIA – On-Call Expectations .............................................................................................. 15 CALL GUIDELINES FOR NON-MTU ROTATIONS ......................................................................................... 15
APPENDIX III – Appropriate Dress .................................................................................................... 17 APPENDIX IV – Guidelines for Residents and Staff ......................................................................... 17 APPENDIX V – First Day Contacts..................................................................................................... 18 APPENDIX VI – CERTIFYING MCQ BLUEPRINT ............................................................................... 18 APPENDIX VII – Formative MCQ Blueprint ....................................................................................... 21 APPENDIX VIII – Formative OSCE Blueprint .................................................................................... 24 APPENDIX IX – Enabling Knowledge Objectives ............................................................................. 25
Essential Diagnoses/Syndromes ................................................................................................................... 25 GENERAL ..................................................................................................................................... 25 MUSCULOSKELETAL AND SKIN ............................................................................................ 27 CARDIOVASCULAR SYSTEM .................................................................................................. 28 RESPIRATORY SYSTEM ........................................................................................................... 29 RENAL - ELECTROLYTES SYSTEM ........................................................................................ 31 ENDOCRINE-METABOLIC ........................................................................................................ 33 NEUROSCIENCES - PART I ....................................................................................................... 35 NEUROSCIENCES - PART II ...................................................................................................... 36 GASTROINTESTINAL ................................................................................................................ 38
Table 1: Summary of the Essential Internal Medicine Diagnoses/Syndromes ......................................... 41 Pharmacology and Therapeutics ...................................................................................................... 43
Table 2: Important Pharmacological agents and their side-effects ........................................................... 43 APPENDIX X – Skills Objectives ........................................................................................................ 44
Physical Examination ...................................................................................................................................... 44 Medical Procedures and Tests ....................................................................................................................... 44 Medical Charting .............................................................................................................................................. 45
APPENDIX XI – Evaluation Plan ........................................................................................................ 46 APPENDIX XII – Wednesday/Friday Learning Sessions .................................................................. 50 APPENDIX XIII – Bedside Teaching Schedule .................................................................................. 50
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OVERVIEW OF THE MEDICAL CLERKSHIP
TERMINAL OBJECTIVE At the end of the ten-week internal medicine clerkship, the clerks will be able to demonstrate the knowledge, skills, and attitudes required to function as a resident on any medical service. As indicated by active participation in the formal teaching activities and the formative midterm MCQ and OSCE examinations, as well as successful completion of the summative written examination and the in-training performance evaluation (ITER) reports.
ORGANIZATION OF THE CLERKSHIP
Clinical Experiences The clinical experiences of the clerkship have been divided into two main parts. The four-week Medical Teaching Unit block and the remaining six weeks of inpatient/outpatient subspecialty selectives. In general, any changes to your scheduled rotations must be done well in advance, through Sibyl Tai, the clerkship supervisor. Last minute changes cannot be accommodated.
Medical Teaching Units (4 weeks) Ideally you will act as the primary physician for four to six “active” inpatients on average. Your role in this position will involve: • Conducting a full history and completing a full physical examination • Complete knowledge of laboratory test results • Complete understanding of management plan • Daily patient visits with progress notes entered on the chart (more frequently for the patient • With rapidly changing or unstable course) • Interacting with allied health staff regarding the patient • Completion of discharge summaries when requested • Always recording a concise off-service note on all your patients when you leave a service • Appropriate sign-over to on-call team members at the end of your day and prior to leaving the • Ward post call or for mandatory clerkship teaching • Availability while on call to see new admissions as well as help manage the emergent • Medical problems of ward patients • Weekend call will involve the assignment of new patients to see and manage Simply put, your patients are yours. You cannot hope that the resident or staff physician will double-check your every move. Remember that, to your patient, you are the link. Their whole day may be spent in expectation of your visit. Medical clerks are expected to participate in all of the team’s activities. This includes but is not limited to: • Walk rounds • Sign-in & sign-out rounds • Patient care rounds • Grand Rounds & Clinical Pathologic Correlation (CPC Rounds) • Morning report
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• Subspecialty teaching rounds on the MTU • Pharmacy teaching You will spend at least one hour a week receiving bedside teaching from the MTU senior resident or staff. Outpatient experiences are not a formal component of this rotation.
Inpatient and/or Outpatient Subspecialty Care (6 weeks) During the inpatient subspecialty rotations you will act as the primary physician. You will be managing from four to six inpatients on average with roles similar to those stated under the “MTU” section. During some of the rotations you will act as a consultant on inpatients or outpatients. It is very important that you speak with your preceptor and/or rotation “contact person” to get an idea of what the expectations are depending on what rotation you are completing. Please also see Appendix XI regarding “on call” and other responsibilities.
Formal Learning Sessions Attendance and participation in the sessions is MANDATORY for all students. Failure to attend these sessions could lead to an overall “Unsatisfactory” rating in the Clerkship. If you are post-call from the MTU or another rotation with in-house call, you will be excused from the session. Please email [email protected] if you will be absent from a session. Please also have one student at the remote sites (RGH/SHC/PLC) email with a list of who is in attendance. NOTES: 1) Check with the individual subspecialties and MTUs for their specific rounds schedule. You may attend all subspecialty and MTU rounds as long as they do not conflict with the mandatory sessions below. 2) Clerks on MTU do not attend bedside teaching sessions during their 4-week MTU rotation, but are expected to attend the mandatory Wed/Fri lectures at FMC or via videoconference. Wednesdays
• 13:00-15:00 – Bedside Teaching* (for all clerks not on MTU) • 15:00-17:00 – IM Learning Sessions (for all clerks)
Fridays • 15:00-17:00 – IM Learning Sessions (for all clerks) • 12:00-17:00 – Course 8 (alternating weeks)
A) *Bedside Teaching: At FMC, meet your group in the long hallway next to Good Earth. At PLC, meet at
the chairs near Second Cup. Detailed schedules will be emailed and posted on OSLER. Please inform your preceptor if you will be absent.
B) Internal Medicine Wednesday/Friday Learning Sessions: Please see OSLER for schedule and room numbers at all sites.
Up-to-date information about teaching rounds can be found online at: http://www.departmentofmedicine.com/rounds/rounds.htm. Note: Course 8 will take up some of the Friday sessions and exams will take up two of the Fridays. As a result, there are only four formalized sessions on Fridays. If you are not scheduled to attend Course 8 you are expected to be on your clinical service.
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The curriculum for Wednesday/Friday is a 12-week curriculum. During your two-week elective, you will not be expected to participate in the Wednesday/Friday internal medicine teaching. Also, we will attempt to make the Wednesday/Friday sessions available via podcasts; http://umepodcast.ucalgary.ca/. If lecture slides have been provided, the coordinator will post them to OSLER in pdf format. Not all physicians will provide slides.
ATTITUDINAL OBJECTIVES: Professionalism At the end of the ten-week clerkship, the clerk will be able to demonstrate conscientiousness, reliability, good team and patient relationships and a desire to learn. The clerk will show constant improvement in knowledge and skills during the twelve weeks, and by successful completion of the in-training performance evaluation reports. It is expected that the clerk will demonstrate appropriate professional behaviours in practice, such as honesty, integrity, commitment, compassion, respect, and altruism. Manifestations of these will include (but are not limited to): regular attendance on the rotation, reliability, truthfulness, cooperativeness in assisting others on the team, respectful treatment of patients and colleagues, and maintenance of appropriate relationships and confidentiality with patients. Professionalism is valued very highly by our committee and profession. Concerns in this regard are taken very seriously. Every professionalism concern on this rotation will be reviewed by our committee and may result in a rating of “unsatisfactory” or “satisfactory with performance deficiency”. It is assumed that you will not interrupt teaching activities and /or group clinical rounding for non-urgent matters (e.g. texting on phone). It is also assumed you will not discuss anything except patient care at the bedside. Appropriate dress is required, if in doubt, ask your preceptors. In general, we expect business casual
ABSENCES, TIME AWAY AND MAKE-UP TIME (including CaRMS)
Absenteeism If you are going to be absent from your clinical duties, you must speak directly to your preceptor. Email or text pages are not appropriate. Please page your preceptor and make sure they call you back and that you inform them personally. You may also inform other team members, but this alone is not sufficient, as the information may not be passed along. You must also submit a time away form via Osler. Depending on the amount of time away, you may be required to carry out make-up time prior to the completion of the rotation.
Time away & make-up time CaRMS
• One day off in the 6 weeks prior to the CaRMS deadline • One of the two weekends off prior to the CaRMS deadline • National CaRMS interview period (2 weeks)
The following steps will help you understand this process if time away is required OUTSIDE of the protected two weeks:
1. Complete a “Time Away Form” via Osler. Please be specific with travel and interview dates. 2. Wait for confirmation of time away from the Clerkship Director or Evaluation Coordinator prior to making
arrangements. 3. Organize any make-up time if necessary (see below).
Non-CaRMS Time Away
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• In general, the only acceptable reasons for absence are illness, domestic affliction, religious requirement, and presentation at conferences. (Note: Only the time to present at the conference, not to attend the remainder of the conference, will be granted).
• If you are a voting member of a committee and need to be present to vote, this will considered. • A student may request 1 personal day (of the 3 total allowed by UME during the year). These will not be
granted during MTU weeks. • Only the minimum time required to complete tasks will be permitted. • Wait for confirmation of time away from the Clerkship Director or Evaluation Coordinator prior to making
arrangements. • All time-away requests for the MTU must be made 8 weeks prior to the start date of your MTU block.
Make-up Time
• If you miss more than 3 weekdays from your rotation, you will be required to make up this time prior to the final exam (i.e., if you miss 5 days, you must make up 2 days). Organize this with your preceptor.
• We prefer that time be made up on the same rotation you miss it from. • This can be done during evenings & weekends (if not otherwise on call), or during the two-week CaRMS
break if available. • If you cannot schedule the make-up time during the rotation, you will be required to complete it at the end
of your clerkship year and your summative examination will not be written until this time is completed. Any questions can be directed to the Internal Medicine Clerkship Director.
EVALUATION AND PROMOTION To receive credit for your Internal Medicine Clerkship, and be considered OVERALL SATISFACTORY (i.e. pass), as per the final “Clinical Clerkship Summary Form”, the following MUST be completed:
• Satisfactory In-Training Evaluation Reports (ITERs) completed by faculty on all rotations (it is your responsibility to ensure that your preceptors complete and submit these in a timely manner)
• Complete and submit log book entries and History and Physical Exam Passport (HAPE Pass) • Complete midterm exam and OSCE. • Complete and submit your OSCE remediation sheet (if necessary). • Pass the summative final examination • Participate in the formal teaching sessions unless post-call • Demonstrate satisfactory professional behaviour • Have no significant ITER concerns
The final overall decision, as to whether the Internal Medicine Clerkship is deemed satisfactory or unsatisfactory, will be made by the Internal Medicine Clerkship Committee, after completion of the 10-week clinical experience and final written examination. Decisions will not be made by this committee prior to completion of both these components. Of note, the 4-week MTU rotation is deemed to be the most important component of the Internal Medicine Clerkship, and the Clerkship Committee will take this into account in terms of overall assessment and remediation recommendations. Issues of professionalism are taken very seriously and may lead to an “Unsatisfactory or Satisfactory with Performance Deficiencies” overall mark. An “unsatisfactory” overall mark on an ITER, for any rotation within the 10 weeks, WILL lead to a remediation period, consisting of additional clinical experience, duration to be determined by Internal Medicine Clerkship Committee. A “performance deficiencies noted” overall mark on an ITER, for any rotation within the 10 weeks, will likely lead to a remediation period, consisting of additional clinical experience.
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Unsatisfactory marks on any individual component of an ITER will be reviewed and may lead to a remediation period. A pattern of performance deficiencies on individual components of an ITER may also lead to a remediation period. A student not reaching the minimal pass level (MPL) on the final examination will be deemed overall UNSATISFACTORY for the Internal Medicine Clerkship. Such a failure WILL lead to a mandatory examination re-write. Prior to the re-write, the student is encouraged to review their certifying examination. This must take place in one sitting and no later than two weeks prior to the re-write date. In addition, such a failure MAY lead to the recommendation for clinical remediation, at the discretion of the Internal Medicine Clerkship Committee, based on both the severity of the failure (i.e. distance from MPL) and/or the student’s performance on rotation ITERs. Note: All students will be assessed on a case-by-case basis, and the final decision to pass the Internal Medicine Clerkship rotation will be at the discretion of the Internal Medicine Clerkship Committee.
EVALUATION TOOLS
In-training Evaluation Report (ITER) – Student Performance Report Form The ITER is an extremely important component of your evaluation in internal medicine. Review this form carefully (available via one-45) so that you are completely familiar with all the components of clinical competence upon which you will be evaluated. In particular, the ITER method of assessment is the primary way by which many of the knowledge, skills, and attitudinal objectives are evaluated. The ITER will be reviewed with you after each rotation. Input into each category of the ITER is broadly sought from some or all of the following individuals:
• Any preceptors you worked with • Allied health staff • House staff (residents)
A passing grade on the ITER is a mark of “Satisfactory - Good” on the section titled “Overall Assessment of Student’s Performance”. IMPORTANT: A student’s performance cannot be evaluated unless he or she is actively admitting patients, writing notes, presenting at rounds, and interacting with his or her preceptors. Prolonged unexplained ward absences or excessive quietness make student evaluation equally difficult. Ensure that you ask your preceptor for feedback at the midpoint, to identify strengths and areas to work on. Examples of factors that would lead to an “Unsatisfactory” evaluation include:
• Unexplained lack of attendance on the wards and at mandatory sessions • Lack of seeing patients (as evidenced by lack of regular clerk progress notes or lack of timely notes in
acutely/severely ill patients) • Lack of availability to see patients promptly when requested to do so by medical or nursing staff • Lack of familiarity with patients and their problems (i.e., the patient’s history, physical exam,
investigations, progress, therapies, and academic aspects of the problem at a level appropriate for a clinical clerk)
• Lack of honesty and/or dependability (e.g., following up on requested tasks) • Lack of respect or evidence of abusiveness to other members of the health care team or patients • Failure to arrange for coverage of patients when unavailable during normal working hours • Inability to work and cooperate with the health care team
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Written Examination – Summative During the final week of the rotation, you will write an objective examination in Internal Medicine. The content of the exam will be based on the knowledge and skill objectives as outlined. This exam may consist of various components including multiple choice questions, interpretation of x-rays, ECG’s, and photos, etc. A student MUST pass this examination to be considered OVERALL SATISFACTORY on the Internal Medicine rotation. **Please see Appendix IX for summative exam details and deferral process details.
