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NEPHROLOGY MODULE: 2007/8

CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE

Course description

Title: Nephrology: Year 4&5 Undergraduate Medicine

Overview
This course is designed to complete the training of the medical undergraduate student
in nephrology within the context of general internal medicine over two rotating 8
weeks clerkships.

Prerequisite
A pass in the MB:BS Phase 1 examination.

Organisation of the Course


The course is taught in two modules
1. Year 4 - at the Eric Williams Medical Sciences Complex (EWMSC), and San
Fernando General Hospital
2. Year 5 - at Port of Spain General Hospital
Depending on availability of personnel and consistent with the service commitment of
the medical teachers involved.

Integration within the Undergraduate Programme in Medical Sciences


Nephrology is one of several components of general internal medicine with which the
student is expected to become familiar over the two final years of undergraduate
training in the Faculty of Medical Sciences and integrates closely with other sub-
specialties including cardiology, cardiothoracic surgery and intensive care medicine.
Over the course of the final 2 years of undergraduate training, students are expected to
become familiar with the management of kidney and urinary diseases within and
across these specialties.

Nephrology as a Discipline within Internal Medicine


The Department of Clinical Medical Sciences is comprised of four units: Adult
Medicine (General Internal Medicine), Paediatrics and Radiology. Nephrology is one
of several disciplines within internal medicine.

Purpose of the Course

The course covers diseases of the kidneys and the urinary system and is often called
nephrology, when the focus is on internal medicine and urology when the focus is on
surgery. Students would be expected to have been exposed to the rudiments of the
examination of the kidneys and history during Phase I training. This course is
designed for students during the final two clinical years of undergraduate medicine.

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At the end of the course, the student will be expected to diagnose and treat the
following major common renal conditions: Acute and chronic renal failure, anuria,
interstitial nephritis, rhabdomyolysis, hepatorenal syndrome, acute upper urinary
tract infections, renal stones and renovascular diseases. The student will also be
expected to understand the differential diagnosis of these conditions and how to
differentiate between these and other medical conditions by laboratory and
radiological investigations.

Letter to the Student

Welcome to the Nephrology component of the Internal Medicine Programme. We


hope that you will see this course as an extension of the learning initiated during your
first three years of training. Whereas in the first year of internal medicine (year 4
undergraduate) we emphasised knowledge of the underlying disease processes and the
acquisition of an accurate history and examination, our emphasis in the final year is
on diagnostic skill, investigation and treatment of common kidney diseases and their
differentiation from other diseases. The best advice we can give you is that learning is
patient-centred and not text-book centred, though your text books will provide a
useful resource. We hope you enjoy your brief time with us in this exciting field.

Contact Information

Tutors: At EWMSC - Dr. T. Seemungal, Dr. D. Coomansingh, Dr. S. Teelucksingh, Dr.


A.L. Nielsen and Associate Lecturers from Thoracic Medicine Unit. At Port of Spain
General Hospital – Dr. T. Seemungal, Dr. S. Teelucksingh and Associate Lecturers
from the Department of Medicine at POSGH
Office: Department of Clinical Medical Sciences, Faculty of Medical Sciences, 2nd
Floor, Building 67, EWMSC, Mount Hope
Contact Phone: Department of Medicine EWMSC 663 4332;
POSGH 623-4030 or ext 2585
E-mail for Dr Nielsen: anielsen@fms.uwi.ttt or anders@lassen-nielsen.com
Content

Signs and Clinical presentation of renal diseases


General observation: Pallor and tiredness, dyspnoea, hydration, bruising, itching and
scratch marks, malaise, confusion, seizure or coma, nausea, anorexia or vomiting.
Hands: nail pigmentation with ‘brown line’.
Pulse and blood pressure: Hypertension.
Face: Yellow complexion and pallor.
Eyes: Hypertensive and diabetic retinopathy.
Lungs: Crackles in fluid overload
Heart: Extra heart sounds, pericardial friction rub.
Abdomen: Inspect scar, palpation of kidney and bladder, sacral oedema. Auscultation
of renal arterial bruits, Rectal examination, prostate enlargement. Ballottement of the
Kidneys.

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Legs: Oedema and peripheral neuropathy.

The student is expected to characterise each of these symptoms by onset (where, when
how), duration and evolution. Common causes of each of these symptoms.

Symptom severity:
Cardiac: Cardiac failure, ECG, pericardial fremitus or murmur, hypertension
Dyspnoea: MRC dyspnoea scale, New York Heart Scale, respiration type
Consciousness: Glasgow Coma Scale
Temperature: With or without peripheral contraction.
Back pain: severity, location of pain in relation to probable cause but even pain
elsewhere.
Urine: Haematuria, protenuria.

Renal History
Past Medical History: importance of comorbidites eg anaemia, cerebrovascular
incidences, hypertension and/or cardiac problems, diabetes, liver problems, dyspnoea,
skin and even recurrent infections.
Intake/output: Importance of amount of fluid intake and loss. Eating habits.
Passing urine: How is it best described? Dysuria, strangury, urgency and frequency,
polyuria, nocturia, oliguria/anuria, incontinence, urge or stress incontinence, nocturnal
enuresis
Drug History: Drug abuse, importance of retrospective diagnosis of renal disease
from the drug history. Adverse effects– ACEIs, Angiotensin receptor antagonists,
NSAIDs. Kidney toxic, Aminoglycosides, amphotericin, lithium, ciclosporin and
tacrolimus, and in overdose paracetamol. Drug for HIV disease.
Allergy history all aspects.
Smoking – definition of a pack year as a measure of smoking burden
Family – genetic basis of some kidney diseases – polycystic kidney disease. Familial
diseases in general.
Social and occupational history: living or working in hot environment. Exposure to
organic solvents, working with aniline dye. Socio-economic status.
Ethnic or geographical situation: Nephropathia epidemica (hanta virus) mainly en
Europe and Russia. Balkan nephropathy. Systemic lupus erythematous with nephritis
in the far east, severe hypertension or diabetes mellitus with renal failure more
common in patients of African origin.

