Students Guide ACUTE CARE

STAGE 3 UMMP ACUTE
CARE STUDENTS GUIDE

2015/2016
Faculty of Medicine,
University of Malaya
Contents
INTRODUCTION .........................................................................................................................................3
COURSE LEARNING OUTCOME ............................................................................................................ 5
STUDENTS CLINICAL RESPONSIBILITY ................................................................................................. 7
Clinical duties .......................................................................................................................................... 7
Independent active learning................................................................................................................ 7
On call duty .............................................................................................................................................. 8
Clinical area teaching ............................................................................................................................. 8
RECOGNITION OF THE CRITICALLY ILL OR DETERIORATING PATIENT ......................................... 8
MANAGEMENT OF THE CRITICALLY ILL PATIENT ............................................................................. 10
KEY READINGS AND REFERENCES.......................................................................................................... 11
PROCEDURES TO BE OBSERVED DURING THE ACUTE CARE POSTING ........................................... 11
PROCEDURES TO BE PERFORMED DURING THE ACUTE CARE POSTING ...................................... 12
MAXIMISING YOUR LEARNING IN THIS BLOCK .................................................................................. 12
LEARNING ACTIVITIES......................................................................................................................... 12
EDUCATION DAY LECTURES (WHOLE-CLASS) ............................................................................ 12
MINI-LECTURES (WITHIN THE POSTING) .................................................................................... 13
SEMINARS .......................................................................................................................................... 14
CLINICAL AREA TEACHING ............................................................................................................. 15
CLINICAL REASONING SESSIONS ................................................................................................... 16
TIME TABLE .............................................................................................................................................. 20
SUCCEEDING IN YOUR ASSESSMENTS .................................................................................................. 21
End of Posting Assessments ................................................................................................................... 21
PPD Component .................................................................................................................................... 21
Written Component ................................................................................................................................ 21
Clinical Component ................................................................................................................................22
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2014 UNIVERSITY OF MALAYA MEDICAL PROGRAMME
INTRODUCTION
Welcome to the Acute Care posting.
This exciting posting lays down the framework for the student to deal with the ill person who
presents acutely and often lacks clear, differentiating symptoms and signs. Experience in the
Anaesthesiology Department and the Trauma and Emergency Unit, in the company of a practicing
clinician, exposes the student to a multitude of scenarios, ranging from the person with troubling but
benign symptoms to a seriously sick person who may be close to death and requires immediate
remedial treatment. Further skills, not only of a practical nature such as airway management or
obtaining adequate venous access, but also important applications of previously learnt
pharmacology and physiology principles will be taught in the Anaesthetic environment.
The Acute Care Posting will be spent in the Trauma and Emergency Unit where commonly the
sickest patients in a hospital are to be found. In addition to revising basic resuscitation principles
already covered during the Stages 1 and 2, there is a focus on learning how to manage people with
complex medical problems, frequently involving multiple body systems. Special emphasis is placed
on the need for teamwork in caring for such patients.
For the Acute Care Posting, management extends beyond the patient, where close relatives and
friends are faced with their loved one being in a calamitous situation. The student should be
prepared to experience the challenges of dealing with a grieving family, unprepared for the possible
and often sudden death of a family member.
It can be seen that the Acute Care Posting brings together the disciplines of Emergency Medicine
and Anaesthesiology, offering the keen student a richness of experience and learning. The acute
and often unexpected nature of medicine found in this posting occurs at any time of day or night,
and the enthusiastic student would be welcomed by any of the teams should they wish to spend
extra time on the floor at night or weekends.
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COURSE LEARNING OUTCOME
Knowledge and 1. Acquire and/or deepen the knowledge and comprehension

Comprehension of the principles of Anaesthesiology and Emergency Medicine
2. Integrate the knowledge of basic clinical science in
Anaesthesiology and Emergency Medicine and recall
transferable knowledge.
Clinical skills 1. Able to interview a patient and obtain relevant information

