MBBS Year 5

MODULE 5A (CHILD &

FAMILY HEALTH WITH

DERMATOLOGY)

Study Guide 2014-2015

Copyright UCL Medical School

The information contained in this study guide is correct at the time of going online but no guarantees can be given that it will not be amended before the commencement of, or during, the degree programme to which it refers.

Module 5A (Child and Family Health with Dermatology) Contents Introduction and Overall Aims 4

In-Course Assessment in Module 5A (Year 5 Portfolio) 6

Paediatrics and Child Health Introduction 7 Aims and Objectives 7 Core Curriculum 8 Community Paediatrics 16 Child Health in Primary Care 17 Child and Adolescent Psychiatry 17 Contacts 18 General Practice Introduction 19 Aims 21 Learning Objectives 22 Staying Safe 28 Assessment 29 Contacts 32 Dermatology 33 Aims and Objectives 33 Study Guide 34 Recommended Reading 35

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INTRODUCTION During this module you will spend most of your time learning about the clinical specialties of Paediatrics, General Practice and Dermatology and, in addition, cover related aspects of other disciplines such as Child and Adolescent Mental Health (CAMH). Throughout the module emphasis is placed on integration of the vertical module themes of pathology, society and the individual, use of medicines, evaluation of evidence, community orientated medicine and professional development (in particular communication skills and medical ethics). Teaching and learning takes place in a variety of settings including lectures, seminars, hospital wards, outpatient clinics, general practice and other community clinics/centres. The module consists of one week of introduction followed by three four-week attachments (Central Paediatrics, District Paediatrics and General Practice). There is core and vertical module teaching on the first and final Friday of each of the 4 week attachments (i.e. weeks 1, 4, 5, 8 9 and 12). Dermatology is taught throughout the module especially during the Central Paediatrics and GP attachments. Aims of the module The aims of this module are to provide students with:

Knowledge, clinical skills and attitudes needed to manage children and their families as patients in hospital and community settings.

Experience and understanding of the care of individuals and families in primary care and awareness of the holistic nature, scope and limitations of the discipline of general practice.

Knowledge of common and important skin disorders in both children and adults with emphasis on diagnosis and management.

Understanding of the principles of child and family mental health and the relationship between physical, psychological and social factors in health and illness.

Experience of working with multidisciplinary teams in child and family health care.

Opportunities to integrate knowledge of basic sciences and pathology with clinical practice.

Opportunities to continue learning related to all elements of the vertical spines and modules (pathology, society and the individual, use of medicines, evaluation of evidence, community orientated medicine and professional development).

Module requirements To fulfil the portfolio requirements, you need to complete the following:

5 SLEs in the following: 3 CBDs (2 in paediatrics, one preferably with emphasis on mental health

issues and 1 in GP) 1 CEXs in paediatrics 1 of your choice

7 Multi Supervisor Reports, 4 of which from the tutor/supervisor of the following attachments: District paediatrics Central paediatrics GP child health Core GP

Record of Procedures card: please upload your completed card to your e-portfolio and submit the hard copy to the CFHD office. All parts of the card need to be

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completed. Formative assessment During the module, you will have the opportunity to complete a formative on-line assessment consisting of SBAs. Details will be given to you in due course. Further information The module has a Moodle site which provides the following information:

Central and District timetables, including appropriate maps

Lecture timetable

Study guide and course workbooks/handbooks

Course resources – Image Bank, Podcasts (iPaediatrics), Narrated Presentations

Assessment details You can access the site at http://moodle.ucl.ac.uk. To log into the site you will need your main UCL IS User ID and password. If you have any problems accessing the site, please contact Natalie Cassius, CFHD’s MBBS teaching administrator on 020 7679 6102 or email: cfhd@ucl.ac.uk Alternatively you can contact Yusuf Ozkizil, CFHD’s MBBS Teaching Coordinator on 020 7679 6101 or email: y.ozkizil@ucl.ac.uk.

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Assessment Your learning in Year 5 will be structured similarly to Year 4, and you will be using a Year 5 e-Portfolio, Record of Completed Procedures Card, and Supervised Learning Events (SLEs: case-based discussions (CBDs), clinical evaluation exercises (CEXs) and Multi Supervisor Reports (MSRs). Failure to submit the required documentations (and/or fully complete the Record of Completed Procedures Card) will result in a meeting with Tutors/Module Leads. Your assessment results will also be withheld. We will not be chasing you for these documents as it is your responsibility to submit them promptly on time. You are expected to keep your e-Portfolio and Record of Completed Procedures Card up to date, as you will need to show them to your supervising consultant when doing the MSRs. If you are having difficulties getting your SLEs or Record of Completed Procedures Card completed, you will need to discuss this with your supervisor. Falsifying any information is a serious professional/probity offence and individuals found to be doing so will be referred to the Faculty/Module Tutor. For further information relating to your end of your summative assessments, please refer to pages 3 and 4 of the Year 5 Student Guide 2013-2014.

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CHILD HEALTH

During the child health component of this module, you will receive teaching and experience in paediatrics and child health as follows:

Lectures and seminars on paediatric topics.

Four weeks Central Paediatrics attachment (Bloomsbury, Royal Free or Whittington).

Four weeks District Paediatrics attachment at one of the hospitals affiliated with UCL.

