1INTRODUCTIONPatients seek medical attention for various reasons These include1 Prevention of illness2 Relief of physical symptoms3 Control or preferably cure of an illness4 To find out about the prognosis of their illness5 Emotional comfortIn order to address these needs physicians need to be able to perform two different butrelated tasks1 To arrive at a formulation of the patientrsquos problem(s) that includes a provisional orestablished diagnosis and possibly a differential diagnosis (Patients often havemore than one problem at a time and thus a ldquoproblem listrdquo is needed)2 To develop a management plan for their problem(s)The goal of the medicine clerkship rotations (Course 441 Med) is to assist the student indeveloping their competency in these tasks in the range of problems addressed by thediscipline of internal medicine up to the level required for students to carry on their practiceas general practitioners or continue their postgraduate training in any discipline includinginternal medicine family medicine and other specialty programsOBJECTIVES OF COURSE 441-MEDICINEAt the end of the 441-Medicine course students are expected to1)Master the skills of history taking and physical examinationWith the ability to Identify abnormal physical findings2)Have asystematic and problem based approach to the diagnosis and management ofcommon medical conditions3)Be able to interpret the results of commonly use diagnostic tests4)Be able to recognise patients with life threatening conditions amphave asafe and organizedapproach to the diagnosis and management of common medical emergencies5)Be able to communicate effectively both orally and in writing with patientsand otherhealth care professionals6)Be able to pracise student centered learning in hisher free time using available resources These objectives will be realized by enforcing the ACTIVE INVOLVEMENT of themedical student in hisher own theoretical teaching and to be an ACTIVE MEMBER of thehospital team managing the patients rather than being merely an observer Thus it is notsurprising that the bulk of the final assessment of the medical student will depend heavily onHOW ACTIVE the medical student was in the above mentioned tasksAppendix D- describes the skills to be acquired by medical students by the end of 441-Coursein Medicine2Description of the CourseThe course will be for twelve (12) weeksThe student will be posted as sub-intern to a consultant of any sub-specialty ofMedicine either in King Khalid University Hospital (KKUH) Security ForcesHospital (SFH) and Riyadh Medical Complex (RMC) for six (6) weeks

In either end or at the beginning of the 7th week they will be changed to the otherspecialty of Medicine or other hospital as the case maybeEach rotation is good for six (6) weeks therefore each student will be rotated twiceAt the end of each rotation the staff member will fill a form marking the studentsattendance behavior ability to take history conduct physical examination etchellip Thismarking will will be reflected in the CLINICAL ASSESSMENT MARKS1 ROLE OF THE STUDENT ON THE WARD TEAMPrinciple Learning at the clerkship level is best achieved by assuming in a gradual mannerthe roles played by real physicians Therefore the student should increasingly assume realand meaningful responsibility for patient care and not act merely as an observerHow the principle is realized The student becomes a full member of the medical teamwhich includes a consultant a senior registrarresident one or more first-year residentsintern and other studentsThe elements of being a full team member include the following tasks1 Performing admission history and physical examination of minimum of 2-3patientsweek as assigned by the supervising consultant2 Attempting to develop a differential and provisional diagnosis and toformulate a problem list3 Documenting the details of the history physical examination impression andplan in the students Log Book (see below)4 Presenting (orally) a summary of their findings to the medical team duringdaily rounds and at other occasions such as the unit round5 Follow up of ones own patients on a regular basis with respect to the progressof their various problems6 Documenting in the students Log Book what is happening with the patient(ie writing progress notes regularly)7 Communicating with other people involved in the care of patients under theirprimary care eg (consultants residents consultation services nurses andothers)8 Gathering and reviewing relevant data including laboratory and radiologicaldata9 Presenting at least one case history per week to the assigned consultantbull An example of writing a proper clinical progress note is provided in Appendix A32-ROLE OF THE STUDENT IN THE EMERGENCY ROOMPrinciple Taking on call duties in ER is an essential component of learning in Internalmedicine as this is where acutely ill patients are first assessedHow the principle is realized1-On-call schedules will be arranged so that every medical student will be on call threeto four times during the cycle excluding weekends ampfinal exam weeks2- Students are should join the on call medical registrar during their assessment ofpatients in ER

3-Students are expected to start their duties at 4PM and finish at 10PM4-Next morning students should attend their usual rounds ampteaching sessions5-Every student is expected to take at least one full historyampphysical examination to bepresented to his consultant next day6-The registrar on call will sign the studentrsquos attendance sheet7- The evaluation of emergency room duties will be included in the clinical assessmentsection3 INTERACTIONS WITH THE ldquoSENIORSrdquoPrinciples1 The consultant is the individual best positioned to provide both formativefeedbacks to students (advice about how to improve based on the studentsperformance so far) and a final judgment about the students performance2 The consultant is the most important internal medicine teacher the student willencounter The attending serves as a professional role model a source ofclinically relevant knowledge and a teacher of clinical skills3 The interns residents and registrars will be the daily supervisors of themedical studentsHow the principles are realizedthe student will join the medical team in their daily rounds and present their ownpatients accordingly The consultant will provide hisher own final assessment ofthe medical student taking in consideration also an overall feedback from thevarious team members The medical student is encouraged to act as a SHADOWto hisher particular team and to be actively involved in its various activities4 TUTORIALSOne tutorial per week on management of medical emergencies for the wholegroup will be given in the afternoon of every Wednesday It can be given in Quiz formatcase scenario format or interactive discussion (Seeschedule below Appendix B)45 NEUROLOGY SESSIONSbull The objective of these sessions is to increase exposure of students topatients suffering from conditions seen mainly in the sub-specialized divisionof neurologybull All students will assemble every Tuesday 1000-1200 noon in the MedicalWard 32-B Level 3 as arranged by Neurology Divisionbull Each session will have one long case and one or two short cases Thestudents will be divided in two groups accordinglybull 32 ndash B Nurses at the station of Neurology Ward should notify thestudents about the case to be used for long case presentation Notice should begiven a day before the presentation no later than 1200 noonbull The assigned student will prepare the case one day earlier and presentit with complete history and physical examination Provisional diagnosis

differential diagnosis and plan for the investigation and management He maythen be asked by the teacher other things related to the case presentedDiscussion is open then to the whole class and exchanged of questions isallowed The student could be asked to demonstrate abnormal physicalfindings and interprets ECG X-RAY or scans of the said patient Between 60minutes should be given for these long case discussionsbull The students assigned for short cases should be asked to do a physicalexam of the patient Student will be asked about the clinical findings after theexamination Physical examination should be timed and evaluated by theteacher Each short case should take about 30 minutes6 INTERNAL MEDICINE MORNING ROUNDLecture Theatre C Level 3 0745-0830AM7 BED SIDE TEACHINGThe objective of bed side teaching is to help the student utilize hisher diagnostic skills toformulate a problem list for individual patients amp be more familiar with how to investigateand manage patientrsquos specific medical conditionsEach group of students will have one sessionweek with medical consultants of differentsubspecialties (excluding neurology) in which specific cases will be given to the studentsbeforehand to take the history amp physical examination amp then the student will present thecase to the consultant who will then discuss with students the patientrsquos problem list how toinvestigate them interpret the results of investigations and put forward a management plan ampfollow up (See the attached schedule)Recommended ReferencesA Textbooks of MedicineAny one of the following excellent books1 Clinical Medicine - A textbook for Medical students and doctors P J Kumarand M L Clark ldquolatest editionrdquo2 Textbook of Medicine - By Souhami andMoxham latest edition53 Davidsonrsquos Principles and Principles of Medicines - C R Edward andIan AD Bonchir latest editionB Physical ExaminationAny one of the following books1 A guide to physical examination and history taking by Barbara Bateslatest edition2 Macleodrsquos Clinical Examination by John Munro and C Edwards3 Clinical Examination - 2nd Edition by Nicolas Talley and SimonOrsquoConnor6

Executive Summary of Mark DistributionShown below a brief overview of the current mark distribution of differentassessments in the course 441-Medicine1) Ward Clinical assessment 20 of the total mark

a) 5 attendance b) 10 unit evaluation c) 5 log book2) Theoretical exam 40 of the total mark3) Final OSCE exam 40 of the total markFor each student it is mandatory to obtain (24 out of 40) in the final clinical(OSCE) to pass this courseATTENDANCEAttendance is continuously monitored and kept to see whether students willmeet the required percentage of attendance set by the UniversityAs early as possible any student noticed to have poor attendance would begiven warning letters to call their attention and give them a chance to improveAs a rule students should have attended at least 75 of each of the courseclinical amp theoretical activities Names of students who will have less than75 attendance will be submitted to the Vice Dean ndash Academic Affairs Officeand will not be included in the exam until the University gives their approval7

IMPORTANT DATE TO REMEMBER CLASSESStart On Saturday 15041430 11042009End On Wednesday 24061430 170620091 FIRST ROTATIONStart On Saturday 15041430 11042009End On Wednesday 18051430 13052009 CONTINUOUS ASSESSMENT EXAMStart On Saturday 21051430 16052009End On Wednesday 25051430 200520092 SECOND ROTATIONStart On Saturday 21051430 16052009End On Wednesday 24061430 17062009 FINAL EXAMINATIONStart On Saturday 20061430 13062009End On Wednesday 24061430 1706200983 Assessment Exams- Theory ExamThis is a clinically-oriented theoretical assessment that involves Single-BestMCQrsquos through patient case scenarios

