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WEEK
PROGRAMMES
GENERAL INTERNAL MEDICINE AND GERIATRICS
Universitas Hospital

Welcome to the firm. Please report to the registrar / intern at ward 6A immediately after
the radiology tutorial on Mondays.

Medical Staff: Prof WF Mollentze, Dr Deon Greyling, Dr Bert Top (SMO), rotating
Registrar, and rotating Intern. Nursing staff: Ward 6A: CPN BN Palada; SPN’s: DK
Lebakeng, MJ Morweng; PN’s: PI Pommer, NJ Mahlehle, Motlhabane; Staff Nurses: LV
Nyamakazi, M Moruri; and Mr Tlahadi (ward secretary). Outpatient staff: Matron
Austin, and Sr van Huyssteen.

This firm admits patients requiring care at a tertiary level including geriatric patients,
patients with multi-system pathology not belonging to any of the subspecialties
at
Universitas Hospital, patients with medical problems discharged from Multidisciplinary
Intensive Care and still in need of hospital care, and patients admitted with overdose and
poisoning (referred from level 2 hospitals).

This firm also admits patients addicted to drugs such as heroin and cocaine for
withdrawal. Three beds are available in ward 3A for this purpose. Dr Bert Top, senior
medical officer, takes responsibility for this service. When he is not available, the
registrar
and intern from this firm take over.

The registrar and intern conducts ward rounds at least twice a day. You are expected to
join the team for these rounds – enquire from the registrar/intern what is required from
you regarding after hours and week-end duties. You must also visit and examine your
patients on your own and report any new/important information immediately to the
registrar or intern (e.g. electrolyte disorders, DVT, shock etc.).

Every patient admitted to our wards must be properly clerked by the student in
the
“blue book” (including side-room investigations). Daily follow-up notes must be
written in
the space provided in the “blue book”. Patients will be divided among students.

You must assist the registrar/intern with administrative duties such as obtaining
results of special investigations, keeping files tidy and entering test results where
appropriate in the flow-chart in the patient’s chart.

The consultant conducts two formal ward rounds during the week: Tuesdays at 14:00
and Fridays at 09:15. Please be on time and see to it that your patients’ clinical notes, Xrays etc. are up to date and available for the round. You will also be provided with a form
used to summarize each patient. This form must be completed for each patient and
handed to the consultant at the start of the ward round (one form for each new patient.)

Out-patient clinics are conducted on Tuesday and Wednesday mornings. The registrar will
allocate patients to you to be seen on your own. After you have completed your
assessment, please discuss your patient with the registrar or consultant.

Thursdays immediately after the case presentation, students must go to the Omega
Service Centre for the Aged at Heidedal to assist dr. Top with an outreach primary
health care outpatient clinic. Please return to the wards after the clinic has been
concluded.