Two days of paediatrics based in General Practice (Child Health in Primary Care) during the District Paediatrics attachment. You will spend two days in different weeks with a GP tutor in their practice learning about child health in the community.

Aims and Objectives of the Child Health Component Paediatrics is the study of health and diseases of children. Child health encompasses the strategies for promoting health and preventing disease during childhood. As always, prevention is better than cure. Your aims for the child health experience during the module are described under the domains of knowledge and understanding, skills and attitudes. 1. Knowledge and understanding

The normal child Knowledge of the normal child and child rearing is an essential prerequisite to the study of disease. This encompasses:

Changes at birth and the normal new-born infant

Principles of infant feeding and nutrition

Growth and development — physical and emotional

Parenting and family dynamics Health promotion and disease prevention in child health

Screening and surveillance including immunisation

Health education and promotion, accident prevention

Child protection Ethics and law in child health An understanding of:

Consent in children and young people o Gillick competence and Fraser guidelines

Parental responsibility

Confidentiality

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Common and important childhood diseases The depth of knowledge expected for the many thousand diseases affecting infants and children clearly varies. Four main documents have been produced to help you organise and prioritise your studying and learning. These are the UCL medical school core curriculum, the Year 5 student guide, this study guide and the paediatric syllabus. You should consult all these documents which are complementary to each other. We have put a list of childhood problems/conditions into Categories as defined below:

Category A Includes diseases which you must know about in detail because they are very common, regardless of severity or common, treatable and potentially life threatening or uncommon, but dangerous to miss. You should be able to describe the epidemiology, typical presentation, clinical signs, key investigations, first line treatment, non-drug management and prognosis for each condition. Category B Includes many conditions which are less common, but not rare, and for which effective treatment is often available. You must know the basic facts about these. Category C Includes conditions that are mostly rare. Although important for those affected, and often of great interest in biological terms, their diagnosis and management is usually the province of the specialist working in a tertiary referral centre.

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Childhood Diseases and Disorders – ‘A B C’ Categories:

A

B

C

The Newborn

The preterm infant Birth asphyxia

Congenital malformations

Meconium aspiration

Neonatal jaundice Breast feeding

Abnormal foetal growth Congenital infections

Haemorrhagic disease of the newborn

Neonatal screening Neonatal sepsis

Neonatal hypoglycaemia

Haemolytic disease of the newborn

The Child

Cardiovascular Disorders

Innocent murmurs

Atrial and Ventricular septal defect Patent ductus arteriosus

Cardiac failure Coarctation of the aorta Cyanotic congenital heart disease Patent ductus arteriosus Rheumatic fever Supraventricular tachycardia

Respiratory Disorders

Asthma Inhaled foreign objects Cystic fibrosis

Pertussis Diphtheria

URTIs Tonsillitis Otitis media Croup Epiglottitis LRTIs Bronchiolitis Pneumonia

Neurological Disorders

Cerebral palsy Epilepsy

Duchenne muscular dystrophy

Neural tube defects Autism

Febrile seizures Meningitis Migraines and Tension headaches

Hydrocephalus Breath-holding attacks

Neurocutaneous syndromes

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A

B

C

Child and Adolescent Psychiatry

Depression and Anxiety Disorders Self-harm Behavioural Problems (including tantrums and conduct disorder)

Attention deficit hyperactivity disorder Autism and Asperger’s Syndrome Anorexia nervosa Sleep related problems

Chronic fatigue syndrome Nocturnal enuresis School refusal Soiling Chronic fatigue syndrome

Infection, Immunology and Allergy

Cow’s milk intolerance Food allergy Rhinitis/Hay Fever Viral exanthems

Kawasaki disease Enteroviral infections

Chronic urticaria Steven Johnson Syndrome Glandular fever Typhoid fever

Measles Herpes infections

Malaria Tuberculosis Viral hepatitis

Giardiasis

Chicken Pox Staphylococcal infections

Secondary Immunodeficiency and HIV Worms

Primary immunodeficiency

Streptococcal infections

Musculo-skeletal Disorders

Transient synovitis Osteomyelitis

Developmental dysplasia of the hip

Perthes disease Juvenile chronic arthritis

Septic arthritis Pulled Elbow Achondroplasia Osteogenesis

imperfecta

Endocrine and Metabolic Disorders

Hypoglycaemia Rickets Type 1 Diabetes Mellitus

Hypothyroidism

Congenital Adrenal Hyperplasia Inborn errors of metabolism e.g. PKU Disorders of Puberty

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A

B

C

Gastro-intestinal Disorders

Acute appendicitis Constipation Gastroenteritis Infantile colic Gastroesophageal reflux Toddler’s diarrhoea

Biliary atresia Coeliac disease Intussusception Inflammatory bowel disease Mesenteric adenitis Pyloric stenosis

Meckel's diverticulum Hirschsprung's disease

Renal and Genitourinary Disorders

Urinary tract Infection Inguinal hernia and hydrocele Nephrotic syndrome Undescended testes Vulvovaginitis

Urinary tract anomalies

Potter's syndrome

Vesicoureteric reflux Acute renal failure Haemolytic uraemic syndrome

Hypospadias Acute nephritis Chronic renal failure

Genetic Disorders

Cystic fibrosis Down syndrome Sickle cell disease

Duchenne muscular dystrophy Fragile X syndrome G6PD deficiency Haemophilia Thalassaemia

