FACULTY OF MEDICINE

PHASE II (CLINICAL YEARS) MBBS CURRICULUM

AUGUST 2012

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TABLE OF CONTENTS

Table of Contents……………………………………………………………………………………………...2

Endorsement/Approval…………………………………………………………………………………….4

Key contact persons………………………………………………………………………………………….5

Mission and Vision Statements…………………………………………………………………………7

General Information……………………………………………………………………………………..…8

Tables of course outlines………………………………………………………………………………….9

Assessment and Academic progression Regulations…………………………………………10

Documentation of Year III MBBS Courses

i. Family Medicine I…………………………………………………………………….17

ii. Internal Medicine I…………………………………………………………………..23

iii. Obstetrics & Gynaecology I……………………………………………………..28

iv. Paediatrics & Adolescent Health I……………………………………………34

v. Surgery I…………………………………………………………………………………41

Documentation of Year IV MBBS Courses

i. Internal Medicine II………………………………………………………………..46

ii. Diagnostic Radiology & Medical Imaging………………………………..49

iii. Special Project……………………………………………………………………….52

iv. Forensic Medicine & Toxicology…………………………………………….53

v. Psychiatry………………………………………………………………………..……54

vi. Public Health Medicine………………………………………………………….68

vii. Surgery II……………………………………………………………………………..71

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Documentation of Year V Courses

i. Family Medicine II…………………………………………………………….78

ii. Internal Medicine III………………………………………………………….83

iii. Obstetrics & Gynaecology II……………………………………………..84

iv. Professionalism, Medical Ethics & Integrity……………………...90

v. Paediatrics & Adolescent Health II……………………………………91

vi. Pharmacology ………………………………………………………………100

vii. Surgery III……………………………………………………………………….101

viii. Acknowledgement………………………………………………………….123

NOTE:

1. RETAIN A COPY OF THIS GUIDE AS YOU WILL NEED IT FOR THE REST OF YOUR
PROGRAM

2. YOUR PHASE I HANDBOOK CONTAINS MOST OF THE INFORMATION THAT YOU NEED
TO

KNOW ABOUT THE ENTIRE MBBS PROGRAM

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 ENDORSEMENT/APPROVAL

School of Medicine Board 12th June 2012

Botswana Health Professions Council 13th June 2012

SOM Advisory Board 18th June 2012

SOM Executive Committee 25th June 2012

Faculty of Health Sciences Executive 29th June 2012

Committee

Senate 27th August 2012

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 KEY CONTACT PERSONS FOR PHASE II
Dean, Faculty of Medicine Acting Deputy Dean, Faculty of Medicine

Prof Sandro Vento Prof Matthew Tanko

Tel: 355 4189 Tel: 355 4468

246/A114 1st floor 246/A115 1st floor

[email protected] [email protected]

Phase II Coordinator

Dr Oatlhokwa Nkomazana

Associate Programme Director

Tel: 355 4566

246/113, first floor FHS

[email protected]

246/113 first floor Associate Program Director

Dr Japhter Masunge

Tel: 355 8223

[email protected]

Internal Medicine Surgery

Pro Sandro Vento Dr Michael Walsh (HOD)

HOD [email protected]

Tel: 355 4189

Block 246/115 Public Health Medicine

[email protected] Dr Jose-Gaby Tshikuka (Acting HOD)

Tel: 355 4603

Paediatrics & Adolescent Health 246/202 FHS

Dr Loeto Mazhani (Acting HOD) [email protected]

Tel: 355 4467

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[email protected]

Assistant Program Director

Paediatrics & Adolescent Health Obstetrics & Gynaecology

Dr Loeto Mazhani Dr Tadele Benti (Acting Head of Department)

Tel: 355 4467 [email protected]

[email protected]

Psychiatry

Emergency Medicine Dr Philip Opondo (Acting HOD)

Dr Megan Cox [email protected]

[email protected]

355 4452

Anaesthesiology

Dr N Bekele (Acting HOD)

[email protected]

Family Medicine

Dr Vincent Setlhare (Acting HOD)

[email protected]

Personal Assistant to the Head, SOM

Mrs Olga Naane

Tel: 355 4189

246/114

[email protected]

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Note:

For curriculum issues, you may contact the respective HOD/rotation coordinator and/or Phase II
coordinator.

The procedure for reporting any unforeseen circumstance that may warrant your absence from
any rotation is detailed in the assessment guidelines in this document.

MISSION AND VISION STATEMENTS

The mission of the Faculty of Medicine of the University of Botswana is to prepare

skilful, productive, ethical and compassionate medical practitioners who advance
and apply in a humanistic and professional manner scientific discovery and
technological innovation to the health care needs of individual patients, their
families and larger societal groups.

The overriding vision of the Faculty of Medicine is to educate, recruit, develop and
retain Batswana medical doctors for the national health care system and to
enhance the health of the people of Botswana. The Faculty will do so through the
establishment of community-oriented programmes that span the four phases of
the professional life of a physician viz: undergraduate education, internship,
graduate education and continuing professional development.

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1.0 General information on the Phase II (clinical years) of the MBBS curriculum

Phase II of the MBBS program consists of years 3-5. The students will be exposed to learning in a
clinical context that will eventually enable them to acquire the competencies for independent
practice as graduates of medicine at the end of their internship program. Acquiring most
competencies in the clinical years is progressive throughout the undergraduate course and into
postgraduate life. Therefore the complete Phase II competencies can only be fully assessed at
the end of the 5th year. The students will be able to meet many of the competencies at the end
of year four. The outcomes are crafted so that acquisition of competencies at any time builds
on previous ones. The clinical experience in year 3 and year 4 is more structured such that the
acquisition of competencies is based on weekly outcomes derived from typical patient
presentations. The advantage of this approach is to shift students’ attention from learning
specific disease entities to contextual (broad-base) learning. For example, instead of saying “a
patient with pneumonia”, we would prefer it to be “a patient with cough and fever”. The
selected presentations for these sessions are to augment and not replace the patients seen on a
daily basis, but the same approach should be followed whatever the case. In year 5 in particular,
the students are expected to concentrate on skills that will enable them to practice
independently and as such, we expect the students to shadow as assistant interns under
supervision. Some of the vertical strands such as organization of services, clinical and
communication skills will run all through the clinical years and they will be encountered
repeatedly taking into account peculiarities that may exist between the different clinical
disciplines. It is the responsibility of the department to issue to students a handbook at the
beginning of their clerkship in that department so that the students can familiarize themselves
with the departmental programs and what is expected of them throughout their clerkship in
that department. This handbook should not contradict the SOM handbook; beside departmental
programs, it should also cover items such as time table, staff and clinical resources available to
students to enhance their learning experience.

In year 3, 4 and 5, Professionalism and Medical ethics will be taught as an integrated module in
all the clinical disciplines. Radiology and medical imaging will also be taught as an integrated
module together with Internal Medicine, Surgery and Paediatrics and Adolescent Health
modules. Forensic Medicine and toxicology will be taught via didactic lectures and tutorials
twice in the course of the year. Throughout the clinical years, lecture-based sessions should be
minimized so that the PBL and self directed learning philosophy is not compromised. So we
expect some of the lecture sessions to be conducted in the form of tutorials (topics assigned to
students to research on) and then present in groups to faculty member(s) during the tutorial
session. This ensures that the same PBL approach is maintained.

Students will rotate in the disciplines indicated for each year. Each rotation shall be of eight
weeks duration.

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COURSE OUTLINES TABULATED ACCORDING TO YEAR OF STUDY

YEAR THREE

COURSE TITLE COURSE CODE DURATION(weeks) CREDITS

Internal Medicine I (General) SOM 402 8 8
Family Medicine I SOM 404 8 8
Surgery I (General, SOM 405 8 8
Anaesthesiology)
Obstetrics & Gynaecology I SOM 406 8 8
Paediatrics & Adolescent Health I SOM 407 8 8

40 40

Lectures/tutorials in Basic Pharmacology will be taught one hour a week as an integrated

module in year three. Assessment shall be 100% CA

YEAR FOUR

COURSE TITLE COURSE CODE DURATION(weeks) CREDITS

Internal Medicine II:( General SOM 502 8 8
Internal Medicine, Infectious
disease, dermatology, Radiology)
Special project/Electives SOM 503 8 8
Psychiatry SOM 504 8 8
Public Health Medicine SOM 505 8 8
Surgery II (Orthopaedics, SOM 507 8 8
Ophthalmology,
Otorhinolaryngology, Radiology)
40 40
Lectures/tutorials in Forensic Medicine and toxicology will be held one hour weekly. Assessment
shall be 100% CA.

YEAR FIVE

COURSE TITLE COURSE CODE DURATION(weeks) CREDITS

Internal Medicine III: (General) SOM 602 8 8
Obstetrics & Gynaecology II SOM 603 8 8
Paediatrics & Adolescent Health II SOM 604 8 8

Family Medicine II SOM 605 8 8

Surgery III: (General, SOM 613 8 8
Anaesthesiology, emergency
medicine)
40 40
Lectures/tutorials in Clinical Pharmacology and therapeutics will be taught as an integrated
module in all the clinical disciplines in the fifth year.

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ASSESSMENT AND ACADEMIC PROGRESSION REGULATIONS

1.0 Regulations guiding assessments in phase II of the MBBS program

1.1 Senate’s General Academic regulations

 The Senate’s General Academic regulations of the University of Botswana (modified

where necessary to accommodate the peculiarities of assessment in medical education),
shall apply to all assessments in phase II.
 All assessments in the phase II of MBBS program shall be blueprinted to the three core
themes of the program:
o Medical and related science
o Doctor-patient relationship
o Public Health & Medicine

1.2 Academic year

 The academic year shall comprise 40 teaching weeks, a one week of reading (revision)
and two weeks of examination.
 All courses in phase II shall be year-long courses and progression decisions shall only be
made at the end of the year. There shall be no semester courses.

1.3 Attendance

 Attendance of all contact sessions (clinical rotation, PBL, community placements,

tutorials and others as may be determined by the department) in all courses in phase II
is compulsory. Students are expected to have 100% attendance during their clinical
rotation and community programmes. Students who have attended less than 80% of the
contact periods in any course (without valid reasons) will not be allowed to participate
in the end of year examination in that course and shall be awarded zero mark in that
particular examination. They will have to repeat the clinical rotation period in that
course and meet up the minimum 80% attendance before being assessed.
 If a student is unable to meet the required minimum of 80% attendance of contact
sessions in any course (s) due to exceptional or extenuating circumstances, the
candidate may be admitted in the end of year assessment provided that the Dean
Faculty of Medicine had been notified in writing (with copies to the Phase II coordinator
and Head(s) of department concerned) within 48 hours of the event. Such letter should
describe the nature of the circumstance. In all cases, the department(s) concerned
should advice on the preparedness of the candidate to sit for the exam or be considered
for a special examination.
 If a student has met all the requirements in any course (s), but is unable to sit for the
end of year examination due exceptional or extenuating circumstance (bereavement, ill
health or other circumstances that may cause emotional trauma), for which the Head of
School has been duly notified, the candidate can apply to be considered for a special
end of year examination. The special examination must take place before the beginning
of the next academic year but not earlier than 48 hours after the student is certified fit
to sit for the examination.
 Once a student has sat for the end of year examination, he or she may not afterwards
apply for a special examination on the basis of unforeseen circumstances.

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1.4 Progression from year to year.

A student must pass all the components of the assessment exam (continuous assessment,
written and clinical examinations, etc.) and meet all the requirements for that year in all courses
before progressing to the next year of study. There shall be no carry over.
The pass mark shall be 50%. All high stakes examinations shall undergo minimum
standardization before being administered, or during the examination in case of the clinical
component.

1.5 Minimum standardization requirements (standard setting)

 Both internal and external moderation of assessment tasks shall occur.

 All written examination questions shall be internally moderated by a panel of examiners
selected from the clinical specialties. This panel will carry out a pre-assessment
moderation of all the questions not later than 4 weeks before the date of the
examination. All internally moderated questions must also be externally moderated by
an external examiner (in each course) appointed by the Dean, FOM on behalf of Senate,
following departmental recommendation and endorsement of the Board. All HODs must
ensure that their internally moderated questions are sent to their appointed external
moderators not later than 6 weeks before the commencement of the examination.
Examination results will be standardised by one of the acceptable methods. Such an
external examiner shall serve for three consecutive years and shall not be re-appointed.
The function of the external examiner shall be limited to the moderation of questions in
all high stakes examination in year 3. In year 4 and 5 however, the external examiner
shall moderate the questions and be invited to examine in the clinical component of the
examination. The honorarium for the external examiners shall be determined by the
Faculty of Medicine from benchmarking in the region.

1.6 Assessment
There shall be two (2) components of the assessment in each year as follows:
 Continuous assessment (CA) -40%
 End of rotation or end of year clinical and written examinations -60% (except in Year 3
where there is no clinical examination.)
In addition, there shall be an integrated final (exit) examination in Year 5.

1.6.1 Continuous Assessment

Assessment of students’ progress shall be on a continuous basis. Formative assessment shall

take place informally all through the clinical rotation period in all the courses. Clinical instructors
are expected to monitor each student’s performance in their courses through various methods
such as case presentations, PBL sessions, directly observed clinical and procedural skills, etc and
promptly give feedback to the students on their level of performances. The summative
continuous assessment shall carry 40% of the year mark in each course. The following shall form
the components to be assessed using the log book (the maximum marks per component will
vary by clinical discipline and year of training):

 Clerking and presentation of patients: Each student in the firm must clerk and present a
minimum of one case per week (assigned by the clinical instructor(s)).

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  Directly Observed Clinical and Procedural Skills (DOCPS): This shall be defined in the
departmental booklets and may consist of mini-CEX including modified OSCE and clinical
procedures involving generic skills. Each student must complete the number of
procedures outlined in the department’s log book. The procedures shall be categorized
into those observed (O), assisted in (A) or performed (P) by the student. This must be
dated and signed by the supervising clinician. Students are expected to carry out 100%
of the listed procedures to be logged in as determined by the department before they
can sit for the examination.
 Formulation of management plan and evidence based decision making: This shall
follow the student’s patient presentations and will involve requisition of Laboratory or
imaging procedures to aid the diagnosis/management and interpretation of the same by
the student etc. In all cases, the student is expected to follow-up the patient until
discharge or demise of the patient. In the latter case, if an autopsy is requested the
student must attend the autopsy session and write down the findings as part of the
documentation of the patient’s illness.
 Engagement with the PBL process: All students are to be assessed during their PBL
session for attendance, contribution and reflective ability on each case.
 Ward evaluation: At the end of the rotation, each student will be evaluated on
the overall performance and professionalism.

The learning framework in the final year is largely contact with a wide variety of patients
through an “assistant intern scheme”. The PBL process continues but the emphasis changes to
consider broader issues of patient management. Apart from the PBL sessions (which should as
much as possible be on real patients), the tutor’s role should concentrate on observation of and
feedback on the student-patient encounter rather than on transfer of factual information which
the students can find out for themselves with appropriate guidance. Students must keep a
record of skills they have acquired which has been signed off by a senior member of staff.

All summative continuous assessment (CA) marks must be ready and be forwarded to the phase
II coordinator not later than one week after the rotation. The Faculty Board shall consider and
formally issue progress reports on each student during the following monthly meeting of the
Board after each rotation.

A student is expected to have a minimum mark of (50%) in the continuous assessment (20 marks
out of 40) to be in academic good standing. Any student who fails the continuous assessment
(course marks) shall not be admitted to the end of year examination. The format of continuous
assessment shall be the same for all the clinical years. The continuous assessment in Public
Health Medicine will consist of student presentations on the field activity (10%), personal
reflection (10%) and report on the community project (20%).

The Forensic Medicine and Toxicology block in year 4 shall be assessed 100% by CA. A student
who fails to pass the CA in these blocks shall be requested to re-take the test in the coming year.
Although failing any of these blocks will not hinder students from progressing to the next year of
study, passing them is a requirement before graduation.

Similarly, the Elective block in year 4 shall be graded as pass or fail. At the end of the 8-week
elective block, students are expected to submit a 1500 words scientific report on the project
and/or what they studied during the elective period under the guidance of a designated

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supervisor (s). It is a requirement to pass the elective block before graduation. A formal report
from the student’s supervisor shall be submitted to the Faculty of Medicine.

1.6.2 End of year or end of rotation Examination

There shall be an end of year or end of rotation examination which shall carry 60% of the year
mark. Progression decisions on each student shall only be made at the end of the year. There
shall be written and clinical components of the examination in all the core clinical specialties
except in year 3 in which the end of year examination shall consist of two written papers. There
shall be no structured oral (viva voce) examination.
In addition, there shall be an integrated final (exit) examination in Year 5.

In year 3, the end of year examination shall consist of the following:

1.6.2(i) Written examination:

This shall normally be held at the end of the academic year.
It shall be administered in each course as follows:
a. Application of knowledge and understanding paper: comprising MCQs and EMIs worth
90marks (1hour 30 minutes) in each course.
b. Key clinical features: short answer questions around clinical presentations worth 90
marks (1 hour 30 minutes)
A student is expected to have a minimum mark of (50%) in the end of year examination (90
marks out of 180) to pass the written examination. All examination questions in all the courses
shall be externally moderated by external examiners appointed by the Senate of the University
of Botswana.

Each component of the assessment must be passed. In Year 3 the components are CA and
written examination. There shall be no compensation of marks from one component to the
other.

In year 4, the following shall form the components of the examination:

1.6.2(ii) Written Examination

This shall normally be held at the end of the academic year. There shall be one written paper per
discipline principally assessing the application of knowledge and understanding. It shall be a 2 –
hour paper comprising of MCQs, EMIs and SAQs. This shall carry 20% of the year mark. The
overall mark allocation to this paper is 120.
All examination questions shall be externally moderated by external examiners appointed by the
Senate of the University of Botswana.

1.6.2(iii) Clinical Examination

This shall normally be in the form of objective structured clinical examination (OSCE).
There shall be a minimum (16 OSCE stations in all) for this part of the examination. The time
allocation to each station must be equal and it will range from a minimum of 10 minutes to a
maximum of 15 minutes per station. This shall carry 40% of the year mark. OSCE stations
assessing communication skills and professionalism must be included. All clinical examination

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shall be externally moderated by the external examiners appointed by the Senate of the
University of Botswana. There shall be one external examiner for each course.

In Public Health Medicine, the following shall be the format of assessment:

1.6.2(IV) Continuous assessment

 Personal reflection (10%).
 Presentations (10%)
 Project report (20%)

1.6.2(V) End of year examination in Public Health

 Shall consist of a 2-hour paper as for the other courses above but it shall carry 60% of
the year mark. The Examination paper shall be externally moderated.
Each component of the assessment must be passed. There shall be no compensation of marks
from one component to the other. Students who fail to pass their CAs may not be admitted to
the end of year examination.

In year 5, there shall be discipline specific clinical and written examinations as well as an
integrated final (exit) examination.
Both the written and clinical components of the integrated final exit examination shall take
place at the end of the year.
The clinical component of the discipline specific examination will be done at the end of each
rotation while the written examination will take place at the end of the academic year.
Both the written and the clinical components of the examination shall be subjected to external
moderation.

1.6.2(VI) Assessment

a. The Continuous assessment shall carry 40% of the discipline specific year mark.
b. The discipline based clinical examinations will comprise of mini-clinical
examination (mini-cex) or Practical observed consultations. It will carry 30% of the
discipline specific mark.

c. The discipline specific examination will principally assess management of

common clinical problems including appropriate investigations, prescribing and
preventive strategies. It shall be a 2 hours 30 minutes paper comprising of MCQs,
EMIs and SAQs and marked out of 150. It shall carry 30% of the discipline specific
mark.

d. The integrated final (exit) examination at the end of the academic year shall consist of the
following components:

i. An integrated clinical application of knowledge and understanding. It will integrate

knowledge of aetiology, diagnosis, special investigations, pharmacological and non-
pharmacological management, professionalism, ethics as well as underlying biomedical
sciences.

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 It shall be a 3 hour paper comprising of MCQs and EMIs. It shall carry 50% of the final
integrated examination.

ii. Final Clinical Practice Examination (FCPE): This shall be in the form of Objective
Structured Clinical Examination (OSCE). There shall be up to 36 OSCE stations altogether
for this component of the examination. Each shall be for a minimum of 10 minutes and a
maximum of 15 minutes. Each station must be of the same time allocation. The FCPE
shall carry 50% of the year mark. OSCE stations assessing Ethics, communication skills
and Professionalism must be included. The examination will take place over two days
and be divided between surgical (Obs&Gyn, Surgery, Anaesthesia, ENT, Ophthalmology,
Orthopaedics and trauma) and medical (Paediatrics, Internal Medicine and Family
Medicine)

1.7.0 Re-assessment opportunity

1.7.1 Supplementary Examination

Subject to the Senate General regulations on assessment (section 00.95), and the School of
Medicine Special Regulations on assessment in the MBBS programme, supplementary
examination for Years 3 and 4 shall be held within six (6) weeks after the end of year
examination and not later than the 3rd week of July. The six weeks’ time shall be a remediation
period for the students who qualify for supplementary examination at the end of year 3 and 4.
Reassessment is only available for up to two failed courses.
In the final (exit examination) at the end of year 5, a reassessment opportunity is only available
6 months after the final exit examination. The 6 months period shall be a remediation time for
students who qualify for supplementary examination.

The following regulations shall apply to students who fail to obtain pass marks at the first
assessment opportunity:

1.7.2 A student who fails to obtain a pass mark in up to two courses (40% of
attempted year credits), shall apply for supplementary examination in the failed
courses. The mark for the reassessed courses shall be recorded as the minimum
required for the student to pass if the student scores higher than this. However,
if a student obtains a lower mark after being reassessed, the initial mark
obtained in the end of year examination shall be recorded as the final mark. The
course marks (CA) for any student supplementing a course shall count in the
final computation of the year mark.

1.7.3 A student who supplements a course(s) and fails to obtain a pass mark shall
repeat the year of study. Such a student must repeat all the courses for that
year and meets all requirements for that year before being admitted to the end
of year examination.

1.7.4 A student who fails to obtain a pass mark at the end of a repeat year shall be
discontinued from the MBBS programme. A student who is discontinued from

15
 the MBBS programme shall not be eligible for re-admission into the programme.
Such a student may apply to another programme for which the student
qualifies.

1.7.5 A student who fails up to 3 or more courses in the year (up to 50% or more of
the year attempted credits), shall repeat the year of study. Such a student must
repeat all the courses for the year and meet all the requirements including
continuous assessment before being admitted to the end of the repeat year
examination. Any student who fails to obtain a pass mark at the end of the
repeat year shall be treated as in (1.7.4) above.

1.7.6 Any student who repeats the final year and fails to obtain a pass mark shall be
discontinued from the MBBS program as in 1.7.4 above.

DOCUMENTATION OF THE PHASE II MBBS CURRICULUM

Year three

3.0 Family Medicine

3.1 General Information and scope of Family Medicine Course

Undergraduates receive a lot of education and training in in-patient care. They also need the
same in the care of patients in a clinic or outpatient set up. They can take 30 to 45 minutes to
examine a patient in a ward situation. However in the clinic a doctor is required to assess and
treat the patient in five to ten minutes or even less. The busy clinic or outpatient department
dictates such an approach for most patients in this setting. This short consultation need not
compromise health care and safety.

Students need to acquire a grasp of the difference in disease pattern and treatment approach in
clinic practice as opposed to inpatient care. They need to be comfortable with uncertainty in
diagnosis and treatment while ensuring patient safety.

The students are theoretically conversant with the biopsychosocial paradigm of family medicine.
They are familiar with most diseases as described in textbooks, journals and lecture rooms. The
challenge is to make theory meet the reality of illness and suffering in the homes of Batswana.
They will learn that many patients have no clear diagnosis but nevertheless need to be helped.
They should appreciate that their role as more than medical scientists dispensing various
treatments. They should begin to see themselves as healers and alleviators of human suffering.
This will help them to appreciate the total care of a patient.

The doctor cannot solve all the patients’ problems alone, certainly not in one patient/doctor
contact. The student should begin to appreciate that the doctor is part of a team of experts in
various fields (dieticians, nurses, social workers, physiotherapists, etc). He/she should be
exposed to and taught by these various cadres so that s/he understands that the various cadres
complement each other and should work hand in glove as different experts.

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3.1.0 Family Medicine I (SOM 404)

3.1.1 Course Description and content (synopsis)

3.1.2 Learning framework

Education and training will be via didactic, PBL, and experiential-learning from patients.

Formal lectures and presentations will be given by faculty and health workers in the various
disciplines.

Students will be based in clinics and outpatients departments of primary and/or district
hospitals. They will be exposed to experiential learning. They will be attached to doctors, nurses,
social workers, psychologists, physiotherapists, occupational health therapists, and other health
workers during their training.

Students will also explore the psychosocial aspect of illness by immersing themselves in the lived
space of the patient. They will follow patients to their homes (after getting a patient’s consent).
In the patient’s home, students will interview the patient and consenting relevant others. They
will also observe relationships and living standards of their patients. Students will then discuss
their findings and experiences in group learning sessions.

Students (especially women) need to do home visits in pairs, for security reasons. Faculty need
to ensure full participation by students.

Weekly time tables will show times and venues of:

i) Didactic, PBL, and experiential learning

ii) Experiential learning with health personnel

iii) Home visits

Students will be required to:

a) Attend all lectures.

b) Be attached to a health worker for at least three hours on designated days.

c) Do at least one home visit a week.

Evaluation and assessment

 At the end of the rotation students will evaluate the program and facilitators. Students
will be assessed during the rotation and at the end of the rotation.

General outcomes

These are outcomes that will apply to all or many of the patients that you will meet in the block
and are similar skills to those needed in other areas of medicine.

By the end of phase ll the student should be able to:

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Communication

 establish interview conditions that are safe and respectful of the interviewees’ rights
including the right to privacy
 use empathic communication skills to establish a rapport and elicit relevant information
from patients and families across the age range, including their ideas, concerns and
expectations
 assess and manage patients and their relatives in a sensitive, non-judgmental way that
takes account of their gender, social, cultural and ethnic background
 elicit patients’ views, concerns and expectations, and negotiate options for their care in
order to reach shared agreement where possible

Patient assessment skills

 formulate a patient’s problem in terms of predisposing, precipitating and maintaining

factors
 formulate a management plan (including the use of medication if necessary) using
information sources; appraise evidence and apply the conclusions for the care of
patients with common problems presenting in the community
 consult with patients in the outpatient and clinic setting expeditiously, reaching a
working diagnosis within a short period without compromising the safety of the patient.
 recognise and distinguish the common patient presentations in a clinic setting
 consult with patients in their homes
 acquire diagnostic and management information from the domestic surroundings.
 learn from the various health cadres.