o
o
o
o
o
in
o
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
Study material:
Good Medical Practice (Chapter 1, Davidson’s and Practice of Medicine, 20 th Edition)
Good Prescribing (Chapter 2, Davidson’s Principles and Practice of Medicine, 20 th Edition),
SAMF 7th Edition (page 1 and 2: Prescribing in the elderly)
Aging and Disease (Chapter 7, Davidson’s Principles and Practice of Medicine, 20 th
Edition),
Poisoning (Chapter 9, Davidson’s Principles and Practice of Medicine, 20 th Edition). An
academic afternoon will also be devoted to poisoning and overdose during
the twoyear cycle.
Issues in older people (panels in chapters in Davidson’s, especially those
mentioned
Box 7.15, page 171).
Syncope and Presyncope (Davidson’s Principles and Practice of Medicine, 20 th Edition,
Chapter pp 551-554); Dizziness, Blackouts and Funny Turns (pp 1165-1167)
Handouts: Geriatric topics from MAE 324 and Tutorials.
Map (Omega Service Centre for the Aged):
De Wetsdorp
De Wetsdorp
Rd, (to
Rd,
Pelonomi)
(to Pelonomi)
OMEGA
OMEGA
GARAGE
GARAGE
BRIDGE
BRIDGE
ROBOT
ROBOT
PULMONOLOGY
M.B, Ch.B IV and V PULMONOLOGY ROTATION
Welcome to this very important rotation! Respiratory conditions form a significant component of
clinical practice (and examinations!). During the residency in Pulmonology you should take the
opportunity to gain as much exposure as possible to the clinical features of respiratory-related
disorders.
Programme for the week:
Please note: Time not specifically allocated is devoted to fulfilling ward duties,
attending the outpatient clinics (Mondays, Tuesdays and Thursdays), admitting new
patients, and self study.
Monday:
 08h00:
Statistics meeting, CJ Nel Lecture Hall Universitas Hospital (first floor).
 08h30:
X-ray discussion Dept Radiology (only MB, ChB V).
 Thereafter meet Dr. Karin Snyman (or the Pulmonology Registrar) in ward 3B,
who will discuss your duties and programme for the Pulmonology rotation.
 11h00:
Lung function discussion and demonstration at Lung Function Laboratory
(Tel 051 4053610/53610) for the students. Contact person: Mr A Smit.
Tuesday:
Follow the programme of the Pulmonology Division (Ward 3B and clinic).
16h00-17h00:
Case presentations at Internal Medicine.
Wednesday:
1. 08h00: Ward duties ward 3B
2. 09h30 Consultants round
3. 14h00-17h00 Academic Afternoon Seminars (Faculty).
Thursday:
Follow the programme of the Pulmonology Division (Ward 3B and clinic).
16h00-17h00:
Case presentations at Internal Medicine.
Friday:
08h00-09h00:
Departmental Academic presentations Kine1 followed by; witnessing of
bronchoscopies at the bronchoscopy theatre (at Pulmonology clinic) and ward work (ward 3B).
Public holidays, weekends and afternoon rounds:
Duties as prearranged with registrar on call.
Ward duties:
1.
Admission of new ward cases in the prescribed format (Internal
Medicine/Pulmonology). After completion of a new admission, formulate the clinical
problem statement and/or compile a problem list. It is important to remain involved
regarding the further planning and management of the patient.
2.
Clinical assessment of your patients every morning.
3.
Daily follow-up notes in the admission file in the SOAP format. (Subjective,
Objective, Assessment, Plan) as guided by Registrar/Medical Officer during rounds.
4.
Tasks relating to your patients as allocated by medical officer or registrar.
Remember to observe the necessary safety measures with regard to sharp objects
during procedures such as venesections. Should the opportunity arise, you may
assist the doctor with procedures e.g. pleural paracenthesis.
Clinic responsibilities:
Attend clinic consultations with the consultant or registrar until pardoned. You will be exposed
to the spectrum of conditions managed on an outpatient basis.
Theoretical knowledge:
Essential knowledge as in the Pulmonology chapter in Davidson’s, the Academic Afternoon
Seminars (including COPD, asthma, bronchus carcinoma, pleural diseases, respiratory
infections), the Monday and Tuesday tutorials during the IVth year and the pharmacology of
respiratory diseases (SAMF).
Clinical Capabilities:
1. Please ensure that you are familiar with history-taking and clinical examination
techniques with regard to the respiratory system (Talley and O’Connor).
2. You must know the indications for any special investigations requested on your patient
and be able to discuss the planned management.
3. Please ensure that you have a systematic approach towards the interpretation of chest
X-Rays and lung functions (flow volume loop).
Case presentations in the ward:
During ward rounds you will be expected to present your patients. Please follow the format as
prescribed by the department of Internal Medicine.
Please initiate the presentation with the following patient-related information:
1.
Name
2.
Age
3.
Occupation
4.
Residential area
5.
Reason for admission
6.
Relevant social information
Be prepared to present in any one of the following formats:
1.
Problem-based summary (Clinical problem statement) NB: Risk factors/Associated
complications or
2.
Problem list or
3.
Full presentation
Diagnostic and therapeutic procedures:
Bronchoscopies are performed on Friday mornings. Please utilise the opportunity to witness at
least two bronchoscopies. Keep record of other procedures performed or witnessed in the
ward, clinic or referral room.
Evaluation:
The following are taken into account when students are evaluated during their rotation:
1.
Clinical capabilities
2.
Execution of ward duties and responsibilities
3.
Attitude towards patients, personnel and work
4.
Knowledge
Conclusion:
Please enjoy the Pulmonology rotation! We trust that you will regard this as an informative and
educational experience. Feel free to discuss any uncertainties with the doctors or other staff of
the Respiratory unit.
Dr M Prins
Consultant
Div Pulmonology
Feb 2011
RHEUMATOLOGY
Date
Time
Activity
Venue
Monday
08:00 - 08:30
Statistics and program of the
week
Prof. CJC Nel lecture hall,
Universitas Hospital, 1st Floor
08:30 - 09:30
Ward rounds and orientation
Ward 6A
09:30 – 13:00
Rheumatology clinic:
patients
Rheumatology clinic
14:00 – 15:00
15:00 – 17:00
Journal club
Writing up and admission of
patients in the ward
Tuesday
07:30 – 09:00
09:00 – 12:00
12:00 – 16:00
Academic ward round
Ward work
Self study
Wednesday
07:30 - 09:00
Ward work and preparation
for academic discussion
09:00 – 11:00
Formal discussions by
students, registrars and
consultants
Ward work
Academic afternoon
11:00 – 13:00
14:00 – 17:00
Thursday
Friday
07:30 – 08:30
08:30 – 14:00
Ward work
Outpatients at UAH –