- Clinical Exam- It consists of one long case for the mid-term exam and OSCE at the endof the coursebull LONG CASEThe mid-term clinical exam will consist of one long case The goal here is tointroduce the medical student to the clinical exam format mid-way in hishertraining period so mistakes could be learned from and avoided in the futureexams Each student has the right to repeat the exam if a clear evidence wassubmitted indicating an unfair exam (eg non-compliant patient) A one-pageldquolong-case feedbackrdquo form will be filled immediately by the examiners thatwill be copied and then given to the student in order to improve hisherperformance for the next examAn example of how this form looks like is shown in Appendix Cbull OSCE (Objective Structured Clinical Examination)- This part will include both of the short clinical cases in addition to theoral part in the old system- Rational this will result in a more objective and standard exam byexposing the same students to the same examiners asking the samequestions and have the ideal answers and mark distribution withmore efficient amp effective use of time and staff- It includes 10 stations and each station lasts for 7 minutes so the totaltime for 1 OSCE is 70 minutes- The stations are divided into the followinga - Data Interpretation Stationsb- Focused Clinical Stationsc -Rest Stationsbull 10-11 students will undertake the OSCE at one time followed by a 10-minute breakthen another 10-11 students will undertake the OSCEbull Each student will be provided with 10 stickers that contain hisher name anduniversity number that heshe will handle to the examiners to avoid wasting time ingetting this information during the start of each station9bull DATA INTERPRETATION It should be emphasized that the goal here is not totest memory recall abilities but rather to test clinical approach to a brief clinicalscenario through proper interpretation of a laboratory investigation Here are someexamples of possible stations in each subspecialtybull CVSbull ECG (eg AMI atrial fibrillation ventricular fibrillation LVHetc)bull Respiratorybull ABG (eg acute respiratory acidosisetc)bull PFT (eg obstructive lung diseaseetc)bull CXR (eg TBetc)bull Pleural fluid (eg exudateetc)bull Endocrinebull Abnormal glucose control (eg DKA)

bull Rheumatologybull knee aspirate (eg septic versus inflammatory)bull HematologyOncologybull CBC (eg anemia PRVhellipetc)bull GIbull Abnormal liver enzymes (eg acute hepatitisetc)bull Ascitic fluid aspirate (eg exudateetc)bull Nephrologybull Electrolyte disturbance (eg hyponatremiaetc)bull Acid-base imbalance (eg metabolic acidosisetc)bull Neurologybull CSF (eg meningitisetc)bull Infectious Diseasesbull Urine CS (eg UTI)bull Blood CS (eg Staph Septicemia in a drug addictetc)10Example 1CXR of a 60 year old man with cough fever and sweating for 4 weeks1 Interpret the main abnormal findings of the CXR ( 2 marks)1048633 Ideal answer Right upper lung lobe infiltration2 List 3 differential diagnoses (3 marks)1048633 Ideal answer a Pneumoniab TB _c Cancer _3 Mention 3 initial and essential laboratory investigations (3 marks)1048633 Ideal answer a Sputum for CSb Sputum for AFBc CBC _4 Mention the initial antibiotic class of choice (2 marks)1048633 Ideal answer Cephalosporin or a penicillin11Example 270 year old man with history of DM HTN and hypercholestolemia He presents with thecurrent ECG (ECG is provided that shows an inferolateral MI)1 Interpret the ECG ( 1 mark )1048633 Ideal answer Inferolateral acute ST elevation myocardial infarction(but If answered Inferior STEMI 12 out of 1 Mark)2 How would you manage this patient ( 6 marks )1048633 Ideal answer1 ASA = 2 marks2 Heparin = 1 mark3 B-blocker = 1 mark4 Fibrinolytic = 2 marks3 How would you decide about successful reperfusion ( 3 marks )1048633 Ideal answer

1 Resolution of the ischemic chest pain2 Resolution of the ST-segment elevation by at least 503 Reperfusion arrhythmia (eg AIVR)II FOCUSED CLINICAL EXAMINATIONbull This is similar to the short case format in the old system but is more focused eginstead of asking about the CVS examination of a patient which is not practical to bedone properly in 7 minutes as being done in the current system the medical studentwill be asked to examine only the JVP and demonstrate it to the examiners over the7minutes period allotted to that stationbull Here are some examples of possible stations in each subspecialtyCVS HematologyOncologybull Precodium murmurs mechanical valve sounds bull Lymph nodesbull Peripheral Pulses GIbull JVP bullLiverbull BP measurement bullAscitisRespiratory Nephrologybull Chest (Percussion amp Auscultation) bullKidneyEndocrine Neurologybull Thyroid bullSpecific Cranial Nerve (eg 7th

Rheumatology cranial nerveetc)bull Knee bullSpecific Motor on sensorydeficilbull Hands bullCerebellar exam12FOCUSED CLINICAL EXAMASSESSMENT FORMATJVP StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Identify the different anatomical landmarks for theJVP and the carotid pulse in the neck ______ _____ 1 mark2 Able to measure the exact height of the JVP ______ _____ 2 marks3 Able to demonstrate the different clinical maneuversused to distinguish JVP from the carotid pulse ______ _____ 3 marksII- Interpretation (40)The medical student is able to properlybull Identify whether the JVP is low normal or high 2 marksbull Mention 2 differential diagnoses for helliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________13FOCUSED CLINICAL EXAM

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

In either end or at the beginning of the 7th week they will be changed to the otherspecialty of Medicine or other hospital as the case maybeEach rotation is good for six (6) weeks therefore each student will be rotated twiceAt the end of each rotation the staff member will fill a form marking the studentsattendance behavior ability to take history conduct physical examination etchellip Thismarking will will be reflected in the CLINICAL ASSESSMENT MARKS1 ROLE OF THE STUDENT ON THE WARD TEAMPrinciple Learning at the clerkship level is best achieved by assuming in a gradual mannerthe roles played by real physicians Therefore the student should increasingly assume realand meaningful responsibility for patient care and not act merely as an observerHow the principle is realized The student becomes a full member of the medical teamwhich includes a consultant a senior registrarresident one or more first-year residentsintern and other studentsThe elements of being a full team member include the following tasks1 Performing admission history and physical examination of minimum of 2-3patientsweek as assigned by the supervising consultant2 Attempting to develop a differential and provisional diagnosis and toformulate a problem list3 Documenting the details of the history physical examination impression andplan in the students Log Book (see below)4 Presenting (orally) a summary of their findings to the medical team duringdaily rounds and at other occasions such as the unit round5 Follow up of ones own patients on a regular basis with respect to the progressof their various problems6 Documenting in the students Log Book what is happening with the patient(ie writing progress notes regularly)7 Communicating with other people involved in the care of patients under theirprimary care eg (consultants residents consultation services nurses andothers)8 Gathering and reviewing relevant data including laboratory and radiologicaldata9 Presenting at least one case history per week to the assigned consultantbull An example of writing a proper clinical progress note is provided in Appendix A32-ROLE OF THE STUDENT IN THE EMERGENCY ROOMPrinciple Taking on call duties in ER is an essential component of learning in Internalmedicine as this is where acutely ill patients are first assessedHow the principle is realized1-On-call schedules will be arranged so that every medical student will be on call threeto four times during the cycle excluding weekends ampfinal exam weeks2- Students are should join the on call medical registrar during their assessment ofpatients in ER

3-Students are expected to start their duties at 4PM and finish at 10PM4-Next morning students should attend their usual rounds ampteaching sessions5-Every student is expected to take at least one full historyampphysical examination to bepresented to his consultant next day6-The registrar on call will sign the studentrsquos attendance sheet7- The evaluation of emergency room duties will be included in the clinical assessmentsection3 INTERACTIONS WITH THE ldquoSENIORSrdquoPrinciples1 The consultant is the individual best positioned to provide both formativefeedbacks to students (advice about how to improve based on the studentsperformance so far) and a final judgment about the students performance2 The consultant is the most important internal medicine teacher the student willencounter The attending serves as a professional role model a source ofclinically relevant knowledge and a teacher of clinical skills3 The interns residents and registrars will be the daily supervisors of themedical studentsHow the principles are realizedthe student will join the medical team in their daily rounds and present their ownpatients accordingly The consultant will provide hisher own final assessment ofthe medical student taking in consideration also an overall feedback from thevarious team members The medical student is encouraged to act as a SHADOWto hisher particular team and to be actively involved in its various activities4 TUTORIALSOne tutorial per week on management of medical emergencies for the wholegroup will be given in the afternoon of every Wednesday It can be given in Quiz formatcase scenario format or interactive discussion (Seeschedule below Appendix B)45 NEUROLOGY SESSIONSbull The objective of these sessions is to increase exposure of students topatients suffering from conditions seen mainly in the sub-specialized divisionof neurologybull All students will assemble every Tuesday 1000-1200 noon in the MedicalWard 32-B Level 3 as arranged by Neurology Divisionbull Each session will have one long case and one or two short cases Thestudents will be divided in two groups accordinglybull 32 ndash B Nurses at the station of Neurology Ward should notify thestudents about the case to be used for long case presentation Notice should begiven a day before the presentation no later than 1200 noonbull The assigned student will prepare the case one day earlier and presentit with complete history and physical examination Provisional diagnosis

differential diagnosis and plan for the investigation and management He maythen be asked by the teacher other things related to the case presentedDiscussion is open then to the whole class and exchanged of questions isallowed The student could be asked to demonstrate abnormal physicalfindings and interprets ECG X-RAY or scans of the said patient Between 60minutes should be given for these long case discussionsbull The students assigned for short cases should be asked to do a physicalexam of the patient Student will be asked about the clinical findings after theexamination Physical examination should be timed and evaluated by theteacher Each short case should take about 30 minutes6 INTERNAL MEDICINE MORNING ROUNDLecture Theatre C Level 3 0745-0830AM7 BED SIDE TEACHINGThe objective of bed side teaching is to help the student utilize hisher diagnostic skills toformulate a problem list for individual patients amp be more familiar with how to investigateand manage patientrsquos specific medical conditionsEach group of students will have one sessionweek with medical consultants of differentsubspecialties (excluding neurology) in which specific cases will be given to the studentsbeforehand to take the history amp physical examination amp then the student will present thecase to the consultant who will then discuss with students the patientrsquos problem list how toinvestigate them interpret the results of investigations and put forward a management plan ampfollow up (See the attached schedule)Recommended ReferencesA Textbooks of MedicineAny one of the following excellent books1 Clinical Medicine - A textbook for Medical students and doctors P J Kumarand M L Clark ldquolatest editionrdquo2 Textbook of Medicine - By Souhami andMoxham latest edition53 Davidsonrsquos Principles and Principles of Medicines - C R Edward andIan AD Bonchir latest editionB Physical ExaminationAny one of the following books1 A guide to physical examination and history taking by Barbara Bateslatest edition2 Macleodrsquos Clinical Examination by John Munro and C Edwards3 Clinical Examination - 2nd Edition by Nicolas Talley and SimonOrsquoConnor6