Achondroplasia Marfan syndrome Neurofibromatosis Tuberous sclerosis Turner syndrome Dysmorphic syndromes

Haematological Disorders

Iron deficiency Anaemia Sickle Cell Disease

Thalassaemia Henoch-Schonlein purpura

Disseminated intravascular coagulation

Haemophilia Haemolytic anaemias

Idiopathic thrombocytopenic purpura

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A B C

Malignant Disease

Acute leukaemia

Wilms tumour Bone tumours Brain tumours

Retinoblastoma Langerhans Cell Histiocytosis

Neuroblastoma Lymphomas

Skin Disorders Eczema Urticaria Acne vulgaris (Dermatitis) Vitiligo Napkin

dermatitis Dermatophytoses (ringworm) Impetigo Rashes and Viral Exanthems Viral warts

Candidiasis Head lice (nits) Pityriasis Rosea Port-wine stains Scabies Strawberry naevi Urticaria

Neurofibromatosis Tuberous sclerosis

Ear, Nose and Throat Disorders

Otitis media, acute

Otitis media, chronic with effusion (Glue ear)

Obstructive sleep apnoea

Tonsillitis Epistaxis

Sinusitis Mastoiditis

Rhinitis Hearing loss

(deafness)

Eye Disorders Pre-septal (peri-orbital) cellulitis Strabismus (squint)

'Sticky eye' in infancy

Retinopathy of prematurity

Cataracts Visual impairment

Paediatric Surgery

Undescended testes

Acute appendicitis Volvulus/malrotation

Torsion of testis Inguinal hernia and hydrocoele

Intussusception Cervical lymphadenitis

Meckel's diverticulum

Balanitis/phimosis

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A B C

Accidents and Emergencies

Shock (circulatory failure)

Coma Trauma including Burns Poisoning

Near drowning Febrile Neutropenia

Meningococcal Disease

Anaphylaxis Acute asthma

Acute stridor Cardiac arrest Convulsions/Seizures Diabetic Ketoacidosis Head injury

Child protection

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2. Skills Diagnosis by history taking and physical examination Ability to make a differential diagnosis in children presenting with the following symptoms, signs or problems:

Simple practical procedures

You should be able to undertake the following:

Test urine using dipstick

Change and feed a baby

Measure occipito-frontal head circumference (OFC)

Plot height, weight and OFC on a growth chart

Measure peak expiratory flow rate, blood pressure

Administer inhaled medication

Advice/administer/use of adrenaline auto-injector Management by initiation of investigation and treatment Investigations

Blood tests Haematology: full blood count; blood film Biochemistry: U&Es, LFTs, bone Microbiology: culture, serology, immunoglobulins.

Urine tests Dipstick Microscopy and culture.

CSF analysis: Biochemistry, microbiology, immunology.

Imaging: Radiology; ultrasound, MRI, CT.

Symptoms Signs Problems

Cough Noisy breathing Difficulties in breathing

Fever Rash Pallor

Faltering growth Short stature Developmental delay

Ear ache Cyanosis 'Fits, faints or funny turns' Sore throat Jaundice Deafness Abdominal pain Stridor Haematuria Vomiting Wheeze Proteinuria Diarrhoea Tachypnoea Heart murmur Constipation Lymphadenopathy Abnormal head size/ shape Headache Abdominal mass Squint Limb/joint pain Hepatomegaly Precocious/delayed puberty

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Treatment You should know about the management and treatment of conditions in the A and B categories. It is particularly important to know the immediate management of the following emergencies:

Cardiorespiratory arrest (basic life support)

Shock (circulatory failure) due to: meningococcal septicaemia/anaphylaxis/diabetic keto-

acidosis

Acute asthma

Upper airways obstruction, e.g. stridor and choking

Birth asphyxia

Acute seizure. In addition, you are expected to understand the principles of managing an infant or child's:

Nutrition including use of nutritional supplements e.g. vitamins, iron

Fluid and electrolyte balance

Therapeutics and how to write a drug chart

Principles of paediatric prescribing including the use of common medications Communication skills Verbal and written communication skills including:

Talking to children of different and anxious parents

Explaining common childhood illnesses and discussing treatment

Breaking bad news and responding to emotional distress

Case-presentations

Satisfactory written medical record keeping

Safe paediatric prescribing

3. Attitudes

Development of satisfactory attitudes towards children, families and colleagues:

Children: Taking account of their special needs and vulnerability. Minimising pain and discomfort. Accepting uncooperative behaviour.

Parents: Inspiring confidence and demonstrating friendliness, whilst showing respect for parental opinion.

Colleagues: Ability to give and take instructions professionally. Work efficiently in a team. Support colleagues and seek help when appropriate.

Personal professional development.

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COMMUNITY PAEDIATRICS Community paediatrics (care of children at home and in the community) is a sub-specialty area within child health. Care of children in the community places a great emphasis on health as opposed to illness which is often the focus in the hospital. The teaching may involve small group seminars and presentations and attending community clinics (e.g. children with complex disabilities). By the end you will know about community paediatrics including child health promotion, the multidisciplinary team, and complex disability. Every child discharged from hospital goes home to their family, community and school. Whatever their illness they need to achieve the 5 outcomes set by the government in “Every Child Matters, Change for Children”.