(critical thinking & for diagnostic purposes and other clinical management.
problem solving) 2. Able to perform physical examination and able to identify
signs.
3. Able to analyse and correlate symptoms and signs in order to
make a clinical hypothesis (differential and provisional
diagnosis).
4. Able to identify and select appropriate investigations (based
on safety, specificity and sensitivity and cost-effectiveness)
for diagnostic purposes, monitoring progression of a
pathology and treatment response.
5. Able to design a treatment plan for current illness (based on
safety, efficacy and specificity and cost benefit)
6. Able to design a plan for rehabilitation and prevention.
Communication skills 1. Able to speak and ask appropriate questions for intended
purposes during a patients interview
2. Able to advise a patient in regards to treatment plan and
option of treatment.
3. Able to educate a patient in regards to prevention and
treatment.
4. Able to present a case and differentiate different types of
presentation in different scenarios (exam scenario, service
round or referral).
5. Able to compose relevant text, organise their knowledge,
ideas and thoughts; and choose the relevant information for
oral presentation.
Procedural skills 1. Able to understand a procedure *(knowledge)

2. Able to explain a procedure (as a presentation or to educate
a colleague or a patient) *(communication skills)
3. Able to perform a taught procedure and repeat it in a similar
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manner
4. Able to apply transferable skills (procedure)
Professionalism 1. Have an insight about ones limitation.

2. Understand and adhere the medical ethics.
3. Behave appropriately (professionally) as what the profession
and the society expected.
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STUDENTS CLINICAL RESPONSIBILITY
Clinical duties
Independent active learning
It is compulsory for all students to participate in clinical duties. Failure to fulfill the minimum
requirements of clinical duties are UNACCEPTABLE; and students may be barred from
Assessments.
Clinical duties begin at 7.00 am to 5.00 pm every day (except public holiday and for on-call
students).At the beginning of each posting, an orientation will be conducted by the Clinical
Departments. During the orientation, each student will be briefed on their duties and responsibilities
in the clinical service area. Students are responsible to appoint a leader, assign patients to assist
with the clinical learning and procedural skills (refer to E-logbook). While performing clinical duties,
students will be assessed on their soft skills and procedural skills as part of the Assessments.
Students in each clinical posting shall be divided into groups (see table).
During these independent active learning sessions, students shall have the opportunity to:
1. Observe, learn and assist in performing a clinical procedure (refer to log book) in the
assigned clinical area.
2. Participate in clinical service ward rounds, clinics, daycare or procedure rooms
3. Observe how the clinical services are conducted and executed by health care personnel
(consultants, clinical specialist and lecturer, medical officers, house officers, nurses and
other health care worker), focusing on their soft skills in managing patients.
4. Make a comparison and understand each of their roles in the patients management.
5. Learn and practice soft skills principally the leadership, teamwork skills and the differences
in communication methods.
6. Learn the administrative aspects of the health care system and understand its purpose and
limitations.
i. Admission system
ii. Appointment system
iii. Financial and economics in the health care system such as payment and
subsidy
iv. Discharge system, follow up and case summary
v. Patients feedback on clinical services, complaints and medico legal issues.
vi. Referral system (verbal or written)
vii. Information technology and retrieving investigations result
viii. Risk management and damage-control procedure in health care system
ix. Patients record keeping system
x. Audit and quality control
xi. Ethics, Good clinical practice and evidence-based medicine
While participating in clinical duties, students shall learn the roles of
i. Nurses
ii. Pharmacist
iii. Rehabilitation health workers (e.g. Physiotherapist, Occupational therapist)
iv. Dietician and nutritionist
v. Social worker
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On call duty
An appointed group leader is responsible to draft an on call schedule and assign each student for
on call duties. Each student is required to complete (successfully) a minimum of 4 on-call duties
(which includes a public holiday) throughout their posting. The on-call duty starts from 5 pm
onwards till 7 am the next morning.
Clinical area teaching
Clinical Area Teaching is a formal guided learning where students may be quizzed and assessed.
Bedside teaching must be carried out every day for each different group. A student from each group
will be required to present a case allocated previously by an academic staff. In this session,
students will learn how to manage patients, not just their diseases.
1. Diagnostic planning
2. Interview and obtaining chief complaint and relevant symptoms from history
3. Examine a patient and identify relevant signs.
4. Interpret and correlate between symptoms and signs to achieve clinical hypotheses.
5. Choose investigations/studies to confirm/narrow down differential diagnoses
6. Learn to make a diagnosis based on ICD 10 codes.
7. Learn the technique to inform patient about their diagnosis and option of treatment.
a. Treatment planning
b. Psychosocial health
c. Rehabilitation
d. Patients education and prevention
e. Execution of plans
RECOGNITION OF THE CRITICALLY ILL OR DETERIORATING PATIENT