Rheumatology clinic
14:30 – 16:00
08:00 - 09:00
09:00 – 13:00
Self study
Presentations
Lupus clinic
New
Cine 2
UAH Lecture Hall
Outpatients – UAH
NEPHROLOGY
NB
Bloods taken, and iv infusions placed, in patients with chronic renal disease should only be done on
the dorsum of the hands to preserve veins for fistulas in future!
Monday:
08h00: Stats meeting CJ Nel lecture hall 1st floor Universitas hospital
After this meeting the students should go to ward 5A and meet the registrar and medical
officer for a ward round. Then the patients admitted under nephrology should be divided
amongst the students and a blue book should be filled in for each (unless otherwise
instructed by the consultant). The student should be familiar with the following
information regarding the patient:
(a)
(b)
(c)
History and examination with a problem list this must be done by the student
themselves and presented in accordance with internal medicine guidelines, important to
have a differential diagnosis. It is important for all students to look at the physical
signs of each others patients as well.
Medication the patient is using, The indication, mechanism of action and important sideeffects
The diseases considered under the differential diagnosis (Davidson’s or notes) read up
briefly
Patients progress The initial problem list must be updated as progress in diagnosis and
management develop
Tuesday:
07h30: Continue with admitting patients and prepare for the round later
10h00: Ward round, registrar will present the patients but the student will have to
demonstrate the clinical signs, discuss assessment and the differential diagnosis
Wednesday:
07h30: Ward round – decide on urines to be examined and bring fresh (warm)
specimens
down to the clinic (OPD) at about 9h00
09h30: Nephrology clinic OPD and make an appointment with the staff at the dialysis
unit for a brief overview of dialysis on Thursday
Thursday:
07h30: Ward round
09h00: Transplant OPD
10h00: Dialysis discussion in the renal unit with the nursing personnel as arranged on
Wednesday
Friday:
07h30:
08h00:
09h30:
11h00:
Patient discussion ward 5A
Departmental academic meeting
Audit meeting ward 5A
Student marks
Saturday and Sunday:
½ The students come on the Saturday and the rest on the Sunday for the ward round starting
at 8h00 in ward 5A
After
1
2
3
the week you should be able to:
Examine urine
Inform your patient regarding the practical aspects of renal replacement therapy
Have examined several patients with important renal diseases such as acute and
chronic renal failure, nephrotic syndrome and hypertension
GASTRO-ENTEROLOGY
Monday
08:00
Internal Medicine statistics meeting
09:00
Meet the registrar in word 7B – Admission of all patients in the ward –
new and old. Ward work with registrar and intern.
Tuesday
17:00
Ward round with the registrar and intern.
08:00
Ward round and ward work with the registrar and intern.
10:00
Attend endoscopy list after ward work has been completed.
15:00
Grand ward round with consultants, registrar, intern, dieticians, social
worker and physiotherapist. Meet in gastro-unit.
Wednesday
16:00
Student presentations – Dept Internal Medicine
08:00
Ward round and ward work with registrar and intern
10:00
Attend endoscopy list after ward work has been completed
12:30
Academic ward round with consultant, registrar and intern. Meet in
Ward 7B
Thursday
14:00
Academic afternoon for students
08:00
Ward round registrar and intern. Ward work and self study for the rest
of the day
Friday
Weekends
16:00
Student presentations – Dept Internal Medicine
08:00
Department Internal Medicine registrar’s case presentations.
09:00
Gastroenterology outpatients in the gastro-unit
12:30
Ward round consultants, registrars and interns. Meet at Ward 7B
Weekend ward rounds arranged with registrar and consultant on call.
CLINICAL HAEMATOLOGY
Dear Student
Welcome to Clinical Haematology. We hope your time with us wil not only be an educational,
but also an enjoyable experience and trust that you would be able to make maximum use of
you time at Haematology.
Monday:
08:00 – 08:30
08:30 – 12:00
13:00 – 14:00
14:00 – 17:00
Tuesday:
08h00 –
09h00
09:00 – 11:15
11:15
Wednesday:
08:00 – 09:00
09:00 – 10:00
10:00 – 12:00
12:00 – 12:30
Afternoon:
Thursday:
08:00 – 09:00
09:00 – 13:00
14:00 – 15:00
Note:
Friday:
08:00 – 09:00
09:30 – 11:30
11:30 –
Week-ends
Internal Medicine Meeting
Ward round at National Hospital. Divide and get to know your patients.
Orientation by the doctors on the ward.
Clinic Discussion (compulsory for 5th Years) at Universitas, Haematology,
Committee Room, R417.
Ward work
Meet for academic program doctors room ward 30
Academic Ward round at National
Ward work
Imaging session
Videos – Dept Haematology (Mrs M Oosthuizen, R416).
Haematology and Thrombophilia Clinic, Haematology Clinic, Faculty of Health
Sciences
a) Tutorial from pathology registrar on thrombophillia
b) Microscope session – Registrars – Dept Haematology, Routine
Laboratory
Haematology and Thrombophilia clinic discussion, Dept Haematology, R417
Academic program – Committee Room, Dept Haematology, R 417, Universitas
Ward work – National
General Internal Academic hour –Cine 1. If no General Internal Academic
hour, the Ward-round starts at 08:00 at National
Multidisciplinary academic ward round, National Hospital
Ward work, National
Students are on call with the registrar or medical officer on duty over weekends. Please confirm time and place where you should meet registrar. Students
may divide themselves in groups of two and split the week-end up between
them if the registrar or medical officer on call is happy with that. If the ward is
very busy, all students may be required to come in.
NB
NO SNEAKERS AND JEANS PLEASE. PLEASE FOLLOW DRESS CODE OF FACULTY.
Haematology is not only a very exciting and rapidly developing subject, but also an integral part
of medicine in general. Haematological illnesses influence every organ and system in die body,
for example pregnancy, surgery, gastro-enterology, psychiatry and neurology. You will be
faced with a full blood count every day of your life as a doctor. The ability to interpret this
would thus enable you to diagnose and treat your patient early and accurately. Although we
often deal with rare diseases, we can still learn the general principles involved in these
diseases. Their diagnoses might be rare but they present with common things like back pain,
hepatosplenomegaly, tiredness, lymphadenopathy, anaemia or bleeding. These are common
problems and the principles in the approach to these common problems will be accentuated.
Ward work:

During this week, a few patients will be appointed to each student.

We expect that you treat this patient as if jou are his or her own doctor. That means that
you must see your patient every day. The ward work on this patient will be your
responsibility.

When you leave the ward, confirm with Medical Officer or registrar about
whether they might require your help later in the day and when and where
you should meet.

Every patient must have complete notes in their blue book every day with your name
and year group next to it. The blue book stays in the patient’s file when you leave Clinical
Haematology.

We expect a urine dipstix result on every patient.

Have the patient’s latest blood and X-ray results ready on the ward round and integrate
them in your problem list.
NB
The breaking of sensitive information:

Be careful with sensitive information. The diagnoses of HIV, cancer or a serious
illness will be discussed with the patient and his or her family by the medical officer or
registrar.

Use the opportunity to watch and see what they say to the patient and especially
how the information is transferred.
Presentations:
We want to use this week to give you the opportunity to practice making a problem list. Please
study and use the examples from your study guides. Take care to prepare the problem
statement before the ward rounds. If anything is unclear, discuss it with the registrar or
medical officer.
What is important?
This is just a guideline. Try to read up about every patient that you have – this way you
will learn the most. Always ask yourself “why?”. Do not take anything for granted and
don’t be afraid to ask questions to the consultant, the registrar and the medical officer
– everybody here is enthusiastic to help you. If we do not know, we usually will know
where to find the answers.
The following is a guideline of the most important sections in Davidson’s. The lectures
that you had in the previous years, including the basic physiology is also important.
NB
Clinical examination in blood disorders – Core knowledge (also see Talley and O’Connor’s,
chapters about hematological clinical examinations).
Functional anatomy and haemopoiesis – Read through for interest and understanding
the
principles.
Major functions of blood cells – Core knowledge. Fig 19.6. – know the main causes.
Haemostasis – Core knowledge. Main topics will be discussed in the tutorial.
Investigation of blood diseases – Important – you will deal with this every day of your life as a
doctor.
Core knowledge.
Blood products – Core knowledge. Again things that you will deal with every day.
Anaemias – Core knowledge.
Congenital anaemias – know main headings – detail is less important (take note : G6PD
deficiency is common in Africans.
Acquired hemolytic anaemia. The most important is warm auto-immune hemolysis. The rest;
just main headings.
Hemoglobinopathies – just main headings concerning the clinical picture and principles of
treatment and diagnosis.
Acute leukemias – just main headings and principles.
CLL – clinical picture and diagnosis.
Myelodysplastic syndromes – just main headings – no detail.
Prolymphocytic leukemia and hairy cell leukemia – not important.
Paraproteinaemias – know what is MGUS and a paraprotein and possible causes; Waldenstrom
(no detail). Myeloma – know what it is; clinical picture, how to diagnose it and the principles of
treatment (no detail). Complications and their management is important (also important for
Internal Medicine in general).
Aplastic anaemias – clinical picture and most important causes.
Myeloproliferative disorders – clinical picture, diagnosis and definitions of each.
Bleeding disorders – Core knowledge, Fig. 19.51 (NB!)
Coagulation disorders – You have to recognize it and know when to suspect a coagulation
disorder, clinical picture and principles of treatment and diagnosis. Hemophilia B and Von
Willebrand – just definitions; acquired bleeding disorders –just main headings; factors deficient
in liver disease; DIC – Core knowledge.
Venous thrombosis – Fig. 19.56. Important to know about genetic diseases like Protein C, S,
Factor V Leiden and PG2O210A. Know main headings. Antiphospholipid syndrome – more
important and common. Treatment of venous Thrombo-embolism – Core knowledge.
The discussions in the tutorials are core knowledge, as well as the matters indicated in the
module guide. We hope that you will have a very pleasant and great learning experience at