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CHILD HEALTH IN PRIMARY CARE During your DGH paediatrics attachment you will spend two days in different weeks with a GP tutor in their practice learning about child health in primary care. Teaching will usually be in groups of 4 students. This is in addition to the four week Core GP attachment. The overall aims are to provide you with opportunities to learn about common paediatric problems in primary care, to practise your basic clinical skills in paediatrics and to help you to understand the role of the community in children’s health care. CHILD AND ADOLESCENT PSYCHIATRY This is a branch of psychiatry that specialises in the study, diagnosis, treatment and prevention of psychiatric disorders and emotional distress in children, adolescents and their families. The objectives of the course will be to understand/learn about:

1. Prevalence of common psychiatric and psychological problems presenting in children.

2. Social and emotional milestones for development.

3. Tools for thinking about emotional problems in children.

4. To begin conducting an assessment of a child psychiatry referral.

5. To gain a deeper understanding of the following disorders:

Hyperkinetic disorders (ADHD)

Neuro-developmental Disorders

Behavioural Disorders

Mood and Anxiety Disorders. These topics will be primarily taught during the Vertical Module Fridays. In addition, each student will have about one day of clinical experience with the CAMHs team during their Central Paediatric attachment. The student will need to complete an ‘In Placement Multisource Feedback’ during the day. The student will also be required to perform one of the CBDs with an emphasis in the mental/psychological aspects of the case.

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PAEDIATRICS - USEFUL CONTACTS

For academic queries about the core teaching weeks please contact:

Dr. Eddie Chung, Module 5A Chair & Bloomsbury Site Lead

E-mail: eddie.chung@ucl.ac.uk

Dr. Minal Gandhi, Royal Free Site Lead

E-mail: m.gandhi@nhs.net

Dr. John Moreiras, Whittington Site Lead

E-mail: john.moreiras@nhs.net

Central Attachments Module 5A MBBS Teaching Administrators:

Bloomsbury Natalie Cassius Tel: 020 7679 6102

cfhd@ucl.ac.uk

Yusuf Ozkizil Tel: 020 7679 6101 y.ozkizil@ucl.ac.uk Royal Free Shannon Hyde Tel: 020 3108 9703 x 59703

s.hyde@ucl.ac.uk

Whittington Jeanette Hanoman Tel: 020 7288 5598 jeanette.hanoman@ucl.ac.uk

For District (DGH) paediatric attachments please contact the DGH Teaching Administrators as listed in the DGH Reporting Instructions issued to students at the start of the academic year when student allocations are released.

For academic enquiries regarding the Child Health and Dermatology in Primary Care Days, please contact, Dr Sophie Park sophie.park@ucl.ac.uk

For administrative enquires regarding the Child Health in Primary Care Days please contact Mrs Ola Inekuku (ola.inekuku@ucl.ac.uk) Tel: 020 7830 2975.

For academic enquiries regarding the Core GP Attachment please contact Dr Joe Rosenthal j.rosenthal@ucl.ac.uk

For administrative enquiries regarding the Core GP attachment and GP Dermatology placements contact Sandra Gerrard (s.gerrard@ucl.ac.uk) at the community based teaching office at the Royal Free Campus, Department of Primary Care and Population Health. Tel: 020 7830-2599 / Fax: 020 7472 6871.

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CORE GENERAL PRACTICE During the CFHD module one of your four-week clinical attachments is based in a general practice in or around London. This “Core GP” attachment is in addition to the two days you spend learning specifically about paediatrics and child health in general practice during your core paediatrics four weeks. When you are in the practice you will be supervised on a one-to one basis by one of the GP tutors associated with the Medical School. Unlike the placements which you have taken in general practice during specialist firms in other years, this attachment is designed to help you learn about the whole range of problems presenting to GPs and the variety of services provided in primary health care. Please note that the London GP attachment also incorporates some elements of your dermatology teaching programme and one seminar on occupational medicine. The four core GP weeks are made up as follows:

One day introduction to primary care in the NHS (at Royal Free Campus).

The equivalent of 12 days core GP experience in your allocated practice.

One seminar on chronic disease management.

One seminar on occupational medicine.

One or two sessions in hospital dermatology clinics.

Two mornings in GP based dermatology teaching sessions (may be your own or, more often, a different practice).

Please note that ALL of these components are considered core teaching and you are expected to attend them all, and your attendance will be taken into account in your end of course assessment. No teaching is scheduled for Wednesday afternoons. These are free for sport or self-directed learning. You may however negotiate a different half day with your practice if it suits you and the practice to do so. Most of your time in the practice will be spent with a GP tutor in the surgery or accompanying them on home visits. If your tutor does not suggest that you see patients alone within the first week then please make the suggestion yourself. In some practices you may have a gap in the middle of the day when there is no formal learning activity arranged. This will give you time to meet other members of the primary health care team and understand their roles (e.g. receptionists, practice nurse, district nurse, health visitor, midwife) to read up on conditions you have seen in the surgery or to visit patients suggested by your tutor. You should also discuss with your tutor whether it is possible for you to gain some experience of out of hours care in general practice. NB – please read notes on Staying Safe in the Community” provided. In this placement we hope you will see community-based problems that do not need referral to a hospital e.g. minor illnesses, chronic diseases, undifferentiated problems, multiple pathologies and the early stages and less severe forms of diseases. You are also likely to focus more on the impact of social and psychological factors on illness, the patient’s perspective and how these affect medical management. It is important for all undergraduates to have this experience as half will become GPs and those who do not clearly still need to know the scope and limitations of this discipline and how it relates to secondary care. Many of you

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will also spend three or four months working in General Practice in year two of your Foundation Programme as newly qualified doctors.

