Uwo clerkship manual

Interestingly, even though lower-performing students demonstrated the greatest post-test improvement, they still left each rotation with knowledge deficits compared to their highest-performing peers. Thus, while they did not catch up to their highest-performing peers, the clinical experience of clerkship appears to be most beneficial for lower-performing students. With a strong basic science foundation being necessary for the successful practice of medicine, there is a need for an educational model that ensures students are competent in the fundamentals prior to clinical training.

Thus, the goal of this research was to provide insights into current strengths and potential areas for improvement with respect to UME basic science education. Treatment efficacy derived from opioids may therefore differ, given the mechanism of neuropathic pain from tumor infiltration may be dissimilar from the mechanism occurring in benign neuropathic pain states. Adjuvant analgesics may help to reduce pain intensity further.

Gabapentin is a voltage gated calcium channel antagonist. It is associated with improved pain control, better mood and sleep. Pregabalin is an analogue with a higher calcium channel affinity and much better bioavailability. The major side effect is sedation and tends to subside after a few weeks of use.

NNT number needed to treat is approximately i. A more sedating TCA, i. Otherwise, desipramine or nortryptiline are preferred because of fewer anticholinergic side effects o Neuropathic pain from tumor infiltration often responds to dexamethasone, at least in the short term. Note each treatment must be tailored to the individual patient. More weekly. Common bioavailable than starting dose gabapentin. Venlafaxine Sleep disturbances, Dose Effexor dry mouth, daily to start.

May adjustment in renal constipation, increase weekly by impairment. Cannot be hypertension, Adapted from Gilron, I et al. Neuropathic pain: a practical guide for the clinician. Pregabalin or B. Yes No Consider adding a Monitor regularly for side Cannaboid e. Please refer the reference by Moulin DE et al below 2.

References 1. Gilron I et al. Pharmacological management of chronic neuropathic pain — Consensus statement and guidelines from the Canadian Pain Society.

Lynch ME. A review of the use of methadone for the treatment of chronic non-cancer pain. Pain Res Manag ; Consultation for pain and symptom management in the ambulatory and inpatient oncology settings is provided by the palliative care service for cancer patients.

Admission to the palliative care unit for investigation and management of complex physical, psychosocial or family issues in advanced cancer patients is also available.

Additionally, the palliative care service works closely with family physicians and other community palliative care providers to assist those patients that have chosen to die in the home setting. Patients admitted in this unit are managed by physicians specializing in palliative medicine. These physicians also provide the palliative care consultation service throughout the hospital and see patients in the weekly ambulatory palliative care clinic in the LRCP.

At the University campus there is a 4 bed palliative care unit where patients are managed by community family physicians.

They are supported by a physician specializing in palliative medicine and by palliative nurse practitioners. The palliative care clinician and NPs at University campus also provide consult coverage to the hospital.

Currently there is also a 10 bed palliative care unit at Parkwood Hospital and patients there are cared for by community family physicians. These patients have less acute symptom management needs. Palliative care affirms life and regards dying as a normal and inevitable process. The provision of palliative care is applicable early in the course of illness, in conjunction with other cancer therapies such as chemotherapy or radiation therapy that are intended to prolong life. Palliative care does not hasten or postpone death, but provides relief from pain and other unpleasant and distressing symptoms while offering support to patients and helping their families cope during the course of the illness.

This is generally termed "supportive care", although some oncologists include wider-ranging issues including emotional and spiritual concerns in the definition of this field, overlapping it with palliative care. This chapter will give an overview over the most common complications and symptoms you may encounter in clinical oncology practice. Fatigue: The most common symptom; more prevalent than pain in patients with advanced cancer.

May be due to advancing disease, endocrine abnormalities primary or secondary to disease or treatment , or treatment. Approach: Rule out medical causes anemia, glycemic control, thyroid dysfunction, uremia Rule out depression Counsel: Promote energy conservation not consistently shown to work Evaluate medications Optimize fluid, electrolyte intake Permission to rest - but also promote exercise periods as tolerated Clarify role of underlying illness Consider dexamethasone if disabling; promotes feeling of well-being, increased energy - effect may wane after weeks - taper off as tolerated Methylphenidate?