List of weekly presentations

Week 1 The patient with fever

Week 2 The patient with acute cough and/or upper respiratory tract symptoms

Week 3; The patient with diarrhoea

Week 4; The patient with headache

Week 5; The patient with abdominal pain and/or dysuria

Week 6; The patient with a rash

Week 7;The patient with abnormal blood pressure

Week 8; The patient with abnormal blood sugar

Week 9; The pregnant patient

Week 1; The patient with fever

 measure body temperature and recognise fever, hyperthermia and hypothermia

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  recognise the body response mechanisms to febrile condition

 recognise by history, physical examination and simple investigations the common

causes of fever in both children and adults

 initiate management for common causes of fever

 explain to patients and/or caregiver/mother (in case of a child) the significance and
management of fever (including self care) taking into account their understanding of
fever

Week 2; The patient with acute cough and/or upper respiratory tract symptoms

 distinguish on history and examination between the common causes of acute cough

 recognise the possibility of airway obstruction (asthma and foreign body) in patients
presenting with cough

 investigate appropriately for causes of acute cough

 discuss with patients the limited effectiveness of antibiotics in most cases of acute
cough

 prescribe symptomatic treatment appropriately

 work with the primary care team in the management of a patient with respiratory tract
infections

Week 3; The patient with diarrhoea

 recognize the common sources of infective diarrhoea

 distinguish the likely causes of diarrhoea on history and examination

 initiate appropriate investigations for diarrhoea

 recognize the clinical manifestations of diarrhoea in adults and children

 estimate the degree of dehydration in adults and children on clinical grounds

 work with the primary care team to manage patients with diarrhoea (with emphasis on
different types of fluid requirements & contents in children versus adults)

 explain to the mother/caregiver how to prepare ORS at home during health education
session

 give advice to staff and patients on the prevention of infective diarrhoea

Week 4; The patient with headache

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  distinguish between the common types of headache on history and examination

 recognise the likelihood of intracranial pathology (tumour, haemorrhage and infection)

requiring urgent referral

 initiate appropriate investigations for patients with headache

 prescribe appropriately for patients with headache

 explore the patient/caregiver/family ideals, fears or feelings or thoughts about

headache (mini project)

Week 5; The patient with abdominal pain and/or dysuria

 distinguish between the common causes of abdominal pain on history and examination
in adults and children

 recognise in patients with abdominal pain the need for urgent referral

 initiate appropriate investigation for patients with abdominal pain

 work with the primary care team in the management of a patients with abdominal pain

 distinguish between the common causes of dysuria on history and examination in adults
and children

 indentify in patients the potential risk factors for dysuria

 initiate and interpret simple investigations for dysuria

 discuss with patients the preventive measures for dysuria

 prescribe appropriately for dysuria

 work with the primary care team in the management of dysuria

Week 6; The patient with a rash

 recognise in patients that skin rash has a major effect on body image

 distinguish in patients the primary and secondary morphological skin lesions (terms)

 distinguish between the common rash conditions in primary care (based on size, colour,
arrangement, morphological lesions, patterns and distribution) in adults and children

 recognise in the history common precipitants of skin rash

 perform basic diagnostic procedures relevant to common rash presentation in primary

care and interpret the results

 work with the primary care team in the management of patients with common rashes

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  recognise severe and life threatening rashes and refer appropriately

Week 7; The patient with abnormal blood pressure

 diagnose hypertension, understanding the limitations of the methodology

 recognise hypertension as risk factor rather than a disease and be able to explain this to
a patient
 recognise long term complications of persistently elevated blood pressure
 recognise and assess end organ damage from hypertension and screen for secondary
causes of hypertension
 work with the primary care team in the management of hypertension
 recognise the patient at high risk from hypertension and be aware of the different
target blood pressure levels for these patients
 discuss with patients the implications of a high blood pressure

Week 8; The patient with abnormal blood sugar

 diagnose diabetes with reference to the WHO diagnostic criteria

 describe the nature and cause of Type 2 diabetes
 outline to patients the dietary principles in the management of diabetes
 instruct a patient in home testing techniques for the assessment of Type 2 diabetes
glycaemic control
 prescribe appropriately for Type 2 diabetes in accordance with recommendations
 work with other members of the health care team in the management of diabetes
 Diagnose the major complications of Type 2 diabetes and understand the potential for
their prevention

Week 9; The pregnant patient

 describe signs and symptoms of pregnancy

 diagnose pregnancy
 recognize physiological changes related to pregnancy
 examine a pregnant patient
 do routine investigations of pregnant patients in ante natal clinics
 know some determinants of high and low risk pregnancy
 to take part in at least two normal delivery processes
 to outline different stage of delivery

Evaluation and assessment

 At the end of the rotation students will evaluate the program and facilitators. Students
will be assessed during the rotation and at the end of the rotation.

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 Core Family Medicine Topics to be covered during Module I

1 Principles of Family Medicine

2 Biopsychosocial model of health and its implication in Family medicine
3 The consultation model

4. 0 Internal Medicine

4.1 General information about Internal Medicine course

Internal medicine course will be taught in three modules of nine weeks duration each in the 3rd,
4th and 5th year respectively. During this period, the students will be exposed to a body of
scientific knowledge on individual disease entities affecting the human body systems in the
adult. This includes causality, epidemiology, natural history of frequent and rare but life
threatening medical conditions. Clinical presentation, diagnosis, treatment, prognosis and
rehabilitation will be a major focus of internal medicine modules. The students will gain
competence in professionalism and clinical reasoning from clinical consultants and other
members of the clinical team through case presentations and discussions. Evidence based
practice, integration of basic science knowledge, pathology and laboratory medicine and
pharmacology will also be emphasized.

4.1.0 Internal Medicine I (SOM402): Junior clerkship in General Internal Medicine (Eight
weeks)

4.1.1 Course description and content (synopsis)

This course which is the mainstay and foundation of clinical medical practice is designed to
introduce the students early on to the professional and technical skills, scientific knowledge and
understanding and application of basic sciences necessary in the care of the sick, their families,
and the community and build up on the art of medical practice. The module also introduces
students to basic nursing procedures through didactic teaching and hands-on practice. The
students are also equipped with knowledge and skills for providing emergency First Aid
resuscitation and support before arranging for secure and safe transfer to an health facility. It
emphasizes on the establishment of close physician-patient relationships, social communication,
and the performance of physical examination based on competent use of professional skills.

The course acquaints students with communication skills; medical ethics; general, regional, and
systemic physical examination of patients; basic nursing skills; First Aid; aetiology, pathogenesis,
natural history, treatment and prognosis of disorders of the respiratory system, cardiovascular
system, endocrine system, neurological system, disorders of the lymphoreticular system,
haematological conditions, cancer. Students are expected to be able to develop professional
skills and experience in conducting a medical interview and examination of adult patients,
prepare patient record and presenting the findings to clinical faculty. The students will also start

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to learn how to make clinical follow-up of patients and their discharge, use laboratory and
diagnostic tools, interpret results and use evidence to make clinical decisions. Topics: The
module covers topics in general medicine (homeostasis, fluid and electrolyte balance; diseases
of blood, blood vessels, lymphoid tissues and the heart; heart failure; lung disease and
respiratory failure; renal conditions and renal failure; diseases of metabolism; endocrine
dysfunction in states of hypo and hyper-function; liver disorders and failure, gastrointestinal
malignancy and disorders of the pancreas and digestive system; stroke and tumors/space
occupying lesions of the brain and meninges; hemi- and paraplegia; allergy and autoimmune
diseases. Topics in laboratory management: basic chemistry of body fluids, enzymatic,
biochemical, and hematological tests on respiratory, circulatory, hemolymphopoietic, and
endocrine systems. This module is organized in clinical clerkships and clinical practice is carried
out in the medical wards of teaching hospitals. Students will rotate through general medical
wards.

Learning outcomes

At the end of phase II, the student should be able to:

Organization of services

 Discuss the role of audit as an approach to quality improvement.

Communication skills
 Establish as much as possible interview conditions that are safe and respectful of the
interviewees rights
 Use empathic communication skills to establish a rapport and elicit relevant information
from patients and their families
 Assess and manage patients and their relatives in a sensitive, non-judgmental way that
takes account of their social, cultural and ethnic background.
 Elicit patients’ views, concerns and expectations.

Clinical assessment skills

 Demonstrate their ability to identify the most important gastrointestinal, endocrine and
renal/urological causes for common patient presentations.
 Gather information from patients considering physical, psychological and social aspects,
using clinical reasoning to reach an appropriate provisional diagnosis.
 Elicit selectively, normal and the most important abnormal physical signs to test
diagnostic hypotheses.
 Use the most important investigations selectively to confirm diagnostic hypotheses.

Weekly topics and outcomes

Weeks 1&2

The patient with liver disease

 identify risk factors for liver disease on clinical grounds

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  understand the effect of the most important drugs on liver function and the effect of
impaired liver function on drug metabolism and excretion
 distinguish pre-hepatic, hepatic, post-hepatic jaundice on clinical and biochemical
grounds
 distinguish between infectious and mechanical causes of biliary obstruction
 initiate appropriate investigations for jaundice and interpret the results
 initiate investigations for hepatomegaly
 recognize the hepatic manifestations of tuberculosis
 recognise the manifestations of chronic liver disease including liver failure and portal
hypertension
 recognise the cause of acute, and acute- on- chronic, hepatic failure, the signs of hepatic
failure
and initiate immediate management
 discuss with patients the options for limiting the risks of liver damage
 detect ascites clinically
 initiate appropriate investigations having regard to the likely causes, with special
reference to viral hepatitis A, B, C, D, E
 initiate management of hepatic ascites
 recognise risk factors for chronic liver disease and identify measures to address them at
an
individual and population level
 recognise common causes of thrombocytopenia
 recognise the causes of hepatocellular carcinoma, identify diagnostic methods and
management
 describe the functions of the spleen
 recognise and distinguish the common causes of splenomegaly (infections,
hematological diseases, portal hypertension, metabolic and collagen diseases)
 describe the complications of splenomegaly and the indications for splenectomy
 describe post-splenectomy complications

Week 3

The patient with lung disease

 recognise common causes of dyspnea (cardiovascular, respiratory, neurological,

hematological and metabolic causes)
 recognise clinical features, identify laboratory and radiological investigations in a patient
with dyspnea
 recognise the role of arterial blood gas analysis in evaluating a patient with dyspnea
 describe the etiological and anatomical classification of pneumonia
 recognise risk factors and stages of pneumonia
 describe management of patients with pneumonia based on suspected etiologies
(hospital vs community acquired pneumonia)
 recognise causes of pleural effusion and evaluate pleural fluid
 describe the epidemiology, classification and risk factors for bronchogenic carcinoma
 describe paraneoplastic syndromes in patients with bronchogenic carcinoma
 describe the role of TNM staging in management of lung malignancies

24
  evaluate and manage a patient with chronic obstructive pulmonary disease/asthma
 describe clinical features and risk factors for pulmonary embolism
 recognise the pretest probability in a patient with suspected pulmonary embolism
 describe investigations, treatment and prevention of recurrent pulmonary embolism

Week 4

The patient with central nervous system disease

 recognise the causes/risk factors for hemiplegia

 recognise cortical and spinal causes of paraplegia
 recognise the importance of neurological examination to localise the site of lesion in a
patient with hemiplegia/paraplegia/paraparesis
 describe the forms of stroke and mode of presentation
 recognise complications of stroke and discuss preventive measures
 describe complications of paraplegia and preventive measures
 describe the investigations for a patient with hemiplegia/paraplegia/paraparesis
 describe the principles of management in a patient with hemiplegia/paraplegia

Week 5

The patient with kidney injury

 recognise the features of acute kidney injury, distinguish it from chronic renal failure and
relate changes to underlying pathophysiology
 identify effective approaches to prevent kidney injury including recognising the
nephrotoxic potential of drugs including traditional medicines
 initiate investigation and management of acute kidney injury
 recognise chronic renal disease
 recognise the potential for drug toxicity in patients with kidney injury
 be able to outline to patients and relatives the management of end stage renal disease
including transplantation
 participate in the management of patients with chronic renal failure including correction
of complications
 recognise the impact of haemodialysis or peritoneal dialysis on physical and social well
being and psychological distress
 recognise obstructive nephropathy and initiate investigations for possible causes in
particular benign prostatic hypertrophy
 recognise renal stone disease and initiate investigations for the common etiological
factors including urinary tract infections
 recognise the possibility of uroepithelial/renal, prostatic and testicular malignancies
(cross refer to cancer block

Week 6

The patient with malignant diseases of the hemolymphopoietic system

 recognise myeloproliferative and lymphoproliferative disorders

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  describe epidemiology and clinical features of acute and chronic leukemia
 describe the general and specific management of leukemia
 recognise the clinical features of Hodgkin’s and non-Hodgkin’s lymphomas
 describe investigations and management of patient with lymphomas
 describe causes of anemia
 recognise consequences of anemia
 describe polycythemia and its complications and treatment
 describe causes of leukopenia
 describe consequences of neutropenia and lymphocytopenia
 describe management of neutropenia
 describe causes of leukocytosis, neutrophilia and lymphocytosis

Week 7

The patient with valvular heart disease

 identify diastolic, systolic murmurs and continuous murmurs

 recognise causes of diastolic , systolic murmurs and continuous murmurs
 describe epidemiology and pathogenesis of rheumatic valvular heart disease
 initiate investigations to confirm a diagnosis of valvular heart diseases
 recognise the major clinical features of rheumatic heart disease
 understand the management of a patient with rheumatic valvular heart disease
 understand mechanism of action, complications and follow up of a warfarin-treated
patient
 understand the secondary prevention of acute rheumatic fever in a patient with
rheumatic heart disease
 describe risk factors, pathogenesis, clinical presentation and treatment of infective
endocarditis
 understand indications for infective endocarditis prophylaxis

Week 8

The patient with cardiac failure

 describe possible causes of bilateral lower limb edema
 recognise epidemiology and causes of heart failure
 describe precipitating factors for heart failure
 recognise different types of heart failure
 describe the pathophysiology of heart failure
 identify pharmacological targets of heart failure treatment based on the
pathophysiology
 describe clinical manifestation of heart failure
 Be able to diagnose heart failure clinically and order appropriate investigations
 explain the nature, causes, management and prognosis of heart failure to patients and
their families
 understand the psychological and social impact of a diagnosis of heart failure
 describe different types of cardiomyopathies
26
Week 9

The patient with thyroid dysfunction and endocrine causes of weight loss

 understand the concept of hormonal control feedback and the inter-relationships of the
pituitary, thyroid and adrenal glands
 understand the causes of thyroid, adrenal and pituitary dysfunction
 understand how pituitary, adrenal and thyroid disease can affect the individual clinically
and socially
 initiate appropriate investigation for thyroid, adrenal and pituitary disease
 recognise under and over activity of the thyroid in patients
 initiate medical treatment for hyperthyroidism and discuss with patients the common
side effects of the medication used and the place of radio-iodine and surgical treatment
 prescribe appropriately thyroid hormone replacement therapy

5.0 Obstetrics and Gynaecology

5.1 General information about Obstetrics and Gynaecology Course

This course introduces students to the diagnoses and treatments of abnormalities and diseases
of the female reproductive system and the normal processes of pregnancy and puerperium and
the management of common obstetrical and gynecological conditions and their complications
(including the management of fertility and infertility and infections involving the female genital
tract), and general maternal health. The course is offered in two modules during the third and
fifth year of study. It begins with introducing students to the organization of services in maternal
health, obstetrics and gynaecology; and communication and clinical skills specific to the practice
of maternal health, obstetrics and gynaecology.

5.1.0 Obstetrics And Gynaecology I(SOM 406): Junior Clerkship (Eight weeks)

5.1.1 Course description and content (synopsis)

PREGNANCY AND LABOUR: This course is designed to introduce students to the management
of common obstetrical conditions and their complications. Students will be able to evaluate
normal and suspect high risk or abnormal pregnancy, carry out selected diagnostic
investigations, develop an intervention plan, observe practical and surgical interventions as an
assistant to clinical faculty member, prepare patient record, present findings to clinical faculty
members, and make proper referrals of patients. Topics covered include : Review of Anatomy
and physiology of the female reproductive system; conception, pregnancy, the management of
normal pregnancy; high-risk pregnancy; abnormal pregnancy; medical conditions and HIV in
pregnancy; abnormal stages of labor; ectopic pregnancy; patho-physiology of high risk and
abnormal pregnancy; obstetric operations, e.g. caesarean section and curettage; supervision of
other caregivers within a health facility or home visits; ethical issues in obstetrics, all with

27
specific reference to practicing in Botswana; Miscellaneous medical disorders; Haematological
problems in pregnancy; Renal disease, Diabetes and endocrine disease; Heart disease;
hypertensive disorders; malpresentation; malposition; cephalopelvic disproportion and obstetric
procedures; induction and augmentation of labour; prolonged pregnancy; preterm labour;
multiple pregnancy; disorders of fetal growth and assessment of fetal well-being; obstetric
emergencies; Trophoblast disease; recurrent miscarriage; spontaneous miscarriage; neonatal
care for obstetricians; puerperium and lactation; analgesia and anaesthesia; fetal monitoring
during labour; antenatal care; pre-conception counseling; Normal fetal growth; the placenta and
fetal membranes; prenatal diagnosis and genetics.
GYNAECOLOGY: This module is designed to acquaint students with the use of their professional
skills to identify diseases affecting the reproductive system, conduct appropriate investigations,
interpret results, explain the underlying patho-physiological processes, and develop a
management plan. Topics covered include anatomy and physiology of the female reproductive
system; The menstrual cycle; Normal and abnormal development of the genital tract;
gynaecologic exploration; major gynaecologic syndromes: leucorrhoea, pelvic pain and
menstrual abnormalities; affections of vulva and vagina; benign and malignant affections of
uterus; ovarian tumors; pelvic inflammatory disease; affections of breasts; uterine prolapse;
climacterium and menopause; contraception and infertility; sexual education and family
planning; Hysteroscopy and laparoscopy; Urinary incontinence; Pelvic floor dysfunction;
uterovaginal prolapsed; menopause and the postmenopausal woman.; assisted reproduction;
infertility; endometriosis; chronic pelvic pain; menstrual problems: menorrhagia and primary
dysmenorrhagia; polycystic ovary syndrome and secondary amenorrhoea; primary
amenorrhoea; Gynaecological disorders of childhood and adolescence; the role of ultrasound in
gynaecology; termination of pregnancy.

Learning Outcomes
At the end of phase II, the student is expected to be able to:

Organisation of Services

 Outline the organisation of Maternal Health services in Botswana including sexual

health, genito-urinary medicine, midwifery, obstetrics and gynaecology
 Identify the variability in how the quality of women’s health services
is measured at local and national level
 Identify the relevance of societal, cultural, economic and political
issues with regard to the provision of obstetrics, gynaecology and sexual
health
 Recognise the contribution which is made to the management of each
individual patient by primary care and specialist service.ganisation of services

Clinical Assessment

 Demonstrate ability to identify the important obstetrical, gynaecological

and sexual health causes for common patient presentations
 Gather information from patients considering physical, psychological
and social aspects, using clinical reasoning to reach an appropriate
provisional diagnosis

28
  Elicit selectively, normal and abnormal physical signs to test diagnostic
hypotheses
 Formulate a management plan (including the use of medication), if necessary
using information sources, appraise evidence and apply the conclusions, for the
care of patients with common obstetrical and gynaecological conditions
 Perform a vaginal, bimanual and speculum examination, taking cervical
screening and microbiological samples
 Outline legal responsibilities and confidentiality issues relevant to sexual
activity and sexual health and HIV care, including issues of consent,
disclosure, providing care for minors, people with learning difficulties, suspected abuse
and rape
 Give examples of how pregnancy and breastfeeding may influence prescribing

Communication Skills
20.0.3 Clinical assessment skills
 Establish interview conditions that are safe and respectful of the
interviewee's dignity, rights, safety and wellbeing
 Use empathic communication skills to establish a rapport and elicit
relevant information including, when necessary, a sexual history and
consent to intimate examination
 Assess and engage with patients and their relatives in a sensitive, non-
judgemental way that takes account of their social, cultural and ethnic
background
 Be aware of their own attitudes and perceptions towards sexual and
reproductive health problems, and present a balanced perspective on
ethical dilemmas
 Elicit patients’ views, concerns and expectations, and negotiate options
for their care in order to reach shared agreement where possible

Weekly topics and outcomes

WEEK 1

A woman with a normal or abnormal Pregnancy

Learning outcomes

 Diagnose intrauterine pregnancy clinically and with simple investigations

 Understand the role of ultrasonography in the diagnosis and management of pregnancy
 Describe the process of antenatal care and the statistical outcomes which are used to
measure its benefit
 Determine gestational age
 Apply the principles of screening to pregnancy
 Outline the screening process for Down’s Syndrome
 Recognize the possibility and outline the management of early pregnancy problems such
as miscarriage, hydatidiform mole and ectopic pregnancy

29
  Explain to both pregnant women and their partners the nature, causes and
management of
common problems in pregnancy including the concept of risk
 Examine a pregnant woman at all phases of pregnancy and recognize and interpret
common discrepancies from expected findings
 Recognize the possibility of multiple pregnancy
 Recognize the causes of bleeding in pregnancy and their significance

WEEK 2

A Pregnant woman with common medical disorders in Botswana

Learning outcomes

 Identify the common medical disorders during pregnancy including HIV in pregnancy,
anemia, cardiac disease, hypertensive disorder of pregnancy.
 To understand the impact of such disorders on the pregnancy outcome
 To recognize the impact of pregnancy on the course of the medical disorders
 To learn how to prevent the negative impact of such disorders on the pregnancy
outcomes
 Acquire knowledge on prevention of mother to child transmission on HIV(PMTCT)
 Describes preventive strategies of HIV infection
 Understand the impacts of common medical disorders especially HIV on the newborn
and its management

WEEK 3
A woman with a normal or abnormal labor and Delivery

Learning outcomes

 Discuss with patients the relative risks and benefits of place of birth
 recognize the circumstances in which pre-term labor may occur and outline
management to the patient
 recognize the onset of labor
 recognize the stages of labor
 Support a woman through labor and manage normally-progressing labor under
supervision
 Describe the drugs commonly used in labor and their benefits and risks
 Discuss with patients the methods of pain relief in labor
 recognize normal and common abnormal patterns of fetal monitoring in labor
 recognize delay in the first stage of labor and participated labor and its management
 recognize prolonged second stage of labor and discuss with patients the need for
 operative delivery including caesarean section
 Outline the issues of multiple gestation and abnormal presentations
 Discuss the measurement of outcomes in labor and delivery

WEEK 4

30
A woman with a normal or abnormal Puerperium

Learning outcomes

 Recognize delay in the third stage of labor and participate in its management
 Recognize excessive bleeding in the third stage of labor and participate in its
management
 Assess puerperal patients so as to identify infection, thrombosis and feeding problems
and assess wound healing
 Recognize factors leading to successful lactation
 Discuss with patients the use of drugs in lactation
 Recognize the possibility of post-natal depression
 Be able to advice on contraception in the puerperium
 Access and interpret national fetal, perinatal and maternal mortality and morbidity
statistics

WEEK 5
A woman with abnormal vaginal Bleeding

Learning outcomes

 Outline the physiology of menstruation

 Recognize and distinguish clinically between the common causes of heavy regular
vaginal bleeding
 Recognize and distinguish clinically between the common causes of irregular vaginal
bleeding
 Explain to patients the treatment options for common causes of abnormal bleeding
 recognize the possibility of gynecological malignancy and initiate appropriate
investigations
 Discuss with patients the significance of an abnormal cervical smear
 Outline the Botswana cervical screening programme

WEEK 6
A woman with a pelvic mass and/or pelvic pain

Learning outcomes

 Recognize and distinguish between important causes of painful periods

 Recognize and distinguish between the important causes of acute and chronic pelvic
pain and
 initiate appropriate investigations
 Describe the basic characteristics of different imaging modalities used to visualize pelvic
masses
 Describe the common types of benign ovarian and uterine tumors
 Describe the clinical features and management options for endometriosis
 Recognize the possibility of gynecological malignancy in patients with pelvic symptoms
 Explain to a patient the procedure of diagnostic laparoscopy
 Recognize possible cases of physical, sexual and emotional abuse

31
  Appreciate the likely diagnosis in patients with dyspareunia (including psychosexual
problems)

WEEK 7
A woman with incontinence and/or genital prolapse

Learning outcomes

 Describe the physiology of micturition and the basis of urodynamic investigation in the
female
 Describe the common causes of female urinary and fecal incontinence
 Distinguish clinically between common causes of urinary and fecal incontinence
 Explore the social and health issues of incontinence with patients
 Examine a patient to demonstrate genital prolapse
 Outline non-surgical and surgical management options for female urinary incontinence
to patients

WEEK 8
A patient with a sexually transmitted infection or a woman with a vaginal discharge

Learning outcomes

 Recognize the important causes of vaginal discharge and initiate appropriate

investigations
 Recognize important causes of genital rashes, pain and pruritus
 Recognize the possibility of HIV-related disease in patients
 Outline the global impact of HIV-related disease
 Describe the basic epidemiology, pathogenesis and common manifestations of STIs in
men
 and women and also understand the public health issues for control of spread of
infection
both locally and globally
 Discuss basic management of STIs including principles of partner notification with
patients
 Identify opportunities for sexual health promotion with patients including opportunities
for
early diagnosis of HIV, as well as explaining principles of safer sex and risk reduction,
and be
able to demonstrate correct condom use.