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Aims of the core general practice attachment:

To enable students to experience and understand the provision of care to individuals and families in general practice and become aware of the nature, scope and limitations of the discipline.

To provide an opportunity for students to practise and integrate their clinical skills in terms of history taking, physical examination, and patient management.

To encourage students to reflect on their experiences in medical education and develop an integrated and holistic approach to patient care.

Getting the most out of your GP attachment

Teaching in General Practice is one of the few occasions during your course where you will benefit from one-to-one teaching. It also provides a chance to gain a lot of practice assessing patients before they have been seen by the responsible doctor. All attachments should start with a discussion of your learning needs. Although we provide you with a list of learning objectives, please remember that this course presents a valuable opportunity for you to learn about a whole range of aspects of medicine in the broadest sense. Try and discuss any personal learning objectives with your tutor in the first two days. You are likely to start off by sitting in with your tutor, observing and discussing consultations. This is an important activity but should not be the sole theme of the placement. Students usually report that the most valuable and enjoyable aspect of this course is the chance to see and assess patients on their own. This is a golden opportunity to practise making initial assessments and concisely presenting your findings. Most of your important learning in this course will come not from textbooks but from participating in the everyday work of your host practice and the discussions with your tutors and in seminars at the medical school. We do however recognise the need for some direction to your learning and so we include in your course materials a list of clinical areas in which we do expect you to be able to demonstrate knowledge by the end of the course.

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Learning Objectives

A Knowledge

By the end of four weeks you should be able to demonstrate a working knowledge of the process and content of general practice so that you can:

Describe, with examples, the presentation, diagnosis, investigation and

management of the common types of problems seen in general practice and describe the other resources that may be involved (e.g. members of the primary health care team, voluntary services).

These problems may be classified as:

Emergencies in General Practice - including acute, severe chest pain, breathlessness, abdominal pain.

Acute Problems in General Practice - including respiratory tract and ear infections, gastrointestinal (D&V), UTI, painful joints, confusional state, febrile infants.

Chronic Problems in General Practice - including diabetes, hypertension, stroke, asthma, COPD.

Psychological and Social Problems in General Practice - including risk assessment, depression, anxiety, somatisation, alcohol and substance abuse and medically unexplained symptoms.

Discuss, with examples, different aspects of health promotion and disease prevention seen in primary care (including cardiorespiratory prevention, cancer prevention, sexual and reproductive health, lifestyle issues and immunisation).

Describe the basic organisation of NHS primary care and some features which distinguish it from health care systems in most other countries.

B Clinical skills

By the end of four weeks you should be able to:

Take a focused history from patients presenting with any symptom or

problem in a short period of time.

Perform brief focused clinical examinations relating to all systems and to

problems which are not easily attributed to any one body system.

Present findings from history and examination in a concise manner with

a basic management plan included in formulation.

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C Communication Skills

By the end of four weeks you should be able to:

Assess patients presenting to general practice using appropriate history-

taking, examination and near patient testing skills to formulate problem lists,

including physical, psychological and social components.

Describe basic theory relating to the GP consultation and discuss how this

can be applied in practice.

Discuss and demonstrate good communication skills, with patients and

colleagues, including effectively communicating medical information to

patients.

D Attitudes

By the end of the four weeks you should be able to demonstrate:

A non-judgmental approach to dealing with individuals and their problems.

The ability to describe and discuss ethical and legal issues in general

practice, including equity of access and service provision, confidentiality

and patient autonomy.

An understanding of the impact of illness on individuals, their families and

carers.

The development of self-directed learning, by showing you have used

incidents in practice as a stimulus for study.

An understanding of the problems more commonly affecting deprived and

inner city populations.

An understanding of the importance of evidence and research in primary

health care.

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More on Knowledge of General Practice

In previous years some students have asked us for more detailed “lists” of the clinical knowledge expected by the end of the Core GP course, not least in order to help them focus their preparation for the end of year written and OSCE exams.

Clearly the “curriculum” for General Practice is difficult to define by virtue of the very generality which defines the discipline. We recognise that your clinical knowledge in areas such as general medicine, ENT, rheumatology, cardiology etc., is tested in other parts of the medical course and our main concern is therefore that you should focus your learning around the general principles of medicine in general practice and the broad aims of the course stated above.

Most of your important learning in this course will come not from textbooks but from participating in the everyday work of your host practice and the discussions with your tutors and in seminars at the medical school. We do however recognise the need for some direction to your learning and so we include the list below of clinical areas in which we do expect you to be able to demonstrate knowledge by the end of the course.

The Core GP attachment is only four weeks long so you should concentrate on common conditions, as listed below however, you should also discuss and read around individual cases you see, even if not covered by the list.

Topic Knowledge Skills Attitude

Emergencies

Chest Pain Risk factors, causes, clinical features, investigation, management.

History taking, examination.

Bio-psycho-social approach.

Breathlessness Risk factors, causes, clinical features, investigation, management.

History taking, examination use of peak flow meter.

Bio-psycho-social approach.

Acute Abdominal Pain

Causes, clinical features, investigation, management.

History taking, examination.

Bio-psycho-social approach.