This is not just starvation, but a state of increased metabolic rate associated with inflammation and loss of appetite. Poor prognosis. Cannot be reversed with feeding alone difference vs. Few interventions shown to be of benefit other than steroids, exercise, and treating the cancer itself; current approaches: Rule out hyperthyroidism rare Exercise Dietician advice to maximise caloric intake Anorexia-treating strategies - frequent small bland meals, avoid strong aromas Dexamethasone appetite stimulant - short term Megace appetite stimulant - longer term but inc.

Gravol is not first line for every cause of nausea. Dopamine antagonists have wider spectrum of action but also have side effects MSK and dose must be adjusted for renal function. Usually continue Dexamethasone and breakthrough PRN x days prophylactically. Weak evidence for serotonin antagonists palanosetron may be better but not available in Canada but commonly used.

Pain - see chapter on cancer pain Mucositis, Xerostomia: Mucositis is an inflammation of the mucosa, most commonly in the mouth.

However, it may occur in other parts of the aerodigestive tract esophagitis, proctitis, etc. The ulcers that form are usually non-infectious in etiology, but may become secondarily infected. Systemic infection can be life- threatening, especially if occurring during an episode of neutropenia. For less severe cases, topical therapy is indicated see below; local protocols can vary. Xerostomia refers to dry mouth, usually as a consequence of radiation to the salivary glands.

Titrate up carefully there is a max dose until symptomatic relief obtained. If asymptomatic, this usually does not warrant therapy. However, if severe, bone marrow suppression can be life-threatening e.

G-CSF is also used in febrile neutropenia complicated by high-risk features hypotension, cultures positive, cancer uncontrolled, change in level of consciousness, pneumonia, etc. Downside: plt refractoriness may develop. If due to bone marrow infiltration low plts have poor prognosis.

Infection C. Diff , neutropenia, and chemotherapy-induced diarrhea can co-exist and be life threatening. Treat with laxatives if no obstruction: Osmotic - milk of magnesia, or lactulose daily to start Once having movements, and stool soft, can add irritant Senna, cascara etc daily for maintenance. Efficacy of stool softeners Docusate sodium [Colace] questionable and definitely not to be ordered PRN, but daily dose of mg works for some patients in combination with other agents.

Dyspnea: May be due to a variety of causes; do not forget the non-malignant ones. Approach: Heart - Lung - Blood [anemia]. Treatment of dyspnea as a symptom in addition to treating the cause of it : oxygen especially if hypoxic, although hypoxia and dyspnea are not always correlated! NB: one may at times be in a situation where consciousness level will be reduced for the sake of symptom relief; discuss with pt and family!!.

Inhaled opioids e. Can use alone or add to opioids. Supportive Care is: The provision of necessary services as defined by those living with or affected by cancer to meet their physical, informational, psychological, social and spiritual needs during prediagnostic, diagnostic, treatment and follow-up phases, encompassing issues of survivorship, palliation and bereavement.

The Supportive Care Department members are integral members of the patient care teams contributing their expertise to help provide holistic care for oncology patients and their families. Social workers and pain and symptom management nurses work both in the Center and on the inpatient oncology floor.

There is a referral form for supportive care with which you can request intervention from the Pain and Symptom Management Team which includes a social worker or Social Work. There is a separate referral for Dietitian intervention.

The social workers and dietitians work on site-specific teams to provide individual, couple and family counseling. Social workers are involved in discharge planning for inpatients and all members of the Supportive Care Department are aware of community resources available to patients and their families.

The Pain and Symptom Management Team have weekly pain and symptom management clinics. Patient or Family Request 2. Problems with Practical Assistance - finances - drug coverage - community resources, i. CCAC has case managers and placement co-ordinators on staff that conduct patient assessments.