Formative Evaluations
OSCE - Objective Structured Clinical Examination A mandatory OSCE to assess clinical skills occurs at the half-way point of the rotation. If a student is unable to attend the OSCE at the scheduled time during their rotation, the rotation is considered INCOMPLETE and promotion is delayed until the OSCE is satisfactorily completed at the next offering (three months later). Students with borderline or unsatisfactory evaluations on an OSCE station will need to review that station with a faculty member (A fellow or resident who is PGY 5 or higher and is FRCPC status may also sign off on the station). Documentation of this review must be provided to the Clerkship Committee in order for promotion to occur.
Formative Online Examination A mandatory mid-term online examination is given for feedback purposes during the first six weeks of the rotation. All students MUST take this test. There will be a formal review session and the exam will be open online for personal review. Students are expected to make a genuine effort at this exam. Clerks are not to be scheduled on call for evening or night shifts prior to the OSCE or final (summative MCQ) evaluation. **Please see appendix XII for a detailed Evaluation Plan.
Exam Deferrals Generally, clerks may request a deferral of any UME exam only on the grounds of domestic affliction, illness or religious holiday. Other considerations may include:
1. Less than satisfactory rating on more than one item of any ITER or a combination of ITERS. 2. General failure of the student to meet the minimum expectations of the rotation as outlined in the core
document prior to writing the summative exam. While student performance will be monitored by IM Clerkship, students are also responsible for self-reporting any of these above flags. A student who fails to self-identify an academic flag, and then goes on to achieve an unsatisfactory result on the summative exam will have forfeited the option to defer the exam due to the academic flag. Any student who is flagged must meet with a representative of the IM Clerkship Committee. Any student for whom deferral is recommended by the IM Clerkship must meet with the Assistant Dean of Clerkship for further discussion and approval of the deferral request. The deferred examination will be rescheduled by the UME to either the pre-CaRMS or post-CaRMS re-write period, according to student preference and scheduling availability.
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All other requests by students for exam deferrals must meet previously established UME and University of Calgary policies, as outlined in the Student Handbook, the Policies and Procedures for Clerkship and the University of Calgary Calendar.
Patient Logbook The logbook MUST be up to date at the midpoint and completed prior to the final examination. This is an important part of accreditation. We need to assure that all students are seeing the important Internal Medicine clinical presentations regardless of what selectives they have and where they rotate through. We are asking you to log each clinical presentation you see during your 10 weeks on the rotation (you only have to log it once, e.g. if you see 6 patients with anemia you only have to log this presentation once). One patient may have more than one clinical presentation. Bedside teaching can count as clinical encounters. Please also log all procedures seen/done/assisted with. Failure to complete the logbook at one or both of these time periods may result in a final clerkship evaluation of Unsatisfactory.
History And Physical Exam Passport (HAPE Pass) The HAPE Pass must be completed prior to, and submitted at, the summative final examination. You will require 6 observed histories, and 6 observed physical examinations. Each observed encounter must be signed-off on by your attending physician. You may use the formative OSCE stations, as these are observed encounters. Please note that a certain aspect of the history or physical examination is adequate (i.e., this does not have to be a complete admission history and physical – for example, a chest pain or diabetes history is adequate).
Abuse of Students by Residents and/or Faculty Student abuse by Residents and/or Faculty, though potentially a real concern, has fortunately been a rare occurrence within the Internal Medicine Clerkship. Clearly, it is the intention of this clerkship to provide a safe, caring and non-confrontational learning environment. Any form of sexual, verbal, physical or emotional abuse within our clerkship will not be tolerated, and will be investigated and dealt with appropriately and swiftly. If you are encountering any form of abuse in a given rotation, we would direct you to the following resources: Clerkship Student Handbook - http://www.ucalgary.ca/mdprogram/files/mdprogram/clerkship-student-handbook-2016_0.pdf Mistreatment - http://mistreatment.ucalgary.ca/ Advice Student Emergency Crisis - http://www.ucalgary.ca/mdprogram/home/advice-student-emergency-crisis
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APPENDICES
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APPENDIX I – Suggested Format for Writing Up Histories and Physical Exams Your history-taking and physical examination reports are legal documents. As such, they must be legible, signed (including your legibly printed name), timed and dated. It is also recommended that you include your pager number here. I. Admission Write Ups
1. Patient identification 2. Thoroughly defined chief complaint 3. History of presenting illness including relevant background medical history and relevant
aspects of functional enquiry 4. History of past health, family history, social history 5. Medications, allergies, tobacco, alcohol, and other drug use 6. Remainder of functional enquiry 7. Physical examination by system 8. Summary of available laboratory and imaging results 9. Summary of problems 10. Impression and differential diagnosis 11. Plans with justification
The interests of most of the people reading the chart will lie under points 9 to 11. However, it is extremely important that points 1 to 8 are accurately documented in order to help your colleagues understand the patient’s problems. It is always desirable to include relevant background information early in the history even if this forces you away from your usual sequence (e.g., mention at the outset that the patient smokes if hemoptysis is presenting problem; mention at outset that the patient has known breast carcinoma if presenting problem is seizure). Similarly, it is desirable (and a sign of sophistication) to include relevant historical points in the history of presenting illness. Do not withhold that information until the functional enquiry (e.g., inpatient with cough mentions hemoptysis, sputum, chest pain, fever, dyspnea, etc. at outset). II. Progress Notes
1. Be concise 2. Refer to problems and plans that had been identified in admission write-up 3. New developments and test results as appropriate 4. New plans as appropriate 5. Discharge plans
POINTER
POINTER
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Consider the SOAP model:
Subjective (how patient feels/concerns)
Objective (what you find) - exam - lab and diagnostic tests
Action and Plan - lab and diagnostic tests - problem list (prioritize!!!), include overall thoughts regarding discharge readiness at end. Each
problem should include a differential / plan i.e.:
1. Anemia - HgB ↓ 120→95 g/L over 24 hours ddx a) GI blood loss (denies) check occult blood b) GU blood loss (denies) urine R & M c) Other blood loss d) Hemolysis retics LDH T. Bili Haptoglobin e) bone marrow suppression – check meds Also in plan: repeat CBC at 1600h today. Note: Normal volume status, no chest pain, no
need to transfuse now, but cross-match NOW for 2 units.
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APPENDIX II – Emergency and On Call Duties During rotations on the MTU and on certain inpatient subspecialty rotations, you will be required to participate in both emergency room care and ward coverage. Sometimes you may have a junior resident working with you. Up to one night in four will be spent “on call.” Unless you have no resident staff working with you, the Medicine Clerkship Committee asks that clinical clerks do not call staff physicians between 2300 and 0730 hours. Calls during those hours are by definition of an urgent or emergent nature. Consequently, such contact is more appropriately made by resident staff. That individual will be better able to summarise the problem at hand in a succinct and relevant manner. The resident, being more experienced than the clinical clerk, will also be able to answer critical questions in an unequivocal manner. This request is not meant to denigrate the enthusiasm or the skills of the clinical clerks. Rather, it is made in response to the observation that many clinical clerks have been unfairly asked to be the “messenger” when discussing acutely ill patients or those with whom critical developments had occurred. Such a role goes beyond that which can be reasonably expected of a third year medical student.
Pregnancy and Call We will adhere to the PARA rules.
Clerk on-call responsibilities 1) MTU rotations (4 weeks)
• The student is expected to be on-call approximately 1/4 nights in their 28 days on the MTUs.
• This will include one Friday, Saturday and Sunday (usually as a Friday/Sunday and Saturday combination).
• Due to the complexity of the MTU call schedule, specific requests to work (or to be off) certain days for personal preference cannot be accommodated. Personal days will not be granted during MTU. ANY SPECIAL REQUESTS MUST BE SUBMITTED TO THE MTU SCHEDULER 8 WEEKS BEFORE STARTING MTU. The MTU schedule is distributed with a deadline date to give clerks an opportunity to arrange their own call switches with another clerk from their own team. Only 2 way switches are allowed, so as not to affect anyone else’s call but the 2 people who are switching. Once clerks arrange a switch they have to have the call changes approved by the scheduler. Tana McPhee ([email protected]) is the scheduler for FMC/PLC/SHC.
• Monica Horne ([email protected]) makes the MTU clerk call schedule for RGH, which you will be provided with when you begin that rotation. Any special requests (i.e. no call on specific weekends) must be provided to Monica a minimum of two months in advance. Please read RGH MTU Resident Orientation Pamphlet on OSLER prior to start particularly the section on patient confidentiality.
• If your first day of MTU falls on a Monday Stat holiday only those scheduled on call need to come to MTU.
a) Additional guidelines particular to the call schedule while on MTU
• Once the call schedule is made, you can only switch nights with a clerk on your own team.
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• There can never be a weekend day that has no team coverage (either junior or clerk). There are no exceptions to this rule, for example, if there is a junior from Yellow and no one from Blue, there must be a Blue clerk on. This is for continuity of patient care – someone needs to know the team. Staff and seniors are often cross covering and do not know the team well.
• Depending on clerk numbers there may be some nights that are double covered by clerks.
• There is only one clerk call room at each site. If there is no call room for the designated second clerk, they may be able to use an empty junior call room (check with your team). If no call room is available, they may be excused from call at 11 pm but will be expected for a full day of clinical work the following day (i.e. no post-call day).
2) Inpatient subspecialty care (see Appendix IX for specific details)
• The student may be expected to be on-call up to 1/4 nights in their 28 days on these services.
• Unless a call room can be provided by the service, the expectation is that the clerk be available to the service until 11 pm.
• This will include at least one Friday, Saturday and Sunday.
*** Failure to comply with on-call responsibilities will be viewed as a serious breach of professional behaviour and may result in an unsatisfactory evaluation. The so-called “26 Hour PARA Rule” whereby residents may leave the hospital following a night of in-house call does apply in principle to clinical clerks, appropriate sign-over is expected to occur prior to departure and it is expected that any new admissions are reviewed with the MTU staff physician prior to your departure. Clerks working on a statutory holiday will be allowed to take a day off in lieu. This must be taken on the same rotation e.g. if you worked a holiday on MTU, the day-in-lieu must be taken during your MTU rotation. This day in lieu may be scheduled for you. If not, please talk to your preceptor or resident to pick an appropriate day. Clerks who are not on call during statutory holidays are NOT expected to come in to work. Clerks cannot be on call, evenings, or nights the day before the OSCE and final examination. If on call the last Sunday of any Internal Medicine Rotation (MTU or selective), prior to starting a new block (peds, family, etc.), the clerk should be relieved by 2300 hours.
“On Call” Rooms for the MTU rotation (FMC, PLC, RGH, SHC): • PLC - There are 5 call rooms for Internal Medicine at the PLC. They are on the basement level in the
northwest corner of the hospital (below Second Cup). They can be accessed by taking the elevator down one floor; again just past the Second Cup. You may also get there from the basement level by taking a somewhat circular route (get one of the juniors or seniors to show you). Your ID access card will get you in the main door. Once in the "call room area" there is no further card access needed. The rooms are officially unlocked and can be locked from the inside. There is one shared bathroom/shower per 2 call rooms. Each call room has a phone and a computer. There is a lounge area with a fridge/food/TV.
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The call rooms are:
1. Senior - 0729 2. Junior #1 - 0728 3. Junior #2 - 0711 4. Junior #3 - 0721 5. Clerk - 0725
The Junior #3 room is given to the clerk if there are 2 clerks and only 2 juniors on call.
• FMC – Call room is G17A in the main building. This room is only for the use of the MTU clerk on call. The key is kept in a lockbox outside the room; clerks will be provided the combination when starting their rotation. Clerks reminded to please leave the key in the lockbox when leaving the room. This key has gone missing in the past and it is difficult to obtain a new one. FMC Security can let clerks into call room if they show their ID badge, but this is a last resort only to be used in an emergency situation.
Junior Resident call rooms can be used by clerks if one is free. The junior resident call rooms are Main EG 19D and 19E (info on wall in U36 teaching room). Clerks should have access via their swipe cards.
• RGH- There are “Sleep Rooms” in the Highwood Basement (former CV Lab Area) with the “Guidelines for
Use" below. We also have a dedicated clerk on call room, which is RGH 3W07. Please sign in so we may track usage.
• If you have any questions please contact [email protected]. To ensure you have access to the sleep rooms now that the swipe card access is installed, please provide:
1. Your name. 2. Your on-call program. 3. The serial number of your access/swipe card.
Email to [email protected]
It is essential that you use the sign-up sheets when using the sleep rooms as it is now the primary method used to track utilization of the sleep rooms.
GUIDELINES FOR USE of the (RGH) Sleep Rooms
Gaining access to the sleep room:
• The Sleep Rooms are monitored several times a day.
• Sign In on the “Sign Up” Sheet before using the Sleep Room. Please print clearly.
• Sign Out on “Sign Up” Sheet when you are finished using the Sleep room.
• The linen cart is located in the corridor, with extra linens available if all beds have been used. After hours Housekeeping for service: 403-943-3432 or 24 hour pager #04133.
• Log any issues, concerns or feedback on the Issues Log on the bottom of the “Sign-Up” Sheets.
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• Lockers are for 24 hour use only & are available in the hallway. Please sign in/out clearly & adhere to the instructions on the sheet at the lockers. If your lock/belongings have been removed as a result of leaving lock on in excess of 1 week, contact RGH Protection Services 403- 943-3430 (Lost & Found). Lock up your personal items. Locks are not provided; please bring your own lock. Management is not responsible for personal items lost or stolen. Please do not leave personal items in the Sleep Room.
1. The sleep rooms are intended to provide physicians who are on-call a place to sleep. They are not on-
call rooms and should not be reserved “just in case”.