Executive Summary of Mark DistributionShown below a brief overview of the current mark distribution of differentassessments in the course 441-Medicine1) Ward Clinical assessment 20 of the total mark

a) 5 attendance b) 10 unit evaluation c) 5 log book2) Theoretical exam 40 of the total mark3) Final OSCE exam 40 of the total markFor each student it is mandatory to obtain (24 out of 40) in the final clinical(OSCE) to pass this courseATTENDANCEAttendance is continuously monitored and kept to see whether students willmeet the required percentage of attendance set by the UniversityAs early as possible any student noticed to have poor attendance would begiven warning letters to call their attention and give them a chance to improveAs a rule students should have attended at least 75 of each of the courseclinical amp theoretical activities Names of students who will have less than75 attendance will be submitted to the Vice Dean ndash Academic Affairs Officeand will not be included in the exam until the University gives their approval7

IMPORTANT DATE TO REMEMBER CLASSESStart On Saturday 15041430 11042009End On Wednesday 24061430 170620091 FIRST ROTATIONStart On Saturday 15041430 11042009End On Wednesday 18051430 13052009 CONTINUOUS ASSESSMENT EXAMStart On Saturday 21051430 16052009End On Wednesday 25051430 200520092 SECOND ROTATIONStart On Saturday 21051430 16052009End On Wednesday 24061430 17062009 FINAL EXAMINATIONStart On Saturday 20061430 13062009End On Wednesday 24061430 1706200983 Assessment Exams- Theory ExamThis is a clinically-oriented theoretical assessment that involves Single-BestMCQrsquos through patient case scenarios

- Clinical Exam- It consists of one long case for the mid-term exam and OSCE at the endof the coursebull LONG CASEThe mid-term clinical exam will consist of one long case The goal here is tointroduce the medical student to the clinical exam format mid-way in hishertraining period so mistakes could be learned from and avoided in the futureexams Each student has the right to repeat the exam if a clear evidence wassubmitted indicating an unfair exam (eg non-compliant patient) A one-pageldquolong-case feedbackrdquo form will be filled immediately by the examiners thatwill be copied and then given to the student in order to improve hisherperformance for the next examAn example of how this form looks like is shown in Appendix Cbull OSCE (Objective Structured Clinical Examination)- This part will include both of the short clinical cases in addition to theoral part in the old system- Rational this will result in a more objective and standard exam byexposing the same students to the same examiners asking the samequestions and have the ideal answers and mark distribution withmore efficient amp effective use of time and staff- It includes 10 stations and each station lasts for 7 minutes so the totaltime for 1 OSCE is 70 minutes- The stations are divided into the followinga - Data Interpretation Stationsb- Focused Clinical Stationsc -Rest Stationsbull 10-11 students will undertake the OSCE at one time followed by a 10-minute breakthen another 10-11 students will undertake the OSCEbull Each student will be provided with 10 stickers that contain hisher name anduniversity number that heshe will handle to the examiners to avoid wasting time ingetting this information during the start of each station9bull DATA INTERPRETATION It should be emphasized that the goal here is not totest memory recall abilities but rather to test clinical approach to a brief clinicalscenario through proper interpretation of a laboratory investigation Here are someexamples of possible stations in each subspecialtybull CVSbull ECG (eg AMI atrial fibrillation ventricular fibrillation LVHetc)bull Respiratorybull ABG (eg acute respiratory acidosisetc)bull PFT (eg obstructive lung diseaseetc)bull CXR (eg TBetc)bull Pleural fluid (eg exudateetc)bull Endocrinebull Abnormal glucose control (eg DKA)

bull Rheumatologybull knee aspirate (eg septic versus inflammatory)bull HematologyOncologybull CBC (eg anemia PRVhellipetc)bull GIbull Abnormal liver enzymes (eg acute hepatitisetc)bull Ascitic fluid aspirate (eg exudateetc)bull Nephrologybull Electrolyte disturbance (eg hyponatremiaetc)bull Acid-base imbalance (eg metabolic acidosisetc)bull Neurologybull CSF (eg meningitisetc)bull Infectious Diseasesbull Urine CS (eg UTI)bull Blood CS (eg Staph Septicemia in a drug addictetc)10Example 1CXR of a 60 year old man with cough fever and sweating for 4 weeks1 Interpret the main abnormal findings of the CXR ( 2 marks)1048633 Ideal answer Right upper lung lobe infiltration2 List 3 differential diagnoses (3 marks)1048633 Ideal answer a Pneumoniab TB _c Cancer _3 Mention 3 initial and essential laboratory investigations (3 marks)1048633 Ideal answer a Sputum for CSb Sputum for AFBc CBC _4 Mention the initial antibiotic class of choice (2 marks)1048633 Ideal answer Cephalosporin or a penicillin11Example 270 year old man with history of DM HTN and hypercholestolemia He presents with thecurrent ECG (ECG is provided that shows an inferolateral MI)1 Interpret the ECG ( 1 mark )1048633 Ideal answer Inferolateral acute ST elevation myocardial infarction(but If answered Inferior STEMI 12 out of 1 Mark)2 How would you manage this patient ( 6 marks )1048633 Ideal answer1 ASA = 2 marks2 Heparin = 1 mark3 B-blocker = 1 mark4 Fibrinolytic = 2 marks3 How would you decide about successful reperfusion ( 3 marks )1048633 Ideal answer

1 Resolution of the ischemic chest pain2 Resolution of the ST-segment elevation by at least 503 Reperfusion arrhythmia (eg AIVR)II FOCUSED CLINICAL EXAMINATIONbull This is similar to the short case format in the old system but is more focused eginstead of asking about the CVS examination of a patient which is not practical to bedone properly in 7 minutes as being done in the current system the medical studentwill be asked to examine only the JVP and demonstrate it to the examiners over the7minutes period allotted to that stationbull Here are some examples of possible stations in each subspecialtyCVS HematologyOncologybull Precodium murmurs mechanical valve sounds bull Lymph nodesbull Peripheral Pulses GIbull JVP bullLiverbull BP measurement bullAscitisRespiratory Nephrologybull Chest (Percussion amp Auscultation) bullKidneyEndocrine Neurologybull Thyroid bullSpecific Cranial Nerve (eg 7th

Rheumatology cranial nerveetc)bull Knee bullSpecific Motor on sensorydeficilbull Hands bullCerebellar exam12FOCUSED CLINICAL EXAMASSESSMENT FORMATJVP StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Identify the different anatomical landmarks for theJVP and the carotid pulse in the neck ______ _____ 1 mark2 Able to measure the exact height of the JVP ______ _____ 2 marks3 Able to demonstrate the different clinical maneuversused to distinguish JVP from the carotid pulse ______ _____ 3 marksII- Interpretation (40)The medical student is able to properlybull Identify whether the JVP is low normal or high 2 marksbull Mention 2 differential diagnoses for helliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________13FOCUSED CLINICAL EXAM

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

3-Students are expected to start their duties at 4PM and finish at 10PM4-Next morning students should attend their usual rounds ampteaching sessions5-Every student is expected to take at least one full historyampphysical examination to bepresented to his consultant next day6-The registrar on call will sign the studentrsquos attendance sheet7- The evaluation of emergency room duties will be included in the clinical assessmentsection3 INTERACTIONS WITH THE ldquoSENIORSrdquoPrinciples1 The consultant is the individual best positioned to provide both formativefeedbacks to students (advice about how to improve based on the studentsperformance so far) and a final judgment about the students performance2 The consultant is the most important internal medicine teacher the student willencounter The attending serves as a professional role model a source ofclinically relevant knowledge and a teacher of clinical skills3 The interns residents and registrars will be the daily supervisors of themedical studentsHow the principles are realizedthe student will join the medical team in their daily rounds and present their ownpatients accordingly The consultant will provide hisher own final assessment ofthe medical student taking in consideration also an overall feedback from thevarious team members The medical student is encouraged to act as a SHADOWto hisher particular team and to be actively involved in its various activities4 TUTORIALSOne tutorial per week on management of medical emergencies for the wholegroup will be given in the afternoon of every Wednesday It can be given in Quiz formatcase scenario format or interactive discussion (Seeschedule below Appendix B)45 NEUROLOGY SESSIONSbull The objective of these sessions is to increase exposure of students topatients suffering from conditions seen mainly in the sub-specialized divisionof neurologybull All students will assemble every Tuesday 1000-1200 noon in the MedicalWard 32-B Level 3 as arranged by Neurology Divisionbull Each session will have one long case and one or two short cases Thestudents will be divided in two groups accordinglybull 32 ndash B Nurses at the station of Neurology Ward should notify thestudents about the case to be used for long case presentation Notice should begiven a day before the presentation no later than 1200 noonbull The assigned student will prepare the case one day earlier and presentit with complete history and physical examination Provisional diagnosis

differential diagnosis and plan for the investigation and management He maythen be asked by the teacher other things related to the case presentedDiscussion is open then to the whole class and exchanged of questions isallowed The student could be asked to demonstrate abnormal physicalfindings and interprets ECG X-RAY or scans of the said patient Between 60minutes should be given for these long case discussionsbull The students assigned for short cases should be asked to do a physicalexam of the patient Student will be asked about the clinical findings after theexamination Physical examination should be timed and evaluated by theteacher Each short case should take about 30 minutes6 INTERNAL MEDICINE MORNING ROUNDLecture Theatre C Level 3 0745-0830AM7 BED SIDE TEACHINGThe objective of bed side teaching is to help the student utilize hisher diagnostic skills toformulate a problem list for individual patients amp be more familiar with how to investigateand manage patientrsquos specific medical conditionsEach group of students will have one sessionweek with medical consultants of differentsubspecialties (excluding neurology) in which specific cases will be given to the studentsbeforehand to take the history amp physical examination amp then the student will present thecase to the consultant who will then discuss with students the patientrsquos problem list how toinvestigate them interpret the results of investigations and put forward a management plan ampfollow up (See the attached schedule)Recommended ReferencesA Textbooks of MedicineAny one of the following excellent books1 Clinical Medicine - A textbook for Medical students and doctors P J Kumarand M L Clark ldquolatest editionrdquo2 Textbook of Medicine - By Souhami andMoxham latest edition53 Davidsonrsquos Principles and Principles of Medicines - C R Edward andIan AD Bonchir latest editionB Physical ExaminationAny one of the following books1 A guide to physical examination and history taking by Barbara Bateslatest edition2 Macleodrsquos Clinical Examination by John Munro and C Edwards3 Clinical Examination - 2nd Edition by Nicolas Talley and SimonOrsquoConnor6