CCAC contract service providers to provide professional services in the community such as visiting nursing, complex care nursing, physiotherapy, occupational therapy, speech therapy, social work, and dietician services. Supplementary services include home support services, drug coverage, equipment rental, dressings and payment of emergency transportation costs.

For London, the number is An intake case manager will assist the caller. An on-site case manager completes assessments for in-home services. Due to the high workload, early referrals are requested to better facilitate discharges. To speak to a case manager directly, one can call pager or leave a voice mail at extension Many patients receiving cancer treatment require services through CCAC.

Occupational Therapy and Physiotherapy play a supportive role for many persons with cancer if the effects of cancer have impacted his or her daily activities of life. Once the therapist receives notification of a written consult, he or she will then independently assess, treat, educate and progress the patient to optimize his or her level of functioning within a holistic framework.

The following summaries will identify those signs, symptoms, or issues that may necessitate a referral to the respective therapies. Physiotherapy assesses and prescribes appropriate ambulatory ambulatory aids and progresses mobility as tolerated. There is close collaboration with other members or the health care team especially Occupational Therapy so the gains in physical status may be incorporated with functional activities.

Each patient receives individualized treatment and is progressed as tolerated. People with cancer represent a patient population where quality of life and safety are central to the therapy provided. Individuals at all stages of disease may require nutritional counselling. Many interventions must be individualised, giving consideration to both the theoretical and practical issues relevant to the patient.

With respect to patients who receive radiation therapy, many of them have some degree of malnutrition before they even start treatment; many others develop malnutrition secondary to radiation therapy side effects3.

Specific measurements, such as weight loss and serum albumin, can be useful prognostic indicators. Likewise, if laboratory values are available, hypoalbuminemia may be used to identify patients with an increased risk of morbidity and mortality from cancer and its treatment8. Arnold randomised 50 ambulatory head and neck patients to oral nutrition supplements or no nutrition supplements during their course of radical radiotherapy9. The patients who received no nutrition supplements had a significant reduction in serum albumin compared to the supplemented patients.

This study suggests that more aggressive feeding regimens are needed for head and neck cancer patients. In accordance with this, the need for enteral or parenteral nutritional support should be considered for patients who are no longer able to maintain an adequate oral intake, even with medical nutritional supplements2. These effects may develop during or after treatment is completed. Examples of acute symptoms that have nutritional consequences include nausea, vomiting, anorexia, mucositis, odynophagia, dysphagia, and dysosmia.

As poor nutrition can lead to interruption or discontinuance of potentially curative therapy, patients who are able to maintain or achieve a reasonable nutritional status during treatment are better able to maintain their immunologic integrity and withstand any further cancer treatment3.

A summary of typical nutritional management strategies for the most common symptoms is attached. One-on-one counselling allows patient- specific goals to be developed as part of a nutrition care plan.

Another important factor for quality of life of some cancer patients is their need to explore complementary or alternative therapies for cancer, which often include a nutritional component e.

As a health care provider, patients need to know you have an honest concern for their situation, as well as the time and knowledge to address their needs. It is a time consuming process to discuss unproven nutritional therapies for cancer, but oncology dieticians and pharmacists often have valuable resources that enable patients to make the most informed choices possible.

These resources can also provide the physician with a basis for talking with a patient about the pros and cons of specific therapies. In conclusion, it is important to consider the nutritional status of patients undergoing radiation therapy.

Anticipation of the nutritional consequences of treatment, or intervention for pre-existing malnutrition can help to improve radiation treatment outcomes and reduce patient morbidity and mortality.

Referrals to oncology dieticians can be an important part of this process, and can provide patients with the support they need to effect changes at any time in the cancer care continuum. Chemotherapy medications have narrow therapeutic indices and dose limiting toxicities.

They also oversee the preparation of chemotherapy. As part of the multi-disciplinary team, pharmacists have a significant role in providing drug information to patients and health care professionals.