SOUTH HEALTH CAMPUS - UNASSIGNED CALL ROOM USAGE GUIDELINES
ASSIGNED call rooms are: 670117 and 670118 – 6th floor, adjacent to the ward; 570118 – 5th floor, but still convenient to the ward. First come first serve, not specifically assigned to Jr, Sr, Clerk, Clinical Assistant, etc. PLEASE NOTE: one of the call rooms will be for a clinical assistant EVERY night. Therefore, only TWO rooms are available for MTU house staff. In the event MTU has three house staff, e.g. Sr, Jr, and Clerk, one of those three trainees will have to use one of the unassigned call rooms on the second floor. If your access card does not get you into the 2nd level call rooms at night n call security to let you in and out as needed. Access cards can be updated at the card access office during weekday hours. The following 8 call rooms have been designated as UNASSIGNED call rooms - 260137, 260138, 260139, 260140, 260141, 260142, 260143 (located on the 2nd floor)
1. Unassigned Call Rooms (UCRs) can be accessed for the following uses:
a. For sleep when coming off of night call. b. As drop-down office space if users need a quiet place to study. c. If all beds have been used, there is a linen cart in the hall, with extra linens available.
2. UCRs are not intended for extended use and cannot be reserved in advance. If a room is unoccupied,
any approved user can access the room.
3. Please sign in on the “Sign Up” Sheet before using the Call Room. Please print clearly. This will signal to other users that the room is in use. In addition, to prevent unwanted entries while the room is in use, the deadbolt has been equipped with an “occupied/unoccupied” indicator that is engaged when the deadbolt is used (please see on OSLER - SHC Sleep Rooms Sign Up Sheet Room # Template).
4. Sign Out on “Sign Up” Sheet when you are finished using the Call Room. Please do not leave personal
belongings in the UCRs as you would a dedicated call room.
5. Log any issues, concerns or feedback on the Issues Log on the bottom of the Sign-Up Sheets.
6. Requests to assign a particular UCR to a specific department will not be considered at this time. Utilization of all UCRs will be monitored and tracked to help assess whether or not future requests for a dedicated call room are appropriate.
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APPENDIX IIA – On-Call Expectations
CALL GUIDELINES FOR NON-MTU ROTATIONS Updated April 2014 Rotation: Cardiology Site: FMC Weeknight call expectations: 2 weeknights until midnight Weekend call expectations: 1 weekend day Call room details: None Available (Clerk leaves at midnight) There is no formal call schedule. Meet with the other clerks at the beginning of the rotation to pick your call nights (there should not be more than one clerk on call at a time). Let the Cardiology resident/fellow know at evening sign-over when you are staying. Rotation: Cardiology Site: PLC Weeknight call expectations: 2 weeknights until midnight Weekend call expectations: 1 weekend day Call room details: None Available (Clerk leaves at midnight) There is no formal call schedule. Meet with the other clerks at the beginning of the rotation to pick your call nights (there should not be more than one clerk on call at a time). Let the Cardiology resident/fellow know at evening sign-over when you are staying. Rotation: Neurology Site: FMC/SHC Weeknight call expectations: One in Four to 11pm Weekend call expectations: One Weekend day per 2-week Block Call room details: No call room, clerks leave at 11pm Your call schedule will be provided to you by Shenaaz Amershi ([email protected]): Meet with other clerks at beginning of rotation to arrange night call schedule Rotation: ICU Site: FMC/PLC/SHC/RGH Weeknight call expectations: 1 in 4 nights (In-house 24 hours) Call room details: yes , one at each site FMC/PLC/SHC: Students will create their own call schedule and submit their nights of call to Thelma Bartolome prior to the start of the rotation. They are responsible for choosing 6 nights of call: 3 weeknight calls and ONE Friday/Sunday and ONE Saturday. Thelma can be reached at [email protected] or by phone at the PLC ICU administration offices (403)943-5488. Only one clerk should be on each night so that you can remain in-house (only one call room available). RGH: New call room assignment effective July 2016. Contact Miranda Kavalench ([email protected]) for location and access. Students will be expected to be on call for 6 nights during the rotation: 3 weeknights and a Friday/Sunday and a Saturday (3 weekend nights). The call room is used by more than one service so call nights must be
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scheduled in advance to ensure availability. Clerks must submit nights that they are NOT available for call to) 6 weeks prior to the start of the rotation. Rotation: ICU Site: RGH (no on call suite until July 2016, see below for info before then) Weeknight call expectations: 4 nights (5 pm to 11pm) Weekend call expectations: 2 weekends per block - One w/e includes Fri night (5 pm to 11pm) and Sunday (8am to 11pm) and one w/e that includes Saturday (8am to 11pm) Call room details: None Your call schedule will be provided to you by: Self-selected by students - dates must be submitted to Thelma Bartolome ([email protected]) 2-weeks prior to the start of the rotation. Students not doing in-house call (going home at 2400) are expected to be present on their post-call day. Currently, we do not have an on-call suite for medical students at the RGH. As such, students are expected to remain in-house until midnight. After midnight, it will be left to the student’s discretion as to whether they wish to remain in-house i.e./ interesting new patients, procedures etc. If the student is busy and opts to remain after midnight, they would be considered “post-call” the next day. **note that when post-call you are expected to come to the ICU at 0800 to hand over your patients from the previous night and can then leave at 1000. This is important for continuity of patient care. Rotation: Hematology Site: FMC/PLC Weeknight call expectations: 3 call days in a 2-week block Weekend call expectations: No Call Expectations Call room details: No call room available, sleeping in hospital rarely required. It is your responsibility to organize your call days and report them to the Administrator Jeanne Sheldon at 944-1993 or ([email protected]).
Rotations: Endocrinology, GI, GIM Consult, Geriatrics, Infectious Disease, Nephrology, Oncology, Rheumatology, Respirology: No call expectations.
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APPENDIX III – Appropriate Dress Some patients have biases and expectations regarding their physician’s attire and behaviour. There is medical literature showing that patients do judge physicians on the basis of attire. Although these beliefs may be unfounded and irrational, the time to assail these prejudices is not when that person is already frightened and ill. Likewise, relatives and friends of your patient in their time of concern and worry should not have to cope with physician behaviour that they perceive to be unprofessional. In general, conservative attire is most appropriate. Accordingly, the following code MUST be followed: ON THE WARDS - no blue jeans, no shorts, no T-shirts.
IN THE OUTPATIENT AREA - no blue jeans, no shorts, no T-shirts. You will also be expected to respect the preferences of your preceptor.
If you are unsure whether something is acceptable it is best to check with your preceptor.
APPENDIX IV – Guidelines for Residents and Staff Residents and Preceptors should:
1. Review all clerk history-taking and physical examination. Completion of a chart review with feedback to improve clerk record keeping.
2. Oversee and ultimately be responsible for clinical clerk care of patients.
3. Attempt to accommodate transfer of stable patients or those with diminishing educational value from the clinical clerk’s care to that of the resident.
4. Teach physical examination skills, technical skills, emergency medical problems, e.g., asthma, pulmonary edema, common medical problems, e.g., hypertension, CHF, diabetes.
5. Contribute to the evaluation of clinical clerks (ITER’s) including assessment of reliability, dependability, honesty, availability, conscientiousness, and (improving) medical knowledge.
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APPENDIX V – First Day Contacts Students, The following is an updated table for instructions regarding the start of each rotation. Depending on circumstances (holidays…) this may change. If you cannot reach the contact person, you can call the Resident/Staff on service or the Program Coordinator at the UME. Rotations are expected to start at 0800am on Monday morning unless otherwise stated.
Internal Medicine First-Day Contacts
Department Site Contact Instructions Cardiology PLC Dr. A. Kealey Present to CICU, Unit 48 at 0800 on the first morning.
Cardiology FMC Dr. A. Kealey Present to CICU, Unit 103A at 0730 on the first morning.
Endocrinology FMC Dr. S.Bhayana Call Dr. Bhayana (403) 221-4476 or Pager 06521 to arrange a meeting during the first week and call senior resident.
Gastroenterology FMC Dr. J. Ferraz Join the GI team on service @ Doc's lounge 0800 Monday or contact the GI staff or fellow on call in order to receive instructions on the rotation.
Gastroenterology PLC Dr. M. Stapleton
Please meet with the GI staff on service and/or any residents at the GI unit at the Peter Lougheed Centre (in the Ambulatory Care area inside the west entrance) at 0800H on the first day of the rotation. If they are not present, the GI unit clerk can page them for you. If the first Monday of the block is a holiday, you are not expected to attend. Please meet on Tuesday morning at 0800H instead.
Infectious Diseases
PLC / FMC/ RGH
Dr. B. Meatherall
Meet at HPTP clinic (all sites), ground floor of McCaig Building at FMC, POD 1 at PLC, Ambulatory Clinic at RGH. 0800.
Medical Teaching Unit (MTU)
FMC Dr. A. Bharwani
Meet the MTU residents on Unit 36 of SSB on the first day of your rotation.
Medical Teaching Unit (MTU)
PLC Dr. P. Leblanc/ Dr. J. Landry
Contact senior resident on the ward.
Medical Teaching Unit (MTU)
RGH Dr. O. Haw For Chin
Email Dr. Haw For Chin 1-week prior to rotation, if possible [email protected] . Meet your preceptor on Unit 93 at 8:30 am and check the Preceptor Assignment Sheet (at the Nursing Station on Unit 93) to find out to which Team and Preceptor you have been assigned. Otherwise, contact Ms. Monica Horne at (403)943-3491 [email protected]
Medical Teaching Unit (MTU)
SHC Dr. Paul Davis Meet at Unit 66, Room 660088 for handover at 0800 sharp.
General Internal Medicine Consult Service
RGH Dr. G. Altabbaa
Email Dr. Altabbaa 1-week prior to rotation. [email protected]
Meet your preceptor on Unit 93 at 8:30 am and check the Preceptor Assignment Sheet (at the Nursing Station on Unit 93) to find out which Team and Preceptor you have been assigned to. Otherwise contact Ms. Monica Horne at (403)943-3491 [email protected]
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General Internal Medicine Consult Service
FMC Dr. C. Banage Contact Dr. Banage’s office the week prior to start of rotation at (403)210- 6614 (Janis Querido)
General Internal Medicine Consult Service
PLC Dr. M. Desreux
Contact physician on service.
Geriatric Medicine
FMC Dr. D. Burback
Contact Pam Gattinger 1- week prior to the start of the rotation. [email protected]
Geriatric Medicine
RGH
Dr. D. Burback
Contact Janet Bennett 1-week prior to the start of the rotation. [email protected]
Hematology FMC Dr. M. Shafey Meet Jeanne Sheldon at 0815 in Room 601 South Tower, FMC on the first day of the selective, for schedule and instructions. Jeanne will contact you prior to start. ([email protected] OR 403-944-1993)
Hematology PLC Dr. J. Lategan Report to the Specialty Clinic on the main floor at 0900 on the first day of the (s)elective, reporting to Dr. Johan Lategan or Dr. Andrew Daly. Call 403-943-5423.
ICU FMC Dr. L. Berthiaume
Meet Stephon Anderson at 0800 in ICU Administration: FMC, ground floor, McCaig Tower – 403-944-2586. Contact Thelma Bartolome/Stephon Anderson to organize call schedule PRIOR to rotation 403-943-5488. [email protected]; [email protected]
ICU PLC Dr. L. Berthiaume
Meet Thelma Bartolome at 0800 in ICU Administration: Room 2406. Contact Thelma Bartolome to organize call schedule PRIOR to rotation 403-943-5488. [email protected]
ICU
RGH Dr. L. Berthiaume
Meet Miranda Kavalench (RGH) or Kari Cranswick at 08:00 in ICU Administration: 4EE51 Fisher Bldg – (403)943-5488. Contact Thelma Bartolome to organize call schedule PRIOR to rotation (403)943-5488 [email protected]
ICU
SHC Dr. L. Berthiaume
Meet Miranda Kavalench (SHC) at 08:00 in ICU Administration: 150069, to the right when facing the front desk and the first left (swipe access is required).
Contact Thelma Bartolome to organize call schedule PRIOR to rotation (403)943-5488 [email protected]
Nephrology FMC Dr. S. Chou On 1st day of rotation, go to the conference room on Unit 27 Special Services Building to meet the Nephrology Team at 0800 for sign-over. If 1st day is a holiday, then page the nephrologist on the acute inpatient service at 0800 the following day for instruction; if no response, please go to Unit 37 Special Services Building to meet the team.
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Neurology FMC Dr. H. Dhaliwal
Contact Shenaaz (Shen) Amershi 1-week prior to rotation start at [email protected]. Otherwise call (403)956-6246
Neurology SHC Angela Russell, NP
Shenaaz will provide you with a schedule. On the first day contact Angela at 403-956-3471 or page 08150. [email protected]
Oncology FMC (Tom Baker/ Holy Cross Ambulatory clinics)
Dr. C. Card (Med Onc); Dr. S. Angyalfi (Rad Onc)
You will be sent an email from Mary Lee Pedora at least 1 week prior to your rotation. You will be scheduled for 1 week of radiation oncology (schedule set out by Dr Angyalfi) and 1 week of medical oncology (you will be assigned to one of the MedOnc Education Teams – and must email the team leader to get your schedule). If you have any questions, please contact Mary Lee at [email protected] or 403-521-3810
Pulmonary
FMC / PLC/RGH
Dr. J. Chan Please go to the Respiratory Medicine Website:
http://www.respiratorymedicine.ca/residents.htm to view the introduction letter for your specific site placement (FMC/PLC/RGH). This has info on where to meet, details of the rotation, etc… If you have any questions NOT answered on the introduction letter(s) please contact please contact Vilma Guertin at (403)944-2325 or [email protected]
Rheumatology Richmond Road
Dr. C. Penney Meet at Richmond Road Diagnostic and Treatment Centre in the Rheumatology Clinic at 08.00am. If you have any questions, please do not hesitate to contact Laura Radomsky at (403)210-8838 [email protected]
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APPENDIX VI – CERTIFYING MCQ BLUEPRINT Internal Medicine Final Examination Class of 2017 Question type Clinical Presentations Diagnosis Investigation Treatment Basic Science Questions ABDOMINAL DISTENSION/MASS/VISCEROMEGALY/ASCITES 1 1
ABNORMAL SERUM CALCIUM CONCENTRATION 1 1 ABNORMAL SERUM HYDROGEN ION CONCENTRATION 2 2 ABNORMAL SERUM POTASSIUM CONCENTRATION 1 1 ABNORMAL SERUM SODIUM CONCENTRATION 2 2 ABNORMALITIES OF BLOOD CHOLESTEROL/LIPIDS 1 1 2 ACUTE ABDOMINAL PAIN ACUTE CONFUSION (DELIRIUM) 1 1 ACUTE VISION LOSS ANEMIA 1 1 BLEEDING TENDENCY/BRUISING 1 1 BLOOD IN STOOL 2 2 CHANGE IN BOWEL HABIT CHEST DISCOMFORT 2 2 1 5 CHRONIC ABDOMINAL PAIN 1 1 COUGH +/- ABNORMAL CXR 4 4 DEMENTIA, MEMORY DISTURBANCES DIFFICULTY SWALLOWING/DYSPHAGIA 1 1 DYSPNEA 4 1 5 FEVER/CHILLS 1 1 GENERALIZED EDEMA 1 1 GENERALIZED LYMPHADENOPATHY 1 1 HAEMATEMESIS HEADACHE 2 2 HEMATURIA 1 1 HEMOPTYSIS HYPERGLYCAEMIA, DIABETES 1 1 2 HYPERTENSION 1 1 2 HYPERTHYROIDISM/HYPOTHYROIDISM 1 1 IMPAIRED CONSCIOUSNESS JAUNDICE/ABNORMAL LIVER ENZYMES 2 2 JOINT PAIN, MONO-ARTICULAR 2 2 JOINT PAIN, POLYARTICULAR 1 1 MUSCLE WEAKNESS 1 1 NUMBNESS AND TINGLING 2 2 PALPITATIONS 2 2 POISONING 1 1 POLYCYTHEMIA 1 1 POLYURIA PROTEINURIA 1 1 RENAL FAILURE, ACUTE 2 2 RENAL FAILURE, CHRONIC 1 1 SEIZURES 1 1 SHOCK 1 1 SKIN RASH VENOUS THROMBOSIS/HYPERCOAGULABLE STATES 2 2 WEIGHT LOSS 1 1 MURMUR Totals by clinical presentation 48 5 6 3 62
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Subspecialty within internal medicine Cardiology 6 1 1 8 Endocrinology 5 1 1 1 8 Gastroenterology & Hepatology 6 1 1 8 Hematology & Oncology 4 1 1 6 Infectious Diseases 4 1 5 Neurology 5 5 Nephrology 11 11 Pharmacology 1 1 Respirology 4 1 5 Rheumatology 5 5 Total by subspecialty 62
Please note: This blueprint is a general framework for all of the Internal Medicine Clerkship written examinations. Although it will be adhered to as much as possible, the final examination product may differ from the original blueprint due to last minute corrections, modifications, or deletions to specific questions, as deemed necessary by the Internal medicine Clerkship Committee.