It is IMPORTANT that you start learning how to recognize a deteriorating or critically ill patient.
You also need to develop a sense of when you need to call for help from senior medical staff.
A good way to approach this assessment and management of problems that need urgent attention is to
prioritise the order in which you do your assessment, and you manage the problems in the same order,
often at the same time as you discover them. You will see examples of the way assessment and
management are prioritised and carried out simultaneously throughout the term eg a trauma team response,
MET team or Code Blue response, resuscitation in the Trauma and Emergency Unit.
A good acronym is ABCD; and it stands for
Airway
Is the airway open? Look, listen and feel for airway obstruction
Are the airway reflexes working? Assess if the cough and gag reflexes are effective
Breathing
What is the respiratory rate?
Is the oxygenation adequate? (Use pulse oximetry)
Are the chest movement and breath sounds symmetrical?
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Circulation
Look for evidence of poor tissue perfusion, such as cold peripheries, increased time for
capillary refill, mottled skin, tachycardia, low blood pressure (not always present), oliguria,
confusion and loss of consciousness.
Pay particular attention to the heart rate and the JVP (as an estimate of preload) and
temperature of the peripheries (as an estimate of the total peripheral resistance)
Disability
Refers to the level of consciousness (assessed by the Glasgow Coma Scale), and the
presence of focal neurological signs (example: weakness/change in motor signs on one side
of the body)
This means that you start with assessment of the airway, and start to deal with the airway problems before
you move on to assessment of the adequacy of breathing, and so on.
While you are assessing a seriously ill patient, you also need to estimate how ill the patient is, and how
much time you have for investigation before starting supportive treatment. There is rarely time to take a
full history or perform a detailed examination before starting treatment if someone is critically ill. The diagnosis
is usually only a 'best guess' for some time after you have started treatment.
You do not need a diagnosis to start some essential treatment for problems that you have identified with
the airway, breathing, or circulation.
Often you concentrate on the information that is required to make the next treatment decision on a 'best
guess' basis, and fill in the gaps of history and examination later. The corollary is that the working diagnosis
needs to be repeatedly reassessed as more information becomes available and on the basis of response to
treatment.
The severity of illness is often best judged by assessing the compensatory response to the primary
abnormality. This usually involves activation of the sympathetic nervous system in proportion to the severity of
the disease, and thus includes an increase in heart rate, increase in blood pressure, increase in respiratory
rate, reduction in peripheral perfusion (increased capillary refill time), coldness of the peripheries, and so on.
Increase in respiratory rate is a very useful sign of illness severity even if there is no lung primary pathology.
Likewise, a marked reduction in conscious state might reflect inadequate brain function secondary to poor
perfusion, hypoxaemia or metabolic abnormalities rather than primary neurological disease.
There are groups of patients who cannot mount a sympathetic response (e.g. those on medications such as
-blockers), or with significant co-morbidities, who cannot sustain a response to sympathetic stimulation
(e.g. heart failure).
Decompensation of the sympathetic response indicates very severe disease (particularly in young fit
patients), and would be shown by a fall in heart rate, fall in blood pressure, slowing of the respiratory rate.
These patients with slow breathing and heart rate are often pre-arrest.
Beware of patients who are at limit of their ability to compensate.
There are many cues that we can use to recognize a critically ill patient. Hospitals that have a Medical
Emergency Team (MET) will also have a published set of warning signs that can act as a trigger to call the
MET. While these calling criteria might vary slightly in each hospital, they are all based on the premise that a
patient who is deteriorating will have a degree of physiological dysfunction that can be picked up by routine
nursing observations.
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Sample Criteria for a MET call
Parameter Values
Blood pressure Systolic < 90mmHg or mean BP < 70mmHg
Heart rate > 140 or < 50/min
Oxygen saturation (SpO2) < 90% despite additional oxygen
Respiratory rate > 30 breaths/min or < 8 breaths/min
Conscious level GCS < 12, or acute drop by 2 GCS points
Urine output < 0.5ml/kg/hour
Worried nurse Concerned experienced nurse
If a patient fulfils one or more MET criteria, you should call for senior medical help, because the
problem should be assessed and managed as soon as possible.
However, these MET criteria are fairly sensitive and not terribly specific when they are considered in
isolation. Most but not all patients who are deteriorating will fulfil one or more MET calling criteria at some
stage, but most patients who fulfil criteria will not be transferred to the High Dependency Unit or the Intensive
Care Unit, and stay on the general ward.
MANAGEMENT OF THE CRITICALLY ILL PATIENT
Certainly on the wards, as a junior medical officer, you will often be the first person called by nursing staff
when a patient starts to deteriorate. Therefore, it is equally important that you start to develop the ability to
manage the problems associated with critical illness that need urgent attention, often before you have
reached an understanding of the diagnosis of the condition. Definitive treatment must wait on a diagnosis,
management of severe problems with ABCD cannot.
The non-specific goals of management will be:

Open the airway
Restore adequate gas exchange (ie give oxygen and remove carbon dioxide!)
Restore cardiac output and organ perfusion
Opening the airway

Start with simple manoeuvres, such as head tilt, chin lift, jaw thrust if the patient is
unconscious.
Use an oropharyngeal / nasopharyngeal airway if the patient will tolerate it.
Suction the oropharynx.
Further airway management such as endotracheal intubation requires skilled help, call for help
early!
Management of a problems with breathing and gas exchange

Sit the patient up as much as possible
Give extra oxygen, sufficient to get the SpO2 > 90% (this applies to ALL patients, even those with
COPD and hypercarbia)
Progressive severe hypercarbia and respiratory acidosis will require mechanical ventilation (do not
remove the supplementary oxygen!)
Diagnose and treat the underlying cause
Management of a problem with the circulation

Intravenous fluid therapy is almost always appropriate, using a colloid or a crystalloid suitable for
resuscitation (balanced salt solution such as Hartmanns or Plasmalyte -or- normal saline). The
amount of fluid given and the speed of administration depend on the suspected underlying problem.
For hypovolaemic or distributive shock, a crystalloid bolus of 10-20ml/kg over 30 minutes might
be appropriate. For cardiogenic shock, a bolus 100-200ml crystalloid would be appropriate.
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The bolus is repeated as necessary, based on the response (signs of peripheral perfusion and blood
pressure) and the development of signs of fluid overload.
Treat any primary arrhythmia.
Management of the comatose patient

Check the blood glucose urgently.
In most cases, a CT scan will be required, but the urgency of the CT scan will depend on the likely
diagnosis. For example, a patient with suspected intracranial haemorrhage will have an urgent CT
scan; if meningitis were suspected, the CT scan would follow blood cultures and administration of
antibiotics.
In general, patients who are unconscious should be placed in the recovery position unless there
are concerns about spine damage.
Patients with a GCS of < 9 that is not likely to improve quickly will often undergo endotracheal
intubation to protect their airway from macro-aspiration.
The ABCD assessment needs to be repeated at frequent intervals until the patient is stable. A
medical officer should remain at the bedside until the patient is stable.
KEY READINGS AND REFERENCES
The SAFE Study Investigators. A Comparison of Albumin and Saline for Fluid Resuscitation in the
Intensive Care Unit. New England Journal of Medicine 2004; 350: 2247-56.
This is a landmark paper dealing with fluid resuscitation
Danis M, Federman D et al. Incorporating palliative care into critical care education: Principles,
challenges, and opportunities. Critical Care Medicine 1999; 27: 2005-2013
A paper that describes some of the ways to approach death and dying in the Intensive Care Unit
PROCEDURES TO BE OBSERVED DURING THE ACUTE CARE POSTING
Procedures to Observe
Oxygen Therapy
Basic Airway Management : Airway Maneuvers, Airway Adjuncts, Bag-Valve-Mask-
Ventilation
Non-invasive Ventilation
Endotracheal Intubation
Electrical Therapy Defibrilation, Synchronised Cardioversion, Transcutaneous Pacing
Chest tube insertion
Delivering Resuscitation Drugs
Bedside Ultrasound
Pericardiocentesis
Central Venous Cannulation
Thoracocentesis
Abdominal Paracentesis
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Foreign Body Removal
Dislocation Reduction
Intraossesus Cannulation
Lumbarpunture
PROCEDURES TO BE PERFORMED DURING THE ACUTE CARE POSTING
Procedures to Perform
Cardiopulmonary Resuscitation
Venous Cannulation
Urinary Catheterisation
Nasogastric Tube Insertion
Arterial Puncture
Cervical Spine Immobilisation
Splinting
Infiltration of Anaesthetic Agent
Toilet and Suturing of Wounds
Nebuliser
MAXIMISING YOUR LEARNING IN THIS BLOCK
LEARNING ACTIVITIES
EDUCATION DAY LECTURES (WHOLE-CLASS)
Disaster Management
To discuss key concepts of principles of on-site disaster management and hospital
phase activation
To describe common types of disaster
To describe the relationship of disaster phases
Pre-hospital Care and Triage