Executive Summary of Mark DistributionShown below a brief overview of the current mark distribution of differentassessments in the course 441-Medicine1) Ward Clinical assessment 20 of the total mark

a) 5 attendance b) 10 unit evaluation c) 5 log book2) Theoretical exam 40 of the total mark3) Final OSCE exam 40 of the total markFor each student it is mandatory to obtain (24 out of 40) in the final clinical(OSCE) to pass this courseATTENDANCEAttendance is continuously monitored and kept to see whether students willmeet the required percentage of attendance set by the UniversityAs early as possible any student noticed to have poor attendance would begiven warning letters to call their attention and give them a chance to improveAs a rule students should have attended at least 75 of each of the courseclinical amp theoretical activities Names of students who will have less than75 attendance will be submitted to the Vice Dean ndash Academic Affairs Officeand will not be included in the exam until the University gives their approval7

IMPORTANT DATE TO REMEMBER CLASSESStart On Saturday 15041430 11042009End On Wednesday 24061430 170620091 FIRST ROTATIONStart On Saturday 15041430 11042009End On Wednesday 18051430 13052009 CONTINUOUS ASSESSMENT EXAMStart On Saturday 21051430 16052009End On Wednesday 25051430 200520092 SECOND ROTATIONStart On Saturday 21051430 16052009End On Wednesday 24061430 17062009 FINAL EXAMINATIONStart On Saturday 20061430 13062009End On Wednesday 24061430 1706200983 Assessment Exams- Theory ExamThis is a clinically-oriented theoretical assessment that involves Single-BestMCQrsquos through patient case scenarios

- Clinical Exam- It consists of one long case for the mid-term exam and OSCE at the endof the coursebull LONG CASEThe mid-term clinical exam will consist of one long case The goal here is tointroduce the medical student to the clinical exam format mid-way in hishertraining period so mistakes could be learned from and avoided in the futureexams Each student has the right to repeat the exam if a clear evidence wassubmitted indicating an unfair exam (eg non-compliant patient) A one-pageldquolong-case feedbackrdquo form will be filled immediately by the examiners thatwill be copied and then given to the student in order to improve hisherperformance for the next examAn example of how this form looks like is shown in Appendix Cbull OSCE (Objective Structured Clinical Examination)- This part will include both of the short clinical cases in addition to theoral part in the old system- Rational this will result in a more objective and standard exam byexposing the same students to the same examiners asking the samequestions and have the ideal answers and mark distribution withmore efficient amp effective use of time and staff- It includes 10 stations and each station lasts for 7 minutes so the totaltime for 1 OSCE is 70 minutes- The stations are divided into the followinga - Data Interpretation Stationsb- Focused Clinical Stationsc -Rest Stationsbull 10-11 students will undertake the OSCE at one time followed by a 10-minute breakthen another 10-11 students will undertake the OSCEbull Each student will be provided with 10 stickers that contain hisher name anduniversity number that heshe will handle to the examiners to avoid wasting time ingetting this information during the start of each station9bull DATA INTERPRETATION It should be emphasized that the goal here is not totest memory recall abilities but rather to test clinical approach to a brief clinicalscenario through proper interpretation of a laboratory investigation Here are someexamples of possible stations in each subspecialtybull CVSbull ECG (eg AMI atrial fibrillation ventricular fibrillation LVHetc)bull Respiratorybull ABG (eg acute respiratory acidosisetc)bull PFT (eg obstructive lung diseaseetc)bull CXR (eg TBetc)bull Pleural fluid (eg exudateetc)bull Endocrinebull Abnormal glucose control (eg DKA)

bull Rheumatologybull knee aspirate (eg septic versus inflammatory)bull HematologyOncologybull CBC (eg anemia PRVhellipetc)bull GIbull Abnormal liver enzymes (eg acute hepatitisetc)bull Ascitic fluid aspirate (eg exudateetc)bull Nephrologybull Electrolyte disturbance (eg hyponatremiaetc)bull Acid-base imbalance (eg metabolic acidosisetc)bull Neurologybull CSF (eg meningitisetc)bull Infectious Diseasesbull Urine CS (eg UTI)bull Blood CS (eg Staph Septicemia in a drug addictetc)10Example 1CXR of a 60 year old man with cough fever and sweating for 4 weeks1 Interpret the main abnormal findings of the CXR ( 2 marks)1048633 Ideal answer Right upper lung lobe infiltration2 List 3 differential diagnoses (3 marks)1048633 Ideal answer a Pneumoniab TB _c Cancer _3 Mention 3 initial and essential laboratory investigations (3 marks)1048633 Ideal answer a Sputum for CSb Sputum for AFBc CBC _4 Mention the initial antibiotic class of choice (2 marks)1048633 Ideal answer Cephalosporin or a penicillin11Example 270 year old man with history of DM HTN and hypercholestolemia He presents with thecurrent ECG (ECG is provided that shows an inferolateral MI)1 Interpret the ECG ( 1 mark )1048633 Ideal answer Inferolateral acute ST elevation myocardial infarction(but If answered Inferior STEMI 12 out of 1 Mark)2 How would you manage this patient ( 6 marks )1048633 Ideal answer1 ASA = 2 marks2 Heparin = 1 mark3 B-blocker = 1 mark4 Fibrinolytic = 2 marks3 How would you decide about successful reperfusion ( 3 marks )1048633 Ideal answer

1 Resolution of the ischemic chest pain2 Resolution of the ST-segment elevation by at least 503 Reperfusion arrhythmia (eg AIVR)II FOCUSED CLINICAL EXAMINATIONbull This is similar to the short case format in the old system but is more focused eginstead of asking about the CVS examination of a patient which is not practical to bedone properly in 7 minutes as being done in the current system the medical studentwill be asked to examine only the JVP and demonstrate it to the examiners over the7minutes period allotted to that stationbull Here are some examples of possible stations in each subspecialtyCVS HematologyOncologybull Precodium murmurs mechanical valve sounds bull Lymph nodesbull Peripheral Pulses GIbull JVP bullLiverbull BP measurement bullAscitisRespiratory Nephrologybull Chest (Percussion amp Auscultation) bullKidneyEndocrine Neurologybull Thyroid bullSpecific Cranial Nerve (eg 7th

Rheumatology cranial nerveetc)bull Knee bullSpecific Motor on sensorydeficilbull Hands bullCerebellar exam12FOCUSED CLINICAL EXAMASSESSMENT FORMATJVP StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Identify the different anatomical landmarks for theJVP and the carotid pulse in the neck ______ _____ 1 mark2 Able to measure the exact height of the JVP ______ _____ 2 marks3 Able to demonstrate the different clinical maneuversused to distinguish JVP from the carotid pulse ______ _____ 3 marksII- Interpretation (40)The medical student is able to properlybull Identify whether the JVP is low normal or high 2 marksbull Mention 2 differential diagnoses for helliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________13FOCUSED CLINICAL EXAM

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

differential diagnosis and plan for the investigation and management He maythen be asked by the teacher other things related to the case presentedDiscussion is open then to the whole class and exchanged of questions isallowed The student could be asked to demonstrate abnormal physicalfindings and interprets ECG X-RAY or scans of the said patient Between 60minutes should be given for these long case discussionsbull The students assigned for short cases should be asked to do a physicalexam of the patient Student will be asked about the clinical findings after theexamination Physical examination should be timed and evaluated by theteacher Each short case should take about 30 minutes6 INTERNAL MEDICINE MORNING ROUNDLecture Theatre C Level 3 0745-0830AM7 BED SIDE TEACHINGThe objective of bed side teaching is to help the student utilize hisher diagnostic skills toformulate a problem list for individual patients amp be more familiar with how to investigateand manage patientrsquos specific medical conditionsEach group of students will have one sessionweek with medical consultants of differentsubspecialties (excluding neurology) in which specific cases will be given to the studentsbeforehand to take the history amp physical examination amp then the student will present thecase to the consultant who will then discuss with students the patientrsquos problem list how toinvestigate them interpret the results of investigations and put forward a management plan ampfollow up (See the attached schedule)Recommended ReferencesA Textbooks of MedicineAny one of the following excellent books1 Clinical Medicine - A textbook for Medical students and doctors P J Kumarand M L Clark ldquolatest editionrdquo2 Textbook of Medicine - By Souhami andMoxham latest edition53 Davidsonrsquos Principles and Principles of Medicines - C R Edward andIan AD Bonchir latest editionB Physical ExaminationAny one of the following books1 A guide to physical examination and history taking by Barbara Bateslatest edition2 Macleodrsquos Clinical Examination by John Munro and C Edwards3 Clinical Examination - 2nd Edition by Nicolas Talley and SimonOrsquoConnor6

Executive Summary of Mark DistributionShown below a brief overview of the current mark distribution of differentassessments in the course 441-Medicine1) Ward Clinical assessment 20 of the total mark

a) 5 attendance b) 10 unit evaluation c) 5 log book2) Theoretical exam 40 of the total mark3) Final OSCE exam 40 of the total markFor each student it is mandatory to obtain (24 out of 40) in the final clinical(OSCE) to pass this courseATTENDANCEAttendance is continuously monitored and kept to see whether students willmeet the required percentage of attendance set by the UniversityAs early as possible any student noticed to have poor attendance would begiven warning letters to call their attention and give them a chance to improveAs a rule students should have attended at least 75 of each of the courseclinical amp theoretical activities Names of students who will have less than75 attendance will be submitted to the Vice Dean ndash Academic Affairs Officeand will not be included in the exam until the University gives their approval7