Acute Psychiatric Illness

Causes, clinical features, investigation, management other involved agencies.

History taking, examination, team working.

Management of psychological illness in a non-judgmental manner.

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Topic Knowledge Skills Attitude

Acute Illness

Respiratory Tract and Ear Infections

Risk factors, clinical features presentation, management.

History taking, examination, use of otoscope, patient education.

Gastrointestinal (Diarrhoea and Vomiting)

Risk factors, clinical features, presentation, investigation, management.

History taking, including foreign travel and dietary history, examination, patient education.

Urinary Tract Infection

Presentation, investigation, management.

History taking including sexual history, examination, urine testing.

Painful Joints Risk factors, clinical features, differential diagnosis investigation, management.

History taking, examination, patient education.

Appreciation of psychological response to potentially chronic or debilitating illness.

Confusional State Risk factors, clinical features, differential diagnosis investigation, management, role of Primary Health Care Team (PHCT).

History taking, examination, use of screening tests for cognitive impairment, urine testing.

Provision of equitable care for all.

Febrile Infants Risk factors, clinical features, differential diagnosis investigation, management, role of health visitor.

History taking from informant, examination of infant, awareness of serious symptoms, taking temperature, collecting urine.

Dealing with families and uncertainty.

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Topic Knowledge Skills Attitude

Chronic illness

Diabetes Risk factors, clinical features, investigation, management, potential complications, involvement of PHCT screening and prevention.

History taking, examination of relevant systems, patient education, prevention use of ophthalmoscope, urine testing.

Management of chronic disease with possible complications appreciating problems with concordance.

Hypertension, Stroke

Risk factors, clinical features, investigation, management, potential complications, involvement of PHCT screening and prevention.

History taking, examination of relevant systems, patient education, prevention taking blood pressure.

Management of chronic disease, with possible complications appreciating problems with concordance.

Asthma, COPD Risk factors, clinical features, investigation, management involvement of PHCT.

History taking, respiratory examination patient education, patient involvement in self-management, use of peak flow meter, use of inhalers.

Appreciating problems with concordance.

Topic Knowledge Skills Attitude

Psychological Problems

Depression, Anxiety and Somatisation

Risk factors, clinical features, investigation, management, risk assessment involvement of PHCT.

History taking, patient education.

Management of psychological illness in a non-judgmental manner dealing with uncertainty.

Substance Abuse Risk factors, clinical features, investigation, management, involvement of PCHT and community services.

History taking, examination, patient education.

Management of substance abuse in non-judgmental manner recognising patient autonomy.

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Seminar Teaching in General Practice

In order to give you a maximum amount of exposure to the day-to-day work of General Practice, and in response to previous student feedback, we have kept the seminar programme during your 4 week GP attachment to a minimum. The small number of seminars is however seen as an important part of the course.

The first day Monday of the attachment helps prepare you plan to get the most out your time in practice and includes seminars on:

Introduction to Primary Care.

The organisation of General Practice.

Common problems in General Practice.

The first Wednesday of the attachment includes two seminars:

Care of chronic illness.

Occupational Medicine.

No formal preparation is necessary though discussion benefits from your raising examples of patients you have seen previously in hospital or general practice. Course materials for individual seminars will be provided on the first day of your GP attachment.

The seminars in the department are an integral part of the course. Full attendance at these is required. Many of those who lead the seminars have given up their time to come to the Department. Please arrive promptly as the seminars will start at the allocated time. It is very disruptive to your group and the seminar leader if people wander in late. If you have a genuine reason for being unable to attend a seminar, please let Mrs Sandra Gerrard, the course administrator, know.

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Staying Safe in the Community

Whilst out on placements in the community you may visit areas you do not know and experience new situations. It is important that you apply common sense during your placement to minimise any risk of attack. It is always important that someone knows where you are and when to expect you back and this is particularly important if you are visiting a patient in their home.

Know where you are going and plan your journey to ensure you avoid any ‘risky’ areas. Do not take shortcuts, stick to main roads and the directions you have been given. If you are worried speak to someone who has been to the place you are visiting to clarify the instructions.

If travelling on public transport don’t wait at deserted stations or stops, and know the times of your trains or buses to avoid waiting. Sit in a compartment with other people or near the driver.

Be alert. Look confident without appearing arrogant and do not wear a personal stereo.

Remember to carry some form of identity — other people are entitled to know you are a genuine medical student, especially if you are visiting a patient at home.

If you experience any form of attack — verbal or physical — or feel threatened at any point during your placement make sure you inform the Practice and the Department of PCPH. This will protect students in the future and alert the department to possible dangers.

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Assessment in General Practice

General Practice is assessed as part of the integrated end of year written exam and OSCE which also cover paediatrics and dermatology. Your GP Tutor also assesses your performance during your placement.

Assessment during the GP attachment has two main functions:

1. To feed back to you about your strengths and weaknesses in terms of your medical knowledge, skills (communication skills, history-taking skills, examination skills and practical skills) and your attitude and general approach (including attendance).

2. To provide a grade to the Medical School.

Your general practice assessment has three components:

Year 5 IPMSF.

Chronic care essay.

Seminar attendance and participation.

The GP tutor’s report is made on a structured assessment form. You will receive a blank copy with your course materials on day one of the attachment. Your tutor should discuss this with you at various points during the attachment, usually at the start, during the second week and on your final day in practice. In this way you can identify particular areas which you may need to work on during the month.