Investigation of Kidney Diseases

I. Urine analysis:
Macroscopic examination: appearance, odour, volume
Biochemical examination: Gravity, pH, glucose, ketones, proteinuria,
haematuria, bilirubin and urobilinogen, nitrite.
Microscopic examination: Cells (red, white, epithelial cells or malignant
cells). Casts (hyaline, granular, red cells, white cells, crystals
Microbiological examination: Morphological assessment of pathogens

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II. Biochemical assessment of renal function. Urea and creatinine, sodium and
potassium, bicarbonate, calcium, protein and albumin, phosphate, urate and
haematological status. Immunological screening.

III. Radiological investigation of renal system:


Ultrasound: Kidney size/shape?position: evidence of obstruction, renal cysts
or solid lesions: stones; gross abnormality of bladder and post-micturition
residual volume, guided kidney biopsy.
Dobler ultrasound: Reduced or absent renal or venous blood flow.
IV Urography: Renal uretic or bladder stones, cysts, tumors, hydronephrosis,
other diseases.
Renal angiography: Renal artery stenosis; possibly proceed to angioplasty
and/or stending.
Magnetic resonance imaging angiography: Renal artery stenosis.
Renal istotope scanning: Renal uptake and excretion of radio-labelled
chemicals.
Abdominal CT scan: Renal, retroperitoneal or other tumour masses or fibrosis.

IV. Biopsy: Indicated in the diagnosis and assessment of parenchymal renal


disease. Low complications rate.

V. Chest radiograph: Fluid (overload) estimation, position of the diaphragm and


to exclude lung infiltrations.

VI. Arterial blood gases: Technique of taking ABG, technique of local anaesthetic,
Allen’s sign, Interpretation of ABG and the Henderson-Hasselbach Equation,
Biochemistry of measurement of pH, CO2, O2, HCO3. To distinguish the
degree of metabolic acidosis versus the decreased ventilation due to interstitial
lung oedema.

Specific Diseases of the kidneys

In the final year several further diseases will be discussed in addition to those studies
during the fourth year:
(1) through (5) – Year 4; All topics in Year 5

In the study of each of these diseases, the principles of history taking and examination
will be emphasised.

Students will be expected to be able to describe the investigation of these diseases and
the principles of management and knowledge of drugs used where applicable.

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Goals/ Aims

The knowledge base developed during the year 4 training in internal medicine will be
expanded in year 5. All diseases discussed during year 4 will be reviewed during
bedside sessions and a few other renal diseases will be discussed.

Students will be expected to attend the Medical Grand rounds at the EWMSC during
their training at EWMSC and to answer simple questions about the cases discussed
during these sessions.

Students are expected to be aware of the latest therapeutic strategies employing


evidence-based medicine. This information may be accessed via the various approved
websites.

By the end of their 2 years’ training in nephrology, students will expect to have
reached an internationally accepted standard in their knowledge and management of
renal diseases within general internal medicine.

General Objectives

At the end of the course you will be expected to


1. understand how to elicit a history of renal diseases
2. be able to elicit the signs of kidney failure
3. state a differential diagnosis for each symptom of renal disease
4. know the causes of each symptom of kidney failure
5. demonstrate time management within the program
6. demonstrate empathy and caring toward your patients
7. submit a short project

Structure of the course: teaching vs bedside learning

The years 4& 5 nephrology module consists of 1 session per week for 8 weeks either
at POSGH or at EWMSC. You will be provided with a seasonal timetable at the start
of the course.

Specific Objectives
1.
Assignments

1. The student will expected to clerk at least 5 patients with renal diseases
described in the content section above and to present and discuss each case

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with any instructor. Clerking of a patient will involve
a. Presenting compliant
b. Complete history
c. Examination of all systems of the patients with special
emphasis on the renal examination
d. A description of what investigations were done and
should be done with details of results where applicable
e. Treatment and response to treatment
f. Follow-up plan for the patient including discharge
2. Students may be given a short project

Assessment/ Evaluation

The purpose of the assessment would be to help you to appreciate where you have
reached in attaining the goals set out in this syllabus and to stimulate you to continue
to study internal medicine and nephrology.
Your assessment will take the following forms
(1) A written examination based on structured questions or MCQs
(2) Evaluation of a project and coursework
(3) Grading of cases clerked
Teaching Strategies
The Department of medicine employs several teaching strategies which will include
1. guided lectures,
2. bed side teaching,
3. small group teaching,
4. non-lecture strategies: projects, group discussions, role play, co-operative learning

Resources
1. Patients on the medical and surgical wards are our most valuable resource.
2. Patients in the medical outpatients’ clinics.

Readings

1. Davidson’s Principles and Practice of Medicine: Renal chapter.


2. Kumar and Clarke: Renal chapter.
3. Chapter 20 ‘HIV and Renal Function’ in ‘HIV Medicine 2006’. Can be downloaded
free of charge from http://www.hivmedicine.com/
4. Some Recommended Websites: The American Society of Nephrology, BioMed-
Nephrology, Nephrology Rounds, Hypertension, Dialysis & Clinical Nephrology
(HDCN), American Society of Hypertension, American Society of Transplant
Surgeons, International Society of Nephrology, European renal association, National
Kidney Foundation

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The student should use sound judgement when searching information from various
other websites. If the student has doubts on the validity of a site, the student is
encouraged to discuss the information with the instructor.

Version 13/04/2007 04:52:00 PM

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