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APPENDIX VII – Formative MCQ Blueprint
Internal Medicine Midterm Examination Question type
Clinical Presentations Diagnosis Investigation Treatment Basic
Science Questions
ABDOMINAL DISTENSION/MASS/VISCEROMEGALY/ASCITES 0 0 0 0 0 ABNORMAL SERUM CALCIUM CONCENTRATION 0 1 0 0 1 ABNORMAL SERUM HYDROGEN ION CONCENTRATION 1 0 0 1 2 ABNORMAL SERUM POTASSIUM CONCENTRATION 1 0 1 0 2 ABNORMAL SERUM SODIUM CONCENTRATION 0 0 0 1 1 ABNORMALITIES OF BLOOD CHOLESTEROL/LIPIDS 0 0 0 0 0 ACUTE ABDOMINAL PAIN 1 1 0 0 2 ACUTE CONFUSION (DELIRIUM) 0 0 1 0 1 ACUTE VISION LOSS 1 0 0 0 1 ANEMIA 0 0 0 0 0 BLEEDING TENDENCY/BRUISING 1 0 0 0 1 BLOOD IN STOOL 1 0 0 0 1 CHANGE IN BOWEL HABIT 0 0 0 0 0 CHEST DISCOMFORT 0 1 0 1 2 CHRONIC ABDOMINAL PAIN 0 0 0 0 0 COUGH +/- ABNORMAL CXR 2 1 0 0 3 DEMENTIA, MEMORY DISTURBANCES 1 0 0 0 1 DIFFICULTY SWALLOWING/DYSPHAGIA 1 0 0 0 1 DYSPNEA 3 0 1 0 4 FEVER/CHILLS 0 0 0 1 1 GENERALIZED EDEMA 1 0 0 0 1 GENERALIZED LYMPHADENOPATHY 0 0 0 0 0 HAEMATEMESIS 0 0 0 0 0 HEADACHE 2 0 0 0 2 HEMATURIA 0 1 0 0 1 HEMOPTYSIS 1 0 0 0 1 HYPERGLYCAEMIA, DIABETES 0 0 1 1 2 HYPERTENSION 0 1 0 0 1 HYPERTHYROIDISM/HYPOTHYROIDISM 1 0 0 0 1 IMPAIRED CONSCIOUSNESS 0 1 0 0 1 JAUNDICE/ABNORMAL LIVER ENZYMES 0 0 0 0 0 JOINT PAIN, MONO-ARTICULAR 1 0 0 0 1 JOINT PAIN, POLYARTICULAR 1 0 0 0 1 NUMBNESS AND TINGLING 1 0 0 0 1 PALPITATIONS 0 1 0 0 1 POISONING 0 0 0 0 0 POLYCYTHEMIA 0 0 0 0 0 POLYURIA 1 0 0 0 1 PROTEINURIA 1 0 0 0 1 RENAL FAILURE, ACUTE 3 0 0 0 3 RENAL FAILURE, CHRONIC 0 0 0 0 0 SEIZURES 1 0 0 0 1 SHOCK 0 0 1 0 1 SKIN RASH 0 0 0 0 0 VENOUS THROMBOSIS/HYPERCOAGULABLE STATES 0 0 0 1 1 WEIGHT LOSS 0 0 1 0 1 WEAKNESS 2 0 0 0 2 MURMUR 1 0 0 0 1 Total 30 8 6 6 50
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APPENDIX VIII – Formative OSCE Blueprint
Clinical Presentations Number of questions ABDOMINAL DISTENSION/MASS/VISCEROMEGALY/ASCITES 0-1 ABNORMAL ECG 0-1 ACUTE ABDOMINAL PAIN 0-1 ACUTE CONFUSION (DELIRIUM) 0-1 ACUTE VISION LOSS 0-1 ANEMIA 0-1 CHEST DISCOMFORT 0-1 COUGH +/- ABNORMAL CXR 0-1 DYSPNEA 0-1 FEVER/CHILLS 0-1 GENERALIZED LYMPHADENOPATHY 0-1 HEADACHE 0-1 HYPERGLYCAEMIA, DIABETES 0-1 HYPERTENSION 0-1 HYPERTHYROIDISM/HYPOTHYROIDISM 0-1 JAUNDICE/ABNORMAL LIVER ENZYMES 0-1 JOINT PAIN, MONO-ARTICULAR 0-1 JOINT PAIN, POLYARTICULAR 0-1 NUMBNESS AND TINGLING 0-1 VISION LOSS 0-1 WEAKNESS 0-1 Total number of questions 8 or 9
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APPENDIX IX – Enabling Knowledge Objectives
Essential Diagnoses/Syndromes Diseases and syndromes within each of the relevant Internal Medicine Clinical Presentations have been divided into ‘essential’ and ‘less important’ entities. At the end of the ten-week clerkship, it is expected that the clerk will be able to diagnose these ‘essential’ diseases and syndromes, and to a lesser extent treat them, as demonstrated by successful completion of the summative written examination and the in-training performance evaluation reports. Conditions deemed ‘essential’ (as summarized in Table 1) have been categorized in this manner for a number of possible reasons, including:
- Common - Acute presentations needing acute management - Potential grave complications of missing diagnosis - Important part of differential diagnosis for a given clinical presentation
For these reasons, ‘essential’ causes will make up most of the examination diagnoses. However, the final diagnosis on an examination question may be a ‘secondary’ cause, but the ‘essential’ cause(s) will feature highly in the differential diagnosis. ‘Secondary’ causes may be common diseases (ex: vasovagal syncope, chest wall pain) that may in fact be the final diagnosis on an examination question, but are listed as ‘secondary’ for reasons such as:
- Benign disease - No specific treatment - Diagnosis of exclusion (excluding the ‘essential’ causes) - No specific diagnostic test for condition
Where a syndrome is listed (ex: hemolysis), the diagnosis of the syndrome is considered essential, and unless stated otherwise, the specific causes (ex: sickle cell) are less important. Drug classes and their side-effects have been listed separately in section D, Table 2. The numbers assigned to each clinical presentation correspond to their numbers in the main University of Calgary Medical School Clinical Presentation list.
GENERAL
03. FEVER AND CHILLS - ESSENTIAL
- INFECTIOUS CAUSES: MENINGITIS, ENCEPHALITIS, PNEUMONIA (ATYPICAL AND TYPICAL COMMUNITY-ACQUIRED +/- EMPYEMA), MYCOBACTERIUM TUBERCULOSIS, HIV, ENDOCARDITIS, UTI/PYELO, SEPTIC JOINT
- NEOPLASTIC CAUSES: LYMPHOMAS, LEUKEMIAS, CARCINOMAS (LUNG) - COLLAGEN VASCULAR DISEASES: SLE, RA - OTHER: SARCOIDOSIS, INFLAMMATORY BOWEL
- SECONDARY - INFECTIOUS CAUSES: ASPIRATION AND NOSOCOMIAL PNEUMONIAS, LUNG ABSCESS, BONE,
GASTROINTESTINAL, SKIN INFECTIONS RHEUMATIC FEVER, SEXUALLY TRANSMITTED DISEASES
- OTHER CARCINOMAS RETICULOENDOTHELIAL 06. ANEMIA/PALLOR/FATIGUE
- ESSENTIAL - MICROCYTIC CAUSES: IRON DEFICIENCY, ANEMIA OF CHRONIC DISEASE
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- NORMOCYTIC CAUSES: ACUTE BLOOD LOSS (SEE 96,97), BONE MARROW FAILURE, MULTIPLE MYELOMA, HEMOLYSIS (INCLUDING TRANSFUSION REACTIONS), CHRONIC RENAL FAILURE (SEE 44)
- MACROCYTIC CAUSES: B12 DEFICIENCY - SECONDARY
- THALASSEMIAS - FOLATE DEFICIENCIES
07. BLEEDING TENDENCY/BRUISING
- ESSENTIAL - PLATELET CAUSES: THROMBOCYTOPENIA
- DECREASED PRODUCTION (SEE ALSO ‘ANEMIA’, BONE MARROW CAUSES) - SEQUESTRATION (SEE ALSO ‘SPLENOMEGALY’) - DESTRUCTION: DIC,ITP,SLE,TTP/HUS
- COAGULATION CAUSES: LIVER DISEASE-RELATED,DIC - VASCULAR CAUSES: VASCULITIS
- SECONDARY - PLATELET CAUSES: VON WILLEBRAND’S - COAGULATIN CAUSES: HEMOPHILIA, VITAMIN K DEFICIENCY
08. ELEVATED HEMATOCRIT/POLYCYTHEMIA
- SECONDARY - POLYCYTHEMIA RUBRA VERA (PRV) - SECONDARY CAUSES: HYPOXIA, ERYTHROPOEITIN-SECRETING TUMOUR
09. PAINFUL LIMB
09A PAINFUL SWOLLEN LIMB - ESSENTIAL
- EDEMA (SEE 35 BELOW), DEEP VEIN THROMBOSIS (SEE 09B BELOW) - SECONDARY
- INFECTIONS (BONE, SOFT TISSUE, JOINT) 09B VENOUS THROMBOSIS/HYPERCOAGULABLE STATES - ESSENTIAL
- DVT TRIAD: TRAUMA, STASIS, HYPERCOAGULAB ILITY - CAUSES OF HYPERCOAGULABILITY: MALIGNANCY, NEPHROTIC SYNDROME, INFLAMMATORY BOWEL
DISEASE - SECONDARY
- OTHER CAUSES OF HYPERCOAGULABILITY: PROTEIN C,S, ANTI-THROMBIN III DEFICIENCY, APC RESISTANCE
09C INTERMITTENT CLAUDICATION - SECONDARY
- PERIPHERAL VASCULAR DISEASE
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10. ABNORMALITIES OF WHITE CELLS - ESSENTIAL
- NEOPLASTIC CAUSES OF LYMPHOCYTOSIS: ALL, AML - SECONDARY
- NEOPLASTIC: CLL, CML - CAUSES OF REACTIVE LYMPHOCYTOCIS (VIRAL, BACTERIAL INFECTIONS) - ALL CAUSES OF: NEUTROPENIA, NEUTOPHILIA
11. LYMPHADENOPATHY: GENERALIZED
- ESSENTIAL - DIFFUSE LYMPHADENOPATHY, NEOPLASTIC CAUSES: LYMPHOMA (HODGKIN’S, NHL) - DIFFUSE LYMPHADENOPATHY, REACTIVE CAUSES: INFECTIONS (HIV), INFLAMMATORY (SLE, RA,
SARCOIDOISIS) - SECONDARY
- CAUSES OF LOCALIZED LYMPHADENOPATHY 12. SPLENOMEGALY
- ESSENTIAL - CAUSES: LIVER DISEASES, INFECTIONS (HIV), NEOPLASTIC (LYMPHOMAS/LEUKEMIAS), HEMOLYSIS,
INFLAMMATORY (SLE, RA, SARCOIDOSIS)
13. FEVER IN THE IMMUNOCOMPROMISED HOST - ESSENTIAL
- SAME AS FOR ‘FEVER’ (003) - SECONDARY
- FEBRILE NEUTROPENIA
MUSCULOSKELETAL AND SKIN 18. JOINT PAIN, MONO-ARTICULAR (ACUTE, CHRONIC)
- ESSENTIAL - OSTEOARTHRITIS - SEPTIC JOINT - CRYSTAL-INDUCED: GOUT/PSEUDOGOUT - SYSTEMIC DISEASE, MONOARTICULAR PRESENTATION: SLE, RA - INFLAMMATORY AXIAL CAUSE: REITER’S SYNDROME
- SECONDARY - TRAUMA - INFLAMMATORY AXIAL CAUSES: ANKYLOSING SPONDYLITIS, PSORIATIC ARTHRITIS, INFLAMMATORY
BOWEL ASSOCIATED
19. JOINT PAIN, POLYARTICULAR (ACUTE, CHRONIC) - ESSENTIAL
- INFLAMMATORY, SYMMETRIC CAUSES: RHEUMATOID ARTHRITIS, SLE - INFLAMMATORY, ASYMETRIC CAUSE: REITER’S SYNDROME - NON-INFLAMMATORY CAUSE: OSTEOARTHRITIS
- SECONDARY - OTHER CAUSES: VIRAL ARTHRITIS, PSORIATIC ARTHRITIS, RHEUMATIC FEVER
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20. REGIONAL PAIN, NON-ARTICULAR (HAND, WRIST, ELBOW, SHOULDER, SPINE, HIPS, KNEE, FOOT) - ESSENTIAL
- NERVE ROOT DISTRIBUTIONS (SENSORY, MOTOR, REFLEXES) - POLYMYALGIA RHEUMATICA/GIANT-CELL ARTERITIS
- SECONDARY - FIBROMYALGIA
CARDIOVASCULAR SYSTEM 23. CHEST DISCOMFORT
- ESSENTIAL - CARDIOVASCULAR CAUSES: ANGINA/MYOCARDIAL INFARCTION, AORTIC DISSECTION, PERICARDITIS
(AND ITS CAUSES) - RESPIRATORY CAUSES: PLEURAL DISEASE (SEE 29C), PNEUMONIA (SEE 03), PNEUMOTHORAX,
PULMONARY EMBOLUS - SECONDARY
- OTHER CAUSES: CHEST WALL, SKIN DISEASES, GASTROINTESTINAL DISEASES, PSYCHOGENIC
24. LOSS OF CONSCIOUSNESS/SYNCOPE/PRESYNCOPE - ESSENTIAL