haematology. – Don’t hesitate to ask if there are any questions or doubts.
HAEMATOLOGY AND CELL BIOLOGY
Practical approach to hepatosplenomegaly, splenomegaly and lymphadenopathy
Hepatosplenomegaly
Example:
There is hepatosplenomegaly, the spleen is enlarged……cm below the left costal margin. The
liver is palpable at…..cm below the right costal margin; it is non-tender, firm and smooth (now
look for clinical anaemia, lympadenopathy and signs of chronic liver disease).
No other signs or clinical anaemia only:
Myeloproliferative disorders.
Lymphoproliferative disorders.
Cirrhosis of the liver with portal hypertension (less likely if there are no other signs of chronic
liver disease).
Hepatosplenomegaly plus palpable lymph nodes‫٭‬
Chronic lymphocytic leukaemia.
Lymphoma.
Other conditions to be considered would include infectious mononucleosis (? sore throat),
infective hepatitis (? jaundice) and sarcoidosis.
Signs of chronic liver disease:
Cirrhosis of the liver with portal hypertension.
Other causes:
Hepatitis B (? jaundice, tattoo marks)
Brucellosis (? farmerworker)
Weil’s disease (? jaundice, sewerage worker or fell into canal)
Toxoplasmosis (glandular fever-like illness)
Cytomegalovirus infection (glandular fever-like illness)
Storage diseases (e.g. Gaucher’s – spleen is often huge; glycogen storage disease)
Amyloidosis (? underlying chronic disease)‡
Other causes of portal hypertension (e.g. Budd Chiari syndrome = hepatic vein thrombosis).
Infantile polycystic disease (in some variants of this, children have relatively mild renal
involvement but hepatosplenomegaly and portal hypertension).
Common causes on a world-wide basis
Malaria
Schistosomiasis
Kala-azar (visceral leishmaniasis – uncommon in S Africa)
‫٭‬These conditions can also occur without palpable lymph nodes.
‡Though hepatosplenomegaly can occur in primary and myeloma associated amyloidosis, it is
commoner in the secondary form. Other organs particularly involved in secondary amyloidosis
are kidneys (nephrotic syndrome), adrenals (clinical adrenocortical failure may occur) and
alimentary tract (rectal biopsy). Conditions associated with secondary amyloidosis include
rheumatoid arthritis (including juvenile type), tuberculosis, leprosy, chronic sepsis, Crohn’s
disease, ulcerative colitis, ankylosing spondylitis, paraplegia (bedsores and urinary infection),
malignant lymphoma and carcinoma.
Splenomegaly (without hepatomegaly)
Why do you think it is a spleen?
1.
Can’t get above it
2.
Descends prominently on inspiration
3.
Distinct edge and medial notch
4.
Not ballottable
5.
Percussion dullness over spleen/Traube’s space#
6.
+/- audible rub
# Traube’s space = A crescent-shaped space about 12 mm wide, just above the costal
margin. It is due to gas in the stomach which produces a vesiculotympanitic sound.
Example:
There is a mass in the left hypochondrium. On palpation I cannot get above the mass, it has a
notch, and on inspiration moves diagonally across the abdomen. The percussion note is dull
over the left lower chest wall and over the mass. I think this is the spleen enlarged at … cm.
Likely causes* to be considered are:
Very large spleen†
1.
Chronic myeloid leukaemia (Philadelphia positive in 90%)
2.
Myelofibrosis
3.
Lymphoma
4.
Chronic malaria
5.
Kala-azar (visceral leishmaniasis – rarely, if ever seen in South Africa, but may become
more common with increasing migration from other countries)
Spleen enlarged 4-8cm (2-4 finger breadths)
The above causes and:
1.
Myeloproliferative disorders‡ (e.g. CML, Myelofibrosis)
2.
Lymphoproliferative disorders§ (e.g. lymphoma and CLL)
3.
Cirrhosis of liver with portal hypertension (spider naevi, jaundice, etc.)
4.
Thalassaemia
5.
Storage diseases (e.g. Gaucher’s)
Spleen just tipped or enlarged 2-4cm (1-2 finger breadths)
The above causes and:
1.
Myeloproliferative disorders‡ (e.g. PV, ET)
2.
Lymphoproliferative disorders§ (? Palpable lymph nodes)
2.
Cirrhosis of liver with portal hypertension (spider naevi, jaundice, etc.)
3.
Infections such as:
3.1
Glandular fever (?throat, lymph nodes)
i.
Infectious mononucleosis (EBV)
ii.
Cytomegalovirus
iii.
Toxoplasmosis
3.2
Infectious hepatitis
3.3
Subacute baterial endocarditis (?heart murmur, splinter haemorrhages,etc.)
3.4
Protozoal (e.g. malaria)
4.
Infiltrations (e.g. amyloidosis, sarcoidosis)
5.
Connective tissue diseases (e.g., RA☼, SLE, PAN)
* To help you remember some common causes to mention in the examination, we have given