To describe the model of an effective PHC
To compare the anglo-american and franco-german models and their applications in
Malaysia
To discuss the concepts of Malaysian Emergency Response Service (999)
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To critique the PHC model in Malaysia based on current literature
MINI-LECTURES (WITHIN THE POSTING)
Basic Life Support
To understand the critical concepts of high-quality CPR

To understand and apply The American Heart Association Chain of Survival
To perform 1-Rescuer CPR and AED for adult, child, infant
To perform 2-Rescuer CPR and AED for adult child and infant
To understand and apply bag-mask techniques for adult, child, infant
To perform rescue breathing for adult,child, infant
To be able to manage choking for adult, child and infant
To be able to perfrom CPR with an advanced airway
Advanced Life Support

To be able to recognize and manage respiratory and cardiac arrest
To be able to recognise and manage peri-arrest conditions
Airway management
To be able to apply related pharmacology
To understand and practice effective communication as a member and leader of a
resuscitation team
To understand and apply Effective Resuscitation Team Dynamic
Trauma Life Support
Demonstrate the concepts and principles of primary and secondary surveys

Establish management priorities in a trauma
Initiate management as necessary in the primary and secondary surveys within the
golden hour
Demonstrate important skills necessary in managing life-threatening injuries which are:
Primary and secondary assessment
Establishment of a patent airway and initiation of assisted ventilations
Endotracheal intubation
Pulse oximetry and capnometer
Cricothyroidotomy
Recognition and management of trauma patients in hypovolaemic shock
Venous and intraosseous access
Pleural decompression via thoracocentesis
Recognition of cardiac tamponade and management
Clinical and radiographic identification of thoracic injuries
Use of FAST and CT in abdominal injuries
Evaluation and management of patients with traumatic brain injury
Protection and evaluation of spinal cord
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Wound Management
To understand the principles of wound healing
To be able to assess wounds according to type and degree of contamination
To learn various methods of managing wound according to wound classification
To have hands-on experience on wound irrigation and suturing
To be able to formulate a proper disposition plan for the various wound classifications
Toxicology
Be able to identify and have a basic knowledge framework on the initial presentation
and management of a poisoned position
( airway,breathing,circulation,disability,exposure apporoach)
Be able to define toxidromes for patients with sympathomimetic,opioid,cholinergic and
anticholinergic poisoning
Be able to discuss the roles and rationale of decontamination of a poisoned patient
Be able to describe the roles and rationale of antidotes
Enviromental Emergencies
Snake bite:
To describe the classess and features of snakes in Malaysia
To identify the venomous snakes according to characteristics of envenomation
To understand snake venom and the role of anti-venom
To discuss on general and specific management of snake bite
Heat emergencies:
To understand the classification of heat emergencies:
Heat oedema,heat cramps,heat tetany,heat syncope,heat exhaustion,heat stroke
To discuss on mechanisms of heat transfer and pathophysiology of heat injury
To describe on clinical features of presentation of heat emergencies
To discuss on heat stroke and its management
SEMINARS
Needle Stick Injury