- SEIZURES (SEE 70) - CEREBROVASCULAR CAUSES: STROKE (TIA) - CARDIOVASCULAR CAUSES:
- MECHANICAL: AORTIC STENOSIS - ELECTRICAL:
- BRADYARRYTHMIAS: HEART BLOCKS - TACHYARRYTHMIAS: ATRIAL FIBRILLATION, VENTRICULAR TACHYCARDIA
- METABOLIC CAUSES: HYPOXIA (SEE 29), HYPOGLYCEMIA - SECONDARY
- REFLEX/UNDERFILL CAUSES: VASOVAGAL, ORTHOSTATIC - PSYCHOGENIC
25. PALPITATIONS (ABNORMAL ECG)
- ESSENTIAL - CAUSES: ATRIAL FIBRILLATION, VENTRICULAR TACHYCARDIA
- SECONDARY - CAUSES: SUPRAVENTRICULAR TACHYCARDIA, WOLFF-PARKINSON-WHITE
26. SHOCK (HYPOTENSION)
- ESSENTIAL - CARDIOGENIC CAUSES: MYOCARDIAL INFARCTION, ENDOCARDITIS, AORTIC DISSECTION - HYPOVOLEMIC CAUSES: ACUTE BLOOD LOSS (SEE 96,97), PANCREATITIS - DISTRIBUTIVE: SEPSIS (SEE 03) - OBSTRUCTIVE: TENSION PNEUMOTHORAX, PULMONARY EMBOLUS, PERICARDIAL TAMPONADE
27. CARDIAC ARREST/CARDIOVASCULAR COLLAPSE
- ESSENTIAL - CAUSES LISTED AS ‘ESSENTIAL’ IN OTHER CLINICAL PRESENTATIONS
29
28. MURMUR 28A SYSTOLIC MURMUR - ESSENTIAL
- AORTIC STENOSIS, MITRAL REGURGITATION - SECONDARY
- TRICUSPID REGURGITATION, PULMONARY STENOSIS, VSD 28B DIASTOLIC MURMUR - ESSENTIAL
- MITRAL STENOSIS, AORTIC REGURGITATION - SECONDARY
- TRICUSPID STENOSIS, PULMONARY REGURGITATION
RESPIRATORY SYSTEM
29. COUGH AND DYSPNEA - ESSENTIAL
- CARDIAC CAUSES: UNSTABLE ANGINA, CONGESTIVE HEART FAILURE (PULMONARY EDEMA), PERICARDIAL TAMPONADE
- RESPIRATORY CAUSES: ASTHMA, COPD, PULMONARY EMBOLUS, PNEUMONIA (SEE 03), PNEUMOTHORAX, PLEURAL DISEASE (SEE 29C), LUNG CANCER, INTERSTITIAL LUNG DISEASES (ESP. SARCOIDOSIS, RA)
- OTHER: ANEMIA (SEE 06), HYPERTHYROIDISM (SEE 48A), METABOLIC ACIDOSIS (SEE 31A) - SECONDARY
- PULMONARY HYPERTENSION, CHEST WALL/MUSCULAR, UPPER AIRWAY, CNS, FOREIGN BODY, PSYCHOGENIC
29A COUGH AND/OR DYSPNEA WITH NORMAL CHEST X-RAY - ESSENTIAL
- CARDIAC CAUSES: TAMPONADE (NORMAL LUNGS ON X-RAY), UNSTABLE ANGINA - RESPIRATORY CAUSES: PULMONARY EMBOLUS, ASTHMA, COPD, - OTHER: ANEMIA (SEE 06), HYPERTHYROIDISM (SEE 48A), METABOLIC ACIDOSIS (SEE 31A)
- SECONDARY - PULMONARY HYPERTENSION, CHEST WALL/MUSCULAR, UPPER AIRWAY, CNS, FOREIGN BODY,
PSYCHOGENIC 29B COUGH AND/OR DYSPNEA WITH DIFFUSE CHEST X-RAY ABNORMALITY - ESSENTIAL
- CAUSES: PULMONARY EDEMA, ATYPICAL PNEUMONIA, TUBERCULOSIS, INTERSTITAL LUNG DISEASES (ESP. SARCOIDOSIS, RA)
- SECONDARY - OTHER CAUSES OF INTERSTITIAL LUNG DISEASES: PNEUMOCONIOSIS, IDIOPATHIC PULMONARY
FIBROSIS, SCLERODERMA, WEGENER’S, GOODPASTURE’S, LYMPHANGITIC CARCINOMATOSIS, RADIATION INJURY, METHOTREXATE LUNG
29C COUGH AND/OR DYSPNEA WITH PLEURAL ABNORMALITY - ESSENTIAL
- PNEUMOTHORAX - PLEURAL EFFUSION
- TRANSUDATIVE: CHF, CIRROSIS, NEPHROTIC SYNDROME - EXUDATIVE: PULMONARY EMBOLUS, MALIGNANCY (LUNG), PNEUMONIA/EMPYEMA (SEE 03), RA,
SLE, PANCREATITIS - SECONDARY
- MESOTHELIOMA - OTHER METASTATIC MALIGNANCIES (BREAST,OVARIAN) - CHYLOTHORAX
30
29D COUGH AND/OR DYSPNEA WITH LOCAL CHEST X-RAY ABNORMALITY - ESSENTIAL
- PRIMARY LUNG CANCER, TUBERCULOSIS, RA - SECONDARY
- OTHER INFECTIONS (HISTOPLASMOMA), PULMONARY INFARCT, WEGENER’S,VASCULAR MALFORMATIONS
- PLEURAL/MEDIASTINAL MASSES 29E COUGH, DYSPNEA AND FEVER - ESSENTIAL
- PNEUMONIA (SEE 03), EXACERBATION OF COPD, PULMONARY EMBOLUS - SECONDARY
- LUNG ABSCESS
30. HYPOXIA, HYPOXEMIA, CYANOSIS - ESSENTIAL
- ALL CAUSES PREVIOUSLY LISTED AS ESSENTIAL UNDER COUGH/DYSPNEA (SEE 29) - SECONDARY
- ALL CAUSES PREVIOUSLY LISTED AS ESSENTIAL UNDER COUGH/DYSPNEA (SEE 29)
31. ABNORMAL SERUM HYDROGEN ION CONCENTRATION - ESSENTIAL
- 31 A: METABOLIC ACIDOSIS - HIGH ANION GAP CAUSES
- ENDOGENOUS: DIABETIC KETOACIDOSIS, RENAL FAILURE (SEE 34) - EXOGENOUS: SALICYLATE OVERDOSE
- SECONDARY - 31A METABOLIC ACIDOSIS
- HIGH ANION GAP CAUSES: - ENDOGENOUS: LACTIC ACIDOSIS, STARVATION KETOACIDOSIS - EXOGENOUS: METHANOL, ETHYLENE GLYCOL OVERDOSE
- NORMAL ANION GAP CAUSES: DIARRHEA, RTA - 31B METABOLIC ALKALOSIS
- CHLORIDE RESPONSIVE CAUSES: VOMITING, DIURETICS - CHLORIDE UNRESPONSIVE CAUSES: CONN’S, CUSHING’S,BARTTER’S
- 31C/D RESPIRATORY ACIDOSIS/ALKALOSIS
32. HEMOPTYSIS - ESSENTIAL
- CAUSES PREVIOUSLY CONSIDERED ESSENTIAL CAUSES OF COUGH AND DYSPNEA (TUMOUR, INFECTION, COPD, SLE, PULMONARY EDEMA, PULMONARY EMBOLUS)
- SECONDARY - CAUSES PREVIOUSLY CONSIDERED LESS IMPORTANT CAUSES OF COUGH/DYSPNEA
(BENING TUMOURS, VASCULAR MALFORMATIONS, WEGENER’S, GOODPASTURE’S)
31
RENAL - ELECTROLYTES SYSTEM 34. RENAL FAILURE, ACUTE
- ESSENTIAL - PRE-RENAL CAUSES: CAUSES OF SHOCK (SEE 26) - RENAL CAUSES:
- GLOMERULAR: SLE, TTP/HUS - ACUTE TUBULAR NECROSIS (ISCHEMIC AND TOXIC) - INTERSTITIAL:
- ACUTE INTERSTITIAL NEPHRITIS: BROAD CATEGORIES ONLY (DRUGS, INFECTION) - RHABDOMYOLYSIS - CAST NEPHROPATHY: GOUT (URIC ACID), MULTIPLE MYELOMA
- SECONDARY - POST RENAL CAUSES - THE SPECIFIC CAUSES OF ACUTE INTERSTITIAL NEPHRITIS - OTHER CAUSES OF ACUTE GLOMERULONEPHRITIS: HENOCH-SCHONLEIN PURPURA, SCLERODERMA,
WEGENER’S, GOODPASTURE’S, POST STREPTOCOCCAL)
36. GENERALIZED EDEMA - ESSENTIAL
- RENAL FAILURE [34], CIRRHOSIS, NEPHROTIC SYNDROME, CONGESTIVE HEART FAILURE, HYPOTHYROID [48B]
- SECONDARY - HYPOALBUMINEMIA (AND ITS SPECIFIC CAUSES) - ANGIOEDEMA, DRUGS, VENOUS/LYMPHATIC DRAINAGE, INCREASED CAPILLARY PERMEABILITY (ANT ITS
SPECIFIC CAUSES)
37. ABNORMAL SERUM SODIUM CONCENTRATION 37A HYPONATREMIA - ESSENTIAL
- HYPOVOLEMIC (DIURETICS) - EUVOLEMIC: SIADH (AND ITS BROAD CATEGORIES OF CAUSES) - EDEMA STATES (SEE 36)
- SECONDARY - ARTIFACTUAL, PRIMARY POLYDIPSIA
37B HYPERNATREMIA - SECONDARY
- DIABETES INSIPIDUS, HYPERALDOSTERONISM
38. POLYURIA - ESSENTIAL
- DIABETES MELLITUS (SEE 53) - SECONDARY
- DIABETES INSIPIDUS, PRIMARY POLYDYPSIA 39. HYPERTENSION
- ESSENTIAL - CAUSES:
- PRIMARY HYPERTENSION (INCLUDING HYPERTENSIVE CRISIS) - SECONDARY CAUSES: RENAL PARENCYMAL DISEASE (SEE 34, 44), ALCOHOL (SEE 76)
- SECONDARY - RENAL: TRANSPLANT, RENAL ARTERY STENOSIS - CONN’S SYNDROME, PHEOCHROMOCYTOMA, THYROID DISEASE - COARCTATION OF THE AORTA
40. ABNORMAL SERUM POTASSIUM CONCENTRATION/WEAKNESS/FATIGUE
40A HYPOKALEMIA - ESSENTIAL
32
- BROAD CATEGORIES OF CAUSES: INTAKE, REDISTRIBUTION, LOSS (RENAL AND GI) - SECONDARY
- THE SPECIFIC CAUSES (UNLESS CONSIDERED ESSENTIAL ELSEWHERE) 40B HYPERKALEMIA (FATIGUE, HYPERPIGMENTATION) - ESSENTIAL
- LEUKEMIAS AS CAUSE OF PSEUDOHYPERKALEMIA - REDISTRIBUTION CAUSES: DKA/INSULIN DEFICIENCY,HEMOLYSIS, RHABDOMYOLYSIS, NON-ANION GAP
ACIDOSIS (SEE 31A) - DECREASE EXCRETION CAUSES: RENAL FAILURE (SEE 34,44), ADDISON’S DISEASE
- SECONDARY - INTAKE INCREASE - REDISTRIBUTION CAUSES: TRAUMA/CRUSH, TUMOUR LYSIS - DECREASED EXCRETION CAUSES: HYPORENINEMIC-HYPOALDOSTERONISM
41. DYSURIA
- ESSENTIAL - URINARY TRACT INFECTION (CYSTITIS, PYELONEPHRITIS)
- SECONDARY - PROSTATITIS, URETHRITIS (STD), IRRITABLE BLADDER
42. HEMATURIA
- ESSENTIAL - DIFFERENTIATING EXTRAGLOMERULAR FROM GLOMERULAR HEMATURIA
42A HEMATURIA, EXTRARENAL - ESSENTIAL
- CYSTITIS - SECONDARY
- NEPHROLITHIASIS, TRAUMA, BLADDER CANCER, PROSTATITIS, URETHRITIS 42B HEMATURIA, INTRARENAL, EXTRAGLOMERULAR - ESSENTIAL
- PYELONEPHRITIS - VASCULAR
- HYPERTENSIVE HEPHROSCLEROSIS - TUBULOINTERSTITIAL
- SLE, SARCOIDOSIS, MULTIPLE MYELOMA, URATE NEPHROPATHY - SECONDARY
- RENAL TUMOURS/CYSTS - TUBULOINTERSTITIAL
- SJOGREN’S, SCLERODERMA, OTHER VASCULAR (DM/PAPILLARY NECROSIS, SICKLE CELL)
33
42B HEMATURIA, GLOMERULAR - ESSENTIAL
- SYSTEMIC (OTHER ORGAN INVOLVEMENT) CAUSES: SLE, HUS/TTP, MALIGNANT HYPERTENSION - POSTINFECTION: ENDOCARDITIS
- SECONDARY - NONSYSTEMIC CAUSES (ISOLATED): IGA NEPHROPATHY - SYSTEMIC CAUSES: WEGENER’S, GOODPASTURE’S, HENOCH-SCHONLEIN PURPURA, POLYARTERITIS
NODOSA - POSTINFECTION: POST-STREP
43. PROTEINURIA
- ESSENTIAL - OVERFLOW PROTEINURIA
- MULTIPLE MYELOMA - TUBULOINTERSTITIAL
- SLE, SARCOIDOSIS, URATE NEPHROPATHY, MULTIPLE MYELOMA - GLOMERULAR/NEPHROTIC SYNDROME
- SLE, DIABETES MELLITUS, MALIGNANT HYPERTENSION - SECONDARY
- TUBULOINTERSTITIAL CAUSES - SJOGREN’S, SCLERODERMA, VASCULAR (DM/PAPILLARY NECROSIS, SICKLE CELL)
- GLOMERULAR CAUSES - PRIMARY GOMERULAR DISEASE (MINIMAL CHANGE, FOCAL SCLEROSIS, MEMBRANOUS GN) - AMYLOIDOSIS
44. RENAL FAILURE, CHRONIC
- ESSENTIAL - SECONDARY GLOMERULAR CAUSES: HYPERTENSION, DIABETES, SLE - TUBULOINTERSTITIAL CAUSES (LISTED AS ESSENTIAL IN 43)
- SECONDARY - PRE-RENAL CAUSES: RENAL ARTERY STENOSIS, EMBOLI - PRIMARY GLOMERULAR DISEASE (SEE 43) - POLYCYSTIC KIDNEY DISEASE - TUBULOINTERSTITIAL CAUSES (SEE 43) - POST-RENAL CAUSES -
ENDOCRINE-METABOLIC 46. ADRENAL MASS
- SECONDARY - CUSHING’S, PHEOCHROMOCYTOMA, CONN’S
48. NECK MASS
- SECONDARY - PAINFUL CAUSES: THYROIDITIS, INFECTION, TRAUMA - PAINLESS CAUSES: CANCER, CYSTS, ADENOMA
48A HYPERTHYROIDISM - ESSENTIAL