IMPORTANT DATE TO REMEMBER CLASSESStart On Saturday 15041430 11042009End On Wednesday 24061430 170620091 FIRST ROTATIONStart On Saturday 15041430 11042009End On Wednesday 18051430 13052009 CONTINUOUS ASSESSMENT EXAMStart On Saturday 21051430 16052009End On Wednesday 25051430 200520092 SECOND ROTATIONStart On Saturday 21051430 16052009End On Wednesday 24061430 17062009 FINAL EXAMINATIONStart On Saturday 20061430 13062009End On Wednesday 24061430 1706200983 Assessment Exams- Theory ExamThis is a clinically-oriented theoretical assessment that involves Single-BestMCQrsquos through patient case scenarios

- Clinical Exam- It consists of one long case for the mid-term exam and OSCE at the endof the coursebull LONG CASEThe mid-term clinical exam will consist of one long case The goal here is tointroduce the medical student to the clinical exam format mid-way in hishertraining period so mistakes could be learned from and avoided in the futureexams Each student has the right to repeat the exam if a clear evidence wassubmitted indicating an unfair exam (eg non-compliant patient) A one-pageldquolong-case feedbackrdquo form will be filled immediately by the examiners thatwill be copied and then given to the student in order to improve hisherperformance for the next examAn example of how this form looks like is shown in Appendix Cbull OSCE (Objective Structured Clinical Examination)- This part will include both of the short clinical cases in addition to theoral part in the old system- Rational this will result in a more objective and standard exam byexposing the same students to the same examiners asking the samequestions and have the ideal answers and mark distribution withmore efficient amp effective use of time and staff- It includes 10 stations and each station lasts for 7 minutes so the totaltime for 1 OSCE is 70 minutes- The stations are divided into the followinga - Data Interpretation Stationsb- Focused Clinical Stationsc -Rest Stationsbull 10-11 students will undertake the OSCE at one time followed by a 10-minute breakthen another 10-11 students will undertake the OSCEbull Each student will be provided with 10 stickers that contain hisher name anduniversity number that heshe will handle to the examiners to avoid wasting time ingetting this information during the start of each station9bull DATA INTERPRETATION It should be emphasized that the goal here is not totest memory recall abilities but rather to test clinical approach to a brief clinicalscenario through proper interpretation of a laboratory investigation Here are someexamples of possible stations in each subspecialtybull CVSbull ECG (eg AMI atrial fibrillation ventricular fibrillation LVHetc)bull Respiratorybull ABG (eg acute respiratory acidosisetc)bull PFT (eg obstructive lung diseaseetc)bull CXR (eg TBetc)bull Pleural fluid (eg exudateetc)bull Endocrinebull Abnormal glucose control (eg DKA)

bull Rheumatologybull knee aspirate (eg septic versus inflammatory)bull HematologyOncologybull CBC (eg anemia PRVhellipetc)bull GIbull Abnormal liver enzymes (eg acute hepatitisetc)bull Ascitic fluid aspirate (eg exudateetc)bull Nephrologybull Electrolyte disturbance (eg hyponatremiaetc)bull Acid-base imbalance (eg metabolic acidosisetc)bull Neurologybull CSF (eg meningitisetc)bull Infectious Diseasesbull Urine CS (eg UTI)bull Blood CS (eg Staph Septicemia in a drug addictetc)10Example 1CXR of a 60 year old man with cough fever and sweating for 4 weeks1 Interpret the main abnormal findings of the CXR ( 2 marks)1048633 Ideal answer Right upper lung lobe infiltration2 List 3 differential diagnoses (3 marks)1048633 Ideal answer a Pneumoniab TB _c Cancer _3 Mention 3 initial and essential laboratory investigations (3 marks)1048633 Ideal answer a Sputum for CSb Sputum for AFBc CBC _4 Mention the initial antibiotic class of choice (2 marks)1048633 Ideal answer Cephalosporin or a penicillin11Example 270 year old man with history of DM HTN and hypercholestolemia He presents with thecurrent ECG (ECG is provided that shows an inferolateral MI)1 Interpret the ECG ( 1 mark )1048633 Ideal answer Inferolateral acute ST elevation myocardial infarction(but If answered Inferior STEMI 12 out of 1 Mark)2 How would you manage this patient ( 6 marks )1048633 Ideal answer1 ASA = 2 marks2 Heparin = 1 mark3 B-blocker = 1 mark4 Fibrinolytic = 2 marks3 How would you decide about successful reperfusion ( 3 marks )1048633 Ideal answer

1 Resolution of the ischemic chest pain2 Resolution of the ST-segment elevation by at least 503 Reperfusion arrhythmia (eg AIVR)II FOCUSED CLINICAL EXAMINATIONbull This is similar to the short case format in the old system but is more focused eginstead of asking about the CVS examination of a patient which is not practical to bedone properly in 7 minutes as being done in the current system the medical studentwill be asked to examine only the JVP and demonstrate it to the examiners over the7minutes period allotted to that stationbull Here are some examples of possible stations in each subspecialtyCVS HematologyOncologybull Precodium murmurs mechanical valve sounds bull Lymph nodesbull Peripheral Pulses GIbull JVP bullLiverbull BP measurement bullAscitisRespiratory Nephrologybull Chest (Percussion amp Auscultation) bullKidneyEndocrine Neurologybull Thyroid bullSpecific Cranial Nerve (eg 7th

Rheumatology cranial nerveetc)bull Knee bullSpecific Motor on sensorydeficilbull Hands bullCerebellar exam12FOCUSED CLINICAL EXAMASSESSMENT FORMATJVP StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Identify the different anatomical landmarks for theJVP and the carotid pulse in the neck ______ _____ 1 mark2 Able to measure the exact height of the JVP ______ _____ 2 marks3 Able to demonstrate the different clinical maneuversused to distinguish JVP from the carotid pulse ______ _____ 3 marksII- Interpretation (40)The medical student is able to properlybull Identify whether the JVP is low normal or high 2 marksbull Mention 2 differential diagnoses for helliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________13FOCUSED CLINICAL EXAM

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

a) 5 attendance b) 10 unit evaluation c) 5 log book2) Theoretical exam 40 of the total mark3) Final OSCE exam 40 of the total markFor each student it is mandatory to obtain (24 out of 40) in the final clinical(OSCE) to pass this courseATTENDANCEAttendance is continuously monitored and kept to see whether students willmeet the required percentage of attendance set by the UniversityAs early as possible any student noticed to have poor attendance would begiven warning letters to call their attention and give them a chance to improveAs a rule students should have attended at least 75 of each of the courseclinical amp theoretical activities Names of students who will have less than75 attendance will be submitted to the Vice Dean ndash Academic Affairs Officeand will not be included in the exam until the University gives their approval7

IMPORTANT DATE TO REMEMBER CLASSESStart On Saturday 15041430 11042009End On Wednesday 24061430 170620091 FIRST ROTATIONStart On Saturday 15041430 11042009End On Wednesday 18051430 13052009 CONTINUOUS ASSESSMENT EXAMStart On Saturday 21051430 16052009End On Wednesday 25051430 200520092 SECOND ROTATIONStart On Saturday 21051430 16052009End On Wednesday 24061430 17062009 FINAL EXAMINATIONStart On Saturday 20061430 13062009End On Wednesday 24061430 1706200983 Assessment Exams- Theory ExamThis is a clinically-oriented theoretical assessment that involves Single-BestMCQrsquos through patient case scenarios

- Clinical Exam- It consists of one long case for the mid-term exam and OSCE at the endof the coursebull LONG CASEThe mid-term clinical exam will consist of one long case The goal here is tointroduce the medical student to the clinical exam format mid-way in hishertraining period so mistakes could be learned from and avoided in the futureexams Each student has the right to repeat the exam if a clear evidence wassubmitted indicating an unfair exam (eg non-compliant patient) A one-pageldquolong-case feedbackrdquo form will be filled immediately by the examiners thatwill be copied and then given to the student in order to improve hisherperformance for the next examAn example of how this form looks like is shown in Appendix Cbull OSCE (Objective Structured Clinical Examination)- This part will include both of the short clinical cases in addition to theoral part in the old system- Rational this will result in a more objective and standard exam byexposing the same students to the same examiners asking the samequestions and have the ideal answers and mark distribution withmore efficient amp effective use of time and staff- It includes 10 stations and each station lasts for 7 minutes so the totaltime for 1 OSCE is 70 minutes- The stations are divided into the followinga - Data Interpretation Stationsb- Focused Clinical Stationsc -Rest Stationsbull 10-11 students will undertake the OSCE at one time followed by a 10-minute breakthen another 10-11 students will undertake the OSCEbull Each student will be provided with 10 stickers that contain hisher name anduniversity number that heshe will handle to the examiners to avoid wasting time ingetting this information during the start of each station9bull DATA INTERPRETATION It should be emphasized that the goal here is not totest memory recall abilities but rather to test clinical approach to a brief clinicalscenario through proper interpretation of a laboratory investigation Here are someexamples of possible stations in each subspecialtybull CVSbull ECG (eg AMI atrial fibrillation ventricular fibrillation LVHetc)bull Respiratorybull ABG (eg acute respiratory acidosisetc)bull PFT (eg obstructive lung diseaseetc)bull CXR (eg TBetc)bull Pleural fluid (eg exudateetc)bull Endocrinebull Abnormal glucose control (eg DKA)

bull Rheumatologybull knee aspirate (eg septic versus inflammatory)bull HematologyOncologybull CBC (eg anemia PRVhellipetc)bull GIbull Abnormal liver enzymes (eg acute hepatitisetc)bull Ascitic fluid aspirate (eg exudateetc)bull Nephrologybull Electrolyte disturbance (eg hyponatremiaetc)bull Acid-base imbalance (eg metabolic acidosisetc)bull Neurologybull CSF (eg meningitisetc)bull Infectious Diseasesbull Urine CS (eg UTI)bull Blood CS (eg Staph Septicemia in a drug addictetc)10Example 1CXR of a 60 year old man with cough fever and sweating for 4 weeks1 Interpret the main abnormal findings of the CXR ( 2 marks)1048633 Ideal answer Right upper lung lobe infiltration2 List 3 differential diagnoses (3 marks)1048633 Ideal answer a Pneumoniab TB _c Cancer _3 Mention 3 initial and essential laboratory investigations (3 marks)1048633 Ideal answer a Sputum for CSb Sputum for AFBc CBC _4 Mention the initial antibiotic class of choice (2 marks)1048633 Ideal answer Cephalosporin or a penicillin11Example 270 year old man with history of DM HTN and hypercholestolemia He presents with thecurrent ECG (ECG is provided that shows an inferolateral MI)1 Interpret the ECG ( 1 mark )1048633 Ideal answer Inferolateral acute ST elevation myocardial infarction(but If answered Inferior STEMI 12 out of 1 Mark)2 How would you manage this patient ( 6 marks )1048633 Ideal answer1 ASA = 2 marks2 Heparin = 1 mark3 B-blocker = 1 mark4 Fibrinolytic = 2 marks3 How would you decide about successful reperfusion ( 3 marks )1048633 Ideal answer