Week 9

A couple or individual with a fertility or contraceptive problem

Learning outcomes

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  Recognize the importance of fertility and its control both for society and for an
individual couple
 Detail the quantitative effects that different lifestyle and pathological factors exert on a
couple’s fertility
 Review the principles of ovulation, gamete transport, fertilization and implantation and
outline
how these processes are investigated in sub fertile couples
 Explain the nature, causes, management and prognosis of subfertility to patients and
their families, including pregnancy rates from natural and from treated cycles
 Advise patients on the method of use, advantages and disadvantages of all major
contraceptive methods to a standard that would allow a couple to make an informed
choice.
 Discuss the medical, social, legal and ethical issues around termination of pregnancy.
 Discuss access by patients to fertility services

6.0 Paediatrics and Adolescent Health

6.1 General information about Paediatrics and Adolescent Health Course

The course in paediatrics and adolescent health introduces students to the evaluation and
management of the newborn, identification and management of diseases of infancy and
childhood including paediatric emergencies. Emphasis will be laid on the evaluation and
management of common paediatric conditions and emergencies in Botswana. It prepares
students in developing clinical reasoning in paediatrics, making laboratory and diagnostic
requests, carrying out simple diagnostic procedures and laboratory tests to aid evidence-based
clinical decision making, developing a management plan, advising children, adolescents and
parents on a health problem, its prevention, and management in a health facility or community.
The course is offered in two modules in year three and year five respectively.
You will need to look through your SOM 303 phase I study guide and your notes to check your
understanding.

6.1.0 Paediatrics and Adolescent Health I (SOM 407): Junior Clerkship (Eight weeks)
6.1.1 course description and content (synopsis)
THE NEW BORN, INFANCY AND EARLY CHILDHOOD: This module acquaints students with
professional skills for the resuscitation of the new born and child care during infancy and early
childhood. Students will be able to recognise and manage diseases of infancy and early
childhood, and paediatric emergencies. A student will be expected to be able to professionally
interview parents or guardian of the new-born, an infant, or a child, carry out physical
examination on paediatric patients, select diagnostic tests, and evaluate results before
proposing an intervention plan. The student will present the patient to clinical supervisor for
review and discussion of the differential diagnosis, treatment plan, description of the
pathogenesis, important concepts and prognosis. The clinical supervisor will then assign specific

33
treatment actions for the student to perform with respect to each individual patient. Topics
covered include: Congenital malformation; neonatology, growth and development; nutrition;
paediatric infectious diseases; HIV/AIDS; diseases of the upper respiratory tract; diseases of the
lower respiratory tract; disorders of the immune system; acute and chronic digestive system
disorders; disturbances of acid-base balance; cardiovascular diseases; renal diseases; nervous
system diseases; hemolymphopoietic and endocrine diseases. Emphasis will be on priority
diseases in Botswana.

CHILD HEALTH AND PAEDIATRICS: At the end of this module, students will be able to recognize
the presence of a health problem in a health facility or community and advise on
intervention/and or prevention measures, handle acute emergency in a child through interview
or by carrying out medical examination. They will be able to initiate life-saving interventions in
emergency situations, stabilize the clinical state of a patient, refer as necessary, request for
appropriate laboratory investigations, interpret findings, explain the patho-physiology of an
illness, and manage a patient under supervision. Topics covered include differential diagnosis,
management and prevention of emergency, acute or chronic illness in childhood and
adolescence, medical documentation, management of terminally ill and bereavement, psycho-
social aspects of diseases in children, resuscitation of new-born, counseling in the setting of
HIV/AIDS, paediatric drug dosages and their side effects, rehabilitation, ethical and medico-legal
issues in paediatrics.

Learning Outcomes

At the end of phase II, the student is expected to be able to:

Communication Skills

 Establish interview conditions that are child friendly and respectful of the
patients/parental rights
 Use empathic communication skills to establish a rapport and elicit
relevant information from patients and families across the age range of children
 Assess and manage patients and their relatives in a sensitive non-
judgemental way that takes account of their social, cultural and ethnic background
 Elicit patients’ and families’ views, concerns and expectations, and
negotiate options for their care in order to reach shared agreement where possible
 Discuss their own attitudes towards and perceptions of children
 Participate in counseling parents/families (including obtaining consent, breaking bad
news, end of life discussions)

Clinical Assessment Skills

 Demonstrate ability to identify the important causes for common patient presentations
in childhood
 Gather information from patients and carers, considering physical, psychological and
social aspects, using clinical reasoning to reach an appropriate provisional diagnosis

34
  Elicit selectively, normal and abnormal physical signs to test diagnostic hypotheses
 Use investigations selectively to confirm diagnostic hypotheses
 Recognise the radiological features of common respiratory disease in children
 Recognise the seriously ill infant and child and take immediate action
 Formulate a management plan (including the use of medication),if necessary using
information sources, appraise evidence and apply the conclusions, for care of patients
with common paediatric problems in health and disease.

Weekly topics and outcomes (PBL cases)

Week 1

The newborn infant

 Describe adaptation to extra-uterine life

 Describe the journey for a newborn baby from the moment of birth in hospital to
discharge home
 Gather information from the parents of a newborn infant with an illness or problem
 Carry out a routine examination of a newborn infant and identify common or serious
problems (eg: jaundice, rashes, cyanosis and hip dislocation)
 Recognise common congenital diseases/malformations in the newborn and the role of
genetic
counselling
 Detect an abnormal heart sound and murmur in a newborn, distinguish between
cyanotic & acyanotic congenital heart disease.
 Revise common inheritance patterns of disease presenting in the neonatal period
 Recognise common neonatal problems associated with premature delivery
 Recognise common neonatal problems associated with a difficult delivery
 Describe and discuss the merits of the main elements of a neonatal screening
programme.
 Advise a mother on breast feeding, its advantages and the alternatives.
 Advise a HIV positive mother on future care of her baby (including mode of feeding,
medications, risk of infections, future HIV testing)
 Discuss with parents the community support available to families of newborn infants
 Discuss with parents the impact of newborn infants on families
 Recognise the factors that contribute to ‘cot death’ (sudden unexplained death) in
infancy
 Recognise common causes of seizures in newborns and initiate appropriate
investigations and treatment.

Week 2

The child with failure to gain weight or height

 Measure height, weight and head circumference, plot these on an appropriate chart and
interpret the results
 Explain to parents the common causes for short stature

35
  Recognise faltering growth or failure to gain weight and the common potential causes in
Botswana (including psychosocial causes)
 Explore the circumstances of the child with failure to gain weight, including extracting
valuable information from the under-5 card.
 Formulate investigations and management plans for children with failure to gain weight
or losing weight.
 Discuss with parents the principles of weaning and nutrition
 Recognise the short and long term implications of nutritional deficiencies
 Work with members of the multidisciplinary team to manage nutrition issues in children
 Discuss with parents methods of feeding and nutritional support in children with special
requirements (eg: cleft palate, cerebral palsy, food allergy, HIV, chronic renal disease)
 Understand the principles of ‘GOBI-FFF’ and the impact on Millennium Development
Goals

Week 3

The child with developmental delay/learning difficulties

 Recognise the key stages of normal childhood development

 Make an outline assessment of a child with suspected developmental delay
 Use playtime to assess the nature and degree of developmental delay
 Recognise major differences between global and isolated areas of delay
 Identify major categories of developmental delay and cerebral palsy in patients
 Initiate appropriate investigations for the cause of developmental delay
 Work with the multidisciplinary team in the assessment and care of patients with
developmental delay
 Assess the impact of delay and/or complex needs on the child and family
 Recognise multiple factors impacting on a child’s ability to learn
 Recognise other comorbid conditions such as seizures and ADHD; and initiate treatment
 Recognise different pain indicators in the verbal or non-verbal child, identify the
appropriate pain-rating scale, apply and initiate treatment
 Outline other risk factors for childhood injury/accidents and methods of prevention
 Recognise features on history or examination which suggest possible non-accidental
injury and outline the different categories of abuse.

Week 4

The child with an elimination problem

 Recognise in patients the common causes of vomiting at different stages of childhood

including gastro-oesophageal reflux
 Recognise the importance of bile stained vomiting and refer appropriately
 Recognise the radiological features of intestinal obstruction
 Recognise the common causes and initiate management of constipation in children
 Discuss with parents the concept of encopresis
 Assess acute diarrhoea in children including an assessment of dehydration
 Recognise the common causes of infectious diarrhea and initiate assessment and
management.
36
  Recognise common complications of acute diarrhea (including electrolyte abnormalities)
and initiate appropriate investigations and treatment
 Discuss with parents the strategies to prevent future episodes of diarrhea, including the
role of oral rehydration solution (ORS)
 Recognise the causes, and initiate appropriate investigations and management of
chronic
diarrhoea in infancy and childhood
 Discuss enuresis and its causes with parents and outline a management plan

Week 5

The child with a fever

 Identify common and important infectious causes of fever on history, examination and
simple
investigation
 Recognise upper respiratory tract infections and give appropriate advice to parents
 Recognise acute stridor and refer appropriately
 Recognise the likelihood of lower respiratory infection, order appropriate investigations
and initiate treatment
 Recognise, investigate and initiate management of meningitis
 Act with others to prevent spread of childhood infection including referral, use of
chemoprophylaxis and control of ward infection.
 Describe and discuss with parents the Botswana immunisation protocol; aims, ethical
issues,
contraindications to vaccination
 Recognise the common parasitic infections in children from Botswana, order
appropriate investigations and initiate treatment
 Recognise the possibility of urinary tract infection in febrile children and initiate
appropriate
investigation and treatment
 Describe the pathophysiology and the various clinical manifestations of tuberculosis in
children and initiate appropriate investigation and treatment.
 Recognise common infections associated with HIV and initiate treatment
 Discuss with parents/family the issues surrounding initiation of anti-retroviral therapy
 Identify a sick-looking, ‘toxic’ child and initiate investigation and therapy for sepsis
 Recognise common causes of a child presenting with acute flaccid paralysis, and initiate
a complete evaluation and therapy

Week 6

The child with an allergy

 Outline the major pathological mechanisms of atopy

 Outline the scale of childhood asthma in Southern Africa compared to Westernized
countries

37
  Recognise the major features of atopy (asthma, hay fever, eczema, food allergy) in
children and initiate further investigations
 Instruct the older child in the performance of a peak flow reading
 Instruct a child and carer in the use of an inhaler and various devices available
 Discuss with parents the principles of managing childhood asthma
 Recognise major causes of childhood wheeze other than asthma and initiate an
appropriate work-up
 Identify risk factors and precipitants of asthma in patients
 Assess acute severe asthma and initiate immediate management
 Initiate treatment for chronic asthma according to South African guidelines and use
stepwise treatment appropriately
 Recognise acute anaphylaxis and its immediate management
 Discuss with parents the principles of managing childhood eczema

Week 7

The child with excessive thirst

 Outline the epidemiology and pathophysiology of childhood diabetes

 Recognise diabetes in children and initiate investigations and appropriate management
 Recognise the metabolic consequences of an absolute loss of insulin especially
ketoacidosis and participate with others in its management
 Discuss the management of diabetes with the parents/family and child
 Understand the principles of insulin therapy and delivery, and initiate management of
diabetes including the appropriate use of long and short acting insulins
 Recognise and treat hypoglycaemia
 Discuss with parents/child the dietary recommendations in childhood diabetes
 Outline a school plan for the diabetic child (including management of emergencies,
meals, sports and school trips)
 Describe the effects of a chronic illness in a teenager, especially the effects of altered
life expectancy at a time when a young person is becoming independent of parental
control and rebellion against disease and its treatment
 Recognise other causes of excessive thirst

Week 8

The pale child

 Recognise the significance of a low haemoglobin taking into account the age and sex of
the child
 Distinguish the type of anaemia from the blood count and together with the clinical
information determine the likely cause in a child
 Initiate investigation of normochromic, normocytic anaemia
 Use laboratory investigation to identify the cause of megaloblastic anaemia and to
institute treatment with appropriate urgency
 Recognise the possibility of and likely causes of haemolytic anaemia from laboratory
investigation and clinical evidence

38
  Treat iron-deficiency anaemia and investigate for other causes of microcytic anaemia
 Review the signs and symptoms of haematological malignancies
 Recognise the possible oncological significance of lymphadenopathy and anaemia on
clinical grounds and from the blood count
 Outline to parents the treatments for, and prognosis of, the common haematological
cancers in children

Week 9

The child with swelling &/or joint pain

 Recognise the possibility of rheumatic fever in a child presenting with fever and joint
pain and distinguish them from other common causes
 Describe the epidemiology & pathogenesis of rheumatic fever
 Initiate investigations to confirm a diagnosis of rheumatic fever
 Recognise the major clinical features of rheumatic heart disease
 Initiate investigations and treatment of a child with suspected Juvenile Idiopathic
Arthritis (JIA)
 Recognise the major pathophysiological mechanisms responsible for tissue swelling
 Describe the clinical features on history and examination that will distinguish between
different causes of swelling, and initiate appropriate investigations.
 Distinguish between nephritic and nephrotic syndrome and other causes of haematuria
and proteinuria
 Identify common etiologies and pathogenesis of nephrotic syndrome in Southern Africa
 Discuss the management strategy of nephrotic syndrome with the parents/family
 Identify common causes of heart failure in children and initiate investigations and
treatment
 Recognise features of hereditary angioedema and order the appropriate investigations
 Outline causes of hypertension in children and initiate investigations and therapy
 Recognise features of renal failure in children

7.0 Pharmacology

7.1 General information on pharmacology course

This course introduces the student to the scope and content of pharmacology: the knowledge of
history, sources, physical and chemical properties; compounding, biochemical and physiological
effects, mechanisms of action, absorption, distribution, metabolism and excretion. Students
gain experience and skills in effective and safe use of drugs in the diagnosis, prevention, or
treatment of disease, and rational use of drugs taking into account frequent inventions and new
drugs or modifications thereof. Students are able to give concise elaboration on the standard /
current treatment regimens in use (local and international), describe the progress in drug
therapy, research, and clinical trials and investigations techniques with the help of other basic
and clinical specialties such as molecular biology. Finally, a student is able to recognize reliable
sources of drug information. Clinical pharmacology and therapeutics will taught in the final
year.

39
7.1.0 Pharmacology I: Basic Pharmacology

7.1.1 Course description and content (synopsis)

This course highlights the fundamental principles of action of medicinal drugs and is semi-
integrated with other modules. The module focuses on pharmacodynamics, pharmacokinetics,
and toxicity of drugs used in treatment and prevention of disease, with emphasis on drugs
frequently encountered in clinical practice. Students will also develop a further understanding of
experimental pharmacology and how it can be used as a tool in the development and/or
reformulation of new drugs. Upon completing this unit students will be able to correlate drug
effects with physiological function and explain a given drug’s mode of action as well as side
effects and the mechanisms by which these drugs modify the physiological system. Topics:
compliance, rational drug use; risk benefit ratio in prescribing; prescribing; use of generics or
trade (brand) names; selection of drugs; route of administration; formulation and dosage;
classification of drugs; metabolism and elimination of drugs; side effects. The module is offered
via didactic lectures and/or tutorials one hour a week using either online resources or
videoconferencing facility. If neither of this technology is commissioned at the time of
implementation, then the module will be taught twice a year.

Learning Outcomes

At the end of this course, the student is expected to be able to:

 Classify medicinal drugs;

 Explain the mode of action, excretion of different medicinal drugs;
 Explain the mechanisms of action, at molecular and biochemical level;
 Differentiate the choice and routes of drug administration including dynamics of
absorption and bio-availability;
 Recognize the side effects of medicinal drugs;
 Explain the mechanisms of toxicity and therapeutic reversal of toxic effects;
 Develop and initiate emergency remedial measures;
 Explain resistance to medicinal drugs;
 Discuss medicinal and non-medicinal drugs abuse and doping in athletes
 Discuss the process of drug discovery and development (product research, scientific
testing and inclusion in national formulary);
 Discuss the logistics management of pharmaceuticals (the drug supply chain)

Assessment of this module shall be 100% continuous assessment. It shall be administered at the
end of the block as written test. The format shall be 1 x 1 hour 30 minutes paper comprising of
MCQs, EMIs and SAGs. Passing this module is a requirement for graduation.

40
8.0 Surgery

8.1 General information about surgery courses

Surgery will be taught in three modules of nine weeks duration each in the 3rd, 4th and 5th year
respectively. The course begins with an introduction to the basic principles of surgery and
surgical procedures in both pre- and post-operative care, dealing with aseptic techniques,
hospital infections and emergency care. It then progresses to more advanced modules which
review prevention, diagnosis and surgical management of common conditions with particular
emphasis to Botswana. The course also discusses diseases of the head and neck region including
the eyes, the ears, the nose and throat. The course is organized in clinical clerkships and
students are expected to participate in the management of patients with surgical problems and
their complications. Anaesthesiology will also feature as an integrated part of the surgical
modules during the Course.

The course will be delivered using bedside teaching on ward rounds and out-patients, tutourials,
problem based learning and supervised teaching of practical skills. . Students will be expected to
take a full part in the work of their firms including morning meetings, ward rounds, out-patients,
and day to day care of patients, working as part of the on-call team and attending theatre. They
will be expected to present their case histories and follow up on the care of their assigned
patients. There will be opportunities to learn practical procedures on wards, in skills lab and in
theatre.

8.1.0 Surgery I: Junior clerkship in General Surgery and Anaesthesiology (SOM405)(Eight

weeks)

8.1.1 Course description and content (synopsis)

This is an introductory course to the basic principles of surgery and surgical procedures,
incorporating both pre-operative and post-operative care, dealing with aseptic techniques,
hospital infections, and anaesthesia. This module is designed to prepare students to manage
common surgical conditions and emergencies, including life-saving procedures. Students will be
able to evaluate patients with surgical conditions, explain underlying patho-physiological
changes, and identify indications for surgical interventions and need for changing of
management or referral of patients; identify surgical disorders affecting the human body
systems, select diagnostic investigations and interpret results as well as implement the
necessary interventions. Topics covered include symptoms and signs of surgical conditions at
different age groups. Students should be able to identify indications for intervention and
prepare patients for emergency surgery and manage surgical complications. This module is
organized as a clerkship, practical surgical management of simple procedures,
assisting/observing in surgical operations, and case presentation in clinico-pathological
conferences. At the end of the module a student will be able to diagnose and initiate the
management of common surgical emergencies. Students will be able to suspect surgical

41
condition by carrying out an interview and physical examination, appropriately select laboratory
investigations, interpret results of laboratory tests, explain underlying conditions, initiate
preoperative management, carry out simple surgical interventions and assist during surgical
operations. Topics covered include principles of surgery; introduction to surgical procedures;
anesthesia; emergency surgical conditions of the abdomen, chest and blood vessels; shock,
trauma and injury; surgical infection, healing and repair; non-visceral tumors; common diseases
of the urinary tract, their manifestation, causes, underlying patho-physiological mechanisms and
their management. During the module, students will be required to participate in the
management of patients with urological problems and their complications. Students will be able
to identify the diagnosis and propose the management of frequent surgical conditions, pre- and
post- operative care; independent management of minor surgical and live saving procedures,
e.g. tracheostomy, thoracocentesis, abdominal puncture; observing/assisting in elective surgery
and surgical emergencies.

Introduction to anaesthesia: occurs during the course and reviews the physiology and anatomy
of the respiratory, cardiovascular and hematological systems as well as introducing the
pharmacology of drugs used for anesthesia. Students grasp physics of gas, fluid mechanics;
compliance, blood gas and haemoglobin dissociation. A student is expected to be acquainted
with pre-operative preparation of the patient and family, the choice of drugs for induction,
intravenous and inhalational anaesthesia; monitoring during anesthesia; complications of
anaesthesia particularly, apnoea. Topics: Gas laws , fluid mechanics, elasticity laplace law,
Sterling law, thermodynamics as they relate to gases: anatomy and physiology of the respiratory
system including concepts of shunting, dead space and compliance; the cardiovascular system:
pulse, rate, rhythm, contractility, preload and afterload; the pharmacology of drugs used for
local anaesthesia, regional and inhalational anaesthesia, pain management; interpretation of
blood gas analysis results. During this module a student will be introduced to practical aspects in
the use of local anaesthesia. This course is integrated with general surgery modules in the third
and fifth year.

Learning Outcomes:
At the end of phase II, the student is expected to be able to:

Communication skills

 Establish interview conditions that are safe and respectful of the interviewees
rights
 Use empathic communication skills to establish a rapport and elicit relevant
information from patients and families across the age range
 Assess and manage patients and their relatives in a sensitive, non-judgemental
way that takes account of their gender; social, cultural and ethnic background;
and any disability
 Elicit patients’ views, concerns and expectations, and negotiate options for
their care in order to reach shared agreement where possible
 Be able to interpret information on risk and communicate this effectively

42
 to patients and relatives
 Develop ability to communicate professionally with other members of the medical
team.
18.0.1 Communication
Clinical Assessment Skills

 Demonstrate ability to identify the important surgical conditions responsible

for common patient presentations in Botswana
 Gather information from patients considering physical, psychological and
social aspects, using clinical reasoning to reach an appropriate provisional
diagnosis
 Elicit selectively normal and abnormal physical signs to test diagnostic hypotheses
 Formulate a management plan (including the use of medication, if necessary)
using information sources, appraise evidence and apply the conclusions for
the care of patients with common surgical conditions.
 Use investigations selectively to test diagnostic hypotheses.

Practical Procedure Skills

 Diagnostic
 Venepuncture
 Arterial Blood gas sampling
 Urine sampling and testing
 Taking microbiological samples
 Therapeutic
 Peripheral venous cannulation
 Insertion of urethral urinary catheter
 Insertion of a naso-gastric tube
 Thoracocentesis
 Basic airway manouveres
 Jaw thrust
 Chin lift
 Insertion of nasal airway
 Insertion of Guedel airway
 Use of oxygen
 Drainage of abscess
 Wound debridement
 Simple suturing of skin
 Knot tying with instruments

43
Anaesthesiology & critical care

 Relate the applied anatomy, physiology and pharmacology to the use of anesthetics;
 Explain the mechanism of action of the commonly used drugs for anesthesia and the
complications;
 Explain the pathophysiology, apnoea, hypoxia, hypotension, ischeamia and
dysarrythymia;
 Describe techniques of airway management;
 Describe the various stages of anaesthesia;
 Interpret findings from blood gas analysis;
 Carry out a professional pre-anaesthesia interview of a patient;
 Assess the findings of the medical interview and the physical examination to establish
possible contra-indications for any drugs used for anaesthesia;
 Differentiate the anaesthetic drugs and techniques;
 Perform selected operative procedures under local anaesthesia;
 Monitor a patient during inhalational anaesthesia;
 Perform cardio-pulmonary resuscitation.

PBL sessions for Junior Surgical Clerkship: weekly topics and outcomes
Students will be expected to explore the possible surgical problems denoted by the
symptoms in each of the weekly topics. This will include important features of the
history, clinical findings and developing a surgical management plan. Factors relevant to
the pre-operative assessment, anaesthetic and post operative care should also be
explored.

Week 1
30 year old farmworker presents with painful swollen leg, he feels hot and unwell.

Week 2
25 year old man complains of a lump in the groin.

Week 3
30 year old vomits fresh blood and collapses
Week 4
50 year old patient complains of difficulty in swallowing and clothes have become loose.
Week 5

20 year old man brought into Emergency Department having been knocked over by a
car
44
Week 6
A 45yr old woman noticed a lump in the breast whilst bathing
Week 7
A 55yr old man presents with a 5 day history of abdominal pain and constipation
Week 8
A 40year old man presents with dribbling when trying to pass urine

45
YEAR FOUR

1.0 Internal Medicine II (SOM 502): Infectious Diseases, Dermatology and Radiology (Eight
Weeks)

1.1 Course description and content (synopsis)

This course introduces students to different diseases that affect the human organism resulting
from infectious agents and parasites as well as medical conditions affecting the skin. Students
are expected to develop professional and clinical reasoning skills, analyze and carry on
differential diagnosis of bacterial, viral, fungal and human parasitic diseases, evaluate the results
and develop treatment plan for individual patients and their families within a health facility or
community setting. The clinical practice will be carried out in medical wards. The course is
organized around clinical clerkships. Topics covered include acute and chronic illnesses resulting
from infectious agents affecting the digestive system, acute and chronic infections of the
locomotor apparatus, neurological systems, respiratory system, cardiovascular system, skin and
urinary system. The course integrates the patho-physiology of infectious diseases, and the
epidemiology of frequent communicable disease with particular reference to Botswana and the
Southern African region. The dermatology module is designed to describe the most common
dermatological diseases, distinguishing normal skin from abnormal skin and significant
abnormalities from insignificant ones, integrating pertinent signs and symptoms into an
appropriate differential diagnosis. Students should recognize common dermatological
conditions, explain the underlying mechanism(s), develop and implement treatment plan or
referral of patients, and explain the pharmacology of frequently used drugs for the treatment of
dermatological problems. Topics covered include: approach to patient with skin disorder;
diagnostic techniques; common skin disorders; infectious dermatosis: superficial mycosis,
dermatosis caused by viruses, including HIV manifestations, dermatosis caused by zooparasites,
pyoderma, skin manifestations of sexually transmitted diseases, leprosy; immunologically
mediated skin diseases, papulosquamous disorders: psoriasis, lichen planus; benign and
malignant pigmented lesions;toxic epidermal necrolysis, Steven-Johnson syndrome; drugs and
preparations in common use for the treatment of common skin conditions. Students will rotate
through the wards, the HIV and dermatology clinics.
The radiology module takes the form of didactic, case based learning and bedside clinical
education. The student grasps clinical reasoning skills necessary for interpreting radiological
studies, understanding the role of imaging in clinical investigation and legislation on radiation
and radiation protection. The students will visit the radiology unit when possible and
appropriate but bed side teaching will occur on the wards.