Submission of a Chronic Care Essay is a case study required of all students as the written component of the in-course assessment in General Practice. In week one your tutor will suggest a patient from their practice with a chronic illness and/or disability. The study will involve interviewing the patient and any carer (s) in their own home, discussing the management with any health and social care professionals involved and preparing a written report for marking by the GP Tutor. The essay should be between 1000 and 2000 words long. The essay must be handed in to your GP tutor by the end of week three so that they have time to mark it and provide feedback. Please also email a copy of your essay to the course administrator, Sandra Gerrard. Further details of this assessment will be provided in your course materials and in the Chronic Care Seminar in week one.

Students whose performance is weak in any aspect of the course or about whom any concerns are raised will be asked to meet with a member of the Department of PCPH at the end of the attachment. A plan to deal with these concerns can usually be drawn up, such as directed reading or supervised practice in particular skills.

Students who fail on the basis of their written work will be required to repeat that work.

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Students who fail on the basis of their practice placement will be required to spend extra time, usually in a different practice.

General Practice is also assessed as part of the integrated end of year written and OSCE. The potential syllabus in General Practice is vast and the Single Best Answer (SBA) questions fall within the following broad themes:

Acute problems in General Practice.

Chronic problems in General Practice.

Health promotion and disease prevention in Primary Care.

Structure and organisation of Primary Care.

Communication skills and consultation theory.

Psychosocial aspects of illness and disease.

Impact of illness on individuals and families.

Example of a General Practice SBA

Options

A Acute coronary event.

B Dissecting aortic aneurysm.

C Oesophageal rupture.

D Pneumothorax.

E Pulmonary embolus.

Answer: B

Scenario

A 68 year old hypertensive man visits his GP describing a dull chest pain, which has suddenly become tearing in nature whilst sitting in the waiting room. The pain is radiating to his back and he has become cold and clammy.

What is the single most likely diagnosis?

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Example of a General Practice OSCE Station

‘Discussing Cardiovascular Risks’ – a 6 minute station involving candidate, one simulated patient, and one clinical examiner.

Candidate Instructions

You are a GP Registrar. This is Peter Mair aged 39. He is a single parent with 2 children aged 8 and 10 years. Because of his family history you advised him two weeks ago to have a cholesterol check. He has now returned for the result which shows a Total Cholesterol of 7.8 mmol/l. His father died of a MI aged 55 when patient was 14. Mr Mair smokes 25 cigarettes a day.

Your task is to convey the result to Mr Mair and motivate him to stop smoking and consider other changes or interventions to reduce his cardiovascular risk.

The marking scheme used by the observing examiner will contain 2 aspects:

1. Consultation skills around establishing a rapport, discussing risk, eliciting patient ideas, concerns, expectations and negotiating a plan with them. 2. Factual content –the interpretation of this result, how it relates to his overall risk of a cardiovascular event, lifestyle and other interventions that could be considered.

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Your Feedback to Us

Your evaluation of the course is valued by the Department. We ask you all to complete an on line evaluation questionnaire that covers both the seminar programme and the practice placement. You will receive instructions for this by email in the second half of the attachment.

If you would also like to give any feedback directly to the course organisers, or discuss any issues relating to your particular practice, please email Sandra Gerrard (s.gerrard@ucl.ac.uk) and she will arrange for one of the members of the academic department to contact you directly.

Useful Contacts for Core GP

Any general queries regarding placements and organisation of the four week core GP attachments should be addressed initially to Mrs Sandra Gerrard based at the community based teaching office (Department of Primary Care and Population Health) at the Royal Free Campus.

Sandra can be contacted between 08.00 and 16.00 Monday to Friday on 0207-830 2599 or email s.gerrard@ucl.ac.uk

Academic queries regarding General Practice in Year Five can be addressed to Dr. Joe Rosenthal. E-mail: j.rosenthal@ucl.ac.uk

For general enquiries regarding GP Paediatrics placements contact Mrs Ola Inekuku (ola.inekuku@ucl.ac.uk). Telephone: 020 7830-2975

For GP Dermatology placements contact Sandra Gerrard (s.gerrard@ucl.ac.uk) at the community based teaching office at the Royal Free Campus, Department of Primary Care and Population Health. Telephone: 020 7830 2599 / Fax: 020 7472 6871.

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DERMATOLOGY

Welcome to Dermatology, a speciality you will encounter in every field of medicine throughout your career. Please note, that this is the only formal dermatology teaching you will receive in medical school, so we recommend that you capitalise. In order to help you learn, teaching occurs in a number of formats: Large group lectures, seminars, hospital and community outpatient clinics. Objectives By the end of the course you should be able to do the following:

Take a dermatological history.

Examine skin, hair, nails and mucosae systematically.

Describe examination findings appropriately.

Suggest differential diagnoses.

Formulate a management plan for the common conditions

Recognise that specialist treatments are available to the dermatologist e.g.

1. Topical therapies e.g. steroids, dithranol, tar, wet-wraps, compression

2. Phototherapy e.g. Psoralen + UVA and UVB

3. Photodynamic therapy

4. Systemic drugs e.g. retinoids, immunosuppressants, biological drugs

5. Specialised surgery e.g. Moh’s micrographic surgery

By the end of the course you should also have an understanding of the following:

Investigations available in dermatology e.g. skin biopsy, patch testing etc.