1 Resolution of the ischemic chest pain2 Resolution of the ST-segment elevation by at least 503 Reperfusion arrhythmia (eg AIVR)II FOCUSED CLINICAL EXAMINATIONbull This is similar to the short case format in the old system but is more focused eginstead of asking about the CVS examination of a patient which is not practical to bedone properly in 7 minutes as being done in the current system the medical studentwill be asked to examine only the JVP and demonstrate it to the examiners over the7minutes period allotted to that stationbull Here are some examples of possible stations in each subspecialtyCVS HematologyOncologybull Precodium murmurs mechanical valve sounds bull Lymph nodesbull Peripheral Pulses GIbull JVP bullLiverbull BP measurement bullAscitisRespiratory Nephrologybull Chest (Percussion amp Auscultation) bullKidneyEndocrine Neurologybull Thyroid bullSpecific Cranial Nerve (eg 7th

Rheumatology cranial nerveetc)bull Knee bullSpecific Motor on sensorydeficilbull Hands bullCerebellar exam12FOCUSED CLINICAL EXAMASSESSMENT FORMATJVP StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Identify the different anatomical landmarks for theJVP and the carotid pulse in the neck ______ _____ 1 mark2 Able to measure the exact height of the JVP ______ _____ 2 marks3 Able to demonstrate the different clinical maneuversused to distinguish JVP from the carotid pulse ______ _____ 3 marksII- Interpretation (40)The medical student is able to properlybull Identify whether the JVP is low normal or high 2 marksbull Mention 2 differential diagnoses for helliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________13FOCUSED CLINICAL EXAM

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

- Clinical Exam- It consists of one long case for the mid-term exam and OSCE at the endof the coursebull LONG CASEThe mid-term clinical exam will consist of one long case The goal here is tointroduce the medical student to the clinical exam format mid-way in hishertraining period so mistakes could be learned from and avoided in the futureexams Each student has the right to repeat the exam if a clear evidence wassubmitted indicating an unfair exam (eg non-compliant patient) A one-pageldquolong-case feedbackrdquo form will be filled immediately by the examiners thatwill be copied and then given to the student in order to improve hisherperformance for the next examAn example of how this form looks like is shown in Appendix Cbull OSCE (Objective Structured Clinical Examination)- This part will include both of the short clinical cases in addition to theoral part in the old system- Rational this will result in a more objective and standard exam byexposing the same students to the same examiners asking the samequestions and have the ideal answers and mark distribution withmore efficient amp effective use of time and staff- It includes 10 stations and each station lasts for 7 minutes so the totaltime for 1 OSCE is 70 minutes- The stations are divided into the followinga - Data Interpretation Stationsb- Focused Clinical Stationsc -Rest Stationsbull 10-11 students will undertake the OSCE at one time followed by a 10-minute breakthen another 10-11 students will undertake the OSCEbull Each student will be provided with 10 stickers that contain hisher name anduniversity number that heshe will handle to the examiners to avoid wasting time ingetting this information during the start of each station9bull DATA INTERPRETATION It should be emphasized that the goal here is not totest memory recall abilities but rather to test clinical approach to a brief clinicalscenario through proper interpretation of a laboratory investigation Here are someexamples of possible stations in each subspecialtybull CVSbull ECG (eg AMI atrial fibrillation ventricular fibrillation LVHetc)bull Respiratorybull ABG (eg acute respiratory acidosisetc)bull PFT (eg obstructive lung diseaseetc)bull CXR (eg TBetc)bull Pleural fluid (eg exudateetc)bull Endocrinebull Abnormal glucose control (eg DKA)

bull Rheumatologybull knee aspirate (eg septic versus inflammatory)bull HematologyOncologybull CBC (eg anemia PRVhellipetc)bull GIbull Abnormal liver enzymes (eg acute hepatitisetc)bull Ascitic fluid aspirate (eg exudateetc)bull Nephrologybull Electrolyte disturbance (eg hyponatremiaetc)bull Acid-base imbalance (eg metabolic acidosisetc)bull Neurologybull CSF (eg meningitisetc)bull Infectious Diseasesbull Urine CS (eg UTI)bull Blood CS (eg Staph Septicemia in a drug addictetc)10Example 1CXR of a 60 year old man with cough fever and sweating for 4 weeks1 Interpret the main abnormal findings of the CXR ( 2 marks)1048633 Ideal answer Right upper lung lobe infiltration2 List 3 differential diagnoses (3 marks)1048633 Ideal answer a Pneumoniab TB _c Cancer _3 Mention 3 initial and essential laboratory investigations (3 marks)1048633 Ideal answer a Sputum for CSb Sputum for AFBc CBC _4 Mention the initial antibiotic class of choice (2 marks)1048633 Ideal answer Cephalosporin or a penicillin11Example 270 year old man with history of DM HTN and hypercholestolemia He presents with thecurrent ECG (ECG is provided that shows an inferolateral MI)1 Interpret the ECG ( 1 mark )1048633 Ideal answer Inferolateral acute ST elevation myocardial infarction(but If answered Inferior STEMI 12 out of 1 Mark)2 How would you manage this patient ( 6 marks )1048633 Ideal answer1 ASA = 2 marks2 Heparin = 1 mark3 B-blocker = 1 mark4 Fibrinolytic = 2 marks3 How would you decide about successful reperfusion ( 3 marks )1048633 Ideal answer

1 Resolution of the ischemic chest pain2 Resolution of the ST-segment elevation by at least 503 Reperfusion arrhythmia (eg AIVR)II FOCUSED CLINICAL EXAMINATIONbull This is similar to the short case format in the old system but is more focused eginstead of asking about the CVS examination of a patient which is not practical to bedone properly in 7 minutes as being done in the current system the medical studentwill be asked to examine only the JVP and demonstrate it to the examiners over the7minutes period allotted to that stationbull Here are some examples of possible stations in each subspecialtyCVS HematologyOncologybull Precodium murmurs mechanical valve sounds bull Lymph nodesbull Peripheral Pulses GIbull JVP bullLiverbull BP measurement bullAscitisRespiratory Nephrologybull Chest (Percussion amp Auscultation) bullKidneyEndocrine Neurologybull Thyroid bullSpecific Cranial Nerve (eg 7th

Rheumatology cranial nerveetc)bull Knee bullSpecific Motor on sensorydeficilbull Hands bullCerebellar exam12FOCUSED CLINICAL EXAMASSESSMENT FORMATJVP StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Identify the different anatomical landmarks for theJVP and the carotid pulse in the neck ______ _____ 1 mark2 Able to measure the exact height of the JVP ______ _____ 2 marks3 Able to demonstrate the different clinical maneuversused to distinguish JVP from the carotid pulse ______ _____ 3 marksII- Interpretation (40)The medical student is able to properlybull Identify whether the JVP is low normal or high 2 marksbull Mention 2 differential diagnoses for helliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________13FOCUSED CLINICAL EXAM

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

bull Rheumatologybull knee aspirate (eg septic versus inflammatory)bull HematologyOncologybull CBC (eg anemia PRVhellipetc)bull GIbull Abnormal liver enzymes (eg acute hepatitisetc)bull Ascitic fluid aspirate (eg exudateetc)bull Nephrologybull Electrolyte disturbance (eg hyponatremiaetc)bull Acid-base imbalance (eg metabolic acidosisetc)bull Neurologybull CSF (eg meningitisetc)bull Infectious Diseasesbull Urine CS (eg UTI)bull Blood CS (eg Staph Septicemia in a drug addictetc)10Example 1CXR of a 60 year old man with cough fever and sweating for 4 weeks1 Interpret the main abnormal findings of the CXR ( 2 marks)1048633 Ideal answer Right upper lung lobe infiltration2 List 3 differential diagnoses (3 marks)1048633 Ideal answer a Pneumoniab TB _c Cancer _3 Mention 3 initial and essential laboratory investigations (3 marks)1048633 Ideal answer a Sputum for CSb Sputum for AFBc CBC _4 Mention the initial antibiotic class of choice (2 marks)1048633 Ideal answer Cephalosporin or a penicillin11Example 270 year old man with history of DM HTN and hypercholestolemia He presents with thecurrent ECG (ECG is provided that shows an inferolateral MI)1 Interpret the ECG ( 1 mark )1048633 Ideal answer Inferolateral acute ST elevation myocardial infarction(but If answered Inferior STEMI 12 out of 1 Mark)2 How would you manage this patient ( 6 marks )1048633 Ideal answer1 ASA = 2 marks2 Heparin = 1 mark3 B-blocker = 1 mark4 Fibrinolytic = 2 marks3 How would you decide about successful reperfusion ( 3 marks )1048633 Ideal answer

1 Resolution of the ischemic chest pain2 Resolution of the ST-segment elevation by at least 503 Reperfusion arrhythmia (eg AIVR)II FOCUSED CLINICAL EXAMINATIONbull This is similar to the short case format in the old system but is more focused eginstead of asking about the CVS examination of a patient which is not practical to bedone properly in 7 minutes as being done in the current system the medical studentwill be asked to examine only the JVP and demonstrate it to the examiners over the7minutes period allotted to that stationbull Here are some examples of possible stations in each subspecialtyCVS HematologyOncologybull Precodium murmurs mechanical valve sounds bull Lymph nodesbull Peripheral Pulses GIbull JVP bullLiverbull BP measurement bullAscitisRespiratory Nephrologybull Chest (Percussion amp Auscultation) bullKidneyEndocrine Neurologybull Thyroid bullSpecific Cranial Nerve (eg 7th