the three or four most common causes of a spleen of a particular size. An alternative way of
dividing up splenomegaly which can be found in many text books is:
1.
Infectious and inflammatory splenomegaly (e.g. SBE, infectious
sarcoidosis)
mononucleosis,
2.
2.1
2.2
Infiltrative splenomegaly
Benign (e.g. Gaucher’s, amyloidosis)
Malignant (e.g. leukaemias, lymphoma)
3.
Congestive splenomegaly (e.g. cirrhosis, hepatic vein thrombosis)
4.
Splenomegaly due to reticuloendothelial hyperplasia (e.g. haemolytic anemias,
ITP)
† Gaucher’s disease and rapidly progressive lymphoma may also cause a huge spleen. Chronic
congestive splenomegaly (Banti’s syndrome = splenomegaly, pancytopenia, portal hypertension
and gastrointestinal bleeding) may also cause massive splenomegaly. A huge spleen developing
in a patient with polycythemia rubra vera, is usually due to the development of myelofibrosis.
‡ When listing the causes of splenomegaly or hepatosplenomegaly in the limited time of the
examination, to use the term myeloproliferative disorders in its broadest interpretation is a
useful way of covering several conditions in one phrase. If asked to explain it, one can mention
the separate entities of CML, PV, ET and myelofibrosis.
§ The lymphoproliferative disorders ar chronic lymphocytic leukaemia, lymphoma,
Waldenstrom’s
macroglobulinaemia,
myeloma
and
acute
lymphoblastic
leukaemia.
Splenomegaly is very rare in myeloma, except in cases with light chain deposition disease.
☼ Felty’s syndrome = uncommon but severe subset of seropositive rheumatoid arthritis
complicated by granulocytopenia and splenomegaly.
Other causes of splenomegaly:
Other infections (brucellosis, typhoid, miliary TB, trypanosomiasis, echinococcosis)
Other causes of congestive splenomegaly (hepatic vein thrombosis, portal vein obstruction,
schistosomiasis, chronic congestive heart failure)
Pernicious anaemia and other megaloblastic anaemias (rare) (? pallor, subacute degeneration
of the cord; Note: associated organ-specific autoimmune diseases, especially autoimmune
thyroid disease, diabetes, Addison’s, vitiligo, hyperparathyroidism)
Generalized lymphadenopathy:
Example for presentation:
There
is
generalized
lymphadenopathy
with/without….cm
splenomegaly
(or
hepatosplenomegaly). The likeliest causes would be a lymphoproliferative disorder like
lymphoma or CLL or an underlying infection.
Differential diagnosis:
1.
Lymphoproliferative disorders (rubbery and firm)
1.1
Lymphoma
Non-Hodgkin
Hodgkin
Leukaemia
1.2
CLL
ALL
2.
2.1
2.2
2.3
3.
Infections
Viral
HIV
Infectious mononucleosis due to EBV (glandular fever)
Cytomegalovirus (CMV) (glandular fever-like illness)
Parasitic
Toxoplasmosis (glandular fever-like illness)
Bacterial
Tuberculosis
Brucellosis
Secondary syphilis
Other
Sarcoidosis (?erythema nodosum or history of)
Collagen vascular diseases e.g. SLE, RA
Thyrotoxicosis (?exophthalmos, goiter, tachycardia, etc.)
Drugs, e.g. phenytoin (pseudolymphoma)
There are a large number of other causes of generalized lymphadenopathy, but these are the
most important ones. In a patient with generalized lymphadenopathy where a biopsy is needed,
the first choice would be a cervical or supraclavicular node. Nodes from the axillary and inguinal
areas often show reactive changes that may make a histological diagnosis difficult. On the other
hand, if there is a very large abnormal node in the inguinal or axillary areas, but not in the
cervical or supraclavicular regions, then biopsy the biggest node, irrespective of the location.
Localized lymphadenopathy:
Differential diagnosis:
1.
Local acute or chronic infection
2.
Metastases from carcinoma or solid tumour
3.
Lymphoma, especially Hodgkin’s disease
Diagnostic significance of localized lymphadenopathy in specific locations
A.
1.
1.1
1.2
2.
a.
b.
c.
d.
3.
4.
Epitrochlear lymphadenopathy
Lymphoproliferative disorders
Non-Hodgkin lymphoma
CLL
Infectious
Miliary TB
Infectious mononucleosis
Secondary syphilis
Localized pyogenic infection
Sarcoidosis
Intravenous drug abuse
B.
1.
2.
3.
Inguinal lymphadenopathy
Venereal disease*
Perianal sepsis or malignancy
Lymphoma
C.
1.
2.
Occipital lymphadenopathy
Scalp infection (e.g.fungal)
Viral (e.g. rubella)
3.
Neoplasm
D.
1.
2.
3.
4.
Cervical lymphadenopathy
Infectious mononucleosis; other viral infection
Streptococcal infection
TB (e.g. scrofula)
Lymphoma
E.
1.
2.
3.
Axillary lymphadenopathy
Catscratch disease; dogbite