To understand needle stick injury definition, risks predisposing, risks of infection (Hepatitis
and HIV)
To be aware of prevention of needlestick or sharps injury
To be aware of the necessary steps to be taken in the event of needlestick or sharps injury
first aid, informing person-in-charge, seeking treatment
Understand the treatment for high- and low-risk exposures
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CLINICAL AREA TEACHING
Mechanical Ventilation
To understand fundamental physiological principles of mechanical ventilation including lung

volumes, mechanics of ventilation, A-a gradient, ventilation-perfusion ratio and pressure-
volume relationship
To understand the indications and contraindications of mechanical ventilation
To understand basic concepts of mechanical ventilation
To familiarise students with the a mechanical ventilator
To develop knowledge of initial ventilator settings
To understand the principles of lung protective strategy
To be able to adjust ventilator settings for specific diseases e.g. COPD, asthma etc
To be able to interpret arterial blood gasses following the initiation of mechanical
ventilation
To be able to adapt mechanical ventilator settings to ventilation issues provided by the
arterial blood gas
To understand complications associated with ventilation, and how to manage those
complications
To develop awareness of the importance of continuous monitoring of ventilated patients
To develop knowledge of post-intubation care
FAST
To understand the physics of ultrasound

To improve understanding on the knobology of an ultrasound machine
To improve understanding on the different types of ultrasound probes
To understand ultrasound orientation
To obtain knowledge on ultrasound anatomy specific to FAST scan
To understand the surface anatomy for probe placement
To develop the skills in order to perform FAST
To develop the skills to improve ultrasound visualisation including probe movements (ART)
To be able to identify a FAST positive scan
To understand the implications of a positive FAST including immediate emergency management
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CLINICAL REASONING SESSIONS
Sessions will be anchored on the Clinical Reasoning Sessions (CRS) with a seminar series and learning
topics. CRS are led by a student with the backup of an appropriately qualified supervisor.
The aim of the clinical reasoning session will be to:
1. Develop skills in clinical reasoning: creating hypotheses about the nature, cause and type of
disorder with which patients are presenting
2. Develop understanding of the clinical features of a particular disorder.
3. Develop skills in applying a biopsychosocial model of the disorder with an emphasis on
identifying biopsychosocial factors that:
a. predispose an individual to that particular disease
b. will trigger or precipitate the onset of the disorder and will maintain or perpetuate
symptoms
4. Develop understanding of the comprehensive, biopsychosocial management of the
disorder, particularly how it relates to the patient.
5. Apply this understanding to the individual whose case has been presented, by developing a
tailored formulation and management plan
Timing of the clinical reasoning sessions (including EBM component)
Session 1 /First half of CRS:

Identified student/s to present a patient, and facilitate discussion about the patient, clinical
features, background and risk factors, differential diagnoses, how the risk factors may lead
to symptom formation, and diagnostic formulation (60 minutes).
Allocation of learning tasks (15 mins).
Session 2/Second half of CRS:

Feedback on student learning and discussion about learning topics (30 minutes)
Evidence based medicine presentations (15 minutes per student)
Discussion about the optimal management of the patient (30 minutes)
Future direction and research issues
No Topic
1 General approach to the patient Demonstrate a systematic approach to the

presenting to the emergency clinical assessment of patients presenting to
department with shortness of breath the emergency department with shortness of
breath (SOB)
List the five most common life-threatening
causes of SOB presenting to the emergency
department
Identify the symptoms and signs for patients
presenting to the emergency department with
life-threatening causes of SOB
Describe the common diagnostic tools used
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in the emergency department to help
differentiate between the common life-
threatening causes of shortness of breath
Interpret the results of the investigations
used as diagnostic tools in the emergency
department
Discuss the initial management of patients
SOB
2 General approach to the patient List the five most common life-threatening
presenting to the emergency causes of chest pain presenting to the
department with chest pain emergency department
Identify the symptoms and signs found in
patients presenting to the emergency
department with life-threatening causes of
chest pain
threatening causes of chest pain
department
chest pain
3 General approach to the patient
presenting to the emergency Demonstrate a systematic approach to the
department with abdominal pain clinical assessment of patients presenting to
the emergency department with abdominal
pain
List the five most common life-threatening
causes of abdominal pain presenting to the
emergency department
life-threatening causes of abdominal pain
threatening causes of abdominal pain
department
abdominal pain
4 General approach to the patient List the five most common causes of life-
presenting to the emergency threatening altered mental status (AMS)
department with altered mental status presenting to the emergency department
a life-threatening case of AMS
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threatening causes on an AMS
department
Discuss the initial management for patients
an AMS
Discuss the recognition and initial
management of common drug overdoses in
the emergency department
5 General approach to shock Demonstrate a systematic approach to the
clinical assessment of patients presenting to
the emergency department with shock
List the causes of shock presenting to the
emergency department
the different types of shock
differentiate between the different causes of
shock
department
chest pain
Student-Selected CRS Case
We suggest you use this format to facilitate your Clinical Reasoning Session based on the case you have
identified. You can of course use your discretion to reorder headings according to the natural progress of your
case.
Case Presentation
Questions/prompts:
What problem/s is the patient presenting with?