Rheumatology cranial nerveetc)bull Knee bullSpecific Motor on sensorydeficilbull Hands bullCerebellar exam12FOCUSED CLINICAL EXAMASSESSMENT FORMATJVP StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Identify the different anatomical landmarks for theJVP and the carotid pulse in the neck ______ _____ 1 mark2 Able to measure the exact height of the JVP ______ _____ 2 marks3 Able to demonstrate the different clinical maneuversused to distinguish JVP from the carotid pulse ______ _____ 3 marksII- Interpretation (40)The medical student is able to properlybull Identify whether the JVP is low normal or high 2 marksbull Mention 2 differential diagnoses for helliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________13FOCUSED CLINICAL EXAM

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

1 Resolution of the ischemic chest pain2 Resolution of the ST-segment elevation by at least 503 Reperfusion arrhythmia (eg AIVR)II FOCUSED CLINICAL EXAMINATIONbull This is similar to the short case format in the old system but is more focused eginstead of asking about the CVS examination of a patient which is not practical to bedone properly in 7 minutes as being done in the current system the medical studentwill be asked to examine only the JVP and demonstrate it to the examiners over the7minutes period allotted to that stationbull Here are some examples of possible stations in each subspecialtyCVS HematologyOncologybull Precodium murmurs mechanical valve sounds bull Lymph nodesbull Peripheral Pulses GIbull JVP bullLiverbull BP measurement bullAscitisRespiratory Nephrologybull Chest (Percussion amp Auscultation) bullKidneyEndocrine Neurologybull Thyroid bullSpecific Cranial Nerve (eg 7th

Rheumatology cranial nerveetc)bull Knee bullSpecific Motor on sensorydeficilbull Hands bullCerebellar exam12FOCUSED CLINICAL EXAMASSESSMENT FORMATJVP StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Identify the different anatomical landmarks for theJVP and the carotid pulse in the neck ______ _____ 1 mark2 Able to measure the exact height of the JVP ______ _____ 2 marks3 Able to demonstrate the different clinical maneuversused to distinguish JVP from the carotid pulse ______ _____ 3 marksII- Interpretation (40)The medical student is able to properlybull Identify whether the JVP is low normal or high 2 marksbull Mention 2 differential diagnoses for helliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________13FOCUSED CLINICAL EXAM

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

ASSESSMENT FORMATSPLEEN StationStudent Name _______________________________________Student No ________________________________________I- Technique (60) The medical student is able to properly do the following-YES NO1 Palpation from the right iliac fossa ______ _____ 2 markstoward the left costal margin2 Percussion able to demonstrate the percussion ______ _____ 2 marksnote over the abdomen amp left lower ribs3 Demonstrate the different clinical maneuversused to distinguish spleen from the kidney ______ _____ 2 marks(Palpation after rolling over the patient towardhimher bimanual technique for the kidneys)II- Interpretation (40)The medical student is able to properlybull Identify whether the spleen is normal or enlarged 2 marksbull Mention 2 differential diagnoses for helliphelliphelliphelliphelliphellip 2 marksEXAMINER NAME ________________ EXAMINER NAME __________________SIGNATURE __________________ SIGNATURE __________________14APPENDIX - ASub-intern Progress Notebull 56 YO man who was admitted yesterday because of unstable angina CCSclass III in the last 1 month He has been having recurrent CP overnightawakening him from sleep requiring multiple NTG puffs +ve SOB ampsweatingbull PEx 17085 95min reg 90 O2 Sat on 2L FiO2 Chest bilateral basalcrackles JVP 5cm ASA with +ve AJR S1+S2+ESM 26 the apex +veLL edema Abd NADbull Invx ECG deeply inverted T-waves in the anterior leads TnT -veFBS104 TChol73 LDL 55102 140 25 104134 223 40 100 120bull Issues (Assessment)1 Unstable AnginaWorsening to class IV with evidence of CHFP To discuss with the SRConsultant regarding transfer to CCU andstart IV NTG heparin IIbIIIa-inhibitors and for possible urgentcoronary cath Today (LAD lesion)2 New CHFP DC IVF IV lasix 40mg then RA StartLisinopril 10 mg OD CXR Echocardiography tocheck LV function

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

3 DM (new Dx)P Start Gliclazide (will check the dose) Consultendocrine service Gluco-check QID Check formicroalbuminurea4 Uncontrolled HTNP BP Goal is less than 13580 bc of DM Willfollow it up after above meds take effect5 HypercholestrolemiaP start Lipitor 40mg ODDrMALQahtaniSubinternPager 230015APPENDIX - BTUTORIAL ON EMERGENCY MEDICINELOCATION Room level DAY Wednesday (100 ndash 330 pm)DATE TIME TOPIC TUTOR100 ndash 130 Liver Function Test Prof Saleh Al Amri130 ndash 330 Arterial Blood Gases (ABG) + Dr100 ndash 330 ECG - Arrythmia and Management Dr Hussam Al Faleh100 ndash 230 Acute GI Bleeding Prof Ibrahim Al Mofleh230 ndash 330 Acute Hepatocellular Failure Dr Ayman Abdo100 ndash 230 Chest x-ray (CXR) Dr230 ndash 330 Pulmonary Embolism Dr Ahmed Bahammam100 ndash 330a) Meningitisb) Malariac) Infective EndocarditisProf Abdulkarim Al Aska Dr Fahad Al Majid100 ndash 230 Infectious Hazards Dr230 ndash 330 Electrolytes Imbalance Dr100 ndash 230 Acute Obstructive Airway Disease Dr Abdulaziz Al Zeer230 ndash 330 Hypertensive Crisis Dr100 ndash 330Endocrine Emergenciesa) Diabetic Ketoacidosisb) Thyroid Emergenciesc) Adrenal CrisisProf Riad Sulimani100 - 330a) CBC Abnormalities and Diagnosisb) Coagulation ndash Abnormalities Dr Abdulrahman Al Diab100 ndash 230 Inflammatory Polyarthritis Prof Abdulrahman Al Arfaj230 ndash 330 Glomerulonephritis ndash acute kidneydiseaseProf Jamal Al Wakeel

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

100 ndash 330ECG General Ischemic Heart DiseaseDr Khalid Al Habib100 ndash 215 Acute Stroke ndash Diagnosis andManagementDr Radwan Zaidan215 ndash 330 Status Epilepticus Dr Mansour Al Moallem16APPENDIX - C441- MED LONG CASE STUDENT FEEDBACK FORM(Please encircle 1 or more)STUDENT NAME ____________________________________________________STUDENT NO ____________________________________________________Major Strengths1 Confident2 Organized3 Proper attitude and bedside manners4 Competent history comprehensive accurate and concise5 Competent physical examination complete and accurate6 Competent differential diagnosis amp managementanalyses synthesizes and integrates all relevant data into a rationallogical management strategyMajor Weaknesses1 Hesitant2 Disorganized3 Improper attitude and bedside manners4 Incompetent history5 Incompetent physical examination6 Incompetent differential diagnosisamp managementFurther commentsadvices for further improvements1 ____________________________________________________________2 ____________________________________________________________3 ____________________________________________________________EXAMINER NAME ____________________ EXAMINER NAME _________________17APPENDIX - DSKILLS TO BE ACQUIRED BY MEDICAL STUDENTS BY THEEND OF THE COURSE 441-MEDICINEI ProfessionalII Medical ExpertSkilled Clinical Decision MakerIII CommunicatorDoctor-Patient RelationshipIV CollaboratorV ManagerVI Health AdvocateVII Scholar

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

I While achieving competency in Medicine Students are expected throughout theclerkship in internal medicine to act in a professional mannera) Demonstrate compassion to his patient eg1 Demonstrates sensitivity to patientsrsquo needs and concerns2 Takes time and effort to explain information to patientsampComfort the sick ones3 Shows respect for patientsrsquo confidentialityb) Demonstrate reliability and a strong sense of responsibility as hesheCompletes assigned tasks timely and fully and takes on appropriate share of team workc) Demonstrate commitment to self-improvement as hesheAccepts constructive feedback reads up on patient cases and attends rounds seminarsand other learning eventsd) Demonstrate respect for others as in the course of relationships with studentsfaculty and staff hesheEstablishes rapport with team members and relates well to other health care professionalsin a learning environmente) Demonstrates integrity by upholding a professional code of conduct as heshe1 Uses appropriate language in discussion with patients and colleagues2 Behaves honestly183 Respects diversity of race gender religion age disability intelligence and socio-12Dresses in an appropriate professional manner (context specific)II At the conclusion of the clerkship in internal medicine the medical student will be aMedical Expert Skilled Clinical Decision Maker1 Demonstrate a thorough knowledge of internal medicine This has three dimensionsa) the student should know the common and life-threatening illnesses affecting adults interms of thei Definitionii Epidemiologyiii Etiologyiv Pathogenesis and pathophysiologyv Clinical featuresvi Complicationsvii Investigations required to confirm a diagnosisviii Principles of preventionix Principles of management- Medical- Surgical- Involvement of allied health professionals- Nutritionalx PrognosisA Check list of common and life threatening illness students should know through the

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

course is included in the students log bookb) The student should develop an approach to the diagnosis of the major presentingproblems encountered in internal medicine In order to do this the student needs to be abletoi List in an organized fashion the major causes of each of theseproblemsii List the most important or life-threatening causes of eachproblemiii Explain how data that may be obtained from the history andphysical examination will affect the likelihood of these diagnostic possibilitiesfor each problemiv Understand the appropriate use and interpretation of diagnostictests (see below)MAJOR PRESENTING PROBLEMS IN INTERNAL MEDICINECardiorespiratoryCardiac arrest respiratory arrestChest discomfortCoughCyanosis hypoxemia hypoxiaDyspneaHematologiconcologicLeukocytosisLeukopeniaAnemiaBleeding tendencybruisingLymphadenopathy19EdemaHemoptysisHypercarbiaHypoxemia and hypoxiaInsomnia sleep-apnea syndromeMurmurs extra heart soundsPalpitations (abnormal ECG arrhythmias)Shock hypotensionSyncope presyncope loss of consciousnessWheezingGastrointestinal hepatobiliaryAbdominal painAscitesAbnormal liver enzyme levelsBlood in stool (hematochezia and melena)ConstipationDiarrheaDysphagiaHematemesisAbnormalities of liver synthetic functionJaundiceVomiting nausea