Structure and function of the skin and its appendages.

The principles of the skin immune system in the pathogenesis of disease and cancer.

The clinical features of common skin diseases.

The psychosocial impact of skin disease on patients lives.

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Study Guide During your attachment, please do not expect to encounter all the conditions listed but be assured that they will be covered in the lectures. You do not have to know all about every dermatological condition but it is very important that you learn to describe skin conditions accurately and recognise important common diagnoses such as skin cancer etc. There is considerable overlap between Dermatology and most other specialities, including general medicine, paediatrics, general practice, rheumatology, oncology and surgery. You will get the most out of your dermatology attachment if you try to put into context the patients you see with us. Try to clerk and present as many new patients as you can, and formulate a differential diagnosis and management plan.

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The following conditions are suggested as the basis for a study guide:

Inflammatory disorders

Eczema (atopic, contact, varicose, discoid) Acne and rosacea

Psoriasis Lichen planus

Pityriasis rosea

Blistering conditions

Bullous pemphigoid Pemphigus vulgaris

Skin and systemic disorders

Hair loss Acanthosis nigricans

Nail changes (e.g. psoriasis, fungal) Drug eruptions

Erythema nodosum Pyoderma gangrenosum

Erythema multiforme Urticaria

Leg ulcers

Infections

Bacterial e.g. Impetigo, cellulitis, erysipelas Infestations e.g. scabies

Viral e.g. VZV / HSV/ HPV Tropical e.g. larva migrans

Fungal e.g. Tinea, candida

Dermatological emergencies

Erythroderma Toxic epidermal necrolysis

Stevens-Johnson Syndrome Pustular psoriasis

Autoimmune and connective tissue

Vitiligo Dermatomyositis

Vasculitis Lupus erythematosus

Neoplasia

Malignant melanoma Benign skin tumours e.g. dermatofibroma, seborrhoeic keratosis

Basal cell carcinoma

Squamous cell carcinoma Naevi and birthmarks

Lecture Schedule The lectures are broadly focussed around the study guide above and occur in the blocks during the introductory week and the final week of the block. One of the session contains a revision lecture. Clinical Teaching You will be allocated 2 consultant-led and 2 GP clinics (although this might vary).

Assessment

Dermatology will be assessed as part of the end of year written paper and OSCE. Useful Contacts Academic Leads for Dermatology & Whittington Site Leads: Dr Adam Friedmann & Dr Natasha Kapur

UCLH Site Lead for Teaching: Dr Susie Morris

RFH Site Lead for Teaching: Dr Mark Griffiths

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MODULE 5A RECOMMENDED READING Paediatrics Suitable undergraduate textbooks include:

Crash Course Paediatrics; 3rd Edition, Bhakthavatsala and Neurson, 2008

Essential Paediatrics; Hull and Johnston, 4th edition, Churchill Livingstone,

2000.

Illustrated Textbook of Paediatrics; 4th Edition Lissauer and Clayden, Mosby,

2011.

Paediatrics; 2nd Edition, Waterston, Helms and Ward Platt, OUP, 2005

Training in Paediatrics: The Essential Curriculum; Gardiner, Eisen and Murphy, OUP, Oxford, 2009

There is also a growing list of material related to paediatrics available on the internet. Links to several of the better sites are provided on our own intranet site via: http://www.ucl.ac.uk/moodle

General Practice

We suggest you select some of the following books. Most of them are not too expensive, and are available in the Royal Free library:

General Practice at a Glance - At a Glance; Booton P, Cooper C, Easton G, Harper M. Wiley, 2012

A Textbook of General Practice; Stephenson A. Arnold, 2011.

Churchill’s Pocketbook of General Practice; Cartwright S & Godlee C. Churchill Livingstone, 2008.

Communication Skills for Medicine; Lloyd M and Bor R. Churchill Livingstone,

2004.

Oxford Handbook of General Practice; Simon C, Everitt H &Van Dorp F. Oxford

University Press, 2009.

Symptom Sorter; Hopcroft K and Forte V. Radcliffe Medical Press, 2007.

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A Text Book of Family Medicine; McWhinney I R. Oxford University Press,

2004.

The Successful Registrar’s Companion to General Practice; Rosenthal J,

Naish J, Singh S & Neighbour R. Churchill Livingstone, 2003.

GP Websites

There are numerous websites related to general practice and quality is variable often with commercial interests affecting content. We do recommend that all students browse the internet to see the sort of information which is available both to patients and to health professionals. In particular the following may be useful:

NHS Direct on: http://www.nhsdirect.nhs.uk/

Department of Health website on: http://www.dh.gov.uk/

Doctors.net.uk on: http://www.doctors.net.uk/

NICE on: http://www.nice.org.uk/

Dermatology

It is expected that students will have read the introductory chapters of one of the recommended texts below prior to embarking on the attachment to familiarise themselves with basic terminology and to make the best use of the short time they are attached to the department.

You should bring a copy of one of these recommended texts with you to dermatology clinics for ease of reference:

Dermatology, An Illustrated Colour Text; Gawkrodger, D. Churchill Livingstone, 2002.

Clinical Dermatology; Hunter, J, Savin, J. and Dahl, M. Blackwell, 2002

Clinical Dermatology; MacKie, RM. Oxford University Press, 1996