Weekly topics and outcomes

Week 1

The patient with sepsis/septic shock

46
  identify risk factors for sepsis
 recognise the source of sepsis
 initiate appropriate investigations for sepsis and interpret the results
 understand the principles of blood cultures
 understand how to interpret blood culture results
 recognise the clinical manifestations of sepsis/septic shock
 initiate immediate management of septic shock
 differentiate between colonisation and infection
 understand the mechanisms of antibiotic resistance and the principles of antimicrobial
resistance assays
 discern situations giving rise to antibiotic resistance
 understand antimicrobial agents, their spectrum of activity, mode of action, toxicity/side
effects and appropriate use (e.g., combination therapy)
 recognise predisposing factors for tuberculosis
 recognise clinical features, identify laboratory and radiological investigations in a patient
with pulmonary tuberculosis
 recognize miliary tuberculosis

Week 2

The patient with pulmonary tuberculosis

 describe clinical features, identify laboratory and radiological investigations in patients

with extrapulmonary tuberculosis

 describe principles and application of tuberculin skin test and interpret it

 describe management and treatment of patients with tuberculosis

 recognise causes of pleural effusion and evaluate pleural fluid

 describe the epidemiology of tuberculosis in Botswana
 explain to family members the transmission of tuberculosis
 understand the features of drug-resistant and extensively drug-resistant tuberculosis
 describe possible treatments for drug-resistant tuberculosis

Week 3

The patient with meningitis

 recognise the causes/risk factors for meningitis

 describe the forms of meningitis and clinical features
 recognise complications of meningitis
 describe the investigations for a patient with meningitis
 identify indications and contraindications to lumbar puncture
 understand how to perform a lumbar puncture
 describe the complications of lumbar puncture

47
  understand the need of a patient to understand the procedure, its usefulness, its risks
and to consent/not consent to lumbar puncture
 describe the principles of management in a patient with meningitis
 recognise the causes and symptoms of encephalitis
 recognise the clinical symptoms of a brain abscess and its treatment modalities

Week 4

The patient with pneumocystis jiroveci pneumonia (PCP)

 identify risk factors for PCP

 recognise the features of PCP and its possible clinical presentations in HIV-infected and
uninfected patients
 distinguish PCP from tuberculosis, bacterial pneumonia and pulmonary Kaposi’s sarcoma
 describe the X-ray and CT-scan appearance of PCP
 Conduct investigations for PCP including the role of sputum induction, bronchoalveolar
lavage and transbronchial biopsy
 Formulate management plan of PCP infection
 Outline treatment of PCP in patients allergic to first line therapies
 Formulate primary and secondary prophylaxis of PCP in HIV-infected patients

Week 5

The patient with HIV and difficulties in swallowing

 describe possible esophageal pathologies in HIV-infected patients

 describe investigations in patients with difficulties in swallowing
 describe symptoms of esophageal candidiasis
 describe symptoms and causes of esophageal ulcer disease
 describe the management of esophageal candidiasis
 describe the management of CMV or herpetic esophagitis
 describe antifungals and their use in fungal diseases
 describe antivirals and their use in herpetic infections
 describe antiretroviral drugs and recommended first and second line regimens in
Botswana
 recognise side effects of antiretrovirals
 identify failing patients on antiretrovirals
 identify non compliant patients on antiretrovirals

Week 6

The HIV-infected patient with purple macules

 recognise the appearance of Kaposi’s sarcoma lesions

 make a differential diagnosis with similar lesions of other etiology
 describe visceral Kaposi’s sarcoma
48
  describe etiology, epidemiology and pathogenesis of classical and HIV-related Kaposi’s
sarcoma
 describe investigations in patients with cutaneous Kaposi’s sarcoma
 describe investigations in patients with visceral Kaposi’s sarcoma
 describe treatment of cutaneous and visceral Kaposi’s sarcoma

Week 7

The patient with well circumscribed erythematous plaques with overlying scale

 identify and describe the morphology of psoriasis

 describe associated triggers or risk factors for psoriasis
 describe the clinical features of psoriatic arthritis
 list the basic principles of treatment for psoriasis
 discuss the emotional and psychosocial impact of psoriasis on patients
 determine when to refer a patient with psoriasis to a dermatologist

Week 8

The patient with rash after taking an antiretroviral

 describe the morphology of common drug eruptions

 list key features of drug-induced hypersensitivity syndrome (DIHS), Stevens-Johnson
syndrome (SJS) and toxic epidermal necrolysis (TEN)
 list the classes of drugs most commonly causing eruptions
 list the antibiotics most commonly causing eruptions
 list the antiretrovirals most commonly causing eruptions
 describe initial steps in management for drug eruptions
 determine when to refer a patient with drug eruptions to a dermatologist

2.0 Diagnostic radiology and medical Imaging

The module builds on the topics already covered by the students in year 1- 3. These include the
various imaging modalities (plain x-rays, contrast studies, CTscan, MRI, nuclear medicine
studies), normal radiological anatomy, preparation and education of the patients and basic
radiological patterns). It will be taught as an integrated component of all the clinical disciplines,
e.g women’s imaging will be taught when the students rotating through maternal health,
obstetrics and gyneacology modules.

Chest imaging

 Common pathological conditions: atelectasis, pneumonia, vascular abnormalities,

pleural abnormalities, masses, adenopathy, interstitial abnormalities, cardiac
abnormalities. (plain X-rays and CT images)

49
  -“Don’t miss” findings: tension pneumothorax, supine film pneumothorax, pulmonary
oedema, pneumomediastinum, TB, signs of aortic dissection, aortic rupture, foreign
body in the trachea/bronchus.( plain X-rays and CT images)

 appropriate imaging algorithms

Abdominal imaging

-Common pathological conditions/findings:

 Free air, small and large bowel obstruction, renal and ureteric calculi, gallstones,
calcified aorta, benign calcifications.

 Malignancy of the oesophagus, stomach and colon, hiatus hernia, peptic ulcer.

 Hydronephrosis, billiary calculi and obstruction, acute cholecystitis.

 Aortic aneurysm. Traumas of liver, kidneys, spleen, free fluid in the abdomen.

 Plain x-rays, Ultrasound, CT scan and MRI images

 “Don’t miss” images: Free air, free fluid, small bowel obstruction, caecal and sigmoid
volvulus

 appropriate imaging algorithms

 Image-guided procedures

Musculoskeletal Radiology

-Common pathological findings:

 Trauma – fractures of the extremities, spine, dislocations, soft tissue injuries

 Arthritis

 Osteoporosis

 Infections – osteomyelitis

 Tumours – osteosarcoma, myeloma, bone metastasis

 Plain x-ray, Ultrasound, CTscan and MRI images with imaging algorithms

Emergency Radiology

-Common pathological findings:

 Trauma - Major organ injury

 Non-traumatic:

50
  PCP, pneumonias, cardiac failure, cardiomegaly, pulmonary embolism, appendicitis,
acute cholecystitis, bowel obstruction, testicular torsion, ectopic pregnancy, ovarian
torsion, placental abruption

 Subarachnoid haemorrhage

 Pediatric emergencies – foreign bodies, intususception

 Iatrogenic pathology – misplaced tubes, central lines

 Plain x-rays, Ultrasound, CT scan images and the appropriate use of the modalities

Women’s imaging

 Breast imaging – comparative and appropriate use of Ultrasound and Mammography

 Pelvic Ultrasound as a first line imaging investigation

 Obstetric Ultrasound – basic rules and applications

 CT scan and MRI appropriateness, algorithms

Neuroimaging

Commonest pathological conditions:

 Trauma, Infections, Tumours, Vascular abnormalities

 CT scan and MRI findings with the comparative appropriate use

Pediatrics

 Technical aspects

 Normal anatomy

 Pathology: trauma, infections, congenital abnormalities, tumours (Wilm’s tumour)

 “Don’t miss” findings

 Plain x-rays, Ultrasound, CT scan and MRI with the appropriate algorithms

Interventional Radiology

 Basic overview of angiography and its use

Nuclear Medicine

 Basic overview of the appropriate applications

2. Learning objectives
51
  Demonstrate skills of systematic interpretation of plain x-ray images of the chest,
abdomen and musculoskeletal system

 Identify structures and conditions on the images of each modality for the different
topics or at least the students should have seen the images

 Determine the appropriate imaging modality for each clinical case

 Demonstrate knowledge of the various imaging modalities and the radiological

algorithms between them.

3.0 Special Project (Medical Electives) (Eight weeks)

3.1 General Information on the School of Medicine Special Project (SOM SOM 503)
One Special Project block of 8 weeks has been established within the School of Medicine MBBS
program in the fourth year. This time is allocated within the MBBS program to allow students to
investigate elements of medicine that are outside/within the core curriculum, that complement
an area of interest or to study subjects in greater detail (experiential learning). It is the
responsibility of the student to seek and secure an elective placement. The School of Medicine
will then officially communicate with the institution or unit where the Special Project placement
has been secured detailing the objectives and expected outcomes of the elective period. It is the
responsibility of the student’s sponsor to cater for all expenses required for the Special Project
period. Although, students are free to secure Special Project placements outside of the country,
the School of Medicine recognizes the challenges that may be encountered and encourages
students to explore placements within the country as their first priority. In any case, only 10% of
students in any particular class will be allowed to go for placement outside of the country. This
decision of the School of Medicine will be conveyed to the sponsor at least one year before the
commencement of the Special Project. The 10% will be determined by the student’s overall
performance for the year. Upon completing the Special Projec,t the student is responsible for
ensuring that his or her evaluation form is completed and submitted to the School of Medicine
for credit. In all cases, students must seek approval of a specific Project and the School reserves
the right to approve or cancel chosen ones. The School of Medicine strongly discourages using
vacation periods for Special Projects as they have been adequately catered for within the phase
II MBBS curriculum. All students in any particular class will proceed on Special Project
placements immediately after the end of examination in year 4. It is important to note that
Special Projects are personal and not group projects.

Learning Outcomes:
At the end of phase II, the student is expected to be able to:

 Manage self-directed learning;

 Work as a member of a team;
 Manage time and financial resources;
52
  Experience other cultures (regional, international) including business culture;
 Extend knowledge and skills in an area of choice, research or future specialization;
Each student is expected to submit a 1500 words scientific report on the topic of interest that
was studied during the elective period.
Assessment will be based on the submitted report and a letter of satisfactory completion of the
elective period from the student’s supervisor at the place of elective. A satisfactory report is a
requirement for graduation. Any student who obtains an unsatisfactory report from the elective
placement shall be required to revisit the chosen topic under the guidance of the supervisor
during the vacation.

4.0 Forensic Medicine and Toxicology

4.1 Course description and content (synopsis)

This course deals with the legal aspects of medical practice. It acquaints students the legal
procedure in Courts of law and the role of the doctor as an expert witness in medico-legal cases.
It equips the student with the knowledge and skills required to deal with the examination of the
living and the dead in a medico-legal context and document the evidence for criminal
investigation and trial. It also familiarizes the student with the laws and rules regulating medical
profession and practice in Botswana. Topics covered include: Legal procedure and medical
evidence; Thanatology: definition of death, certification of death, post-mortem changes;
Traumatology: mechanical injuries, regional injuries, transportation injuries, medico-legal
aspects of wounds; Asphyxial death; Sexual offences; Foetal death and abortion; Disputed
paternity; Sudden natural deaths; Medical jurisprudence and ethics; Forensic toxicology:
general principles of detection and treatment, common poisons diagnosis and treatment,
alcoholic intoxication and drugs of abuse.The module is taught via didactic lectures and tutorials
one hour a week in year four. Special arrangements will be made for students to witness
forensic autopsy sessions and court sessions or mock court sessions during this period.

Learning outcomes

At the end of this module, a student is expected to be able to:

 Comprehend the medical obligations in his day-to-day practice of medicine

 Understand the nature of medical evidence competently present such in a court of law.

 Understand the medico-legal aspect of wounds/injuries, wound certificate and

workman’s compensation claims

 Examine offenders and victims of sexual offences

 Assess and manage victims of poisoning

 Appreciate and document autopsy findings in common medico-legal death.

53
Assessment of this module shall be 100% continuous assessment. The format shall be 1 x 1 hour
written paper. Although a fail in this module does not prevent the student from progressing to
the final year, a pass is required before the student can graduate.

5.0 Psychiatry

5.1 General information about psychiatry Course (SOM 504)

5.1.1 Course description and content (synopsis) Eight weeks

The course is offered in the academic year and focuses on Psychiatric diagnoses of patients with
mental/psychiatric disorders, with a strong (but not exclusive) focus on neuropsychiatry,
behavioral neurology and psychopharmacology. Students will apply medical and
psychopathological knowledge and procedural skills that are used to collect and interpret data,
make appropriate clinical decisions and carry out diagnostic procedures using an appropriate
combination of biological, psychological and sociological methods, including up-to-date, ethical
and cost-effective clinical practice and effective communication with patients, other health care
providers and the community. Topics include neuropsychiatry and behavioral neurology;
psychopharmacology, theories of personality and psychopathology; examination of the
psychiatric patient; classification of mental/psychiatric disorders; Students are expected to draw
on their prior knowledge of the clinical manifestations of mental disorders (SOM 207, Mental
Health), jointly with neuropsychiatry and behavioral neurology, internal medicine, general
pharmacology, psychopharmacology and gross and functional anatomy of the brain (including
neuro-imaging) to make psychiatric diagnoses. At the end of this module students should be
able to perform a psychiatric interview, identify clinical signs of mental disorders, make
differential diagnoses, interpret results of diagnostic investigation (including neuropsychiatry
and behavioral neurology), explain the psycho-pathology, neuropsychiatry and behavioral
neurology of psychiatric disorders, and present this to clinical faculty member(s).
It focuses on intervention, rehabilitation and prevention regimes used in psychiatric practice.
Students will have mastered principles to a range of psychotherapies (e.g., psychoanalysis and
psychoanalytic psychotherapy, behavior therapy, group psychotherapy, combined individual and
group psychotherapy, family and couple therapy, cognitive therapy, interpersonal
psychotherapy), combined psychotherapy and pharmacotherapy, biological therapies, and
principles of electroconvulsive therapy and neurosurgical treatments, with applications to
special populations such as Primary Health Care settings; psychiatric emergencies; adult and
child in- and outpatient psychiatry; geriatric psychiatry; hospice and palliative care; and
community psychiatry (including rural settings). Special topics include: consultation liaison
psychiatry, adult ambulatory services, substance abuse and addiction services, prevention and
public awareness services; and legal and ethical issues in Psychiatry. At the end of course,
students should be able to perform a psychiatric interview, identify clinical signs of mental
disorders, make differential diagnoses, interpret results of diagnostic investigation, explain the
54
psycho-pathology of mental disorders, develop a treatment, rehabilitation and/or prevention
plan and present this to clinical faculty member(s).
5.1.2. Mental Health in Botswana
Although the care of patients with mental health problems seems to be organized somewhat
separately to that for physical problems, patients with psychiatric problems are more likely to
first come into contact with a general nurse or medical officer. Indeed a closer liaison between
the two has been a feature of medical practice for 20 years. Good psychiatric knowledge and
skills are important for all doctors

There are 390 psychiatric beds, about 10% of the total. There are organized as follows:

Sbrana Psychiatric Hospital, Lobatse; 300 beds

Jubilee Psychiatric Unit, Francistown; 8 beds
Sekgoma Memorial Hospital, Serowe 20-30 beds
Mahalapye District Hospital, Mahalapye; 20-30 beds
Scottish Livingstone Hospital, Molepolole; 20-30 beds
Letsholathebe ll Memorial Hospital, Maun; 20-30 beds
Princess Marina Hospital, Gaborone; outpatient facilities only

Patients are also seen at Primary and District Hospitals without beds and Health Clinics and
Mobile Clinic Services

See www.moh.gov.bw for more details of the organization of medical services.

See http://www.elaws.gov.bw/ for details of legislation relating to mental health
See also the Botswana National Policy on Mental Health

It is important to realize that psychiatric nurses (with a Diploma in Advanced Community Mental
Health Nursing) deliver most community-based psychiatric. Botswana has only 6 Government
Psychiatrists so you can expect to learn much from medical officers and nurses. You should be
aware that much stigma still surrounds mental health issues and you may need to address your
own attitudes to patients with mental health problems.

5.1.3. Prevalence

In the 2001 Census 902 cases of severe mental retardation were recorded in the homes and 6 in
the institution. There were 3,127 cases of moderate mental retardation in the homes under
primary health care and 78 were in the institutions under secondary and tertiary health care. In
the same census 2,697 cases of severe mental illness were recorded in the community under
primary health care with 216 in the institutions under secondary and tertiary health care. On
the whole, mental illness and mental retardation of all degrees account for about 10% of the
prevalence of all medical conditions.

5.1.4. Outline of block

55
In year one you spent four weeks exploring the close relationship between physical and
psychological aspects of health. You met patients, carers and families and discussed with them:

 what psychological impact physical illness can have

 how they cope with serious mental illness
 the emotional, social and systemic consequences of having a family member with
serious
physical or psychological morbidity
 the interplay between physiology and psychology.

You also improved your communication skills by talking about a variety of personal,
emotionaland social issues with a wide range of people.

In this block, you will take these skills further. You will come across a range of people with
mental illness in different settings. You will acquire new skills in interviewing and discussing
sensitive issues with patients and their carers. You will explore psychopathology further and you
will learn how to recognise and assess mental illness, and the rudiments of what actions to take
in these circumstances.

5.1.5. Keeping the big picture

Although the arrangement of the block seems to suggest, as for other blocks, that you will be
doing one specialty followed by another followed by another, it is important that you consider
the learning as a whole. While this block is focused on mental illness, you will probably see
patients with psychosocial, psychological and emotional problems in every block during your
medical training.

It is important that you maintain a general focus to your learning and in particular that you build
up your clinical skills with a wide variety of patients and their problems.

The Phase I Psychological Health block considered models for understanding psychological
processes whenever you meet a patient. You will need to call on and build upon your Phase I
knowledge as you progress.

Some of the conditions you see in this block will also be seen in other blocks. For example, you
will see patients with dementia and delirium in medical blocks and you will see deliberate self-
harm when you are in Accident and Emergency. In family medicine, a large percentage of people
presenting with physical complaints also have psychological morbidity such as depression or
anxiety, or taking drugs or are drinking alcohol to excess. This will affect (in some instances
greatly) how patients present and how they respond to treatments for other physical illnesses,
56
and great care should be taken to consider this. Pharmacology and pharmacokinetics, and how
these relate to mental state and disordered physiology, will also be assessed.

Some subspecialties, such as forensic psychiatry, are generally considered to be a post-graduate

subject so there is no formal attachment; however, you may meet patients who have been in, or
are about to go into, the care of forensic services. You may find these admitted as Mentally
Abnormal Offenders or presenting as outpatients for court reports.

5.1.6. Your future

Some of you will become psychiatrists and this block will be a stepping-stone of experience and
knowledge towards that end. Botswana needs psychiatrists. Whatever specialty you go into, you
will meet patients with psychological morbidity on a very regular basis. This placement will be a
key learning experience as you equip yourself to deal with this.

5.1.7. Weekly presentations

This block consists of eight weeks. Each week has a central topic and presentation, although
there will be many other things to learn during this week. Remember that all of these are
exemplars rather than examples, i.e. that they are true patient presentations, not diseases. If
you see a patient who presents as a worrier, this is an opportunity to learn about other issues
besides anxiety, even if that is the diagnosis; for instance, the context in terms of the person’s
experiences (every story is different), their intellect, development and associated physical or
mental illnesses and life events. You may also consider their personality, resilience, coping
strategies, family background, relationships, and responses from family and/or community. They
will have a unique tale, which extends way beyond a diagnostic label.

Each week follows the same pattern. There will be a plenary at the beginning of the week. This is
intended to be a signpost to the topic. It will not be an exhaustive lecture covering all aspects of
the topic, but rather a taster to inspire your enthusiasm and point you in the right direction.
During the week there will be activities to carry out and observe, and skills to obtain.

5.1.7. Safety

The presentation of some persons with mental illness can be alarming, and the presentation by
the media more alarming still. Psychiatric settings are likely to be unfamiliar. This does not
mean that seeing patients in a mental health setting is dangerous. The vast majority of people
are grateful for your help and support as they attempt to return to full heath. However, as in
any medical setting, it is important to consider the safety of yourself and others.

Always observe the following guidelines.

57
  Discuss any person you are going to see with an experienced member of staff first, and
heed their advice.
 It would not be expected for students to visit patients or families in their own home
unaccompanied. Home visits would usually be with another professional.
 If you feel unsafe or at risk in a situation, politely request to leave, and discuss it with a
senior colleague.
 Do not disclose information about yourself to patients. This is to prevent transference
and counter transference issues
 Ensure others are aware of your whereabouts.
 Do not assess a patient on your own. Always ensure that another staff member is with
you.

5.1.8. History Taking

As in medical practice in general, the history given by the patient yields far more information
than any other means of investigation. In psychiatric practice the scope is wider than in general
medical settings, encompassing psychological and social as well as biological factors, therefore
the history from an informant is always helpful and seeking to answer the questions:

 What are the problems?

 Why now?
 What factors are predisposing, precipitating and perpetuating the problems?
 What protective factors exist?
 What risks are there to the person, their health, others?

Books of particular relevance include the following:

ICD - 10: The ICD-10 Classification of Mental and Behavioural Disorders : Clinical Descriptions
and Diagnostic Guidelines, The WHO, (1 Jan 1992)

Primary Healthcare Psychiatry: A Practical Guide [Paperback] Sean Baumann(30 Jan 2008)

Textbook of Psychiatry for Southern Africa, by Brian Robertson, Christopher Allwood and C.
Gagiano (21 Dec 2000)

Textbook of Psychiatry, 3e [Paperback] Basant K. Puri MA PhD MB BChir BSc(Hons)MathSci

MRCPsych DipStat MMath Professor (Author), I. H. Treasaden MB BS LRCP MRCS FRCPsych LLM

We STRONGLY suggest that you read a chapter on interviewing and evaluation from any of the
textbooks above during the first week.

You will be given a “CASE PRESENTATION EXAMPLE” form, which you should follow closely for
your weekly case presentation write-ups. You can also refer to the History Taking Format used in
58
Botswana Mental health Services and the outline in the Mental Health Card MH 1030 developed
by Sbrana Psychiatric Hospital and Jubilee Psychiatric Unit. (See the Appendix to this Study
Guide.)

5.1.9. Mental State Examination

In mental health, the physical examination of the patient can still be very important. For
example:
 as a means of ruling out physical causes such as thyroid dysfunction
 as a means of assessing the physical effects of mental health problems on the patient
(e.g.:
alcohol damage, consequences of severe depression etc)
 as a means of monitoring side-effects of medication
 as part of good clinical care.

However, an additional and very important examination is Mental State Examination. This
means examining the mental health of the patient, which is different from history, and involves
you collecting objective evidence of mental health signs and symptoms in your encounter with
the patient.

You will be expected to comment on:

 Appearance and Behaviour

 Form of Speech
 Physiological/Vegetative functions (Appetite, Sleep, Libido)
 Mood
 Suicidality/Homicidal tendencies
 Abnormal beliefs/delusions
 Abnormal experiences/hallucinations
 Neurotic symptoms
 Intellectual functions

and the following Cognitive functions

 Orientation
 Attention and Concentration
 Memory
 General Knowledge and Intellectual functioning
 Judgement
 Abstract thinking
 Insight
Investigations to rule out physical conditions e.g. Anaemia, Malaria, TB, HIV etc

59
By way of example, in the history the patient may give an account of auditory hallucinations.
The Mental State Examination is a means by which you can examine whether, in the room with
you, the patient is distracted by voices or responding to voices. It explores here-and-now
evidence of the presence of hallucinations.

5.1.10. Block Outcomes

5.1.10.1 General Outcomes

These are outcomes that will apply to all or many of the patients that you will meet in the block
and are similar skills to those needed in other areas of medicine. In Week 1 you will learn some
additional skills and knowledge applicable to the practice of psychiatry in general and in
Botswana in particular.