What are the most likely and important conditions to account for the problem/s?(you can add your own
questions/prompts to this list.)
Problem formulation & differential diagnosis
History
Questions/prompts:
What additional history do you need to make each differential diagnosis more or less likely?
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Are there new problems/issues?
What alternatives should be considered?
Examination
Questions/prompts:
What signs on physical examination will make each diagnosis more or less likely?
Are there new problems/issues?
What alternatives should be considered?
Investigations
Questions/prompts:
What special investigations make each diagnosis more or less likely and/or help define the disease
severity?
Working diagnosis
Questions/prompts:
What is my working diagnosis?
Management
Questions/prompts:
If left untreated, what will happen?

What are the available interventions?
What are the benefits and harms of the available interventions?
Disease prevention & health promotion

Questions/prompts:
How could this condition have been prevented?

What factors should be considered regarding this patient's continuing care in the community?
Outcome
Discussion points & learning topics

Questions/prompts:
What discussion points and learning topics do you think arise from this case?
References & websites
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TIME TABLE
Week 1 Week 2 Week 3 Week 4 Week5 Week 6 Week 7 Week 8
Monday Introductio Anaesthesiol Emergency Anaesthesiol Emergency Anaesthesiolo END OF END OF
n ogy mini Mini lecture: ogy mini Mini lecture: gy mini POSTING POSTING
Emergenc lecture: lectures: lecture: ASSESSMEN ASSESSMEN
y Mini Wound Environmental TS TS
lecture: Life-centred management Providing emergencies Managing a
care oxygen patient in acute
BLS Toxicology therapy pain
Managing the
Advanced acutely Preparing the
life support deteriorating pre-operative
patient patient
Trauma life
support
Tuesday EDUCATION DAY
Wednes Seminar: CRS Simulation: Seminar: CRS Simulation:

day
Needle Chest pain Wound Needle prick Chest pain Wound
prick management management
and suturing and suturing
Thursda Simulation CRS CRS Simulation: CRS CRS
y :
Shortness of Altered mental BLS Shortness of Altered mental
BLS breath status breath status
Advanced life
Advanced support
life support
Friday Simulation CRS CRS Simulation: CRS CRS
:
Acute Shock Trauma life Acute shock
Trauma life abdomen support abdomen
support
Attendance (100%) is a course requirement and absences will be noted by your tutor and passed
onto MERDU. Please make immediate contact with your Tutor and MERDU in the event of any
problems relating to attendance. In some instances remediation may be required.
Any student who takes leave from the program may be required to submit a remediation plan
outlining strategies to make up missed structured teaching and clinical learning along with a
justification for their absence. This is to be submitted to your Tutor and the Head of Department.
You may have to repeat the term if it is deemed that you have inadequate attendance.
Appropriate documentation MUST be submitted for any non-attendance
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SUCCEEDING IN YOUR ASSESSMENTS
End of Posting Assessments
Assessments in Stage 3.1 consists of Formative And Summative Assessments for each posting
(End of Posting Assessments). The formative and summative assessments are based on the four
themes; namely Basic and Clinical Science (BCS), Patient-Doctor (Pt-Dr), Population Medicine
(PopMed) and Personal and Professional Development (PPD).
The End of Posting Assessment is divided into PPD, Written and Clinical Components. The results
to be allocated for each Component shall be as follows:
Component Mode of Examination Results
PPD Assignment/Project Satisfactory/Unsatisfactory