- GRAVE’S DISEASE - SECONDARY
- PITUITARY TUMOUR - THYROIDITIS, MULTINODULAR GOITRE, TOXIC ADENOMA
34
48B HYPOTHYROIDISM - ESSENTIAL
- HASHIMOTO’S - SECONDARY
- THYROIDITIS (POSTPARTUM, SUBACUTE) - PITUITARY FAILURE
49. ABNORMALITIES OF BLOOD CHOLESTEROL/LIPIDS
- ESSENTIAL - SECONDARY CAUSES OF:
- HYPERCHOLESTEROLEMIA (LDL): NEPHROTIC SYNDROME, HYPOTHYROIDISM, CHOLESTATIC LIVER DISEASES (ESP. PRIMARY BILIARY CIRROSIS)
- HYPERTRYGLYCERIDEMIA: ALCOHOL (SEE 76), DIABETES (SEE 53) - SECONDARY
- PRIMARY CAUSES OF ABNORMAL LIPIDS - OTHER LIFESTYLE (DIET, SEDENTARY, SMOKING) CAUSES OF ABNORMAL LIPIDS
53. HYPERGLYCAEMIA, DIABETES (HYPOGLYCEMIA)
- ESSENTIAL - PRIMARY CAUSES: IDDM, NIDDM (INCLUDING ALL COMPLICATIONS, DKA) - SECONDARY CAUSES: HEMOCHROMATOSIS - IATROGENIC HYPOGLYCEMIA
- SECONDARY - SECONDARY CAUSES: PREGNANCY, ACROMEGALY, CUSHING’S, PHEOCHROMOCYTOMA, PANCREATIC
INSUFFICIENCY (CHRONIC PANCREATITIS, CF) - HYPOGLYCEMIA: POSTPRANDIAL, EXERCISE, INSULINOMA
54. ABNORMAL SERUM CALCIUM CONCENTRATION
54A HYPERCALCEMIA - ESSENTIAL
- HYPERPARATHYROIDISM, LUNG CARCINOMA (SQUAMOUS CELL), MULTIPLE MYELOMA, SARCOIDOSIS - SECONDARY
- MILK-ALKALI SYNDROME, OSTEOLYTIC METASTAES, IMMOBILIZATION, PAGET’S, VITAMIN D RELATED 54B HYPOCALCEMIA - ESSENTIAL
- HYPOPARATHYROIDISM, PANCREATITIS, RENAL FAILURE - SECONDARY
- OSTEOBLASTIC METASTASES, CALCITONIN EXCESS, LOW VITAMIN D/MALABSORPTION
35
NEUROSCIENCES - PART I 57. MUSCLE WEAKNESS (PARALYSIS, PARESIS)
- ESSENTIAL - CNS/BRAIN STEM CAUSES: CEREBROVASCULAR ACCIDENTS (HEMORRAGE, THROMBOTIC OR EMBOLIC
INFARCTION) - SPINAL CORD CAUSES: B12 DEFICIENCY - PNS CAUSES: GUILLAIN-BARRE SYNDROME, DIABETIC (SEE 53)/ALCOHOLIC NEUROPATHY (SEE 76) - MYOPATHY: THYROID DISEASE (SEE 48), HYPERPARATHYROIDISM, ALCOHOL (SEE 76), POTASSIUM
DISTURBANCES (SEE 40) - SECONDARY
- CNS BRAIN STEM CAUSES: TUMOURS, ABCESS - SPINAL CORD CAUSES: MULTIPLE SCLEROSIS, SPINAL CORD TUMOUR/ABCESS, ALS - PNS CAUSE: OTHER NEUROPATHIES - NEUROMUSCULAR JUNCTION: MYASTHENIA GRAVIS, EATON-LAMBERT SYNDROME - MYOPATHY: MUSCULAR DYSTROPHY, POLYMYOSITIS/DERMATOMYOSITIS, CUSHING’S
58. NUMBNESS AND TINGLING
- ESSENTIAL - UPPER AND LOWER EXTREMITY NERVE ROOT DISTRIBUTIONS - CNS/BRAIN STEM CAUSES: TRANSIENT ISCHEMIC ATTACKS - SPINAL CORD CAUSES: B12 DEFICIENCY - PNS CAUSES: GUILLAIN-BARRE SYNDROME, DIABETIC (SEE 53)/ALCOHOLIC NEUROPATHY (SEE 76)
- SECONDARY - SPINAL CORD COMPRESSION FROM METASTASES, TUMOUR, ABCESS, HEMATOMA, DISC HERNIATION - OTHER NEUROPATHIES
60. SPEECH AND LANGUAGE DISTURBANCES
60A HEMIPLEGIA/HEMISENSORY LOSS APHASIA - ESSENTIAL
- CEREBROVASCULAR ACCIDENT - SECONDARY
- CNS TUMOR/ABCESS
61. INVOLUNTARY MOVEMENTS - ESSENTIAL
- PARKINSON’S DISEASE, ALCOHOL WITHDRAWAL (SEE 76), HYPERTHYROID (SEE 48) - SECONDARY
- CEREBELLAR DISORDERS, TICS AND CHOREA
62. GAIT DISTURBANCES (ATAXIA) - ESSENTIAL
- ALCOHOL INDUCED CEREBELLAR ATROPHY, PARKINSON’S DISEASE - SECONDARY
- OTHER CEREBELLAR DISORDERS, SPASTICITY POST-CEREBROVASCULAR ACCIDENT
36
NEUROSCIENCES - PART II 63. DIZZINESS AND VERTIGO
- ESSENTIAL - VERTEBROBASILAR (BRAINSTEM) OR CERBELLAR CEREBROVASCULAR ACCIDENTS
- SECONDARY - MULTIPLE SCLEROSIS, INNER EAR DISEASES (MENIERE’S)
65. VISION LOSS
65B ACUTE VISION LOSS - ESSENTIAL
- TRANSIENT ISCHEMIC ATTACKS, TEMPORAL ARTERITIS
67. DIPLOPIA 67A DIPLOPIA - ESSENTIAL
- BRAIN STEM CEREBROVASCULAR ACCIDENT - SECONDARY
- BRAIN TUMOURS, MYASTHENIA GRAVIS 68. COMA (IMPAIRED CONSCIOUSNESS) AND ACUTE CONFUSION (DELIRIUM)
- ESSENTIAL - CAUSES ‘OUT OF THE BRAIN’
- SUBSTRATE DEFICIENCIES: HYPOXIA (SEE 30), THIAMINE (SEE 76), HYPOGLYCEMIA (SEE 53), ANEMIA (SEE 06)
- MAJOR ORGAN FAILURE: RENAL FAILURE (SEE 34), CIRROSIS/ENCEPHALOPATHY, CHF - ELECTROLYTE ABNORMALITIES: SODIUM (SEE 37), CALCIUM (SEE 54), ACIDOSIS (SEE 31) - ALCOHOL INTOXICATION/WITHDRAWAL (SEE 76) - ENDOCRINE: HYPOTHYROID (SEE 48B), ADDISON’S - HYPERTENSIVE ENCEPHALOPATHY (SEE 39) - SEPSIS (SEE 03)
- CAUSES ‘IN THE BRAIN’ - CEREBROVASCULAR ACCIDENTS, MENINGITIS/ENCEPHALITIS, SEIZURES/POST-ICTAL STATE (SEE
70) - SECONDARY
- CAUSES ‘OUT OF THE BRAIN’ - SUBSTRATE DEFICIENCY: HYPOPHOSPHATEMIA - ELECTROLYTE ABNORMALITIES: MAGNESIUM - ENDOCRINE: HYPOPITUITARISM, CUSHING’S
- CAUSES ‘IN THE BRAIN’ - TRAUMA/SUBDURAL HEMATOMA
37
70. SEIZURES 70A SEIZURES IN ADULT/STATUS EPILEPTICUS - ESSENTIAL
- GENERALIZED SEIZURES - PRIMARY EPILEPSY - SECONDARY CAUSES
- CNS: CEREBROVASCULAR ACCIDENTS, MENINGITIS/ENCEPHALITIS - METABOLIC: HYPO/HYPERNATREMIA (SEE 37), HYPOCALCEMIA (SEE 54B), HYPOGLYCEMIA (SEE
53) - ALCOHOL INTOXICATION AND WITHDRAWAL (SEE 76)
- SECONDARY - PARTIAL SEIZURES, ABSENCE SEIZURES, PSEUDOSEIZURES - GENERALIZED SEIZURES: HYPOMAGNESEMIA
72. DEMENTIA, MEMORY DISTURBANCES (OTHER COGNITIVE CHANGES)
- ESSENTIAL - IRREVERSIBLE CAUSES
- ALZHEIMER’S, PARKINSON’S - REVERSIBLE CAUSES
- HIV, ALCOHOL (THIAMINE), NORMAL PRESSURE HYDROCEPHALUS, HYPOTHYROIDISM (SEE 48B), SODIUM/CALCIUM DISTURBANCES (SEE 37,54), MAJOR ORGAN FAILURE
- SECONDARY - IRREVERSIBLE CAUSES
- MULTI-INFARCT, CREUTZFIELD-JACOB AND PICK’S DISEASE, - REVERSIBLE CAUSES
- SYPHILIS, BRAIN TUMORS/ABCESS, SUBDURAL HEMATOMA, FOLATE/NIACIN DEFICIENCY, WILSON’S DISEASE
74. HEADACHES - ESSENTIAL
- CLINICAL SIGNS OF WORRISOME (BLEEDS, RAISED ICP) HEADACHE - INTRACRANIAL HEMORRAGE, TEMPORAL ARTERITIS
- SECONDARY - TENSION HEADACHES - MIGRAINE AND OTHER VASCULAR HEADACHES - BRAIN TUMOURS - REFERRED PAIN
76. SUBSTANCE ABUSE
- ESSENTIAL - ALCOHOLISM AND ITS MULTISYSTEM DETRIMENTAL EFFECTS
38
GASTROINTESTINAL
83. WEIGHT LOSS - ESSENTIAL
- DECREASED INTAKE CAUSES - PEPTIC ULCER DISEASE, INFLAMMATORY BOWEL DISEASE
- INCREASED METABOLISM - HIV, HYPERTHYROIDISM (SEE 48A)
- LOSS OF NUTRIENTS - DIABETES MELLITUS
- SECONDARY - OTHER CAUSES OF DECREASED INTAKE - MALABSORPTION - HYPERMETABOLISM FROM UNDERLYING MALIGNANCY
94. DIFFICULTY SWALLOWING/DYSPHAGIA
- SECONDARY - REFLUX-INDUCED STRICTURE, ESOPHAGEAL CANCER, ACHALASIA, SCLERODERMA
95. ABDOMINAL PAIN
95A ACUTE ABDOMINAL PAIN - ESSENTIAL
- CARDIORESPIRATORY CAUSES: PULMONARY EMBOLUS, MI, PNEUMONIA - GASTROINTESTINAL CAUSES:
- ACUTE PANCREATITIS, PEPTIC ULCER DISEASE, ACUTE HEPATITIS, PEPTIC ULCER DISEASE, INFLAMMATORY BOWEL DISEASE, IRRITABLE BOWEL SYNDROME
- METABOLIC CAUSES: DKA - URINARY CAUSES: UTI/PYELO
- SECONDARY - GASTROINTESTINAL CAUSES: ‘SURGICAL’ CAUSES, ABDOMINAL MALIGNANCY - METABOLIC CAUSES: SICKLE CELL, HENOCH-SCHONLEIN PURPURA - GENITOURINARY CAUSES: KIDNEY STONES ALL GYNE CAUSES
95B CHRONIC ABDOMINAL PAIN - ESSENTIAL
- CARDIORESPIRATORY CAUSES: ANGINA, RECURRENT PULMONARY EMBOLUS - GASTROINTESTINAL CAUSES: PEPTIC ULCER DISEASE, INFLAMMATORY BOWEL DISEASE, IRRITABLE
BOWEL SYNDROME - SECONDARY
- GASTROINTESTINAL CAUSES: ESOPHAGITIS, ABDOMINAL MALIGNANCY, BILIARY COLIC, CHRONIC PANCREATITIS
- ALL GENITOURINARY CAUSES
96. HEMATEMESIS - ESSENTIAL
- PEPTIC ULCER DISEASE, CIRROSIS WITH VARICES - SECONDARY
- ESOPHAGITIS, UPPER GI CANCER, MALLORY-WEISS TEAR, AORTO-ENTERIC FISTULA
97. BLOOD IN STOOL - ESSENTIAL
- INFLAMMATORY BOWEL, BRISK UPPER GI BLEEDING, HEMOLYTIC-UREMIC SYNDROME - SECONDARY
- INFECTIOUS COLITIS, DIVERTICULAR DISEASE, ANGIODYSPLASIA, COLON CANCER, HENOCH-SCHONLEIN PURPURA
98. HEARTBURN (VOMITING/NAUSEA/ANOREXIA/INDIGESTION) - ESSENTIAL
39
- ANGINA/MYOCARDIAL INFARCTION - GASTROINTESTINAL CAUSES: PEPTIC ULCER DISEASE, INFLAMMATORY BOWEL - METABOLIC CAUSES OF NAUSEA AND VOMITING: ADDISON’S, RENAL FAILURE (SEE 34, 44),
HYPOTHYROID (SEE 48B), DIABETES MELLITUS (SEE 53), HYPERCALCEMIA (SEE 54A) - SECONDARY
- GASTROINTESTINAL CAUSES: ESOPHAGITIS BILIARY COLIC, CHRONIC PANCREATITIS, ABDOMINAL MALIGNANCY
- NAUSEA FROM RAISED INTRACRANIAL PRESSURE
99. ABDOMINAL DISTENSION/MASS/VISCEROMEGALY/ASCITES - ESSENTIAL
- HIGH ALBUMIN GRADIENT CAUSES: CIRRHOSIS (PORTAL HYPERTENSION), NEPHROTIC SYNDROME, CONGESTIVE HEART FAILURE/RIGHT HEART FAILURE/ PERICARDIAL DISEASE
- SECONDARY - HIGH ALBUMIN GRADIENT CAUSES: BUDD-CHIARI, TRICUSPID REGURGITATION, - LOW ALBUMIN GRADIENT CAUSES: PERITONEAL CARCINOMATOSIS (97%), PERITONEAL
TUBERCULOSIS, PERITONEAL FUNGAL INFECTION, CHYLOUS ASCITES, PANCREATITIS - CAUSES OF:
- CONSTIPATION/BLOATING - HEPATOMEGALY - SPLENOMEGALY (SEE 12)
100. JAUNDICE/ABNORMAL LIVER ENZYMES
- ESSENTIAL - JAUNDICE
- PREHEPATIC CAUSES: HEMOLYSIS - HEPATIC CAUSES: ACUTE VIRAL HEPATITIS (ESP. B AND C), CIRROSIS, ACUTE ALCOHOLIC
HEPATITIS (SEE 76) - ELEVATED LIVER ENZYMES
- CHRONIC LIVER DISEASE, HEPATOCELLULAR PICTURE - HEPATITIS B AND C - HEMOCHROMATOSIS
- CHRONIC LIVER DISEASE, CHOLESTATIC PICTURE - ALCOHOL (SEE 76) - PRIMARY BILIARY CIRROSIS
- SECONDARY - JAUNDICE:
- PREHEPATIC CAUSES: GILBERT’S - HEPATIC CAUSES: ACUTE DRUG-INDUCED HEPATITIS, ISCHEMIC HEPATITIS (SHOCK LIVER) - POST HEPATIC CAUSES: STONES, MALIGNANCIES (PANCREATIC, AMPULLARY,
CHOLANGIOCARCINOMA) - ELEVATED LIVER ENZYMES
- CHRONIC LIVER DISEASES, HEPATOCELLULAR PICTURE - ALPHA1ANTITRYPSIN DEFICIENCY, WILSON’S DISEASE, AUTOIMMUNE HEPATITIS
- CHRONIC LIVER DISEASES, CHOLESTATIC PICTURE - PRIMARY SCLEROSING CHOLANGITIS, INFILTRATION (FAT, AMYLOID, GRANULOMAS,
MALIGNANCY)
101. CHANGE IN BOWEL HABIT - ESSENTIAL
- CAUSES OF CHRONIC DIARRHEA - ULCERATIVE COLITIS, CROHN’S DISEASE, IRRITABLE BOWEL SYNDROME
- CAUSES OF ACUTE DIARRHEA - INFECTIONS
- HEMOLYTIC-UREMIC SYNDROME - INFLAMMATORY
- ULCERATIVE COLITIS, CROHN’S DISEASE
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- SECONDARY - CAUSES OF CHRONIC DIARRHEA
- CELIAC DISEASE - CAUSES OF ACUTE DIARRHEA
- LARGE BOWEL PREDOMINANT ORGANISMS - SHIGELLA, CAMPYLOBACTER, E.COLI 0157, ENTAMOEBA HISTOLYTICA - CLOSTRIDIUM DIFFICILE
- SMALL BOWEL PREDOMINANT ORGANISMS: - VIRUSES, SALMONELLA, YERSINIA, TOXIGENIC E.COLI (TRAVELLERS),GIARDIA
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Table 1: Summary of the Essential Internal Medicine Diagnoses/Syndromes
DIAGNOSIS/SYNDROME CLINICAL PRESENTATION(S) MENINGITIS 03, 69, 71, 70 ENCEPHALITIS 03, 69, 71, 70 PNEUMONIA 03, 29B, 30, 32, 95A TUBERCULOSIS 03, 06, 07, 12, 29D, 99 HIV 03, 11, 12, 72, 83 ENDOCARDITIS 03, 26, 34, 42B UTI 03, 41, 42A, 95A SEPTIC JOINT 03, 18 HODGKIN’S DISEASE 03, 07, 11, 12 NON-HODGKIN’S LYMPHOMA 03, 07, 11, 12 ALL 03, 07, 10, 12, 40B AML 03, 07, 10, 12, 40B LUNG CARCINOMA 03, 09B, 29D, 30, 32, 54A SLE 03, 06, 11, 12, 18, 19, 29C, 34, 42B, 43, 44 RA 03, 11, 12, 18, 19, 29B SARCOIDOSIS 03, 11, 12, 29B, 42B, 43, 44, 54A CROHN’S DISEASE 03, 09B, 83, 95, 97, 98, 101 ULCERATIVE COLITIS 03, 09B, 83, 95, 97, 98, 101 IRON DEFICIENCY ANEMIA 06 ANEMIA OF CHRONIC DISEASE 06 BONE MARROW FAILURE 06, 07 MULTIPLE MYELOMA 06, 34, 42B, 43, 44, 54A HEMOLYSIS 06, 12, 40B, 100 B12 DEFICIENCY 06, 57, 58 DIC 07 TTP 07, 34, 42B HUS 07, 34, 42B, 97, 101 ITP 07 CIRROSIS 07, 29C, 36, 37, 69, 71, 96, 99, 100 DVT/PE 09A, 23, 26, 29A, 30, 32, 34, 95A NEPHROTIC SYNDROME 09B, 29C, 36, 37, 43, 49, 99 GOUT/PSEODOGOUT 18, 34, 42B, 43, 44 REITER’S SYNDROME 18, 19 OSTEOARTHRITIS 19 POLYMYALGIA RHEUMATICA/ARTERITIS 20, 64, 74 ANGINA/MI 23, 26, 29A, 34, 95, 98 AORTIC DISSECTION 23, 26, 34 PERICARDITIS/TAMPONADE 23, 26, 29A, 30, 34, 99 PLEURAL EFFUSION 23, 29C, 30 PNEUMOTHORAX 23, 26, 29C, 30, 34 STROKE/TIA 24, 57, 58, 60, 63, 65, 67, 69, 71, 70, 74 AORTIC STENOSIS 24, 28A HEART BLOCKS 24 ATRIAL FIBRILLATION 24, 25 VENTRICULAR TACHYCARDIA 24, 25 DIABETES/HYPOGLYCEMIA/DKA 24, 31A, 38, 40B, 43, 44, 49, 53, 57, 58, 69, 71, 70, 3, 95A, 98 PANCREATITIS 26, 29C, 34, 54B, 95A MITRAL REGURGITATION 28A MITRAL STENOSIS 28B AORTIC REGURGITATION 28B PULMONARY EDEMA/CHF 29B, 30, 32, 36, 37, 69, 71, 99
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ASTHMA 29A, 30 COPD 29A, 30, 32 INTERSTITIAL LUNG DISEASE 29B, 30 HYPERTHYROIDISM/GRAVE’S 29A, 48A, 57, 61, 83 HYPOTHYROIDISM/HASHIMOTO’S 36, 48B, 49, 57, 69, 71, 72, 98 SALICYLATE OVERDOSE 31A, 69, 71 ACUTE TUBULAR NECROSIS 34 ACUTE INTERSTITIAL NEPHRITIS 34 RHABDOMYOLYSIS 34, 40B SIADH 37, 69, 71, 70, 72 PRIMARY HYPERTENSION 39, 42B, 43, 44, 69, 71 ALCOHOL ABUSE 39, 49, 57, 58, 61, 62, 69, 71, 70, 72, 76, 100 ADDISON’S 40B, 98 PRIMARY BILIARY CIRROSIS 49, 100 HEMOCHROMATOSIS 53, 100 HYPERPARATHYROIDISM 54A, 57, 69, 71, 72, 98 HYPOPARATHYROIDISM 54B, 70 GUILLAIN-BARRE SYNDROME 57, 58 PARKINSON’S DISEASE 61, 62, 72 PRIMARY EPILEPSY 69, 70, 71 ALZHEIMER’S 72 NORMAL PRESSURE HYDROCEPHALUS
62, 72
PEPTIC ULCER DISEASE 83, 95, 96, 97, 98 ACUTE/CHRONIC HEPATITIS B
95, 100
ACUTE/CHRONIC HEPATITIS C
95, 100
IRRITABLE BOWEL SYNDROME 95, 101
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Pharmacology and Therapeutics At the end of the ten-week clerkship, the clerk will be able to use the following medication classes and recognise their indications, contraindications, drug interactions, monitoring common and important side effects as well as special metabolic circumstances such as the elderly, pediatrics, liver and renal failure as demonstrated by participation in the Wednesday Learning Session and the successful completion of the summative written examination.
Table 2: Important Pharmacological agents and their side-effects
PHARMACOLOGICAL CLASS CLINICAL PRESENTATION INVOLVED IN SIDE-EFFECT
COMMENTS
GENERAL S/E OF potentially ALL DRUG CLASSES
03, 13 06(BONE MARROW) 10, 11, 12, 26 (ALLERGY/ANAPHYLAXIS) 57 (NEUROPATHY) 98, 100, 101
ANTIBIOTICS 34, 42B, 63 -ATN, VERTIGO:AMINOGLYCOSIDES -INTERSTITIAL NEPHRITIS: essentially all other classes
BETA BLOCKERS 24, 29B, 57 -DYSPNEA: EXACERBATION OF COPD/CHF
NITRATES 24, 74 ACE INHIBITORS/ARB 24, 29A, 34, 36 (ANGIOEDEMA), 40B -PRERENAL FAILURE ONLY WITH
BILATERAL RENAL ARTERY STENOSIS
DIURETICS 24, 34, 36, 37, 40A/B, 49 -RENAL FAILURE: PRE-RENAL/ INTERSTITIAL - HYPONATREMIA: ESPECIALLY THIAZIDES
CALCIUM CHANNEL BLOCKERS 24 DIGOXIN 98 ANALGESICS: ACETAMINOPHEN,OPIOIDS
30, 61, 69, 71 -INVOLUNTARY MOVEMENTS: OPIOID WITHDRAWAL
NSAIDS 07, 34, 42B, 95, 96, 97 -RENAL FAILURE: VASCULAR EFFECT/INTERSTITIAL
ANTICOAGULANTS: ASA, HEPARIN,COUMADIN
07, 95, 96, 97 -ABDOMINAL PAIN: ASA-INDUCED ULCER
BENZODIAZEPINES 30, 61, 69, 71 -INVOLUNTARY MOVEMENTS: BENZO WITHDRAWAL
BRONCHODILATORS 25 CORTICOSTEROID THERAPY 07, 10, 39, 53, 57 -WEAKNESS:
PROXIMAL MYOPATHY DIABETES THERAPY: ORAL HYPOGLYCEMICS,INSULIN
31A
PEPTIC ULCER THERAPY: NOTABLE DIAGNOSES NOT DEEMED ‘ESSENTIAL’:- PSORIATIC ARTHRITIS, WEGENER’S, GOODPASTURE’S, METHANOL OVERDOSE, CONN’S, CUSHINGS, PHEO, SCLERODERMA, POST STREP, POLYARTERITIS NODOSA. AMYLOIDOSIS, POLYMYOSITIS, CML. CLL, PKD
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APPENDIX X – Skills Objectives
Physical Examination At the end of the ten-week clerkship, the clerk will be able to demonstrate the following clinical skills as shown by successful completion of the formative OSCE, and the in-training performance evaluation reports. IMPORTANT SKILLS TO DEMONSTRATE DURING THE MEDICINE ROTATION
1. Assess a patient’s volume status. 2. Interpret vital signs. 3. Demonstrate correct technique for determining blood pressure. 4. Properly examine the fundus for diabetes, hypertension, and raised intracranial pressure. 5. Examine the thyroid. Assess thyroid function clinically. 6. Interpret jugular venous pulse. 7. Examine for signs of congestive heart failure and pericardial tamponade. 8. Examine the heart and interpret cause of murmur. 9. Examine for peripheral arterial disease. 10. Examine for the most reliable signs of:
i. pleural effusion; ii. consolidation; iii. airway obstruction; iv. loss of volume; v. clubbing.
11. Examine the liver. Identify signs of liver disease. 12. Examine for the presence of ascites. 13. Examine for splenomegaly. 14. Examine for lymphadenopathy 15. Perform a digital rectal examination. 16. Examine the breasts for evidence of cancer. 17. Examine the prostate and testicles for evidence of cancer or BPH. 18. Demonstrate examination of hands, knees, hips, and feet, and findings of rheumatoid arthritis. 19. Differentiate septic arthritis from osteoarthritis and rheumatoid arthritis. 20. Differentiate upper motor neuron findings from lower motor neuron findings. 21. By history and physical findings, localise a lesion to:
i. cerebral hemisphere; ii. brainstem; iii. spinal cord; iv. root or peripheral nerve
22. Perform a general screen for the musculoskeletal system (GALS).
Medical Procedures and Tests At the end of the ten-week clerkship, the clerk will be able to, where appropriate, perform and/or interpret the following procedures and tests as demonstrated by active participation in Friday Teaching Rounds, and successful completion of the formative OSCE, summative written examination, and the in-training performance evaluation reports. Exposure to procedures may be limited. The best way to procure the opportunity to perform a procedure is to be keen, involved and a key player on your team. Remember the old adage: see one, do one, teach one…observation is the first step! Let your team know you are interested!!! You may have the opportunity to participate in the following procedures; and you will be expected to interpret the results:
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1. Arterial blood gas
2. Urinalysis (microscopic) - Interpret patterns of: i. glomerulonephritis; ii. pyelonephritis; iii. hematuria; iv. pyuria; v. proteinuria; vi. crystals.