Communication
 Establish interview conditions that are safe and respectful of the interviewees’ rights
including the right to privacy
 Use empathic communication skills to establish a rapport and elicit relevant information
from patients and families across the age range, including their ideas, concerns and
expectations
 Assess and manage patients and their relatives in a sensitive, non-judgemental way that
takes account of their gender, social, cultural and ethnic background
 Elicit patients’ views, concerns and expectations, and negotiate options for their care in
order to reach shared agreement where possible

Patient assessment skills

 Formulate a patient’s problem in terms of predisposing, precipitating and maintaining
factors
 Formulate a management plan (including the use of medication if necessary) using
information sources; appraise evidence and apply the conclusions for the care of
patients with common mental health problems

5.1.10.2 Glossary of common terms in mental health

A brief glossary of relevant common terms used in this field of medicine is included in each
chapter, and you are invited to note down their meanings. The lists are not exhaustive and we
invite you to add to them. In relation to the patient descriptions in the groups above, find out
the definitions and clinical importance of the following terms relevant to the subject. Write a
brief description for each term below:

ICD-10/11 CLASSIFICATION

DSM V
60
MULTIDISCIPLINARY APPROACH

PERSONALITY DISORDER

PREVALENCE/INCIDENCE

PSYCHOPATH

5.1.10.4 Top 10 Conditions for Presentation in Botswana

1. Depression and Anxiety

2. Schizophrenia and Schizoaffective disorders
3. Epilepsy (covered elsewhere in the course)
4. Acute psychotic disorder
5. Alcohol abuse
6. Substance abuse (Cannabis)
7. Mania , Mood /bipolar disorder
8. Mental retardation/Learning disorders
9. Organic mental disorders, Senile Dementia, including HIV related conditions
10. Hyperkinetic disorder

61
SDL – 8 hours, Lecture/Tutorial – 4 hours, PBL – 4 hours, Clinical Sites – 20 +hours

5.1.11.1 Time table for Sbrana Hospital

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

8 am Plenary PMH Clinic and PMH Clinic and TUTORIAL – PMH Clinic
Lectures Consults Consults Discussion of and Consults
9am (SOM) Topics

10am PBL 2:
PBL1: Wrap-Up
Case of the
Week
11am SDL

12-1 L U N C H

2pm PMH Clinic and SDL SDL SDL SDL

Consults
3pm [4th Year wide 4th year lectures
class??]
4pm SDL

5pm CALL W/FIRM (SBRANA ONLY*)

onward

62
5.1.12.1. Organization of Weekly Presentation Topics
Week 1. Intro to Psychiatry in Botswana and Psychiatric history taking
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

8 am Plenary TUTORIAL –
Lectures Discussion of
9am (SOM) Topics

10am PBL 2:
PBL 1: Wrap-Up
Case of the
Week
11am

12-1 L U N C H

2pm

3pm

4pm

5pm CALL W/FIRM (SBRANA ONLY*)

onward

Week 2. Psychotic Disorders

Week 3. Mood Disorders, Grief, Suicide and Self-Harm,

Week 4. Substance Use Disorders

Week 5. Anxiety Disorders

Week 6. Somatoform Disorders and Personality Disorders

Week 7. Cognitive Disorders and Sleep Disorders

Week 8. Normal and Abnormal Human Development: Childhood disorders & Intellectual Disabilities)

63
Week 1: Introduction to Psychiatry in Botswana

By the end of Phase III students should be able to:

 be aware of their own attitudes and perceptions towards mental health problems and present a
balanced perspective on ethical dilemmas
 define advocacy and stigma in relation to mental health difficulties
 discuss the stigma surrounding mental health with patients, relatives and other health care staff
 discuss with patients, relatives and other staff the relative roles of allopathic medicine and
traditional healers in the management of mental illness
 take a full psychiatric history, including an outline assessment of personality
 recognise the local idioms for the expression of mental distress
 relate psychiatric presentations to cultural norms
 perform a mental state examination, including cognitive function
 perform a physical examination relevant to mental disorders
 perform an abbreviated but adequate psychiatric evaluation when required by service demand
 formulate a patient’s problem to include psychiatric diagnosis, developmental and intellectual
abilities, physical problems, personality and psychosocial factors
 be able to screen for common mental health problems in non-psychiatric settings and establish
initial management
 recognise the main diagnostic categories used by the World Health Organisation (ICD-10/ICD-11)
(and DSM) with reference to each of the weekly topics.
 recognise risk in the clinical environment and act to minimise it, and be able to use de-escalation
techniques where risk to self or others is present
 be able to manage patients who may be potentially violent
 understand the organisation of services for psychiatric patients in Botswana and the role of the
staff who care for them especially Community Mental Health Workers
 be able to refer patients appropriately to the psychiatric services

REVIEW A CHAPTER ON INTERVIEWING IN A PSYCHIATRIC TEXTBOOK

Week 2: Psychotic Disorders

By the end of Phase III the student should be able to:

 define psychosis and recognise the psychopathological terms used

 recognise common symptoms of psychosis and the terms used to describe psychosis on the
mental status examination

64
  be familiar with the legal framework applicable to the care of patients with psychiatric illness in
particular the National Policy on Mental Health 2003, Mental Disorders Act 1971, part XII
Criminal Procedure and Evidence Act, the Penal Code and Children’s Act Chapter 28:04 Laws of
Botswana.
 outline human rights legislation in relation to these laws
 explain the indications, side effects and toxicity of commonly used antipsychotic drugs in the
context of an understanding about the biochemical mechanisms
 explain the principles and mechanisms underlying current practice for rehabilitation in the
community and for the prevention of relapse
 recognise in patients the impact of race/ethnicity, culture and age on the diagnosis of psychosis
 outline risk assessment (for patients potentially dangerous to themselves or others), especially
as it relates to compulsory admission to a psychiatric facility
 initiate management of a psychotic person

COMPLIANCE/ADHERENCE

DEPOT ANTIPSYCHOTIC PREPARATION

EXTRAPYRAMIDAL/MOTOR SIDE EFFECTS

FLATTENING OF AFFECT

FLIGHT OF IDEAS

HALLUCINATION AND DELUSION

HYPERPROLACTINAEMIA

IDEAS OF REFERENCE

INSIGHT

POSITIVE AND NEGATIVE SYMPTOMS

PSYCHOSIS

THOUGHT DISORDER

PSYCHOSOCIAL REHABILITATION

BIOPSYCHOSOCIAL APPROACH
65
Week 3: Mood Disorders, Grief, Suicide and Self-harm

By the end of Phase III the student should be able to:

 recognise the common presentations of depression

 assess level of depression including potential risk of self-harm
 use the Beck Depression Inventory
 explain the mechanisms of action, indications and common side effects of the following physical
treatments: antidepressant drugs, mood stabilisers and electroconvulsive therapy
 summarise the main recommendations from the WHO guidance for the treatment of depression
including the evidence for their effectiveness
 recognise the clinical features of bipolar affective disorder
 recognise normal and abnormal grief reactions (these will additionally be addressed in your
palliative care placement in another block)
 recognise in patients the relationship between socio-cultural factors and the experience and
treatment of depressive illness
 initiate management of disturbed, suicidal or agitated people and seek appropriate help
 explain to patients and relatives the following psychological treatments: counselling, problem
solving therapy and cognitive-behavioural therapy
 list the risk factors for repetition of non-fatal deliberate self-harm and completed suicide, and
be able to assess a patient’s risk to themselves and others following an act of self-harm
 communicate effectively with individuals who have self-harmed
 outline the epidemiology of deliberate self-harm and suicide
 discuss with patients the strategies for managing deliberate self-harm, including problem-
solving techniques and referral to Government, Private and NGO agencies
 explore your own feelings on how you view self-harm

ANHEDONIA

ANTICHOLINERGIC

CNS SEROTONIN (5-HT) AND NORADRENALINE

COMMUNITY MENTAL HEALTH TEAM

COUNSELLING

ELECTROCONVULSIVE THERAPY (ECT)

66
EMPATHY vs. SYMPATHY

GRIEF REACTION

LIFE EVENT

POVERTY OF SPEECH

SOMATIC (BIOLOGICAL) FEATURES OF DEPRESSION

STIGMA

MULTIDISCIPLINARY APPROACH

RISK ASSESSMENT

SUICIDAL INTENT

Week 4: Substance Use Disorders

By the end of Phase III the student should be able to

 screen for problem drinking e.g. using AUDIT (Alcohol Use Disorder Identification Test) and
BENDU (Botswana Epidemiologic Network for Drug Utilisation) Questionnaires
 recognise the impact of alcohol and other drug misuse on society and the family
 recognise the individual and societal factors at work in the genesis and maintenance of drug
taking, including risk factors
 list the substances commonly misused and their major effects
 outline the psychological and physiological theories of alcohol dependence syndrome
 describe how health promotion can impact upon alcohol intake and misuse
 explain the psychological, social and pharmacological management of cannabis abuse and
outline the side effects and toxicity of medication use
 recognise the physical, mental and social complications of alcohol misuse and the many
presentations that this may have
 recognise that patients may be at different places in the cycle of change (motivational
interviewing) and that interventions offered should be tailored accordingly
 summarise the evidence for the effectiveness of psychological, social and pharmacological
approaches to the management of substance misuse

67
  explain how effective co-working with other Government Departments, Private agencies and
NGOs maintains high quality patient care
 be able to recognise and initiate management of acute alcohol withdrawal
 advise patients of the support groups available in the community

COLLUSION

CONFABULATION

DELIRIUM TREMENS

DENIAL

DEPENDENCE

MOTIVATIONAL INTERVIEWING

WERNICKE-KORSAKOFF SYNDROME

WITHDRAWAL SYNDROME

HARM REDUCTION

DEMAND REDUCTION

SUPPLY REDUCTION

Week 5: Anxiety Disorders

By the end of Phase III students should be able to:

 recognise the various manifestations of anxiety

 explain the physiological mechanisms involved with anxiety
 explain how cognitions, emotions, behavior, physiology and environmental factors can interact
in individuals experiencing anxiety
 recognize post-traumatic stress disorder, symptoms, presentations and treatments
 recognise panic disorders and agoraphobia including common precipitants
 recognise phobic anxiety and be able to discuss their fears with patients

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  recognise obsessive-compulsive disorder and outline evidence based treatments
 recognise adjustment disorders
 recognise how a person’s personality, coping strategies, resilience factors and problem-solving
skills affect their levels of anxiety
 initiate evidence-based management of anxiety states

COGNITIVE BEHAVIORAL THERAPY

COMPULSION

DEREALISATION-DEPERSONALISATION

FIGHT OR FLIGHT RESPONSE

GRADED EXPOSURE

HABITUATION

HYPERVENTILATION

NEUROSIS

OBSESSION AND COMPULSION

PHOBIA

SOMATIC (AUTONOMIC) FEATURES OF ANXIETY

STRESS

VICIOUS CYCLE OF PANIC

Week 6: Somatoform Disorders and Personality Disorders

By the end of Phase III the student should be able to

 Outline how early life experiences influence the development of personality

 Evaluate the concept of personality disorder and the arguments for and against its use
 recognise the possibility of a personality disorder in a patient
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  Give examples of the broad ethical and legal issues in dealing with individuals who present a risk
of violence to others
 recognise the physiological presentations of psychiatric and psychological problems
 recognise that psychiatric symptoms may be the manifestation of medication
 demonstrate consultation skills needed in work with patients whose beliefs and attributions
about their illness are different from your own
 recognise the psychological effects of physical illness, both chronic and acute
 explain healthy and unhealthy adjustment responses to physical symptoms and the impact of
personal, family and cultural influences
 identify patients who are using an excuse of ill-health to avoid work or school and recognise
feigned illness, psychological mechanisms associated with it and initiate management
 recognise the relationship between neurological disorders (e.g. Parkinson’s Disease) and the
psychological morbidity associated with them
 recognise the range of medically unexplained symptoms and their relationship with
psychological distress
 recognise the psychiatric manifestations of HIV/AIDS including issues of consent for testing
 demonstrate strategies for managing patients who present (repeatedly or otherwise) with
physical symptoms in the absence of an identifiable organic cause
 explore with parents how to manage social and psychological stress manifesting with physical
presentations in childhood
 initiate management for serious psychological sequelae in physical illness

CHRONIC FATIGUE SYNDROME

CONVERSION (DISSOCIATIVE) DISORDER

DISEASE vs. ILLNESS vs. DISORDER

HYPOCHONDRIASIS

ILLNESS BEHAVIOUR

MALINGERING

PSYCHOSOMATIC

SICK ROLE

SOMATISATION

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TRANSFERANCE

COUNTERTRANSFERENCE

Week 7: Cognitive Disorders and Sleep Disorders

By the end of Phase III students should be able to:

 screen an individual for dementia

 outline the effects of the normal ageing process and physical illness on mental health, taking
into account the social and family consequences
 recognise common forms of dementia and be aware of the possible interventions
 recognise the effects of ageing on presentation of mental illness, on the pharmacokinetics of
drug treatments and the implications for prescribing
 recognise the possibility of depression in older people who appear to have dementia
 explain how issues of consent, capacity and confidentiality relate to mental health care
 give examples of the effects of dementia on carers, and models of support available to carers
and those suffering with dementia, as in community or residential support
 recognise, investigate and initiate treatment for delirium (acute confusional state) and
distinguish it from dementia
 Differentiate a primary sleep problem from one secondary to a serious physical (e.g. asthma) or
psychiatric cause (e.g. anxiety or depression)
 Advise patients on simple techniques for self management of primary insomnia
 Recognise the indications and limitations of using medication in insomnia

COGNITIVE FUNCTION

ETHICAL DUTY OF CARE

DELIRIUM (ACUTE CONFUSIONAL STATE)

DEMENTIA

PSEUDODEMENTIA

HIERARCHY OF DIAGNOSIS

MENTAL CAPACITY VS. COMPETENCE

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PERSEVERATION

RECENT/REMOTE MEMORY

MINI MENTAL STATE EXAMINATION

Week 8: Normal and Abnormal Human Development (childhood disorders and Intellectual Disabilities)

By the end of Phase III students should be able to:

 recognise important milestones in the normal emotional, cognitive and social development of
childhood and adolescence and theories of human development
 explain how psychosocial factors, cognitive factors, family dynamics and developmental factors
are important in childhood problems
 recognise the importance of prevention in child mental health, including normalising of
professional or parental anxiety when appropriate (for example in the management of
bedwetting, school refusal and tantrums)
 identify the important psychiatric disorders of childhood and adolescence including: conduct
disorders and attention deficit hyperactivity disorder; autism spectrum disorders; depression
and anxiety
 outline common treatment approaches used by child mental health services, including cognitive
behaviour and family therapy, social services, school and medications
 screen for physical, sexual and emotional abuse and refer appropriately
 describe the support and services available to carers of children with autism spectrum disorders
and mental retardation
 use effective communication skills with people with severe mental illness or complex mental
health problems
 recognise co-morbid diagnoses for those with serious mental health problems
 define learning disability in terms of both IQ and level of functioning, and state how it differs
from mental illness
 outline the biological, psychological and social factors that are involved in the onset and
maintenance of mental health problems in people with learning disabilities
 give examples of the problems that people with sensory impairments may have accessing
mental health services
 outline the government support services available in the community
 outline basic strategies for managing behavioural problems in those with learning disability,
including an awareness of the multi-agency approach

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  recognise legal and ethical dilemmas that occur when managing individuals with a mental health
problems and learning disability, such as responses to serious intercurrent illness, fertility issues
(e.g.: contraception)

ATTACHMENT

ATTENTION DEFICIT – HYPERACTIVITY DISORDER

AUTISTIC SPECTRUM DISORDERS

CHILDHOOD ABUSE

ENURESIS AND ENCOPRESIS

FAMILY THERAPY

GENOGRAM

SCHOOL REFUSAL (vs. TRUANCY)

STATEMENT OF SPECIAL EDUCATIONAL NEEDS

CARER’S ASSESSMENT

DISABILITY, IMPAIRMENT and HANDICAP

DOWN SYNDROME

FRAGILE X SYNDROME

INTELLIGENCE QUOTIENT (IQ)

ERIK ERIKSON

JEAN PIAGET

SIGMUND FREUD

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Appendix A: Case Presentation Example
Your Name
Case Presentation #
Week #
Date Completed:

PATIENT HISTORY

Identification: Patient INITIALS , AGE, RACE/NATIONALITY, SEX, from VILLAGE/CITY currently

EMPLOYMENT STATUS as a JOB TYPE…

Chief Complaint: State whether complaint given by patient or by informant. If informant state
relationship to patient. The chief complaint is whatever the patient or informant said when you asked
why they were here in their “own words.”
HPI: Patient XY presents with _____________ (or WAS REFERRED BY ____________) for problems or
symptoms of ____________ etc.

Should start with information regarding syndrome of the CC and include description of the following:
 Problem and or symptoms related to chief complaint or reasons why patient was referred by
family/police/etc, (i.e. events leading to seeking treatment). Include pertinent positive and
negative symptoms of CC, as well as associated/comorbid symptoms.
 Why is the patient getting help now?
 Severity and level of function/impairment/distress – how are their problems affecting their life?
 Related psychosocial stressors that may have precipitated or perpetuated problem
 Any current treatment for problem and if it is helping, including traditional treatments
 Include pertinent dates, name informants who may have given collateral information and you
should comment on informant reliability if appropriate.

Psychiatric Review of Symptoms: (very important, you will have troubles making a differential diagnosis
and working diagnosis if you do not do this)

Include a set of screening questions in your interview under the main categories of psychiatric illness
and include any findings here. Some of the categories below have multiple syndromes and you should
begin to develop a screening question for each. Be explicit about what you found in your interview as
we cannot assume that you did this unless you tell us. For example, you cannot say that patient had no
anxiety related syndromes if you only screened for worry but did not ask about panic, OCD, PTSD etc.
Instead you can only say “patient denied problems with worrying.”

 Mood symptoms
 Psychotic symptoms
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  Anxiety symptoms
 Cognitive symptoms
 Substance abuse issues

Past Psychiatric History:

 Past diagnoses (these may or may not be true, but ask)
 Outpatient and inpatient history, including dates of admission or treatment and reason for
treatment.
 Past medications, efficacy and side effects, any negative reactions
 History of dangerous behavior:
o suicide attempts or SI, homicide attempts or HI, any history of violence behavior (fights,
assault, breaking things, arguing/yelling with strangers)

Past Medical and Surgical History:

 Include any pertinent findings
 HIV risk factors and testing, status, CD4, VL
 Smoking
 Traumatic brain injury, accidents or prolonged hospital admissions for medical problems

Family History:
 Father
 Mother
 Siblings
 Family structure and raised by whom?
 ***History of mental illness or substance abuse*** (very important)

Personal / Social History:

 Childhood history: birth details and developmental milestones
 School history: regular or special ed, grades, highest level of education
 Employment history: first and last job, longest duration of any job
 Friends and other social supports: peer relationships, how frequently do they socialize
 Marital history and children: duration, ages, relationship with prior partners
 Psychosexual history: age at puberty, age of first sexual encounter, number or partners
 Abuse history: any history of physical or sexual abuse or neglect
 Forensic history: arrested, prison time, reason, number of offenses, dates
 Substance abuse history: what, when, how long, how frequently, what problems has it caused
(unable to fulfill social or occupational roles), related illegal activity? CAGE questions ______
 Religious affiliations:
 Premorbid personality: quiet, outgoing, interests, hobbies, reaction to stress, coping skills
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  Reliability of history obtained. This is your observation on whether history obtained is reliable or
not

Physical Examination, Vital Signs, Laboratory Values:

(If available)

MENTAL STATUS EXAMINATION

 Appearance: be detailed!! Race, height, build, dentition, distinguishing features, hygiene,

grooming and style of dress

 Behavior and Attitude: calm, psychomotor retarded or agitated, cooperative or hostile, eye
contact

 Speech: rate, rhythm, volume, quantity, spontaneity, tone, prosody

 Mood: the patients description, sad, depressed, happy, good, fine, angry

 Affect: your objective view – dysphoric, euthymic, euphoric, elated, labile, restricted, flat,
blunted, inappropriate or incongruous to mood or content

 Thought Process: linear, organized, goal directed, incoherent, circumstantial, tangential,

disorganized, incoherent, illogical, loose associations, flight of ideas, perseverative

 Thought Content: SI, HI, delusions (specific type and example), perseverations

 Perceptions: hallucinations (auditory, olfactory, visual, tactile, gustatory), illusions

 Cognition:

 Alert or not ( Level of consciousness)

 , orientation

 Attention and concentration

 Memory (immediate, recent and remote)

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  Intelligence

 judgment and impulsivity

 Abstract thinking

 insight.
If there is evidence of cognitive impairment you must do a MMSE (mini mental state examination and
score it)
o MMSE: Orientation, registration, attention, calculation, recall, language (naming,
repetition, comprehension, writing), and visual-spatial construction
NOTE:
 Insight: refers to patients global (not situational) understanding of their diagnosis and how this
affects their life as a whole and need for treatment; explain if it is poor, fair or good and give
explanation for your assessment.

 Judgment and impulsivity: Patients global (not situational) ability to make sound decisions in
their life regarding their personal well-being or well-being or others, especially dependents;
explain if it is poor, fair or good and give explanation for your assessment. Impulsivity: How able
a patient is able to control thoughts before they act on them: Specify low, medium and high,
and give reason for your assessment.

DIAGNOSES

Differential Diagnoses: Think broadly in each category. If patient has one disorder in a category you will
want to strongly consider other diagnoses in the same category.
 Mood DO’s
 Psychotic DO’s
 Anxiety DO’s
 Substance Use DO’s (intoxication, withdrawal,
 Substance Induced Psychiatric Disorders (psychosis, mood, anxiety, cognitive, sleep, sexual
dysfunction
 Cognitive DO’s
 Adjustment Disorders
 Dissociative DO’s
 Somatiform DO’s
 Psychiatric Disorders due to a General Medical Condition (these MUST be excluded!)

Working Diagnosis and explanation:

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  You must give your working diagnoses (their may be more than one) and defend why you chose
them over others in your differential.
 Many students struggle to fully think through making a broad differential and communicating
their argument. Some students have found it very helpful to complete a chart for this until they
become better at psychiatric differential diagnoses. Here is an example:

Differential For Against Additional

Diagnoses: information required
Example: mood sx’s to clarify
and alcohol use
Major Depressive Low mood Sleeps well Symptom time course
Disorder Poor concentration Eats well and severity
Guilty thoughts No suicidal thoughts
Etc.
Bipolar Disorder Same as above Didn’t get a history of History of mania?
mania
Substance induced Binge drinking Time course of mood
Mood Disorder disorder in relation to
drinking
Alcohol Abuse Tolerance of alcohol Never tried to cut
Etc down
Doesn't seem to
effect function
Mood disorder due to Etc.
GMC
Etc. - This is only a
partial list not a
complete
differential!!

FORMULATION

Discuss the contributing bio-psycho-social factors of the patient’s case with an understanding of how
they are predisposing, precipitating, perpetuating, or protective. Consider the patient’s CURRENT
EPISODE as part of the LARGER DIAGNOSIS as the problem you are formulating. (Ex. Formulating the
current episode of depression in a bipolar patient and what precipitated the episode).Be clear on
whether you are formulating the current episode or the initial presentation if the patient is not a new
patient.

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You may use a chart but be prepared to explain the main factors as well. These are examples below, but
certainly not an exhaustive list.

BIO PSYCHO SOCIAL

Predisposing Health problems Trauma/abuse Poverty
(in the past before Borderline IQ/MR Neglect Poor education
problems started) Family Hx of Loss Early family
substance or mental Grief death/abandonment
Substance problems Divorce
Etc…

Precipitating Ex. Newly diagnosed Poor self esteem Personal

(stressors leading to HIV or cancer, Poor coping skills Occupational
BPS problems) hospital admission, Social
Economic
Legal
Religious
Abuse

Perpetuating Ex. Worsening of Ex. Poor insight, “ “

(things the prolong medical condition, denial as a coping
and continue the etc… skill…
problems

Protective High intelligence Good coping skills Strong social supports

(strengths) Good health Good ego function (married), good
Good adherence Hopeful, future job/finances/housing,
oriented Completed secondary
Help seeking education
Sense of humour and Religious community
other mature
defenses

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PROGNOSIS
FINISH THE FORMULATION WITH A STATEMENT ON THE POSSIBLE PROGNOSIS OF THE PATIENTS
PROBLEM.

MANAGEMENT PLAN
1. Continuing assessment:
a. Collateral and records review, additional screening and diagnostic questioning
b. Medical work-up
2. Safety Assessment and Plan: for inpatient or outpatient
3. Biological treatments:
a. Medications, sleep alterations, nutrition, etc.
4. Psychological treatments: (this is only a brief list of possibilities)
a. Psychotherapy
b. Psychoeducation
c. Substance abuse treatment
5. Social interventions: (this is only a brief list of possibilities)
a. Family sessions
b. Family therapy, couples therapy, parent-child therapy
c. Social work interventions
d. Educations supports
e. Occupational therapy
f. Social skills training

Appendix B: Mini-Mental State Examination

Orientation:
Year Month Day Date Season ______/5
Country Town District Hospital Ward/Floor ______/5

Registration:
Name 3 objects: ____________ ____________ ____________ ______/3

Attention and Calculation:

Subtract 7 from 100, then repeat from result.
Continue 5 times: 100 93 86 79 65 ______/5
Spell WORLD backwards: DLROW ______/5
(Take the best of these scores for the total)

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Recall:
Ask for the names of the 3 objects:
____________ ____________ ____________ ______/3

Language:
Name a pencil and a watch ______/1
Repeat “No, ifs, ands or buts.” ______/1
Give 3 step command. Score 1 for each stage.
Eg. “Pick of this piece of paper in your right hand,
fold it in half and place it on the desk.” ______/3
Read and obey a written command. “Close your eyes.” ______/1
Write a sentence. (Sensible subject and verb) ______/1

Copying:
Copy a pair of intersecting pentagons. ______/1
Total: ______/30

6.0 Public Health Medicine [PHM]

6.1 General Information on Public Health Medicine Course (504) – Eight weeks

6.1.1 Course description and content (synopsis)

Public Health is “The science and art of preventing disease, prolonging life and promoting health
through the organized efforts of society” *Acheson 1988+. It is multidisciplinary, population-based,
action oriented and community targeted. The discipline of public health medicine [PHM] examines and
responds to the health of whole populations, rather than focus on the health of individual patients. This
strengthens our understanding of the causes of ill-health and informs the development of effective
interventions, exploring the impact of geographic, environmental, economic, social and cultural – as well
as biological – influences on health and health care.

PHM looks at modes of delivering care that meet demonstrated community needs, and at policies to
support this. In doing so it takes account of resource utilization, and has a particular interest in
promoting equity, efficiency and sustainability. Health care provision is seen as a necessary component
of social development. It takes into account the linkages between population health and progress in
other sectors (for example, water and sanitation, education, economic policy and welfare policy).

PHM examines the whole health system – locally, nationally and globally – since a community’s health
status is the result of dynamic interactions among many components and forces, both within and
outside of the health sector. The role of government is important, including the provision of health and
social services for the poorest, regulation of the private sector, and public-private partnerships to
extend options for the delivery of care. Not-for-profit non-governmental organizations (NGOs) also play
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key roles. PHM acknowledges the need for inter-sectoral and team approaches in dealing with most
health problems. It thus takes strong interest in the management, training and motivation of health
professionals as a critical component of effective health care delivery.

Good public health practice depends on a sound evidence base, drawing on a range of investigative,
diagnostic and analytic tools, methods and approaches. This applies to the evidence base for preventive
medicine as well as clinical effectiveness to ensure the resources available for the health care of
populations is distributed in an equitable manner.

Learning about PHM in Phase 2 will build on the integrated public health learning outcomes covered in
Years 1 and 2, and during the community placements. The same principles of PHM learning weave
through Phase 2 during other modules, as well as a 9 week block in the 4th year. The main teaching will
be done in the first 3 weeks of the Block, followed by 5 weeks doing community projects. The students
will return to SOM to prepare reports during the last week and make presentations on their community
projects on the last Friday of the module.

Learning objectives of Public Health Medicine module Year 4

Classroom teaching weeks 1-3

The teaching methods used in these 3 weeks will mainly take the form of tutorials, case studies and
practical exercises. There will also be time allocated to plan for the community projects to be
undertaken in weeks 4-8.

Following learning on this block the fourth year medical students will have:

 An overview of the scope and practice of public health medicine at a global, international,
national and local level.
 Insight into key public health challenges facing communities and health systems in Botswana.
 Knowledge and practice of the issues and techniques involved in studying the effect of diseases
on communities, families and individuals.
 The ability to describe the state of health and burden of illness affecting a community by
interpreting demographic, mortality and morbidity data and qualitative data, and to analyse
health service utilization data.
 The ability to use epidemiologic approaches in addressing problems of public health importance.
 Awareness of the principles of promoting health and preventing disease including surveillance
and population screening.
 An understanding of the structures, organization, management and financing of the health
system in Botswana.
 Appreciation of the roles the public and private sectors, community organisations, non-
governmental organisations, families and patients play in improving their health and health
care.
 Appreciation of environmental and social causes of, and influences on, the prevention of illness
and disease.
 Understanding of how to assess the quality of a service, using techniques of clinical audit,
quality assurance and evaluation in doing this.
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  Insight into how to conduct themselves ethically as health professionals in communities.

Community projects: Weeks 4-8

The medical students will undertake some tasks common to all the groups. In addition they will design
and implement community projects in groups of 3-4 students in selected areas of interest.