Written Written Pass/Fail
Clinical Clinical Pass/Fail
End of Posting Assessments are used to evaluate student learning, skill acquisition, and academic
achievement at the end of each posting. It certifies competence at a particular point of the program
or for graduation.End of Posting Assessments represents a barrier that a student must pass in order
to progress within the program or to graduate.
PPD Component
PPD Component comprises of:
1. PPD Teaching Evaluation Exercise

Students will be required to evaluate all UMMP teaching and learning sessions for a
designated period of time.
The Teaching Evaluation Exercise will be conducted throughout the stage.
This task will be completed online.
2. PPD Attitude Evaluation

The PPD attitude evalution comprises of Attendence, E-logbook, Attitude Evaluation
The PPD attitude evaluation includes enthusiasm and participation, rapport with
colleagues, staff and patients, overall professional attitude and attendance
Written Component
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A written task is designed to assess students competence of relevant themes within a posting.
Written tasks also allows identifying of students who do not demonstrate the level of competence
required to progress to the next stage, and students who require remediation and reassessment.
Summative Written Assessment for the End of Posting Assessments are as follows:
Summative Posting Theme Format

Assessment
60 Single Best
End Of Posting Acute Care All Themes Answers (SBA)
(Written) and/or Extended
Matching
Questions (EMQ)
Clinical Component
A clinical task allows students to perform a supervised focused clinical investigation of a real patient
or standardized patient. The clinical task is primarily used to assess students basic clinical skills
and competency. The Summative clinical assessments for the End of Posting are as follows:
Summative Posting Theme Format

Assessment
4 OSCEs
End Of Posting Acute Care Patient-Doctor
(Clinical) (Pt-Dr)
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Students Guide ACUTE CARE

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Students Guide ACUTE CARE

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STAGE 3 UMMP ACUTE

CARE STUDENTS GUIDE

Knowledge and 1. Acquire and/or deepen the knowledge and comprehension

Clinical skills 1. Able to interview a patient and obtain relevant information

Procedural skills 1. Able to understand a procedure *(knowledge)

Professionalism 1. Have an insight about ones limitation.

Independent active learning

While participating in clinical duties, students shall learn the roles of

Clinical area teaching

RECOGNITION OF THE CRITICALLY ILL OR DETERIORATING PATIENT

A good acronym is ABCD; and it stands for

Beware of patients who are at limit of their ability to compensate.

MANAGEMENT OF THE CRITICALLY ILL PATIENT

The non-specific goals of management will be:

Opening the airway

Management of a problems with breathing and gas exchange

Management of a problem with the circulation

Management of the comatose patient

KEY READINGS AND REFERENCES

PROCEDURES TO BE OBSERVED DURING THE ACUTE CARE POSTING

PROCEDURES TO BE PERFORMED DURING THE ACUTE CARE POSTING

MAXIMISING YOUR LEARNING IN THIS BLOCK

EDUCATION DAY LECTURES (WHOLE-CLASS)

Pre-hospital Care and Triage

MINI-LECTURES (WITHIN THE POSTING)

Basic Life Support

To understand the critical concepts of high-quality CPR

Advanced Life Support

Trauma Life Support

Demonstrate the concepts and principles of primary and secondary surveys

Needle Stick Injury

To understand fundamental physiological principles of mechanical ventilation including lung

To understand the physics of ultrasound

Timing of the clinical reasoning sessions (including EBM component)

Session 1 /First half of CRS:

Session 2/Second half of CRS:

1 General approach to the patient Demonstrate a systematic approach to the

Student-Selected CRS Case

What problem/s is the patient presenting with?

Problem formulation & differential diagnosis

What is my working diagnosis?

If left untreated, what will happen?

Disease prevention & health promotion

How could this condition have been prevented?

Discussion points & learning topics

References & websites

Wednes Seminar: CRS Simulation: Seminar: CRS Simulation:

Appropriate documentation MUST be submitted for any non-attendance

End of Posting Assessments

Component Mode of Examination Results

PPD Assignment/Project Satisfactory/Unsatisfactory

Clinical Clinical Pass/Fail

PPD Component comprises of:

1. PPD Teaching Evaluation Exercise

2. PPD Attitude Evaluation

Summative Posting Theme Format

Summative Posting Theme Format

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