Lymphoma
Lung or breast cancer
* Groove sign = adenopathy above and below the inguinal ligament is said to be classic of
Lymphogranuloma venereum (LGV)
TELEPHONE NUMBERS
CONSULTANTS CLINICAL HAEMATOLOGY
Prof V Louw
53043
Cell:
072 768 9024
(6777 SD/KK)
Dr Mike Webb
52137
Cell:
083 451 2425
(6734 SD/KK)
CONSULTANTS HAEMATOLOGY AND CELL BIOLOGY
Prof Marius J Coetzee
53116
Cell:
082 550 1968
(6357 SD/KK)
Dr Frieda Pienaar
Cell:
083 262 0651
(6740 SD/KK)
Dr Lelanie Pretorius 52910/53288
Cell:
072 434 9487
(6360 SD/KK)
Dr Debbie Jafta
Cell:
082 782 0203
(6359 SD/KK)
Cell:
083 694 4350
(6674 SD/KK)
52910/53288
FELLOW:
Dr J Janse Van Rensburg
REGISTRARS
Dr R Weyers
52910/53288
Cell:
083 626 3494
(6044 SD/KK)
Dr Jan-Gert Nel
52910/53288
Cell:
083 415 9852
(6040 SD/KK)
Dr E Mberi
52910/53288
Cell:
071 330 9447
(6800 SD/KK)
Dr J Joubert
52910/53288
Cell:
082 687 7773
(7104 SD/KK)
Dr Daleen Van Jaarsveld
Cell:
083 274 1894
(6877 SD/KK)
Dr C Barret
52137
Cell:
082 771 8104
(6308 SD/KK)
WARD / SAAL 29
4052081
WARD / SAAL 30
4052136
REGISTRARS AND MEDICAL OFFICERS
3 Military Hospital: Internal Medicine
Welcome to the Department of Internal Medicine at 3 Military Hospital. We hope you will enjoy your rotation.
We believe that the person rendering the service determines the quality of service and not the environment
(although we are looking forward to our new hospital). To help you to slot into this philosophy, read through
this document. It is by far not exhaustive, but intends to undercut specific issues.
Feel free to discuss any suggestions or comments to improve the quality of our service with one of the
consultants
Program
Monday
0800 stats meeting at Universitas – CJC Nel auditorium
08:30 Hand over round at Clinic
Rest of the morning: Ward work/Clinic
Get topic for Homework
Tuesday
0730 Homework Discussion at Clinic
0830 X-Ray discussion at 3 Mil Radiology
0900 Academic Ward round
Wednesday
08:00 ward work commences
Clinical Signs discussion with registrar during the morning
Ward work/Clinic
Thursday
08:00 Ward work/Clinic
Get topic for homework on next Tuesday
Friday
0800 Case Discussion at Universitas
0930 Multidisciplinary meeting at Mental Health Seminar room (make sure all files, special investigations and
imaging are available)
1200 See problem patients with consultant
Calls
All consultations must be seen with the Intern or Registrar (in hours and after-hours)
Please make sure that the person on call has the student on call’s phone number. Students organize their
own roster - all patients must be seen on admission by a student (who will then be involved in the care and
decision making). There must be at least one student on every ward round over the weekend and available
for new referrals.
Clinic
Make sure that you attend at least one new patient consultation with one of the consultants
Attend at least one Stress ECG and Lung function – arrange with nursing staff in the clinic
Ward rounds
Date and time all entries and who is conducting the consultation. Note what we think is wrong with the patient,
why we think so and what are we going to do about it
Patient Files
The left hand page of the file is for a Problem list – Differential diagnosis – Plan. The problem list must be
updated whenever new results become available, the patient is seen, etc.
There must be a flow diagram with relevant results.
The middle part of the file is for notes. Please make sure that every entry is timed and dated and that notes
are made during consultant ward rounds.
All results are filed on the Right hand side.
Laboratory
Service is rendered by the NHLS with a depot on site (next to Internal Medicine Clinic ) Routine bloods should
be requested the day before and should be delivered to the ward by the laboratory staff and filed by the
nursing staff before ward rounds.
Other Specialties at 3 Mil Hosp
Radiology
Dr M Naude
All x-rays and ultrasounds are done on site
Surgery
Dr Simon Maseme
Gastroscopy and Colonoscopy - Done on site by surgery
Psychiatry and Mental Health
Dr Matete and dr Balance
Paediatrics
Dr Cronje, dr Lewis and dr Babst
Orthopaedics
Dr Bruwer and dr Brown
Anaesthetics
Dr Pearson and Senekal
Sessional Consultants
Gynecology, Urology, ENT, Neurosurgery, Dermatology – Specialist Outpatient Clinic
Firm 1 - Pelonomi Hospital - Dr Kachovska
Monday
08:00
Internal Medicine statistics meeting at Pelonomi
09:00
Meet the registrar in word M3 – Admission of all patients in the ward - new and old