Common assignments:

1. Investigate what routine surveillance is carried out at district level

2. Explore information and data flows from clinic level to MOH and what actions are taken as a
result of these data flows.
3. Assist with a clinical audit routinely carried out by district hospitals [eg maternal mortality or
childhood immunization]
4. Describe the structure, functions and responsibilities of the District Health Management Teams
5. Develop a report on the district focusing on areas of inequitable access to healthcare and make
suggestions of how these inequities could be addressed [demonstrate understanding of the
difference between inequalities and inequities].
6. Investigate how Polio surveillance is carried out in this named district.

Community projects

Each group [3-4 students] will identify one community project from the list below [or develop their own
idea of a project] to conduct, write a report and prepare a presentation on. The last week of the module
is available for doing additional research and writing up. Presentations on the community project and
discussion of common assignments will take place on the last Friday of the module to an audience of
students and faculty of the School of Medicine, Faculty of Health Sciences and other interested persons.

The list of projects below is not exhaustive and other ideas for projects may be discussed with
supervisors. For example, if there is an outbreak of a communicable disease at the time of the visit, the
medical students may be able to assist with investigating the outbreak as their community project.
Medical students will be expected to demonstrate application of theoretical knowledge and legislation
in their projects, for example behaviour change models, the Ottawa Charter, Public Health Act,
Demographical profile of Botswana.

1. Knowledge of families on prevention of diarrhoeal diseases, use of oral rehydration salts and
home-made remedies, steps taken when children develop diarrhea.
2. Application of health promotion models towards increasing blood donations in communities.
3. Attitudes and beliefs of communities towards maternal [or infant] deaths and how these impact
on early attendance at health facilities with problems.
4. Attitudes and beliefs of families towards immunization of children – how this has changed over
time.
5. Aspects of the work environment that increase the risks of developing non-communicable
diseases
6. The role of traditional healers in the community, the belief system aligned to their methods of
healing, legislation pertaining to their practice.

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 7. Factors influencing morale and motivation of health staff in primary and secondary care and
how to improve these.
8. Compiling a community diagnosis of a defined community.
9. Evaluation of the extent to which primary care services are patient-centred or provider centred.
10. The epidemiology of tuberculosis [or other disease of public health importance] in the district,
how services are managed, indicators for evaluation of quality of services and performance in
improving quality.
11. Challenges in provision of mental health services, how these relate to traditional attitudes and
approaches to mental illness, what possibilities there are for joint care of patients.
12. The extent to which present day changes in lifestyle are pre-disposing people to long-term
illness in the community, what health education is provided for this and how receptive
communities are to responding to these messages.
13. The media the community has access to and the influence each media source has on health.
14. The role of named community organisations or non-governmental organisations in provision of
health care, how they are funded and regulated.
15. Explore the difference in the age structure in rural areas compared to urban areas [refer to The
National Census for this] and what the implications are for planning health services.
16. Describe the features of the environment in the stated community that promote the spread of
communicable diseases and how to make an impact on this.
17. Identify one vulnerable group in this community and describe their health needs and risks.
18. Conduct a survey on infant feeding in this community, including related attitudes, beliefs and
practices, and develop a plan to promote breast feeding based on your findings.
19. Using the Ottawa Charter and key informant interviews, develop a proposal for reducing
hypertension in the named community, including details on risk factors for the members of the
community.
20. Describe aspects of the social environment of this community that promote substance abuse
including irresponsible alcohol use and suggest evidence based interventions that could address
this.
21. Describe the water and sanitation services provided in this community and suggest a risk
assessment of how this may impact on the health of the community.

7.0 Surgery II (SOM 502): Orthopaedics/Radiology, Ophthalmology and Otorhinolaryngology (ENT)

(Eight Weeks)
7.1 Course description and content (synopsis)
Orthopaedics: The orthopaedic module acquaints students with the prevention, diagnosis, surgical, and
non-surgical management of common conditions affecting bones, joints, ligaments, muscles, and
connective tissues. Students should be able to assess orthopaedic health conditions through medical
interviews and clinical examination of a patient, select and request for appropriate diagnostic
investigation, interpret findings, explain the underlying pathology, and outline a management plan of
the case. Topics covered include clinical approach to articular and musculoskeletal disorders; interview
and physical examination of patients; radiographic anatomy; diagnosis, treatment, rehabilitation, and
prevention of traumatic and non-traumatic musculoskeletal disorders; underlying patho-physiological

84
mechanisms; multiple injury and response to trauma; complications of traumatic lesions; external and
internal immobilization methods; foreign body.

Learning Outcomes:
At the end of this course, the student is expected to be able to:

Week 1

The patient with joint pain or swelling

 Describe the impact of restricted movement and pain on daily life and refer appropriately
 Distinguish between the common types of articular and non-articular swellings around joints
 Distinguish between inflammatory and non-inflammatory arthritis
 Describe the immunolo-pathological basis of rheumatoid disease relating this to investigative
findings
 Recognise bone and joint infections and participate in their management
 Recognise osteoarthritis of the hip and knee clinically and initiate appropriate investigations and
management
 Recognise the possibility of acute bacterial arthritis and take appropriate action
 Recognise common musculoskeletal presentation of systemic conditions and the generalized
nature of auto-immune responses
 Recognise the major complications of joint replacement surgery and refer appropriately
 Prescribe appropriately, if necessary in collaboration, first-line drugs commonly used in the
management of joint pain or swelling taking into account the likely side-effects and toxicity
 Discuss with patients the role of disease modifying agents in rheumatoid arthritis
 Discuss with patients the range of aids to daily living that are available and the referral pathways
to physiotherapy and occupational therapy

Week 2

The patient with upper limb trauma

 Recognise the possibility of fractures, apply first aid and initiate appropriate radiological
Investigations and participate in their management
 Recognise those fractures in children which might lead to abnormalities in growth and
deformity and refer appropriately
 Discuss with the patient the possibility of osteoporosis and its management
 Recognise shoulder dislocations clinically and radiologically and be able to reduce it if
appropriate
 Discuss the possibility of fractures as an indicator of non-accidental injury possibly resulting
from domestic violence
 Outline to a patient operative and non-operative management of common fractures, including
rehabilitation
 Identify important soft tissue (muscles, ligaments, nerve, vessels) involvement as a potential
complication of fractures
 Recognise tendon injuries of the hand
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  Identify and distinguish between different nerve injuries in the hand
 Demonstrate the ability to suture a soft tissue wound
 Outline to patients the rehabilitation process in shoulder, elbow and hand injuries
 Discuss the potential longer term functional and socioeconomic consequences of upper limb
trauma for the patient

Week 3

The patient with lower limb trauma

 Demonstrate a systematic approach to the examination of the patient with lower limb
trauma
 Outline to patients the operative and non-operative management of common open and closed
fractures of the lower limb
 Identify important soft tissue (nerve, muscle, tendon, ligament, vessel) involvement in lower
limb injuries
 Recognise complications that can occur following the operative management of lower limb
fractures and participate in their management
 Recognise the complications of the non-operative treatment of lower limb injuries, including
DVT, PE, compartment syndrome
 Recognise hip fracture clinically and radiologically and participate in its management
 Identify the likely predisposing causes of hip fracture and act to prevent them as far as
possible
 Recognise for patients, their families and the wider community, the psychological and
socioeconomic consequences of hip fracture and how these may modify management
 Recognise the impact of amputation on an individual’s life
 Outline to the patient the rehabilitation process following amputation
 Recognise the impact of motivation on recovery
 Safely apply a plaster of paris back slab to a limb

Week 4

The patient with multiple trauma / head injury

 Outline the epidemiology of accidents and multi-trauma

 Recognise that the presenting injury may not be the only injury (eg: presence of head injury)
 Describe the priorities of trauma care
 Outline the principles of the Advanced Trauma Life Support course approach (ABCDE) to the
multi-trauma patient, also recognising the utility of scoring systems
 Identify immediately life-threatening complications of multi-trauma, particularly with regard to
airway, breathing and circulation
 Initiate immediate management of life threatening complications (again with regard to airway,
breathing and circulation)
 Use investigations to help identify life-threatening complications
 Recognise limb-threatening complications of multi-trauma (including vascular problems)

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  Identify medium-term life-threatening conditions (coagulation, fat embolism, crush syndrome,
PE, ARDS)
 Identify patients with head or spinal injury and collaborate with others to refer to specialist
rehabilitation services where possible or applicable
 Work with the team caring for patients with multiple injuries, beyond the period of initial
assessment
 Demonstrate awareness of the impact (physical, social and psychological), of multi-trauma on
the patient and their family
 Collaborate with others in assessing disability in these patients
 Outline to patients and their families rehabilitation services available for them

Week 5

The patient with musculoskeletal pain

 Outline the management of acute musculoskeletal pain (including demonstrating the ability to
prescribe appropriate drugs and physical therapies)
 Explain to a patient why pain may persist without any residual sign of injury
 Recognise that psychosocial and behavioural factors in the patient and those around them
that can contribute to the development of chronic pain
 Obtain a history from a patient with longstanding and extensive pain, eliciting their beliefs and
concerns about their problem
 Obtain a history and perform a focused physical examination on a patient with back pain
 Initiate appropriate investigation and participate in the management of back pain
 Recognise when investigations and medical management are no longer helpful
 Help patients with chronic pain move from a medical model of pain to a self-management
approach
 Discuss with patients the role of cognitive factors, (such as fear of re-injury) and how these can
lead to avoidance behaviour and maintenance of chronic pain
 Discuss with patients the evidence for cognitive behavioural therapy in the management of
chronic pain
 Describe the role of placebo effect in both orthodox and complementary therapies
 Work with different health professionals in the management of chronic pain
 Recognise conditions presenting with widespread and persistent pain such as fibromyalgia that
have no discernible musculoskeletal cause
 Explain to a patient the potential adverse effects of orthodox medical and complementary
therapies
 Describe the main forms of complementary therapy used by patients with musculo-skeletal pain
and why patients use them
 Recognise how use of complementary therapy may affect other treatments received by patients
 Describe the impact of medically unexplained symptoms on people’s lives

Week 6

The child with an abnormal gait or posture

 Discuss the role of screening for congenital and developmental musculoskeletal abnormalities
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  Explain to parents the treatment for different types of flat foot
 Examine a child with in-toeing and identify the causes
 Explain to colleagues the key features of genu varum and valgus that would require referral
 Recognise scoliosis and its effect on patients in the adolescent
 Recognise rickets and initiate appropriate investigations
 Work with a multidisciplinary team caring for children with cerebral palsy (or other neurological
conditions)
 Differentiate bone infections from malignancies
 Examine and initiate appropriate investigations and management of a child or adolescent with a
painful hip. (Perthe’s disease and slipped upper femoral epiphysis)
 Discuss the clinical features with other health professionals (including gait) that might indicate
the presence of muscular dystrophy and the value of genetic counselling
 Explain to parents the natural history of benign apophyseal disorders (Osgood Schlatter’s and
Sever’s etc) in order to allay anxiety
 Describe the social impact of abnormal gait/posture on the patient and their family

Week 7

The patient with a soft tissue disorder

 Obtain an appropriate history from a patient with a soft tissue problem (eg: cervical whiplash)
and exclude any potentially serious damage
 Examine, request appropriate investigations and initiate management of a patient with a painful
shoulder
 Form a differential diagnosis of the common causes in a patient with shoulder pain distinguishing
between joint, tendon disease and other causes
 Examine a patient with pain and numbness in the hand and distinguish between different
nerve entrapment syndromes
 Discuss with a patient the management of common tendonopathies (eg: De Quervains, palmer
flexor tenosynovitis and trigger finger)
 Diagnose and with others initiate appropriate management of common entheseal problems (eg:
tennis and golfers elbow and ‘trochanteric bursitis’)
 Examine, request appropriate investigations and initiate management in patients with soft
tissue ankle injuries
 Discuss with patients the appropriate use of NSAIDs and injections and make them aware of their
potential side effects and toxicity
 Work with a variety of other health care professionals (including occupational therapists,
physiotherapists and other allied professionals eg: osteopaths and chiropractors)

Ophthalmology: The ophthalmology module discusses the structure, function, diseases and basic
remedies of the eye Students should be able to examine the eye, carry out tests for visual acuity and
color, diagnose diseases of the eye and ocular manifestations of systemic diseases as well as carry out
simple treatment procedures under supervision, or follow proper referral procedures. Topics covered
include: anatomy and physiology of the eyeball, socket, and visual pathways; signs and symptoms of
primary eye diseases; congenital, immunological, inflammatory, and infectious diseases of the eye; eye
trauma and foreign bodies; neoplasia; causes, diagnosis, and treatment of progressive loss of vision;
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causes, diagnosis, and treatment of sudden visual loss; haemorrhages; alterations of the eyeballs
position; ocular complications of systemic diseases; exploration of the ophthalmic patient; minor eye
surgery; blindness prevention; Tests for visual acuity and colour; imaging for eye investigations.

Relevant Phase I study guide.

You will need to look through SOM 307 study guide and your notes to check your understanding.

Week 8

The patient with visual loss

 Recognise hypertensive and diabetic retinopathies and papilloedema

 Detect cataract in adults and children and appreciate a normal red reflex
 Explain to the patient the relationship between cataract, diabetes and ageing and outline to
them the potential benefits and complications of cataract surgery
 Discuss with the diabetic patient the importance of detection and management of diabetic
eye disease
 Describe the community management of diabetic eye disease
 Recognise glaucoma and distinguish between acute and chronic glaucoma
 Explain to patients the systemic side effects of glaucoma drugs
 Recognise symptoms associated with acute retinal detachment and age-related macular
degeneration
 Recognise conjunctivitis, corneal abrasion, dendritic ulcer, corneal foreign body and orbital
cellulitis
 Perform fundoscopy and recognize normal and abnormal fundi
 Recognise leukocoria in a child and distinguish its different causes
 Describe trachoma and its management
 Recognise the relationship between diseases of the eye and various systemic diseases
 Recognise ocular complications of HIV
 Recognise the different types of ocular trauma
 Recognise the potential significance of a squint and refer appropriately
 Outline Botswana and global patterns of visual loss
 Discuss Vision 2020
 Recognise the significance of bitemporal hemianopia
 Describe the role served by optometrists and ophthalmic nurses in the management of eye
diseases
 Describe amblyopia

Otorhinolaryngology (ENT): This module discusses diseases of the head and neck regions where some of
the most common infectious diseases encountered by internists and other primary care physicians are
found. Although these infections are usually mild enough to be treated on an outpatient basis, the
student has to recognize the serious complications that may arise from such diseases and therefore
identification and treatment of these potentially life-threatening infections of the head and neck are

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crucial. At the end of the module, students should be able to recognize diseases affecting the head and
neck, develop differential diagnoses, select appropriate diagnostic tests, interpret test results, and
develop a treatment and disease prevention plan, as well as carryout live-saving and emergency
procedures involving ENT conditions under supervision. Topics covered include: congenital ENT
conditions, nasal hemorrhagic syndrome (epistaxis), nasal obstructive syndrome (sinusitis, foreign
bodies, injury), nasal tumors, infections of the oral cavity and pharynx (adenoiditis, tonsillitis,
pharyngitis), airway obstruction syndrome (laryngitis, croup, and epiglottitis), afflictions of vocal cords,
neck tumors, ear and mastoid infections (auricular cellulitis, perichondritis, otitis externa, otitis media,
mastoiditis), hypoacusia and vertiginous syndrome.

Relevant Phase I study guide.

You will need to look through SOM 307 study guide and your notes to check your understanding.

The patient with Hearing Loss

 Recognise congenital ENT conditions

 Discuss common causes of nasal haemorrhagic syndrome (epistaxis) and their management
 Recognize nasal obstructive syndromes such as sinusitis, foreign bodies, injury, nasal tumours
 Recognize and diagnose infections of the oral cavity and pharynx and air way obstructive
syndromes.
 Recognise and distinguish between conductive and sensory neural deafness
 Refer patients appropriately for audiometric assessment
 Recognise a perforation of the tympanic membrane
 Recognise the possibility of neo-natal and childhood deafness and outline the process of
screening for hearing loss
 Discuss the evidence-base for intervention in glue ear and explain the options for the
management to parents
 Explain to patients when they may need a hearing aid, assisted devices in the home or a
cochlear
 Explain the nature and management of tinnitus to patients
 Give advice on the prevention of deafness
 Recognise vertigo, particularly in relation to a unilateral hearing loss, and initiate investigation
 Perform otoscopy and rhinoscopy
 Explain to patients management options of impacted wax in the external auditory meatus

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YEAR FIVE

1.0 Familiy Medicine II (SOM 605) – Eight weeks

1.1 Course description and content (synopsis)

1.1.1 Problem identification and general needs assessment

Fifth year medical students will have good knowledge of medicine. Their consultation skills and
examination skills will be of such a standard that they can manage patients under supervision. It is
however crucial in this phase of their training, for them to recognise patients who are in danger; those
patient that need extra attention or referral to senior colleagues or appropriate health facilities.

The fifth year rotation should be geared to clinical work and feeling in gaps in knowledge and practice.

Primary care 101 is going to be the main treatment guideline in primary care. Students need to be
comfortable using it.

Students need to be introduced to research such that they may contribute to knowledge about health in
Botswana.

Students need to interact with important stake holders in primary health care; the police, DHMT, the
chief and politicians

Students have a fresh/new way of looking at things and this should be made use of.

1.1.2 Targeted needs assessment

Students need to be comfortable consulting patients and treating them in a clinic setting. This is an
environment where decisions need to be made in a short space of time because of the large volumes of
patients that need to be seen.

Students also need to feel confident about the treatments that they give and should not endanger
patients. This is where PC 101 will be helpful.

Students may not have been introduced to research and will need teaching in this area.

Students will participate in meetings in the clinic concerning the health work. This is an opportunity for
them to air their fresh ideas without being over critical or obnoxious. This is also an opportunity for
them to start showing leadership in health teams.

The hospital and clinic workers have to be told about the role that the fifth year students will play in the
facilities. Supervising doctors have to be told what their role will be vis a vis the students. The students

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themselves have to know that they are junior to all qualified health staff in a facility and that they will
learn a lot from non medical staff (nurses, dieticians etc).

Faculty have to prepare important stake holders (police, DHMT, chiefs and councilors) about the fifth
year program and their role in it. Topics of potential interest to students should be discussed with them
(rape, mentally ill people in the community, TB and HIV programs, health budgets, state of clinics and
ambulances etc)

1.1.3 Goals and objectives

At the end of the nine weeks, the student will be able to consult and treat patients under supervision, in
a clinic or outpatients department.

She will recognize the cases that are beyond her level of competence and refer them to senior
colleagues or competent health facilities (after consulting senior colleagues).

The student will be able to use PC 101 and will be able to perform simple procedures that are done in a
clinic.

They will be able to do simple research projects and audits.

They will know the role of other stake holders in health care e.g. the role of police in accidents, rape,
and mentally ill people; the role of social workers in TB and HIV care; the members and role of the
DHMT in primary care.

The first three days of the rotation will be devoted to training in PC 101; mornings and afternoons will
be set aside for this.

Mornings will be devoted to consulting and treating patients in clinics and outpatients departments.

Four afternoons will be devoted to lectures, and tutorials in FM, or training in research/audits.

One afternoon will be devoted to meetings with other stakeholders in health, DHMT, police, social
workers, laboratory scientists, dieticians, physiotherapists, psychologists, occupational health therapists,
etc.

Fifth year students will do at least one A&E call per week including one Saturday or Sunday call.

At the end of their rotation students will be asked to write a report of no more than three pages. They
will be asked to reflect on their experiences during the rotation and to suggest how healthcare can be
improved in the units they served in.

1.1.4 Educational strategies

The content of the rotation is outlined in the topics and learning objectives.

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The topics for this rotation will be taught in PBL sessions,lectures and tutorials.

Experiential learning will be taught in clinics, outpatients departments and in A&E departments (during
calls).

Stakeholders will be met at their places of work (preferably) or at FM department premises.

Students will be asked to write about significant events during their rotation. They will be told that this
will help them when they write their final report on their experiences at the end of the rotation.

1.1.5 Implementation

Faculty will be trained as trainers of PC 101.

The program will be discussed with stakeholders and their cooperation will be asked for.

The program will also be discussed with residents, doctors, and other health professionals working in
clinics, outpatients departments and A&E departments. Their role in the program will be explained and
their cooperation will be solicited.

One FM faculty member will supervise the program but its implementation is the responsibility of all
faculties.

Transport will need to be arranged for students to be at their training sites on time.

Chiefs, councilors, and other community leaders will be consulted and their support of the program will
be solicited.

1.1.6 Evaluation and feedback

At the end of the rotation students will evaluate the program and facilitators. Students will be assessed
during the rotation and at the end of the rotation.

Weekly topics and outcomes

Week/Topic Learning outcomes

1
Abnormal weight and  Understand the use of the “Under Five Card/Road to Health” card
height (adult & child)  Be able to plot height, weight and head circumference on growth charts
+ developmental  Be able to calculate Body Mass Index and understand its implication
delay – failure to  Differentiate between definitions for abnormal weight in adults and
thrive/infant feeding children
problems/nutritional  Describe common nutritional problems seen in childhood
problems (child),  Describe the common developmental problem in children and how to
obesity (child & assess for these
adult)
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2  Describe the different contraception methods available in the Botswana
Sexual health primary care setting
problems &  Outline the routine care of a patient using contraception
screenings - Urethral  Be able to assess a patient with loss of lobido/importance
discharge/genital  Recognise the common genital symptoms in men and women(urethral
ulcers and warts/ discharge;vaginal discharge; genital ulcers; genital warts)
vaginal discharge,  Understand how to treat a patient with genital symptom and his/her
loss of partner(s)
libido/impotence &
contraception

3  Recognise and and understand the approach to manage a patient who is

Fits (adult), falls unconscious and fitting
(including non-  Define Status Epilepticus and describe its management
accidental injury),  Outline the routine care of a patient with Epilepsy
numbness & tingling  Recognise signs suggestive of Non Accidental Injury (History and
examination)
 Outline a management approach to dealing with a patient with Non
Accidental Injury
 Identify the common causes of numbness and tingling
 Recognise the patient with Stroke needing urgent attention
 Outline the routine care of a patient with stroke

4
Patient with ENT  Recognise the common causes of Nose bleed
problems- nose  Be able to manage nose bleeding
bleed, hearing loss &  Recognise the common causes of difficulty with hearing
dizziness + vertigo  Recognise the patient with dizziness needing urgent attention
 Recognise the different causes of dizziness
 Outline the approach to manage a patient with dizziness
5  Recognise the patient with a bite needing urgent attention
Envenomation &  Outline the approach to managing the different types of bites( Human/
scorpion bite Insect(Scorpion etc)/Snake

6  Recognise symptoms suggestive of Depression and Anxiety

Medically  Outline the routine care of a patient with Depression and Anxiety
unexplained  Recognise the patient with substance abuse
symptoms + sleep  Outline the routine care of a patient with Substance abuse
disorders (including  Be able to assess for and advise the patient on sleep hygiene
obstructive sleep  Be able to exclude possible causes of difficulty in sleeping
apnoea)  Understand when to consider the diagnosis of Fibromyalgia
 Outline the routine care of a patient with Fibromyalgia
 Outline an approach to the patient with General Body Pain

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7  Be able to recognise a patient with back pain needing urgent attention
Low  Outline an approach to the patient with back pain
back  Recognise the patient with a joint symptom needing urgent attention
pain and  Be able to do a Musculoskeletal screen to assess joints
sciatica  Be able to identify/diagnose Chronic Arthritis
plus  Be able to differentiate between Osteoarthritis and Inflammatory Arthritis
chronic  Outline the routine care of a patient with Chronic Arthritis
joint  Recognise the symptoms suggestive of Gout
pain  Outline the principles of treatment of Acute Gout and Chronic Gout
 Outline the routine care of a patient with Gout
 Recognise the patient with leg symptoms needing urgent attention
 Outline an approach to the patient with Leg symptoms

8  Understand the processes involved in HIV counselling and testing

HIV/AIDS, Anaemia &  Recognise common symptoms that can trigger a diagnosis of HIV/AIDS
lymphadenopathy in primary care
 Become familiar with the staging of HIV disease
 Asses the patient needing HAART
 Follow local guidelines for routine care of a patient with HIV/AIDS
 Recognise the symptoms suggestive of Anaemia
 Describe the common causes of Anaemia
 Describe the common causes of enlarged Lymph node(s)
 Outline an approach to a patient with lymphadenopathy

9  Define Palliative Care(WHO)

The  Outline the routine care of a patient who needs end of life care
patient  Describe and apply the WHO analgesic step ladder in Palliative care
needing
palliative
care

Workshops or tutorials:

 Week 1: Days 1-3 Introduction to a symptom based guideline in Primary Care and
Botswana Primary Care Guideline(BPCG): ( workshop)

o Discuss cases in PALSA or other cases that help in learning how to use BPCG.
o Each student will present at least one case study to illustrate the use of BPCG

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  Day 4. Students apply BPCG in clinics/OPDS Discussion of cases seen during the past
week.
 Day 5. Students report back on their experiences with using BPCG. Discussion of
remedial steps.

Weeks 3-8: Students continue using BPCG in their assigned clinics.

 The student sees a patient presenting with symptoms related to the 9 general topics
listed above (one patient each week/different topic). Follow BPCG with guidance from
the facilitator at the clinic (BPCG trained Nurse or Doctor). Facilitator provides feedback
after every case and signs off student for case of the week.

Core Family Medicine Topics to be covered during Module II

1.The consultation
 The patient centred clinical method
2. Community Oriented Primary Care (COPC)
 Weekly home visit
 Longitudinal project (week 1-9) e.g, follow up a pregnant woman in labour and continue
seeing the family at home after delivery.

2.0 Internal Medicine III (SOM602): Senior Clerkship in General Internal Medicine (Eight Weeks)

2.1 Course Description and content (synopsis)

This course enables students to acquire clinical skills in Internal Medicine and under the supervision of a
qualified Internist(s), shadow as an intern to gain practical hands-on-experience and under supervision
provide professional care to individual patients, their families, and population groups. At the end of the
module, a student will be able to independently carry out a professional interview and physical
examination of an adult patient, suspect the presence of a medical condition(s), institute cost-effective
investigative plan to confirm the diagnosis, develop safe and effective treatment plan, including
therapeutic procedures and after-care management. The student should be able to acquire practical
skills on the epidemiology, pathogenesis, preclinical and clinical manifestations of communicable and
non-communicable diseases. The student should be eligible to perform the professional tasks of a newly
graduated physician in the management of illnesses resulting from physical agents, chemicals, infectious
agents, physiological and anatomical abnormalities, and degenerative processes affecting the nervous,
respiratory, cardiovascular, urinary, digestive, and endocrine systems, haematological, locomotor
apparatus, and epidemiological health problems.

