Ahhh Internal Medicine. My passion. So much so my fiancée and I started the world's very first student internal medicine society at Wits! (The Physician Society, check it out!) This block will certainly teach a lot, especially that Lupus is, sometimes, the answer. I was at Bara, but I'm sure the following will apply everywhere.
As all other clinical blocks in GEMP III the focus is on your clinical skills. How you engage with a patient, how you examine the patient, how you think. In this block you will only require one textbook - Clinical examination: A systematic guide to physical diagnosis by NJ Talley & S O’Connor (or as everyone calls it - Talley's). Everything you need to know is here.
The thing about Internal medicine is that if you don't practise, the physicians will see that. If you haven't clerked a Respiratory patient, Prof Wong at Bara will go to town on your proverbial behind. Don't just use tutorials as clerking opportunities. After a long day when it seems oh so tempting to go home, go and see a patient.
If you are "lucky" like I was, you will be on call on your very first day. Yeah,that's right, not knowing much, you will be expected to be on intake. It sucks at first, but then you get better at it. Some doctors will expect you to see, diagnose, and start management on patients. It's the best. You actually feel like a doctor. Oh, and might I remind you that there is no shame in Googling stuff... Other doctors will be more passive. So calls become what you make of them. On your first day be sure to take a pair of scrubs and enough food for supper, just in case you're the lucky unit on call that evening. Call at Bara was until 21h00.
The block is essentially only five weeks long, as in the sixth week you write exams. During the block you will spend time in the wards in the morning during post intake ward rounds if you were on call the night before. These are usually just business rounds, so don't expect to learn too much. Ask questions though. Remember, there is no such thing as a stupid question, just a stupid answer (as I once told a doctor at CHSE who didn't answer my question). After that you will have a lot of tutorials. For the tutorials I would suggest that you give the doctor giving the tutorial a call and ask if they have a patient, if they prefer a certain system (CVS, Resp, etc.) or if you can choose any patient. Before each tutorial make sure everyone has seen, felt, heard or smelled the signs. Everyone doesn't have to do a full clerk. Use the tutorial as a chance to sharpen your skills. Rather look like a fool here than in the exam.
The physicians want your clerked case presented in a very specific way. In internal medicine, you always start your presentation with an overall assessment of the patient. No one told us that, and boy did we pay for it. Below is an example which can be used in any patient, regardless of the system or diagnosis. In brackets I will put the importance. Then I will give you a template for cardiology tutorials, which will differ greatly.
Mrs Jones (the name is very important!), a 46 year old accountant from Sandton (a personal touch which some physicians regard very highly), a known diabetic patient, well controlled on medication for ten years, (here you mention their chronic ailments) presented with a three day history (time period is important) with signs and symptoms suggestive of meningitis (don't list positive Brudzinsky and Kernig, with a fever!), with a differential including encephalitis and neoplasm (only include a differential if you are not 99.99% sure of the diagnosis), complicated by focal neurological signs, specifically seizures and weakness of the left lower limb (mention the complications, and grade it if possible, including presence/absence of any prognostic factors).
In cardiology they want to know the following cardinal things : What is the NYHA class of the patient (is the patient in heart failure?); does the patient have infective endocarditis (splenomegaly, Roth spots, proximal splinter haemorrhages); does the patient have a history of Rheumatic Fever (Ducket Jones criteria...); is there pulmonary hypertension; and if there are any murmurs (and grade them). The thing about murmurs and heart failure - they are not diagnoses, just signs of an underlying diseases. For example: Mrs Jones (she's very ill this Jones lady), a 46 year old accountant from Sandton, a known well controlled diabetic for ten years, now presents with signs and symptoms of heart failure, most likely a dilated cardiomyopathy, secondary to chronic ethanol abuse (we don't say she drinks like a fish in front of the patient, or professor); NYHA functional class III; no signs of infective endocarditis; no history of Rheumatic Fever; no murmurs; no signs of pulmonary hypertension. (and that, ladies and gents, is how you make a cardiologist very happy!)
The logbooks are pretty important. Make sure you fill in every single patient you see. Whether it's on intake (calls) or for tutorials. When you present it to a consultant, registrar or intern (in order of preference, intern being least) you must have them sign you off in your log book. For procedures that you observe or carry out, make sure you write it all in! Just not things like popping in a drip or doing an arterial blood gas. If you see an intern doing something, watch them. The next time you can do it! Make use of your time. Putting a huge needle into someone's spine and catching whatever fluid comes out is scary. For both you and the patient. After your second or third LP, though, you'll be fine.
Some general tips. GEMP I and II hasn't taught us well. Every clinical examination starts with the hand (apart from Neuro, which starts with gait). When is comes to cardiology you must know what you are going to hear before you place your stethoscope on the chest of your patient. For example, say you feel a collapsing pulse, a positive Corrigan's sign and hippus pupils, you must expect to hear an early diastolic murmur, as you should already know that it is aortic regurgitation.
When it comes to the other systems, be thorough as well. Use Talley's to guide you in what order to go. From day one you must have an idea of what systems you want to study when and then practice the skills it teaches you the next day. Prepare well for tutorials as well. If you clerk a patient today, go and read up on that system and make sure you've picked up all the signs. If you haven't, just go and do it the next morning.
The exams are straight forward. An impossible MCQ and then the clinical exam. It's all very well explained in the handbook they provide.
I hope this was helpful. It probably doesn't answer all your questions, so if you have any other, please just send me a message and I will answer as best I can.
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