( Monday is admission day).Clinical methods by the patient’s bed
(consultant/registrar)
18:00
Ward round and casualty round with the registrar, intern and the consultant.
Students on Call with Intern and Registrar until 23:00.
Tuesday
08:00
Post admission ward round and ward work with the registrar and intern.
10:00
Ward round with the consultant. The students presenting the patients from
admission.
Wednesday
12:00
Clinical methods by the patient’s bed (consultant/registrar)
16:00
Student presentations – Dept Internal Medicine
08:00
Grant round and academic discussion (the students have given topics for the
discussion from the previous day).
Thursday
11:00
Ward work with the registrar and intern.
14:00
Academic afternoon for students
08:00
Ward round with the registrar and intern. Clinical methods by the patient’s bed
(consultant/registrar). Ward work and self study for the rest of the day
Friday
Weekends
16:00
Student presentations – Dept Internal Medicine
08:00
Department Internal Medicine registrar’s case presentations.
09:30
Internal medicine outpatients in the outpatient’s clinic
12:30
Ward round consultant, registrar and intern. Meet at Ward M3
Weekend ward rounds arranged with registrar and consultant on call.
Firm 2 - Pelonomi Hospital - Dr Otto
Monday
Tuesday
08:00
Internal Medicine statistics meeting at Pelonomi
09:00
Ward round M2 and m3. Ward work with registrar and intern.
10:00
Outpatients at Specialist Block for the rest of the day.
08:00
Ward round and ward work with the consultant, registrar and intern.
10:00
Attend bronchoscopies after ward work has been completed.
11:00
Discussion with consultant on various topics.
16:00
Student presentations – Dept Internal Medicine
18:00-
On call at Referral Room.
23:00
Wednesday
Thursday
Friday
08:00
Intake round and ward work with consultant, registrar and intern
10:00
Ward work.
11:00
Discussion with consultant.
14:00
Academic afternoon for students
08:00
Ward round registrar and intern. Ward work and self study for the rest of the day
16:00
Student presentations – Dept Internal Medicine
08:00
Department Internal Medicine registrar’s case presentations.
09:00
Ward round with consultant, registrar and intern, followed by ward work and
Bluebook presentations.
12:30
Weekends
Signing of forms and giving marks.
Weekend ward rounds arranged with registrar on call & consultant.
Firm 3 - Pelonomi Hospital - Dr Kachovska
Monday
08:00
Internal Medicine statistics meeting at Pelonomi hospital
09:00
Meet the registrar and consultant in ward M2 or M3 for ward round. This is an
academic round and includes a patient discussion/clinical methods.
Tuesday
Wednesday
Thursday
08:00
Ward round and ward work with the registrar and intern.
10:00
Attend medical clinic 2nd floor specialist block
16:00
Student presentations – Dept Internal Medicine
08:00
Ward round and ward work with registrar and intern
10:00
Attend hypertension clinic, meet with consultant
14:00
Academic afternoon for students
18:00
On call. Meet registrar at referral room.
08:00
Ward round registrar and consultant.Post intake round-students will be expected
to present their patient/s.
Friday
Weekends
16:00
Student presentations – Dept Internal Medicine
08:00
Department Internal Medicine registrar’s case presentations.
09:00
Meet registrar for ward round
Weekend ward rounds arranged with registrar and consultant.
Firm 4 - Pelonomi Hospital - Dr Steyn
Monday
Tuesday
Wednesday
08:00 – 08:30
Internal Medicine statistics meeting at Pelonomi
09:00 – 12:00
M2 - General ward duties with Registrar Firm4
08:00 – 11:00
M2 – General ward duties with Registrar
11:00 – 12:30
Academic round M2 (Consultant Firm4)
08:00 – 11:00
M2 - General ward duties with Registrar Firm4
09:30 – 13:00
Everyone – General intern out patients (All students and Registrar Firm 4
and Registrar infectious diseases)
Unfinished ward duties to be completed after the clinic
Thursday
08:00 – 12:00
M2 - General ward duties with Registrar Firm4
10:30 – 12:00
Firm 4 on call
Admission of new patients at casualty and referral room
Side room examination of patients
Complete blue books
Friday
08:00 – 09:00
Department Internal Medicine Registrar’s case presentations
09:30 – 12:00
Post ward round M2 - Registrar Firm4
Student presentations not done on Thursday evening to Consultant Registrar DG4-
Weekends
08:00 – 10:00
Weekend ward and casualty rounds arranged with Registrar on call &
Consultant.