Learning Outcomes
At the end of this course, the student is expected to be able to:

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  Professionally carry out a medical interview, examine adult patients, prepare patient record and
present the findings to clinical faculty
 Apply professional and clinical reasoning skills
 Consistently practice evidence-based clinical decision making
 Analyze and carry on differential diagnosis of diseases
 Evaluate the results and develop treatment plan for individual patients
 Implement the treatment plan or referral of patients under supervision
 Explain the underlying mechanism(s) of abnormalities
 Explain the pharmacology of frequently used drugs for the treatment of medical, infections or
dermatological problems, prescribe under supervision and identify side effects and their
management
 Perform clinical follow-up of patients and change treatment plan on the basis of new evidence
 Use laboratory and diagnostic tools, and interpret results
 Identify the indications for requesting for X-ray and other specialized imaging diagnostic
procedures, and make a request for the procedure
 Examine X-rays, radiographs, or dynamic images
 Differentiate normal and abnormal X-ray and laboratory findings
 Interpret patient clinical presentation on the basis of the findings
 Evaluate the indications for laboratory requests, choice of diagnostic tests, and procedures
 Interpret laboratory findings and explain patient signs, symptoms, and disease progression on
the basis of laboratory test results and pathophysiology
 Identify abnormal images, and explain the pathogenesis of the diseases and the mechanisms
there of leading to changes observed in radio-images
 Request cost-effective and rational use of laboratory tests in clinical reasoning and decision-
making processes
 Prepare a patient discharge and follow-up plan
 Request for postmortem examination, participate in the examination as necessary and explain
the findings and introspect of the clinical presentation and treatment
 Evaluate clinical care outcomes for individual patients, for the clinical unit or health facility
 Interrogate a wide range of learning media especially online scientific journals to test hypothesis
generated during medical treatment of a patient to obtain for the patient the benefits of the
most current scientific advances in medicine
 Select Internal Medicine for future specialization.

3.0 Obstetrics and Gynaecology II (SOM 603): Senior Clerkship – Eight weeks

3.1 Course description and content (synopsis)

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This course enables students to practice gynaecological and obstetrical care of patients and, under the
supervision of a Gynaecologist-Obstetrician, shadow as an intern and gain practical hands-on-experience
in the care of individual patients with conditions affecting the reproductive organ-systems and their
functions in women during the entire reproductive cycle as well as during states of pregnancy and
lactation and deliver reproductive health care in a health facility, household, or community. At the end
of the module, a student will be able to independently conduct professional interview and physical
examination of a patient, suspect the presence of health risk or medical condition(s) affecting sexuality
and reproduction, institute emergency care and propose a cost-effective investigative plan to confirm a
diagnosis, safe and effective treatment, including reproductive care for adolescents, a pregnant mother
and her family, as well as other therapeutic procedures, and after-care management and rehabilitation
of a patient. Perform the listed obstetrical procedures and assist in frequently performed surgical
operations. Students acquire practical skills in the assessment of sexuality, hereditary conditions, normal
pregnancy and high risk pregnancy, home delivery and institutional management of labour;
complications during labour, caesarean section and assisted delivery, indications and contra-indications
of frequently used procedures and interventions, puerperium, contraception, infertility, the
epidemiology, pathogenesis, preclinical and clinical manifestations of communicable and non-
communicable diseases that affect the reproductive system and functions including sexually transmitted
diseases, that are prevalent in Botswana and neighbouring countries, emergencies affecting pregnancy
and the reproductive systems, evidence-based care for women and adolescents, invasive and non-
invasive diagnostic and therapeutic procedures, cost-effective and rational use of drugs, surgical
interventions and laboratory investigations, screening for disease markers for prevention of diseases,
health care for populations and health groups, ethical issues and the gate-keeping role of physicians,
health resource allocation and management, and health systems research in gynaecological-obstetrical
care.

Learning outcomes

At the end of this module, the student is expected to be able to:

 Accurately record findings from patient and present to clinical faculty

 Analyze and generate the differential diagnosis of the condition;,
 Evaluate the results and develop treatment plan for the individual patient, spouse and their
families within a health facility or community setting.
 Explain the underlying mechanism(s), of presenting complaints and /or health problem;
 Develop and implement treatment plan or referral;
 Explain the pharmacology of frequently used drugs used during gynecology, pregnancy and
labor including anti-retroviral drugs, pain management, and anesthetics; their side effects and
counter measures; contraindications of drugs and medicines for women and during pregnancy;
 Develop professional and clinical reasoning skills;

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  Shadow a midwife or obstetrician in the treating a patient with gynecological problem,
monitoring of pregnancy, management of normal labor, including the resuscitation of the new
born child;
 Use laboratory and other diagnostic tools, and interpret results with respect to the treatment of
women in states of pregnancy or no pregnancy, and in the evaluation of labor;
 Identify the indications and contra-indications of requesting for X-ray and other specialized
imaging diagnostic procedures for women;
 Initiate and prepare patients for the procedure diagnostic procedures;,
 Examine X-rays, radiographs, or dynamic images;
 Differentiate normal and abnormal X-ray and laboratory findings,
 Interpret patient clinical presentation on the basis of the findings.
 Evaluate the indications for laboratory requests, choice of diagnostic tests, and procedures;
 Interpret laboratory findings and explain patient signs, symptoms, pregnancy and labor
progression on the basis of laboratory test results and pathophysiology;
 Diagnose normal pregnancy, high risk pregnancy, concomitant medical conditions during
pregnancy and grasp the approaches to their management during the periods of pregnancy and
labour;
 Monitor labour, identify complications and initiate emergency treatment or consultation;
 Initiate emergency treatment of during pregnancy and labor;
 Attend operation theatre and assist in surgical intervention for women including Caesarean
section;
 Advise individual, couple, family or community group on fertility, contraception, promotion of
reproductive health rights and prevention reproductive health disease;
 Identify domestic violence and initiate measures to prevent and protect individuals or families;
 Make a medical consultation and referral;
 Make clinical follow-up of patients,
 Interrogate a wide range of learning media especially online scientific journals to test hypothesis
generated during medical treatment of a patient to obtain for the patient the benefits of the
most current scientific advances in medicine;
 Select obstetrics and gynecology as a field for future specialization

3.2 Topic guide and practical skills for senior clerkship in Obstetrics and gynaecology
General
History taking and physical examination in obstetrics and gynecology
Anatomy and physiology of female genital tract and reproduction
The menstrual cycle
Obstetrics
I. Embryological development of the placenta, membranes and umbilical cord
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II. The physiology and diagnosis of pregnancy
III. Antenatal care
 Aims of antenatal care
 Risk assessment
 Drugs used in obstetrics
 PMTCT
 Prevention of anemia during pregnancy

IV. Abnormalities of pregnancy

1. Minor disorders of pregnancy
2. Medical diseases
 Anemia
 Cardiac diseases
 Renal disease
 Diabetes mellitus
 Infectious disease
3.Complications during pregnancy
 PROM, preterm labor
 Post term pregnacy
 Hypertensive disorders during pregnancy [preeclampsia, eclampsia and chronic hypertension]
 Ante partum hemorrhage
 Oligohydromnios & polyhydromnios
 Multiple pregnancy
 Antepartum and intrapartal fetal surveillance

Normal labor
 Physiology and mechanism of normal labor
 Management of normal labor
 Resuscitation & care of the new born
 Partographic management of labor
 Analgesia and anesthesia in labor
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 Abnormal labor patterns
 Faults in birth canal
 Faults in the fetus
 Faults in the uterine function
 Cord prolapse
 Non reassuring fetal heart rate
 Breech presentation
 Prolonged and obstructed labor [Rupture of the uterus]

Complications of third stage of labor

 Retained placenta
 Post-portal hemorrhage
 Active third stage management of labor
 Inversion of the uterus

Obstetric operations
External and Internal version
 Episiotomy, genital tear, and laceration
 Manual removal of placenta
 Forceps delivery
 Vacuum extraction
 Assisted breech delivery
 Destructive deliveries
 Caesarian section & trial of labor/ VBAC
 Modified obstetric procedures related to HIV/AIDS

V. The normal and abnormal puerperium

 Physiology and management
 Complications of puerperium
 Post-natal examination and care
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VI. Common breast feeding problems in lactating women - [engorgement, cracking nipples,
blocked ducts and "insufficient breast milk"]

Gynecology
 Physiology of normal menstrual cycle
 Abnormal uterine bleeding
 Climacterics –Menopause
 Congenital abnormalities of the genital tract
 Gynecologic disorders of childhood and adolescence
 Disorders of the Vulva
 Disorders of the vagina
 Disorders of the cervix
 Disorders of the uterus
 Incontinence of urine & utero vaginal prolapse
 Disorders of the ovary
 STIs and PID / Syndromic management

1. Early pregnancy complications

 Abortions & post abortion care
 Ectopic pregnancy and
 Gestational trophoblastic diseases
2. Contraception
3. Infertility
4. Amenorrhea
5. Acute abdomen
6. Sexual assault [Diagnosis and management]

TEACHING METHODS
Primarily PBL based
i. Lecture & discussion
ii. Bed side teaching

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 iii. Round Teaching
iv. Problem based case discussions
v. Demonstration

4.0 Professionalism, Medical Ethics and Integrity

4.1 General information on Medical ethics and integrity course

Medical ethics is the cornerstone for the honorable practice of medicine. The philosophy of the School
of Medicine is that during the entire MBBS degree program, students are guided and modeled to gain
proficiency in the tenets of medical practice, most importantly, conduct on the resolution of moral
issues in the holistic care of patients. Thus the course on Medical Ethics should be viewed as an invisible
strand running through each course of study. During phase I students received insight on Sociology of
Health and Disease and professional ethics, focusing on doctor/patient relationships as well as principles
of human dignity, equity, social justice and human rights as fundamentals of the healthcare delivery
system. In the third year of study, students received teaching and training on how to make judgment
and the decision making process for the health professional. In addition students should explore issues
on Codes of Medical ethics and Research, end of life decisions, and continual learning as a means to
remaining competent in the era of rapidly changing medical practice, genetic engineering and other
technologic advances. The course on Medical Ethics is not finite but assists students to develop a
personal philosophy for lifelong practice of medicine and ongoing professional growth. The module is
offered as an integrated component of the core clinical disciplines in year five with occasional didactic
and/or tutorial sessions.

4.1.1Course description and content

Medical ethics and integrity: This course is designed to describe the basic principles of professional
conduct, ethics, and legal practice in health, with particular emphasis on social values, norms, and
culture of the Botswana society. A student will be able to professionally engage in his/her medical
practice, observe professional conduct with regard to patients, their families, and professional
colleagues, evaluate ethical dilemmas and give professional evidence in a court of law. Topics covered
include: basic principles of ethics and philosophy in health; social obligations, values and norms with
emphasis on the Botswana society regarding health; the patient-physician relationship; common ethical
dilemmas: fundamental ethical guidelines, conflicts between beneficence and autonomy, dealing
patients who lack decision-making capacity, decision about life-sustaining interventions, conflicts of
interest; HIV/AIDS research and ethics; international codes and declarations; Hippocratic and other
oaths in medicine.

Learning Outcomes:
At the end of this course, the student is expected to be able to:
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  Maintain confidentiality;
 Work as a member of a team, with equal respect to others regardless of discipline or rank;
 Cope with ambiguity including in matters of faith;
 Advise patients, couples, family members on results from clinical finding or laboratory test;
 Make ethical choices for patients under his/her care;
 Advocate for the health rights of individuals, family or population group /community;
 Maintain professional discipline and conduct;
 Promote the image of the profession in personal life and avoid behavior /practices that might
put the profession into disrepute;
 Remain competent in medical practice and area of specialization through continuing medical
education and self directed learning;

Assessment of this module shall be on a continuous basis and in the clinical examination. It shall be
an integrated assessment within the core clinical specialties. In the OSCE examination, stations
assessing these competencies must be included. A satisfactory grade is required for graduation.

5.0 Paediatrics And Adolescent Health II (SOM 601): Senior Clerkship (Eight Weeks)

5.1 Course description and content (synopsis)

This course enables students to practice medical and health care of neonates, children and young
adolescents and, under the supervision of a paediatrician, shadow as an intern and gain hands-on-
experience in treating children from the time of conception to early adolescence and provide
professional care to individual patients, their families, and population groups within the setting of a
hospital, a household, or community. At the end of the course, a student will be able to independently
obtain clinical history from a child, parents, or guardian, and perform physical examination on the
newborn or child, confirm normal growth and development of a child or suspect the presence of a
medical condition(s), institute cost-effective investigative plan to confirm the diagnosis, administer safe
and effective emergency treatment; develop a comprehensive treatment plan including therapeutic
procedures, counselling, after-care management, and assessment of the quality of care. The student
will perform satisfactorily all the listed clinical procedures in the paediatric log for undergraduates. The
student acquires practical skills in the assessment of pre-gestational states and conditions that affect
normal growth and development of the unborn, the neonate, and during the childhood periods,
resuscitation of the newborn, growth monitoring of a child, emergency paediatric care, epidemiology,
pathogenesis, preclinical and clinical manifestations of communicable, non-communicable, and tropical
diseases of children prevalent in Botswana and neighbouring countries, integrated management of
childhood diseases, evidence-based practice in child and adolescent health care, simple invasive and
non-invasive diagnostic and therapeutic procedures, cost-effective and rational use of drugs and
laboratory investigations, disease prevention and rehabilitation, population and group health, medical
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ethics and gate-keeping role of a physician, health resource allocation and management, and health
systems research in paediatrics and adolescent health.

5.1.1 Learning Outcomes:

At the end of this course, a student is expected to be able to:
 Evaluate results before proposing an intervention plan
 Write patient record and present the case to clinical faculty member(s)
 Identify the presence of a health problem or acute emergency in a child through interview or by
carrying out medical examination
 Initiate life-saving interventions in emergency situations
 Stabilize the clinical state of a patient, refer as necessary
 Request for appropriate laboratory investigations
 Interpret findings, explain the patho-physiology of an illness
 Use laboratory and diagnostic tools, and interpret results
 Identify the indications for requesting for X-ray and other specialized imaging diagnostic
procedures, initiate and prepare patients for the procedure
 Examine X-rays, radiographs, or dynamic images for a patient in his/her care,
 Differentiate normal and abnormal X-ray and laboratory findings
 Interpret patient clinical presentation based on the findings
 Perform simple invasive diagnostic or treatment procedures on children
 Manage a patient independently while under supervision
 Monitor the normal growth and development of a child
 Identify developmental problems in a child and in collaboration with clinical psychologist or
other specialist manage the condition
 Prepare a patient discharge and follow-up plan
 Request for postmortem examination, participate the examination as necessary and explain the
findings and introspect of the clinical presentation and treatment
 Evaluate clinical care outcomes of individual patient, the clinical unit or health facility
 Interrogate a wide range of learning media especially online scientific journals to test hypothesis
generated during medical treatment of a patient to obtain for the patient the benefits of the
most current scientific advances in medicine
 Counsel and prepare a child for entry into adolescence and puberty
 Select Child Health and paediatrics as a field for future specialization.

5.1.2 The problem oriented (competency-based) curriculum below outlines the level of proficiency
expected by the end of MBBS year 5.

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Level Theory/Knowledge Clinical Picture Skills list
1 Nice to know Recognise or place Only theory
2 Of some relevance Tentative diagnosis Theory & seen or have been
demonstrated
3 Advisable knowledge Diagnose & refer Apply or perform under supervision
4 Essential knowledge Diagnose & treat Routine performance

Problem Cognitive content Knowledge Skill content Skill level

level
The new born infant Routine prenatal care 4 Perform Apgar score 4

Adaptation to extra-uterine life 4 Neonatal examination 4

Routine neonatal care 4 Perform Ballard score 4

Breastfeeding 4 List infections in neonates 4

The high-risk infant Prematurity 4 Prevent infections in neonates 4

Low birth weight 4 Administer feeds & fluids to preterms 4

Influence of maternal drugs, 4
alcohol, nicotine Prevent, diagnose & treat 4
hypothermia
The abnormal infant Asphyxia 4
Prevent, diagnose & treat 4
Oedema of the newborn 4 hypoglycaemia in neonate

Hypothermia 4 Use Kangaroo mother care 3

Hypoglycaemia 4 Pass a nasogastric tube and manage 4

tube feeding in neonates
Birth injuries 3
Understand & promote bonding 3
Infections during pregnancy 4
Administer phototherapy 4
Congenital infections 3
Use an under-5 card 4
Vertical transmission of HIV 4
Assess milestones, 4
Respiratory distress 4 neurodevelopment, hearing and sight
in neonatal follow-up 4
Apnoea attacks 4
Advise on weaning foods 4
Causes of deafness in neonates 2
Perform neonatal resuscitation 4
Convulsions 4
Diagnose & treat hypoxic ischaemia 3
The dysmorphic baby Congenital abnormalities 2 encephalopathy
Dysmorphology
Teratology Diagnose & treat intracranial 2
Embryology haemorrhage
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 Know when to use & how to interpret 1
screening methods for congenital
abnormalities
Problem Cognitive content Knowledge Skill content Skill level
level
The ill neonate Neonatal jaundice 4 Know the difference between a 2
Bilirubin metabolism screening test & diagnostic test
Causes & dangers
Haemolytic disease Manage a dysmorphic newborn 2
Physiological jaundice
Jaundice in prematurity Manage a newborn with cleft lip &/or 3
palate
Bleeding tendency 3
Intracranial haemorrhage Communicate bad news 4
Subaponeurotic bleed
Cephalhaematoma Diagnose & treat congenital syphilis 4
Haemorrhagic disease
Diagnose & list treatment of shock, 4
Anaemia in the neonate 3 convulsions, acidosis, hypoglycaemia
Normal haematological values
Diagnose respiratory distress, initiate 4
Infection in the neonate 4 treatment and know when to refer
Sepsis
Superficial – umbilicus Administer & monitor oxygen therapy 4
Meningitis
Pneumonia Perform an Apt test 2
Gastroenteritis
Urine infection Diagnose & initiate management of 3
birth trauma
Necrotising enterocolitis 3
Test vision and hearing in infants 2
Neonatal death Neonatal death 2
Use a development chart to identify 3
Counseling the family Early childhood development 4 abnormal development & to refer
Milestones appropriately
Risk factors for delay
Hearing & vision Manage a baby born to a HIV positive 4
Impact of poverty woman

Healthy & growing Well-baby care 4 Calculate & interpret perinatal, 3

infant neonatal & infant mortality rates
Immunisation 4
Diagnose & manage bleeding in the 4
Surveillance & growth 4 newborn
monitoring
Know when and how to refer an ill 4
Ethics of resource allocation in 3 neonate
neonatal intensive care
Understand the grieving process & 2
Health systems compliance and 3 know how to perform the essentials of
audit as it affects infant care counselling
The child with cough Acute respiratory infection 4 Take full history including allergy 4

The child with chronic Chronic lung conditions 3 Perform full physical examination 4
respiratory symptoms Tuberculosis 4
Cystic fibrosis 2 Tuberculin skin tests – perform and 4

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 interpret results
The child with stridor Croup 4
Foreign object in airways 4 Gastric aspirates for AFB 3

The wheezy child Bronchiolitis 4 Use of pulse oximeter 4

The ‘allergic child’ Asthma 4
Tracheo- & laryngomalacia 3 Perform peak flow meter 3
Vascular ring 2
Bacterial tracheitis 2 Request lung function test 2
Problem Cognitive content Knowledge Skill content Skill level
level
The child with acute Acute pneumonia 4 Request Chest x-ray & evaluate fully 4
respiratory distress Surgical causes of respiratory 2
distress Request sputum induction, RAST test, 2
IgE, sweat test & allergy skin tests

Intercostal drain insertion 2

The acutely sick child Evaluation of illness 4 Communication with family & child 4

The cyanosed child Respiratory, cardiac, 3 Take an accurate history 4

neurological & haematological
causes of cyanosis Full clinical examination 4

The child with rash & Infectious diseases 3 General sickness evaluation 4
fever Auto-immune diseases 2
Nutrition assessment 4
The child with fever Fever diagnoses & treatment 4
Paediatric aspects of Hydration assessment 4
Typhoid 4
Malaria 4 Paediatric coma scale 3
Tuberculosis 4
Syphilis 4 Measurement of oral, rectal, axillary 4
Basic virology 2 temperature

The child with HIV/AIDS 4 Perform dextrostix 4

frequent infections Other immune deficiency 2
Perform venepuncture 4
The child with rash Atopic eczema 4
Seborrheic dermatitis 2 Perform arterial blood gas 2
Congenital skin rashes 2
Skin infections 4 Interpret blood gases 4
Nappy rash 4
Set up a drip infusion 4
The unconscious child Coma & encephalopathy 4
Poisoning 4 Administer oxygen therapy 4
Cerebral oedema 3
CNS infections 4 Administer glucose to correct 4
hypoglycaemia
The convulsing child Convulsive disorders 4
Epilepsy 4 Request & interpret x-rays 4

The child with feeding Normal feeding at different ages 3 Notification of disease 4
problem Malnutrition & nutritional 4
The child with failure deficiency syndromes Request & interpret full blood count, 4
to thrive or losing Vitamin D deficiency rickets 4 blood chemistry
weight Haemorrhagic disease 4
Vitamin E deficiency 2 Obtain bacterial culture 4

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 Anorexia nervosa 2
Feeding difficulties 3 Obtain samples for virology
2
The swollen child Generalised oedema 4 Malaria smear
Nephritic syndrome 3 2
Cardiac failure 4 Basic life support & airway control
Nephrotic syndrome 4 Intubation & resuscitation 3
Kwashiorkor 4 Treatment of anaphylaxis 3
Sickle-cell syndrome 2 Seizure control 3
Liver failure 3 4
Lymphoedema 2 Lumbar puncture
Angio-oedema 4 4
Perform rapid HIV test & dried blood
spot for PCR 4
Problem Cognitive content Knowledge Skill content Skill level
level
The child with a sore Stomatitis 4 Take a full history including dietary 4
mouth history

The child with Pyloric stenosis 3 Perform full clinical examination with 4
vomiting & diarrhea Gastro-oesophageal reflux 3 emphasis on nutritional assessment,
Gastroenteritis 4 hydration assessment & abdominal
The child with bleeding Dysentery 4 examination
per rectum
Thrombocytopaenia 3 Obtain a throat swab for culture & 4
The child with bleeding Clotting defects 2 sensitivity
tendency Haemophilia 3
DIC 2 Prescribe & monitor oral rehydration 4
The child with cancer Childhood malignant disease 2
Leukaemia 3 Prescribe & monitor intravenous 4
The pale child Anaemia & poor circulation 4 rehydration
Iron deficiency 4
Aplastic anaemia 2 Interpret blood gas for acid-base 4
Haemolytic anaemia 2 disturbances

The child with Intestinal parasites 4 Manage electrolyte abnormalities, 3

intestinal parasites including sodium, potassium, calcium
Psychogenic vs organic pain 2
The child with Acute abdomen 4 Request stool microscopy 4
abdominal pain Peritonitis 3
Colic 2 Perform stool clinitest 2
The child with Recurrent abdominal pain 2
abdominal distension Intusussception 2 Insert nasogastric tube & confirm 4
Appendicitis 2 placement
The child with Peptic ulcers 2
haematemesis & Volvulus 2 Request stool Fat assay 2
melena Meckel’s diverticulum 2
Request stool alpha-1-antitrypsin 1
The child with Constipation 4 clearance
constipation Hirschsprung disease 3
Request fecal elastase assay 1
The child with chronic Chronic diarrhea 3
diarrhea Inflammatory bowel disease 2 Request Vitamin B12 absorption tests 1
Food intolerance 2
Allergic enteropathy 2 Request breath hydrogen tests 1
Coeliac disease 1
Cystic fibrosis 2 Request sweat test & genetic testing 1

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 Malabsorption 3 for cystic fibrosis

The child with acute Acute hepatitis 4 Request & interpret blood chemistry 4
jaundice Acute liver failure 2 for liver function testing, INR & PT/PTT

The child with Neonatal hepatitis 2 Request factor assays 2

persisting neonatal Biliary atresia 3
jaundice Perform rectal examination 3

The child with Chronic liver disease 2 Request upper & lower endoscopy 2
enlarged liver &/or Portal hypertension 2
spleen Request barium swallow & follow- 2
through
The mother with Physiology of lactation 4
breastfeeding Breast engorgement & mastitis 3 Request barium enema examination 2
problems Insufficient milk 3
Breast refusal 3 Diagnose & manage problems of let- 3
down & milk production reflexes
Use a breast pump 1
Problem Cognitive content Knowledge Skill content Skill level
level
The child with heart Heart failure 4 Take history & perform full 4
failure Myocarditis 3 examination including cardiac
Pericarditis 3 evaluation
Normal ranges for BP, pulse 4
Hypertension 3 Perform blood pressure recording 4
with baumanometer, Doppler
The child with joint Rheumatic fever 4 apparatus & capillary flush method
paints & heart murmur Acute rheumatic heart disease 3
Chronic rheumatic heart disease 3
Determine JVP, pulse rate 4
The child with irregular Dysrrhythmia 2
heart beat Perform an ECG recording 4
Acyanotic heart disease 3
The child with a heart PDA 3 Interpret an ECG 2
murmur VSD 3
Coarctation 2 Request a chest x-ray and evaluate 4
Bacterial endocarditis 3 heart size, vascularity, chamber
Functional murmurs 3 enlargement

The child with a heart Cyanotic heart disease 3 Request a cardiac ECHO 2
murmur and cyanosis Transposition 3
Fallot’s tetralogy 3
The child with a Choanal atresia 3 Take full history including ‘allergic’ 4
blocked nose Infective rhinitis 4 history
Allergic rhinitis 3
The child with chronic Foreign bodies 3 Examine oropharynx, nose, throat 4
runny nose Sinusitis 3
Adenoid hypertrophy 4 Perform otoscopy 4