Pharmacists counsel patients on their medication to maximise compliance and advise patients on the use of complementary and alternative therapies, especially he use of herbal products. Ottery FD. Cancer cachexia: prevention, early diagnosis and management. Cancer Pract. Shils ME. Nutrition needs of cancer patients.

In: Nutrition Management of the Cancer Patients. Ross BT. In: Nutrition Management of the Cancer Patient. Am J Med. Brookes GB. Head Neck Surg. Sem in Onc. Johnson et al. Tayek J. Nutritional and Biochemical Aspects of the Cancer Patient. In: Nutritional Oncology.

Arnold C et al. Cancer Invest. The patient workload in Canada unfortunately does impinge upon time available for research.

About fifty per cent of chemotherapy in the province is delivered outside the eleven cancer centres in Ontario. Some physicians in private practice do a combination of medical oncology, haematology and internal medicine, though the latter are becoming rare.

Elevated in some benign conditions Bolus Tissue equivalent material e. Usually indicated for close or positive surgical margins, or gross residual disease Brachytherapy Radiotherapy at a short distance, e. Occasionally elevated with breast, lung and other adenocarcinomas. A relatively new technology using 3D imaging e. CT, MRI to localize the target, and precise radiotherapy treatment delivery equipment to maximize dose delivered to the target, and minimise dose delivered to normal tissues Cytology A technique to examine small numbers of cells e.

Electrons deposit dose primarily in the superficial tissues, after which the dose falls off rapidly Emetogenic Treatment is associated with nausea and vomiting Gantry A rotatable component of a linac or other radiation generator from which the radiation beam is delivered Hickman catheter A type of central line, with external ports on the chest wall Immunohistochemistry Used by pathologists to identify cell surface markers e.

Considered critical when the ANC absolute neutrophil count is less than 0. This is to verify correct patient setup, and is recorded with film, although some new technologies using electronic media i.

Requires the use of diagnostic imaging modalities eg fluroscopy, computerised tomography Stomatitis mucositis of the mouth Thrombocytopenia Decreased platelet count, commonly seen with oncology treatments. T2N1M0 carcinoma of the breast. Breast A 41 year old woman finds a lump in her breast on breast self exam.

It does not change over 3 monthly menstrual cycles. It is slightly tender, firm and not fixed but not easily mobile throughout this time.

She is a premenopausal, G2P2, otherwise healthy woman. She is adopted. Required Questions: 1. Investigations reveal a diagnosis consistent with breast cancer. What surgical options are available for this patient? What criteria would determine the requirement for adjuvant treatment? What are the options for systemic treatment for this lady?

If she was postmenopausal? List the acute and long-term side-effects of chemotherapy, hormonal therapy and radiation therapy. Two years later this lady presents for regular follow-up with complaints of fatigue, generalized weakness and constipation.

She also has had back discomfort, relieved with tylenol, for several weeks. List the clinical problems and three possible causes. What further questions could you ask in the history to differentiate between these? On review of systems she has had some difficulty walking, with stumbling and is having urinary hesitancy and stress incontinence. On examination CVS is normal, chest normal to percussion and auscultation. Abdominal exam reveals soft non-tender abdomen, no masses but a fullness above the pubic symphysis that is tender to palpation.

Neurological exam shows normal fundi, CN normal, no neck stiffness. Gait is wide-based and awkward. Sensation to pinprick is abnormal to the level of the umbilicus. Finger- nose test is normal but heel-shin is inaccurate.

What possible neurological diagnoses could explain her neurological exam? What imaging techniques would distinguish between the above differential diagnoses? Assume it is a spinal cord compression, how would you manage this problem? At home or in hospital? Therapeutic modalities? The patient asks her prognosis regarding the neurological problems and her survival.