3. ECG
i. ischemia changes; ii. supraventricular tachycardias; iii. ventricular arrhythmias; iv. heart block; v. hyperkalemia.
5. Basic Radiology - Interpret
i. chest x-ray (pneumonia, pulmonary edema, COPD, interstitial infiltrates, nodules, pleural effusions);
ii. abdominal - three views (bowel obstruction, perforation); iii. spine/pelvis x-rays (osteoporosis, metabolic and metastatic bone disease). i. Thoracentesis/Paracentesis transudates; ii. exudates.
4. Lumbar Puncture - patterns of meningitis, subarach. haem (SAH).
5. Joint (Knee) Aspiration
i. infection; ii. inflammation; iii. crystal arthropathy.
6. Basic Spirometry – Interpret
7. Peripheral Blood Smear – Interpret
8. Fecal Occult Blood Testing
Medical Charting At the end of the ten-week clerkship, the clerk will be able to demonstrate accurate, complete, clear, and insightful medical records as shown by successful completion of the in-training performance evaluation reports. The medical chart is a legal document. Do not remove originals from this chart if you are leaving the unit. Make a copy first!!! Ensure all copies of patient information are kept confidential. There are confidential shredding recycling bins around the hospital for this reason: your copies must go in there.
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APPENDIX XI – Evaluation Plan
A. Students must fulfill the following requirements during the IM Clerkship Rotation:
1. Final written MCQ – summative (must achieve MPL) 2. Preceptor ITERs - (must achieve satisfactory performance, see below for explanations) 3. Mid-term OSCE – formative (must participate in exam and remediate unsatisfactory stations) 4. Mid-point MCQ – formative online (must participate in exam) 5. Completed logbook – at midpoint and end of rotation 6. Completed History And Physical Exam Passport – at the end of rotation 7. Meet on-call expectations 8. Meet clinical expectations 9. Meet professionalism expectations 10. Meet all expectations outlined in the Core Document
B. What is the minimum expectation that students must achieve on each evaluation in order to achieve a satisfactory
result?
1. Final written MCQ–summative: Must achieve final score that is above the MPL. 2. Preceptor ITER: * Must achieve an overall score of Satisfactory. Two or more areas rated less than satisfactory on ITERs
(regardless of overall rating) may also be considered below expectations. Must submit ITERs via one45 in a timely manner. 3. Mid-term OSCE – formative: Participation is mandatory and any unsatisfactory station must be reviewed with an attending
and “signed off” prior to the end of the Internal Medicine Clerkship. 4. Formative mid-point MCQ: *Must complete, but do not need to achieve MPL. However, an unsatisfactory result may require
a meeting with a representative of the IM Clerkship Committee for further discussion (including the possible need to defer the final IM summative exam).
5. Completed logbook: Must complete at midpoint and by date of final exam. 6. Completed History And Physical Exam Passport: Must be completed by, and submitted at, the final exam. 7. On-call expectations: Must meet. It is the student’s responsibility to determine the on-call expectations for each rotation. 8. Clinical expectations: Must meet. 9. Professionalism expectations: Must meet. It is the responsibility of the student to inform the Clerkship Director or Evaluation
coordinator of any deficiencies or problematic performance that have been brought to the attention of the student. Failure of the student to seek assistance related to deficiencies or problematic performance will be considered a professionalism issue. From: http://medicine.ucalgary.ca/undergrad/ume/student : The student will be responsible, with faculty assistance, for mastering skills in all domains of medical competence including: medical expertise, communication, collaboration, health care management, health advocacy, scholarly, and professional growth.
*Students who fail to meet any of the basic requirements of this rotation may be required to meet with a representative of the IM Clerkship Committee, and may be counseled to defer the IM exam to either the pre-CaRMS or post-CaRMS rewrite date. Students who feel they are struggling, or who have deficiencies brought to their attention by preceptors, are asked to “self-identify” (i.e. bring this to the attention of the Clerkship Director or Evaluation Coordinator).
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C. What would be grounds for an unsatisfactory result of this aspect of the evaluation?
1. Final written MCQ – summative: Student result is below MPL 2. Preceptor ITER: Overall ITER rating on any ITER of Performance Deficiencies or Unsatisfactory. Any sub-categories rated
less than satisfactory on ITERs. In rare cases and with extenuating circumstances, and if only occurring on one ITER, an exception may be made and this may not lead to an unsatisfactory overall rating at the discretion of the IM Clerkship Committee.
3. Mid-term OSCE – formative: Station rated Unsatisfactory by examiner would be considered a “failed” station. Failure of the student to remediate a failed station and submit the remediation form by the final exam date would be considered unsatisfactory.
4. Mid-point MCQ - formative: Student result is below MPL. 5. Completed logbook: Failure to submit the midterm and final logbook at end of block. The midpoint logbook is mandatory and
if not submitted by the seventh Friday of the block will result in a performance deficiency. The same applies to the mandatory final logbook which must be submitted by the date of the final exam.
6. Completed History And Physical Exam Passport: Failure to complete and submit the passport. 7. On-call expectations (list is not exhaustive):
-Failure to do expected call for a rotation -Failure to respond appropriately on call (e.g. be available in timely fashion, answer pager, see patients when asked to do so, proper documentation, etc.)
8. Clinical expectations (list is not exhaustive): -Failure to meet patient care expectations/responsibilities -Failure to attend/ participate with team (e.g. rounds, teaching sessions) -Failure to document notes in the medical chart or falsifying records
9. Professionalism expectations (list is not exhaustive): -Persistent tardiness -Inappropriate behavior toward patient/other staff/team (e.g. emotional outbursts, harassment, disrespectfulness, abuse, dishonesty) -Failure to complete a time-away form for absences due to CaRMS or other absences.
D. How will an unsatisfactory result be remediated?
1. Final written MCQ–summative: If the student is below the MPL, but the ITER’s are satisfactory, the student is required to re-
challenge the summative examination and remediation may be offered or recommended. 2. Preceptor ITER: Knowledge/clinical performance deficiencies may result in clinical remedial time if this is a recurrent or deemed
serious matter. Remediation of professionalism issues are discussed/decided by the Internal Medicine Clerkship Committee on a case by case basis.
3. Mid-term OSCE – formative: For any unsatisfactory station, the student must review the skill and demonstrate for a preceptor, who will sign their sheet outlining unsatisfactory stations. This sheet must be submitted by the date of the final exam.
4. Formative mid-point MCQ: The exam is reviewed by the Clerkship Director or Evaluation Coordinator with the students as a group each block. Students who are struggling are asked to self-identify and request individual meetings.
5. Completed logbook: No remediation. Student will be rated Satisfactory with Performance Deficiencies for the block. The Office of the UME will be notified, in writing, of any student that fails to meet all logbook deadlines and requirements.
6. History And Physical Exam Passport: No remediation. Student will be rated Satisfactory with Performance Deficiencies for the block. The Office of the UME will be notified, in writing, of any student that fails to complete and submit this.
7. On-call expectations: Decided on individual basis by committee. Student may have to make up the time, depending on the individual circumstances surrounding the incomplete/unsatisfactory call.
8. Clinical expectations: Decided on an individual basis by committee. 9. Professionalism expectations: Decided on an individual basis by committee.
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E. How and when will written feedback regarding problematic progress and performance be delivered to the student? (note that significant concerns will also be relayed to the UME office for inclusion in the student’s file)
1. Final written MCQ–summative: Student receives exam result the week after the exam. Clerkship Committee will write a
letter following committee meeting at end of block (usually within 2 weeks of exam except when meeting delayed by Christmas break, in which case meeting is first Monday back at work). This letter will be distributed to the student.
2. Preceptor ITER: The preceptor provides the ITER at end of rotation, ideally with mid-rotation feedback if there are concerns. Any student receiving an overall rating of less than Satisfactory on an ITER will receive a request to meet with a representative of the IM Clerkship Committee. This will also occur if there are multiple sub-category flags, or for significant professionalism concerns that are brought to attention. A formal letter at end of block is sent to the trainee depending on the concerns.
3. Mid-term OSCE – formative: Letter from Evaluation Coordinator (within two weeks of OSCE) with sheet of unsatisfactory stations which must be signed off by a preceptor.
4. Formative mid-point MCQ: Students receive exam result the week after the exam. 5. Completed logbook: Clerkship Committee will send a letter at end of block. Mid-point reminder will be sent. 6. Completed History And Physical Exam Passport: Clerkship Committee will send a reminder at end of block. 7. On-call expectations: Student should receive feedback from preceptor. The student would be contacted by email and asked
to meet with a representative of the IM Clerkship Committee once we are notified of an issue. The Clerkship Committee will send a letter if necessary.
8. Clinical expectations: Student should receive feedback from preceptor. The student would be contacted by email and asked to meet with a representative of the IM Clerkship Committee will meet with student once they are notified of issue. Clerkship Committee will send a letter if necessary.
9. Professionalism expectations: Student should receive feedback from preceptor. The student would be contacted by email and asked to meet with a representative of the IM Clerkship Committee once they are notified of issue. Clerkship Committee will send a letter if necessary.
F. How will you notify UME when there is a problem with student performance?
1. Final written MCQ – summative: A representative from the Clerkship Committee will write a letter (evaluation coordinator or
director) to the attention of Sibyl Tai and the Assistant Dean of Clerkship. 2. Preceptor ITER: A representative from the Clerkship Committee will write a letter (evaluation coordinator or director) to the
attention of Sibyl Tai and the Assistant Dean of Clerkship. 3. Mid-term OSCE – formative: N/A 4. Formative mid-point MCQ: N/A The Office of the UME (Assistant Dean of Clerkship) may be notified of problematic results
which may necessitate a deferral of the IM final exam. 5. Completed logbook: A representative from the Clerkship Committee will write a letter (evaluation coordinator or director) to
the attention of Sibyl Tai and the Assistant Dean of Clerkship. 6. Completed History and Physical Exam Passport: A representative from the Clerkship Committee will write a letter
(evaluation coordinator or director) to the attention of Sibyl Tai and the Assistant Dean of Clerkship. 7. On-call expectations: Clerkship Committee will send a letter to UME if necessary. 8. Clinical expectations: Clerkship Committee will send a letter if necessary. 9. Professionalism expectations: Clerkship Committee will send an email as soon as an issue becomes apparent. At the end
of a rotation, the Clerkship Committee will send letter and speak with assistant dean in the UME if necessary.
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G. How will interruptions due to CaRMS be accommodated?
1. Final written MCQ–summative: Students missing more than 3 weekdays must do make-up time before writing the final exam. Please see the section on “Time Away for CaRMS” for details on this. We would prefer that students make up this time during the IM block (evenings or weekends when not on call, or during the “Protected” CaRMS period). They can then write the exam as usual at the end of the block. If this is not possible, the time will have to be made up at the end of the year, prior to writing the final exam. Makeup time cannot be done during other rotations, elective time or during vacation time.
2. Preceptor ITER: An ITER may be “incomplete” if there is significant time away due to CaRMS. We try to avoid this by allowing a maximum of 3 days away, with any further days made up on the same rotation. The Evaluation Coordinator and /or Clerkship Director will use their discretion (in discussion with the IM Clerkship Committee if necessary) to decide whether or not they should be deemed satisfactory or otherwise. Discussion with the specific rotation head may be necessary to come up with a final ITER grade in these circumstances.
3. Mid-term OSCE – formative: Formative OSCE must be done before student can write final exam. Students that have not completed all rotation requirements prior to the regularly scheduled summative exam will be required to complete the summative exam at the end of clerkship, during the re-write period scheduled by the Office of the UME.
4. Formative mid-point MCQ: Formative midterm MCQ must be done before student can write final exam. Students that have not completed all rotation requirements prior to the regularly scheduled summative exam will be required to complete the summative exam at the end of clerkship, during the re-write period scheduled by the Office of the UME.
5. Completed logbook: N/A 6. Completed History and Physical Exam Passport: N/A 7. On-call expectations: Call requirements will be reduced if away due to CaRMS. Only the number of days present will be
used in 1:4 call requirement 8. Clinical expectations: Make-up time may be required as noted above. 9. Professionalism expectations: It is expected that the student will have appropriate time-away form completed and discuss
time-away with attending physician.
H. How are the blueprint/marking scheme/expectations pre-circulated to students?
1. Final written MCQ – summative: The blueprint is outlined in the Core Document posted in OSLER and discussed during the orientation session on Day 1 of our clerkship.
2. Preceptor ITER: A copy of the ITER and expectation for ITER success are provided to the students via the UME and discussed during the orientation session on Day 1.
3. Mid-term OSCE – formative: The Core Document outlines general “skills” that we expect students to become competent in during the rotation (Skills section).
4. Formative mid-point MCQ: The blueprint is outlined in the Core Document posted in OSLER and discussed during the orientation meeting on Day 1 of the clerkship.
5. Completed logbook: Informed at mandatory orientation and in Core Document. 6. Completed History and Physical Exam Passport: Informed at mandatory orientation and in Core Document. 7. On-call expectations: In Core Document and individual handouts for rotations. 8. Clinical expectations: In Core Document and individual handouts for rotations. 9. Professionalism expectations: In Core Document and individual handouts for rotations. Professional expectations are also
outlined in the clerkship –wide guide distributed by the UME.
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APPENDIX XII – Wednesday/Friday Learning Sessions (See separate handout and posting on OSLER)
• Examination dates (OSCE, Formative and Certifying) are listed on this document. For any questions please contact the Program Coordinator at [email protected]
APPENDIX XIII – Bedside Teaching Schedule (See separate handout schedule and posting on OSLER)
• If you have any questions or suggestions about bedside teaching, please page Dr. Michaela Walter on pager 09382, office 403-943-4555, [email protected]