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

Renal fluid-electrolyteMetabolic acidosis and alkalosisRespiratory acidosis and alkalosisHypo- and hyperkalemiaHypo- and hypernatremiaHematuriaHypertensionProteinuriaUrinary frequency (associated with dysuriaassociated with polyuria)OliguriaEndocrineHyperglycemiaHypo- and hypercalcemiaHypo- and hyperphosphatemiaHirsutism and virilizationPolycythemiaSplenomegalyFebrile neutropeniaRheumatologicJoint pain (mono-articular and poly-articular)Painful limbBack painNeurologicalComa impaired consciousnessConfusion deliriumDementia memory disturbancesDiplopiaDizziness vertigoGait disturbances AtaxiaHeadacheNumbness and tinglingPupil abnormalitiesSeizuresSpeech and language abnormalitiesTremorVisual disturbance lossWeakness paralysisGeriatricsFallsFailure to thrive (elderly)Urinary incontinence (elderly)General internal medicineAllergic reactionsDying patientFatigueFever and chillsPainPoisoningPruritusSubstance abuse drug addiction withdrawal

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

Weight gain obesityWeight loss3 Demonstrate clinical skillsa) Students should be able to obtain and document both a complete and a focused medicalhistory as the situation requires The history will be thorough and organized andsupplemented as needed by information from other sources (family members otherhealth care institutions other physicians etc)b) Students should be able to perform and document both a complete and a focusedphysical examination as the situation requires In order to do this students must beable to demonstrate- An understanding of the physiologic basis of clinical findings20- A logical comprehensive organized approach to the physical examinationthat is adaptable to specific circumstances- Proper techniques of physical examination- Appropriate attention to patient comfort hygiene and privacy- An understanding of the significance of and the ability to detect thepresence of the most important physical examination abnormalities pertinentto internal medicineMAJOR PHYSICAL EXAMINATION ABNORMALITIES IN INTERNAL MEDICINEGeneralPallorCyanosisClubbingIcterusCachexiaVital signsHypertension hypotensionTachypnea bradypneaTachycardia bradycardiaFeverHead and neckFundoscopic changes(hypertensive diabetic and papilledema)Proptosis and lid lagThyroid nodule and goitreParotid enlargementMeningismusCardiovascularEdemaFindings of peripheral arterial insufficiencyElevated JVP hepatojugular refluxCarotid bruitCarotid upstroke delayedDisplaced apical impulseParasternal lift heaveAbnormalities of S1(loud soft variable)Abnormalities of S2 (loud P2 paradoxical split

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

fixed split)S3 S4Friction rubSystolic murmursDiastolic murmursRespiratoryTracheal deviationFindings of pleural effusionFindings of consolidationFindings of pneumothoraxWheezingBronchial breath soundsDullness on PercussioAbdominalFindings of ascitesHepatomegalySplenomegalyTendernessOther massesNeurologicalCranial nerve abnormalitiesWeaknessTremorSpasticity and flacciditySensory abnormalitiesHyper and hyporeflexiaAtaxia and postural instabilityMusculoskeletalJoint tendernessJoint swellingStress painCrepitusReduced range of joint motionJoint deformityMuscle atrophySkinLocal lesionsDiffuse skin rashLymphaticCervical lymphadenopathyAxillary lymphadenopathyInguinalfemoral lymphadenopathy21c) Students should be able to interpret commonly-employed diagnostic tests The majortests those are pertinent to internal medicine In order to use these effectively studentsneed to know their indications contraindications risks and in general terms their testcharacteristics (sensitivity and specificity)MAJOR DIAGNOSTIC TESTS IN INTERNAL MEDICINEHematologic tests (complete blood count blood film coagulation studies ESR)Biochemical blood tests

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

(electrolytes urea creatinine osmolarity bilirubin liver enzymes ammonia ketones lactatecalcium magnesium phosphorus albumin and total protein glucose uric acid arterial bloodgases drug screen ferritin iron TIBC vitamin B12 folate )Endocrine blood tests(Thyroid function tests glycosylated hemoglobin cortisol aldosterone urinary catecholamines PTHprolactin vitamin D levels cholesterol and triglyceride)Immunologic tests(serology including rheumatoid factor ANA and related autoantibodies ANCA complement levelsserum and urine protein and immuno-electrophoresis immunoglobulin levels)Urine tests (urinalysis 24 hour collection)Microbiology tests(gram stain andor culture and sensitivity of blood sputum urine joint fluid CSF and other bodyfluids viral serology tests for tuberculosis and fungi)Stool tests (occult blood culture leukocytes)Tests of other body fluids including pleural fluid ascites joint fluid bone marrow and CSFElectrocardiographyPulmonary function testsImaging tests- Chest radiography (major emphasis)- Plain abdominal X-ray films and CT scan of the brain(recognition of life-threatening abnormalities)(Students should also have a general understanding of the role of other imaging modalities in thedifferential diagnosis of presenting problems including in particular ultrasound of the abdomenDoppler ultrasound of leg veins and carotid arteries CT scan of the chest and abdomen nuclearmedicine studies of lungs and bone plain films of bones DEXA scanning and MRIBiopsy of specific organs (eg liver lymph node kidney)22d) Students should be able to integrate the above history physical findings anddiagnostic test results into a meaningful diagnostic formulation This requires that thestudent can- Generate a problem list and a differential diagnosis for each of theproblemse) Students should be able to demonstrate therapeutic and management skills In orderto do this the student needs to be able to(i) Suggest appropriate additional investigations for each problem(ii) Propose a management strategy for each of the problems based on knowledge of theproperties of medical therapies in terms of their indications contraindications andmechanisms of action side effects cost and monitoringMAJOR MEDICAL THERAPIESOxygenNasal prongsFace maskIntravenous fluidsNormal saline half-normal saline hypertonicsalineDextrose solutions (5 10 amp 50)Ringerrsquos LactateAlbumin (5 20)Nutritional therapies

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

Oral supplementsEnteral feeding via NG- and G-tubeTotal parenteral nutrition (general principles only)Emergency drugsEpinephrineAtropineLidocaineProcainamideCardiovascular drugsACE inhibitors and angiotensin receptor blockersBeta-blockersAlpha-blockersCalcium channel blockersDiureticsDigoxinNitratesAntiarrhythmic medications-Amiodarone-Lidocaine-Propafenone-SotalolAntithrombotic therapyMedications used to treat diabetes mellitusInsulinSulfonylureaMetforminThiazolidinedionesMeglitimidesAcarboseMedications used to treat dyslipidemiaHMG-CoA reductase inhibitorsFibric acid derivativesCholestyramineNicotinic acidMedications used to treat thyroid diseaseThyroid hormone replacementMedications for Gravesrsquo disease (PTUmethimazole)AntimicrobialsAntibioticsPenicillinsCephalosporinsMacrolidesVancomycinAminoglycosidesTrimethoprim and sulphonamidesMetronidazoleFluoroquinolonesTetracyclinesClindamycinAntivirals

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

AcyclovirAmantadine23Antiplatelet agents- ASA- Clopidogrel- TiclopidineAnticoagulants- Warfarin- Heparin (unfractionated and low molecularweight)Antriretroviral therapyAntifungalsImidazoles (fluconazole etc)AmphotericinMedications to treat mycobacterial infectionsIsoniazidRifampinEthambutolPyrazinamideMedications used to treat obstructive airwaysdiseaseBronchodilatorsLeukotriene antagonistsCorticosteroidsTheophyllineMedications used to treat acid-peptic disordersProton pump inhibitorsH2-blockersAntacidsMedications used to treat arthritisDMARDsNSAIDsCorticosteroids (local and systemic)Biological agents (Infliximab Etanercept)AnticonvulsantsPhenytoinBenzodiazepineValproic acidPhenobarbitalCarbamazepineGabapentinMedications used to treat inflammatory boweldiseaseSteroids (local systemic)BudesonideAntibioticsSalicylate preparationsImmunosuppressivesBlood and blood products

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

-Packed RBC-FFP (fresh frozen plasma)-PlateletMedications for Parkinsonrsquos diseaseL-dopaBromocriptineAmanatidineMedications for Alzheimerrsquos diseaseAriceptAnalgesicsOpioidsAcetaminophen NSAIDsMedications for neuropathic painMedications for bone painLaxativesBulk laxativesMagnesium-based catharticsLactulosePEG-based solutionsStimulant catharticsAnti-emeticsDimenhydrinateProchlorperazineNabiloneOndansetronMedications for osteoporosisBisphosphonatesCalcitoninSERMs (eg raloxifene)EstrogenChemotherapyGeneral principles amp emphasis on side-effects24f) Students are encouraged to be familiar with the technical skills necessary to performmany of the common procedures used in internal medicine as well as show that theyunderstand the indications risks and benefits of these procedures A check list of themajor procedures that medical student should be familiar with is included in thestudent log bookIII CommunicatorDoctor-Patient RelationshipAt the conclusion of the clerkship in internal medicine the medical student will be able toa Communicate effectively with patients and establish professional relationshipcharacterized by understanding trust respect empathy and confidentiality takinginto consideration the influence of factors such as the patientrsquos age gender ethnicitycultural and spiritual values socioeconomic background and medical conditionsIV CollaboratorAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Develop a care plan for a patient heshe has assessed including investigation treatmentand continuing care in collaboration with the members of the interdisciplinary teamb) Participate in interdisciplinary team discussions demonstrating the ability to accept

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate

consider and respect the opinions of other team members while contributing anappropriate level of expertise to patient careV ManagerDuring the clerkship in internal medicine the medical student will deepen hisherunderstanding of the appropriate use of health care resources in the internal medicine contextVI Health AdvocateAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Accept appropriate responsibility for the health of patients assigned to their careb) Recognize important determinants of health and principles of disease prevention pertinentto internal medicineVII ScholarAt the conclusion of the clerkship in internal medicine the medical student will be able toa) Demonstrate the ability to engage in self-directed learning This involves identifyingpersonal learning objectives and then finding and using a variety of resources to addresslearning needsb) Assist in teaching others and facilitating learning where appropriate