What would you tell her? Urinary Hesitancy A 68 year old man presents with difficulty initiating urinary stream and post-void dribbling. He has had nocturia for 18 months which has worsened from X to X. He has recently retired and been well. He has not seen a physician for many years. What is the differential diagnosis? On digital rectal examination there is a moderately enlarged prostate with a firm nodularity on the left lobe. What other investigations are required?

The PSA is 9; the biopsies show the palpable lesion to contain prostatic carcinoma with a Gleason score of 6; remaining biopsies negative. He is otherwise healthy. These electives, assist students in developing their clinical knowledge and practicing their skills in clinical and community settings outside the teaching centre.

Medical student applicants should be aware that, although there is funding provided for travel and accommodation, they must have access to their own transportation as many of the electives are in communities that are not reached through public transportation.

Electives will be awarded on a first-come, first-serve basis, as there are a limited number of electives available for research and clinical electives only. Distributed Education Richmond Street N. The undergraduate medical curriculum is a four-year program. A course taking place from September to the end of December will support and assess learner competence on key topics in the foundational and specific clinical sciences necessary for critical thinking, problem-solving, and clinical decision-making.

The curriculum will incorporate the social determinants of health, ethics, cultural competence, health promotion and prevention. This and all subsequent courses will be aligned with issues prominent in Canadian health care, especially those applicable to Southwestern Ontario. Body system of Hematology and an introduction to Infectious diseases, Immunology and Microbiology offer clinical application for learning. This course will serve as a secure grounding for learning in other parallel and subsequent Program courses.

Students will be introduced to the grounding for EPAs in demonstrating the tasks of a physician. Each course, January 2 to mid-June of year 1 for Principles of Medicine I and September 2 to end January for Principles II , will support student development of competence in the key principles of body system or medical discipline based learning drawn from existing courses in the present curriculum with first and second year.

Integration of content objectives will occur across the course using a case-based and application model of active learning at the end of course, and with parallel PCCM and subsequent courses Transition to Clerkship and Clerkship.

Curricular competencies learned and assessed in these courses extend beyond medical expert to include all curricular competencies. Course goals are to integrate foundational and clinical sciences with learning related to social determinants of health and social accountability, while establishing competence to enter clinical bedside learning.

Case-based learning will serve as an environment for key integration and competency assessment. Students will see their growth as a clinician in their maturation of effectiveness in the Entrustable Professional Activities. This course examines the process of the doctor-patient interaction. Using a patient-centred approach, instruction is given in interviewing and physical examination.

Clinical reasoning and decision making are explored through the Problem-Orientated Clinical Record. Professionalism and ethics are emphasized as they relate to the clinical setting. Integration of knowledge, application of skills and development of appropriate attitudes are evaluated in this course. An important area of medical education is supporting the development of professional identity in students. This course will span all four years. Spanning February to late June of Year 2, students will be assessed for early clinical competency by clinical immersion in key Clerkship rotations while expanding their decision-making in seminar or small group multi-system or theme based learning.

Another key deliverable will be to support students for their career choices by immersion in mini-rotations of Clerkship. Using a patient-centred approach instruction is given in interviewing and physical examination. Clinical reasoning and decision making is explored through the Problem-Orientated Clinical Record. Students participate in early patient contact that emphasizes a patient-centred approach to medicine, beginning in Clinical Methods in Year 1.

This experience enhances the understanding of the communities where patients live. The weekly timetable is often structured around a case which is introduced at the beginning of each week. The case provides the stimulus for instruction, and is designed to highlight a number of objectives of the MD program.

Throughout the week, the student is exposed to a variety of teaching methods including: small group tutorials, problem-based learning, lectures and large group discussions, self-instructional materials, and laboratories. Time is also provided in the curriculum for students to explore career opportunities. During Clerkship, the student becomes an active member of clinical care teams in the following medical disciplines: family medicine, medicine, obstetrics and gynaecology , paediatrics , psychiatry, and surgery.

Under the supervision of faculty and more senior housestaff , clerks are given graded responsibility in the diagnosis, investigation, and management of patients in hospital, clinic and outpatient settings.