Pharyngitis 4 Perform fundoscopy 2

The child with a sore Tonsillitis 4
throat Epiglottis 3 Check for red reflex 4

Otitis media 4 Removal of ear wax 3

The deaf child Otitis externa 4
Middle ear effusion 3 Determine visual acuity with Snellen 3

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The child with earache Ear wax 4 chart
Deafness 2
Delayed speech 2 Order lateral neck x-ray and interpret 3

Paralytic strabismus 2 Refer for speech & hearing evaluation 2

The child with Non-paralytic strabismus 2
strabismus Bulging eyes 2
Red or discharging eyes 4
The child with poor Absent red reflex 3
vision Cataract 3
The child with swollen Congenital dislocated hip 4 Examine neonatal hips 4
bones & joints Congenital bone deformities 1
Metabolic bone disease 1 Examine large joints of the body 3

The child with painful Monoarthritis 3 Arthroscopy 2

joints Polyarthritis 3
The child with limb Flitting arthritis 3 Order appropriate x-rays for bone 3
pain Arthralgia 3 deformities

The child with a limp Acute & chronic osteitis 3

SCFE 3
Legg-Calve-Perthes 3
The child with an Scoliosis 2
asymmetric skeleton TB spine 4
Problem Cognitive content Knowledge Skill content Skill level
level
The child with Endocrine disorders of growth 2 Measure height & length and know 4
abnormal growth Normal & abnormal growth in 4 the difference
childhood
Plot measurements on a growth chart 4
The short child Growth failure 3 & interpret them
The child who is not Short stature 3
growing well Rickets & abnormal skeleton 3 Use of a stadiometer 4

The child with Delayed puberty 2 Genital examination 3

abnormal pubertal Precocious puberty 2
development Puberty development 3 Testis size measurement by tape 2
measure & orchidometer
The child with Diabetes insipidus 2
abnormal water SIADH 2 Determine skin fold thickness & mid- 2
balance upper arm circumference 4

The child with diabetes Diabetes mellitus 4 Determine Tanner staging of puberty 4
mellitus
Endocrine causes of polyuria 2 Know how & when to refer a child 2
The child with polyuria Renal causes of polyuria 2 with abnormal growth & development
Psychogenic causes of polyuria 2
Use & interpret urine dipstix for 4
glucose & ketones, specific gravity

Manage diabetic ketoacidosis 2

The child with dysuria Urine infection 4 Pass urine catheter 4

The child with blood in Glomerulnephritis 3 Determine & chart daily/hourly urine 4
the urine Infection 4 output
Stones 2
Malignancy 2 Use & interpret intake & output charts 4

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The child with high
blood pressure Renal hypertension 3 Use & interpret urine dipstix 4

The child with anuria Acute renal failure 3

The child with urinary Enuresis 4

incontinence & Bladder control 2
enuresis Neurogenic bladder 2

The child with Disorders of sex development 2

ambiguous genitalia
The child with a The difference between 2 Know when to refer a child for further 2
metabolic crisis acquired & congenital metabolic metabolic workup
disease

The child with a Indications for metabolic 2

metabolic disturbance diagnosis

The child with Examples of clinical syndromes 1

recurrent & due to inherited metabolic
progressive symptoms disease
& biochemical Product deficit
disturbances Precursor accumulation
Alternative pathway

The child with Hypoglycaemia 4

hypoglycaemia Causes
Investigations
Management
Problem Cognitive content Knowledge Skill content Skill level
level
The child’s normal Normal development 4 Obtain full neuro-developmental 4
development history

The child with delayed Developmental delay 4 Perform full neurological assessment 4
development Cerebral palsy 4
The child with mental Mental retardation 3 Developmental assessment 4
retardation & learning
problems Order CT brain & interpret results 3

The child with enuresis Pyschiatric & behavioral 2 Order MRI brain & interpret results 2
& encopresis disorders
The child with Inherited metabolic disorder 2 Know when to refer to neurologist 3
abnormal behavior Brain tumours 3
Know when to refer for neurosurgeon 3
The ‘fidgety’ child Attention deficit & hyperactivity 3
Consult social worker 2
The child with Headache disorders 3
headache Consult psychiatrist or psychologist 2

The child with ataxia Movement & tone disorders 2

Involuntary movements 2

The floppy child The floppy child 4

Muscular disorders 2
Muscle weakness or paralysis 3

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The child with Demyelinating & metabolic 1
milestone regression brain syndromes

The child with a big Hydrocephalus 4

head Neural tube defects 3

The child in Child abuse & neglect 2

exceptionally difficult Divorce, death, abandonment 2
circumstance Orphans 3

6.0 Pharmacology II: Clinical Pharmacology and Therapeutics

6.1 Course Description content (synopsis)

A continuation of Pharmacology I, this module looks at the pharmacology of drugs used in the
treatment of the central nervous system (CNS), immunotherapy and the regulation of inflammation and
autoimmunity and in the chemotherapy of infections and cancers. Upon completing this course
students will understand the etiology of CNS diseases, commonly prescribed drugs, and the mechanisms
by which these drugs modify the physiological system. Drug dependence will also be investigated with
students developing an understanding of the mechanisms underlying this phenomenon. Immune
dysfunction can have systemic effects. Here students will develop an understanding of both the innate
and cellular immune systems and how drugs can be used regulate them individually or in a coordinated
fashion. This course introduces the pharmacology of drugs used in the treatment of systemic diseases of
the cardiovascular, urinary, digestive and peripheral nervous systems. Finally, students will look at the
agents of chemotherapy used in ameliorating infections and cancers. The module will be taught via
didactic lectures, tutorials and therapeutic seminars as an integrated component of the clinical
disciplines.

6.1.1Learning Outcomes:
At the end of this course, the student is expected to be able to:

 Differentiate the choice of core drugs in relation to body system such as infectious diseases,
cardiovascular disorders, respiratory disorders, gastrointestinal, hepatic and biliary disorders,
renal, urinary tract and prosthetic disorders, endocrine and metabolic disorders, blood
disorders, disorders of bones and joints, neurological disorders, psychiatric disorders and pain
management;
 Explain the mechanism of action of core drugs on diseases affecting body systems
 Explain the mechanism of action and choice of drugs for local, regional and general anesthesia;
 Describe the principles of cancer chemotherapy;
 Describe clinical management of poisoning;
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  Explain the factors and mechanisms of drug dependence and abuse;
 Explain the mechanisms of immune-suppression and drug therapy for allergies, connective
tissue disorders and primary immune-deficiency;
 Discuss the ethical considerations in relation to drug use for different age groups and population
groups including minors and patients with psychiatric disorder;
 Evaluate the logistics management system for pharmaceuticals (the drug supply chain)
 Describe rational drug use

Assessment shall be integrated within the core clinical specialties.

7.0 Surgery III (SOM 604): Senior Surgical clerkship including Anaesthesiology and Emergency
Medicine-Eight weeks

7.1 Course description and content (synopsis)

General Surgery: This week course enables students to practice surgical care of patients and, under the
supervision of a specialist in surgery, shadow as an intern to gain hands-on-experience in general
surgery, including performing selected operations and rehabilitation of individual patients of all ages,
their families, and population groups in a health facility, household, or community.

Emergency Medicine: The students will have clinical rotation in the Emergency Medicine Department
for three consecutive weeks in this last module of surgery. This rotation will acquaint students with the
aetiology, pathology, diagnosis, management and prevention of common medical and surgical
emergencies in Botswana. This includes epistaxis; acute asthma; upper and lower respiratory infections;
pneumothorax; Pulmonary oedema; Acute respiratory failure; acute coronary syndromes; Pulmonary
embolism; Hypertensive emergencies; Anaphylactic reactions; Shock; Diabetic ketoacidosis;
Hypoglycaemic syndromes;; Urinary retention; electrolyte abnormalities; Acute psychotic states;
seizures ; Meningitis; altered mental status; Multiple injury patient; head injuries; fractures; Acute
abdomen; Acute poisoning (toxicology); wound care; Burns; Septicaemia; paediatric emergencies; Snake
bites; PV bleeding ;Ruptured ectopic gestation and cardio- respiratory arrests.

Students will keep log books to help with discussion and learning objectives. Students will be expected
to complete a number of Basic Emergency medicine skills in liaison with the other areas of practice in
this last module.

Anaesthesia practice
This module builds on year 3 module. Students will be attached to the anaesthetic team in small groups
of two to three during these nine weeks of surgery and emergency medicine clerkship and rotate on a
weekly basis. Students will be exposed to the practice of anaesthesia in different settings (newborn,
infancy, childhood adulthood, the aged and under different medical conditions). A student shadows as
assistant anaesthesiologist, in conducting pre-operative assessment and pre-medication, during

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induction, in-tubation and monitoring during operation theatre procedures, ex-tubation and post-
operation monitoring. The student will gain experience in administering all forms of anaesthesia. Topics:
Pre-operative evaluation; fluid management; massive transfusion; invasive hemodynamic monitoring;
sedation; recovery room management; post-operative nausea and vomiting; critical care medicine;
assisted respiration; pain management; anesthesia during pregnancy and labour; anesthesia for cardiac;
neurosurgery, ear nose and throat surgery; anesthesia neuropharmacology; adverse drug reaction,
coagulation and coagulopathy; anesthesia during infancy, childhood and the aged; ultra sound guided
vascular techniques. A student will satisfactorily perform all the listed practical procedures in the
Anaesthesia log.

PBL weekly patients

Week 1
A 40 year old man 3 days following a laparotomy for bowel obstruction develops chest pain and
shortness of breath

Week 2
A 40year old diabetic women presents to the emergency room complaining of a painful swollen foot and
she feels very thirsty

Week 3
A 30 year old woman complains of progressive difficulty in breathing and a slowly enlarging swelling in
her neck.

Week 4
A 55 year old man 7 days after an oesophageal resection becomes drowsy and confused on the ward. He
has been nil by mouth since the day before his surgery

Week 5
A 30 year old man with a previous history of rheumatic fever presents in the emergency room
complaining his right leg is painful and feels cold

Week 6
A 60 year old retired miner with an irreducible painful inguinal hernia would like to discuss options for
anaesthesia for repair of his hernia.
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Week 7
3 young men are brought to the emergency room having been involved in a road traffic collision whilst
riding in the rear of an open truck. They were ejected from the truck. One walks in saying he has a
painful arm and shoulder, one is unconscious with noisy breathing and feels cool to touch, the third is
bleeding from a wound in his right groin and is confused. The emergency room consultant asks you to
assess them, prioritise them for treatment and arrange the involvement of appropriate surgical teams

Week 8

A 16 year old boy known to be asthmatic has been struggling to breath for several hours. His parents
have brought him to the emergency room when he stopped talking and his breathing became quiet.

Week 9

A 30 year old man came home late on a winters evening after drinking heavily. He fell asleep and rolled
into the house fire. He is bought to the emergency room in pain, has soot on his face, his eyebrows are
singed and he has the remnants of charred clothes over his chest and abdomen

Learning outcomes

 Communication Skills
 Build on skills developed in I & ii clerkships
 Communicate bad news to patients and families in an appropriate and
compassionate manner
 Communicate professionally with members of the multi-disciplinary team
 Maintain ability to communicate clearly and calmly in stressful and time
pressured situations

 Clinical Assessment Skills

 rapidly identify signs suggesting severe illness requiring urgent intervention on patients
presenting to the emergency room or deteriorating on the wards
 independently conduct a professional interview and physical examination of a patient,

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  suspect the presence of surgically treatable condition
 identify co-morbidities that may affect the outcome of surgery
 identify common complications of surgery
 Apply the use of a primary and secondary survey to injured patients
 Interprate chest, abdominal and pelvic radiographs

Clinical Management and treatment

 Instigate the initial treatment of critically ill patients to maintain their vital functions
 Develop a cost-effective investigative plan to confirm the suspected diagnosis;
 propose a safe and effective surgical management plan
 Instigate appropriate treatment of medical co-morbidities prior to surgery
 prepare patient for theatre, including pre-operative resuscitation and arranging for anaesthetic
pre-operative consultation
 Understand when patients require critical care and be able to arrange a critical care referral
 instigate treatment of common post-operative complications
 Understand and be able to prescribe pain relieving medications
 Have knowledge of the drugs used for local and general anaesthesia
 Have knowledge of and be able to prescribe appropriate antibiotics for surgical infections
 Management the post operative fluid, electrolyte and nutritional requirements of surgical
patients.
 Understand and be able prescribe the use of blood and blood products

Professional Practice

 Be able to plan and conduct a surgical audit

 Take part in surgical morbidity and mortality meetings and contribute in a constructively critical
but non judgemental manner
 Understand the safety requirements required in operating theatres
 Understand the rational for and be able to use the WHO surgical checklist
 Deal appropriately with patient and relative complaints

Practical Skills for Senior Surgical Clerkship

 Diagnostic
 Use of Ultra Sound as an extension of clinical examination to be able to:
 Identify abdominal free fluid
 Identify haemo and pneumothorax
 Identify pericardial fluid
 Use as a guide for central venous cannulation

 Therapeutic
 Central venous cannulation
117
 Saphenous venous cutdown
 Insertion of a suprapubic urinary catheter
 Tube Thoracostomy
 Advanced Airway Maneuvers
 Endotracheal Intubation
 Surgical cricothyroidotomy
 Use of mechanical ventilation
 Making and closing abdominal incisions
 Suturing in different tissues
 Hand knot tying
 Act as second assistant at major surgery
 Administer local anaesthetic agents
 Cardio-pulmonary resuscitation (Basic and Advanced life support)

118
Topics guide for the Overall Surgery Curriculum

The range of topics and specialties in surgery is very wide. Students are advised to see as many patients
as possible during their clinical attachments to ensure as wide an exposure to surgical problems as
possible. It is also good practice to use the patients that have been encountered as the basis for reading
around the subjects and broadening surgical knowledge.

Level Theory/Knowledge Clinical Picture Skills list

1 Nice to know Recognise or place Only theory
2 Of some relevance Tentative diagnosis Theory & seen or have been
demonstrated
3 Advisable knowledge Diagnose & refer Apply or perform under supervision
4 Essential knowledge Diagnose & treat Routine performance

Problem Cognitive content Knowled Clinical picture or Skill level

ge level content
Wound Healing & Types of Wound 4 Clinical Assessment 4
Plastic Surgery
Mechanisms of healing 4 Suturing 4
Management of wounds 4 Debridement 3
Removal of sutures 4
Secondary Suturing 3
Pathophysiology and 4 Initial assessment of burns 4
clinical features of
different types of burn
Initial management of the 3
burnt patient
Perform skin graft 2
Pathophysiology, and 3 History and clinical 4
clinical features of skin examination of skin tumours
malignancies
Congenital deformities of 1 reconstructive surgery for 1
face and limbs congenital deformities
Use of flaps 1

Nutrition Assessment of 3 Clinical assessment of 4

nutritional status nutritional status
Role of nutritional 3 Select patients for nutritional 4
replacement supplements
Methods of nutritional 3 Select method of nutritional 3
replacement replacement
Insert NG feeding tube 4
119
 Insert gastrostomy 2
gastrojejunostomy
Insert tunneled feeding line 1

Fluids & Basic sciences of fluids 4 Clinical evaluation of fluid 4

Electrolyte & electrolyte balance balance
balance
Causes of fluid and 4 Use of fluid balance charts 4
electrolyte disturbance
Effects of fluid & 4 Choose and prescribe fluids 4
electrolyte imbalance
Causes of renal failure in 4 Choose and prescribe 3
surgical patients Electrolyte replacement
Use of Fluid challenge 4
Use of diuretics 3
Use of Renal support 2
Evaluate U&E results 4
Evaluate blood gas result 4

Haemostasis & Understand coagulation 4 Assess shock 4

Transfusion system
Pathophysiology of 4 Assess cause of shock 4
clotting disorder
Pathology of 4 Initiate treatment for shock 4
thromboembolic disease
Assess degree of bleeding 3
Apply pressure to stop 4
bleeding
Use a tourniquet 2
Identify patients requiring 3
surgery to stop bleeding
Appropriate blood 4
prescription
Choose and Prescribe 3
clotting products
Insert peripheral cannula 4
Insert central venous catheter 3
Venous cutdown 3
Insert intra-osseous cannula 3
Deep vein thrombosis 4
Pulmonary embolus 4

Effect of co- Respiratory 4 Identify and manage 3

existing disease perioperatively
on surgery
patients
Cardiovascular 4 Identify and manage 3
perioperatively
120
 Renal 4 Identify and manage 3
perioperatively
Diabetes 4 Identify and manage 3
perioperatively
Obesity 4 Identify and manage 3
perioperatively

Post-operative Pain management 4 Prescribe appropriate post 4

care operative analgesia and use
analgesic ladder
Fluid management 4
Reinstitute oral fluids and 4
food
Understand causes and 4 Prevention, identification and 4
pathophysiology of treatment of complications of
surgical complications surgery

Drains, Tubes & Understand role, 4 Insert & remove Naso gastric 4
Catheters indications and tube
complications of naso
gastric tube
Understand role, 4 Insert & remove urethral 4
indications and catheter
complications of urinary
catheters
4 Insert & remove suprapubic 2
urinary catheter
Understand role, Insert and remove chest drain 3
indications and
complications of chest
drains
Insert wound drains 2
Remove wound drains 3

Infections in Surgical presentations of 4 Protect self and other team 4

Surgery HIV members during procedures
Risks of surgery in HIV 4 Identify patients at risk for 4
patients having HIV
Long term surgical 4 Manage anti-retroviral 3
complications of HIV and medications peri-operatively
its treatment
Microbiology and clinical 4 Identify and initiate treatment 4
features of Cellulitis of cellulitis
Microbiology and clinical 4 Identify and treatment of 4
features of Abscess abscess
Microbiology and clinical 4 Identify and initiate 4
features of different resuscitative treatment of
forms of gangrene infective gangrene
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 Surgery for gangrene 2
Microbiology and clinical 3 Identify and treatmeat 2
features of myositis myositis
Surgical presentations of 4 Identify patients with TB 3
TB
Management of TB 3 Surgical management of TB 2
during surgical treatment
for other conditions
Causes, 4 Hand hygeine 4
pathophysiology and
prevention of wound
infections
Aseptic technique 4
Use of prophylatic antibiotics 4
Identify and manage wound 4
infections
Scrubbing gowning and 4
donning gloves for surgery

Breast Disease Pathology and 4 History and clinical 4

presentations of benign examination of breast
breast conditions
including fibrocystic
disease, fibroadenoma,
gynaecomastia, nipple
discharge
Pathology, epidemiology 4 Identify clinical features of 4
and presentations of breast conditions
breast malignancy
Role of investigations 4 Breast Biopsy 2
including ultrasound,
mammography and
needle biopsy in breast
disease
Adjuvant chemotherapy 2
and radiotherapy for
breast cancer
Lumpectomy 2
Mastectomy 2
Axillary clearance 2
Breast reconstruction 1
Breast feeding and 4 Drainage of breast abscess 3
complications

Oesophageal Causes and pathology of 4 Take history and relevant 4

Disorders dysphagia examination from patient with
dysphagia
Pathology, epidemiology 4 Plan investigations for 4
and presentations of dysphagia
122
 oesophageal malignancy
Role of palliative care in 3 Surgery for oesophageal 2
oesphageal malignancy malignancy
Institute palliative care 2
Pathology, epidemiology 3 Communication of role of 2
and presentations of palliative care to patient and
peptic oesophageal family
disease including Hiatus
Hernia, reflux and
Barretts oesophagus
Effects of Caustic 4 Initial management of patient 3
ingestion following ingestion of caustic
substance
On going care of patient 3
following caustic ingestion

Gastroduodenal Causes, pathology, 4 History and clinical 4

conditions epidemiology and clinical examination of patient with
features of causes epigastric pain
epigastric pain including
peptic ulcer disease,
gastric tumours

Plan investigations for 4

patients with epigastric pain
Prepare patients for gastric 3
surgery
Upper GI surgery 2
Causes, pathology, 4 Initial management of patient 4
epidemiology and clinical with GI bleed
features of upper GI
bleeding
Endoscopy for Upper GI 2
bleed
Anaesthetic 3 Surgery for GI bleed 2
considerations for
patient with GI bleed
Causes, pathology & 4 Identification and initial 4
clinical features of management of patient with
generalized peritonitis perforated peptic ulcer
Surgery for perforated ulcer 2
Post-operative care following 4
upper GI surgery

Small bowel Causes, pathology and 4 History, clinical examination 4

disorders clinical features of small of patient with SBO
bowel obstruction (SBO)
Initial management of SBO 4
Surgery for SBO 2
123
 Clinical features of 3 Surgery in abdominal TB 2
abdominal TB
Tumours of the small 1
bowel
Disturbances of small 1
bowel physiology
Causes, pathology, 4 Management of patients with 4
clinical features of diarrhoea
Infectious diarrhoea
Causes, pathology,
clinical features of 2
Crohns disease
Causes, pathology and 2
clinical features of
mesenteric ischaemia

Colo-rectal Pathology, 4 History, clinical examination 4

disorders epidemiology, clinical and initial management of
features of acute patient with acute
appendicitis appendicitis
Differential diagnosis of 4 Surgery for appendicitis 2
right iliac fossa pain
Causes, Pathology, 4 History, clinical examination 4
epidemiology, clinical and initial management of
features of large bowel patient with LBO
obstruction (LBO)
Surgery for LBO 2
Causes, Pathology, 4 Digital rectal examination 4
epidemiology, clinical
features of perianal
conditions including
haemmorrhoids, anal
fissure, perianal fistulae
& pilonidal sinus
Causes, Pathology, 4 Drainage of perianal abscess 3
epidemiology, clinical
features of perianal
sepsis
Pathology, 4 History, examination & 4
epidemiology, clinical investigation plan for patient
features of colon cancer with suspected colon cancer
Causes of faecal 2
incontinence

Hepato- Causes, pathology, 4 History, examination and 4

pancreato-bilary epidemiology and clinical investigation plan for patient
surgery features of right upper with right upper quadrent pain
quadrent abdominal pain
Initial treatment of patient with 4
124
 right upper quadrent pain
Causes, pathology, 4 History, examination and 4
epidemiology and clinical investigation plan for patient
features of jaundice with jaundice
Initial treatment of patient with 4
obstructive jaundice
Causes, pathology, 4 History, examination and 4
epidemiology and clinical investigation plan for patient
features of acute with suspected acute
pancreatitis pancreatitis
Initial treatment of patient with 4
acute pancreatitis
The use of ERPC 2
Clinical features of liver 2 The use of ultrasound to 2
abscess investigate hepato-bilary
diseses
Causes, pathology, 4
epidemiology and clinical
features of hepatic
malignancy
Clinical features of 2
hydatid cyst
Causes, pathology, 4 Surgery for hepato-bilary- 2
epidemiology and clinical pancreatic malignancy
features of pancreatic
malignancy
Causes, pathology, 2
epidemiology and clinical
features of bilary tree
malignancy
The Acute Causes and 4 History and examination of 4
Abdomen pathophysiology of acute patient with acute abdominal
abdominal pain pain
Causes and 4 Formulate a differential 4
pathophysiology of Non diagnosis and management
surgical causes of acute plan for patient with acute
abdominal pain abdominal pain
Interperate abdominal and 3
chest radiographs
Interperate initial blood tests 3
Initiate treatment for patients 4
with acute abdominal pain
Identify patients requiring 3
urgent surgery
Laparotomy 2
Abdominal Mechanism of injury, 4 Initial assessment and clinical 4
Trauma Pathophysiology and features of abdominal injury
clinical features of
abdominal injury
125
 Abdominal injury in the 4 Order and interprate 3
context of multiple Diagnostic tests in abdominal
injuries injury
The use of diagnostic 4 Laparotomy 2
tests in abdominal injury
Indications for surgery in 4
abdominal injury

Herniae
Definition of hernia 4
Different sites and types 4 Take history and appropriate 4
of herniae clinical examination for
patients with herniae
Anatomy, pathology 4 Perioperative care for 4
epidemiology and elective hernia repair
clinical features of
abdominal wall herniae
including inguinal,
femoral, umbilical,
obturator and lumber
Elective Surgery for 2
abdominal wall herniae

Resuscitation and 4
perioperative care for
emergency hernia surgery
Complications of 4 Emergency Surgery for 2
abdominal wall herniae abdominal wall herniae

Endocrine History and clinical findings of 4

surgery patient with neck swelling
Pathophysiology, 4 Formulate differential 4
epidemiology and diagnosis of patient with
presentation of thyroid goitre
disese
Plan investigation of patient 3
with goitre
Interprate thyroid function 3
tests
Thyroidectomy 2
Identify and manage 3
complications of thyroid
surgery
Pathophysiology, 1
epidemiology and
presentation of para
thyroid disese
Pathophysiology, 1
epidemiology and
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 presentation of adrenal
tumours
Pathophysiology, 1
epidemiology and
presentation of Multiple
endocrine neoplasia
Pathophysiology, 2
epidemiology and
presentation of carcinoid
tumours

Vascular Surgery Causes and clinical 4 History and examination of 4

features of the acutely patient with suspected limb
ischaemic limb ischaemia
Initial management of patient 4
with ischaemic limb
Causes and clinical 3 Arterial operations 2
features of patient with
chronic limb ischaemia
Vascular disease in HIV 3
Causes, pathology, 4 Identify the clinical features of 3
epidemiology and clinical an aneurysm
features of arterial
aneuryms
Vascular complications 4
of diabetes
Pathology and clinical 4 History and examination of 4
features of Diabetic foot patient with diabetic foot
conditions problems
Initiaial management of 4
patient with diabetic foot
infection
Limb amputations 2
Minor foot amputations 3
Causes, pathology, 4 History and examination of 4
epidemiology and clinical patient with varicose veins
features of varicose
veins

History and examination 4 History and examination of 4

of patient with varicose patient with chronic venous
veins chronic venous insufficiency
insufficiency
Varicose vein surgery 2
Causes, pathology, 4 Identify patient with 4
epidemiology and clinical suspected deep vein
features of venous thrombosis and or pulmonary
thrombo-embolic embolus
disease
127
 Initiate treatment for acute 3
DVT or PE
Instigate prophylactic 4
treatment in surgical patients
to prevent thromboembolism
Causes, pathology, 3 History and examination of 4
epidemiology and clinical patient with leg ulcers
features of leg ulcers

Neurosurgery Pathophysiology, 4 Identification, clinical 4

epidemiology and examination and initial
presentation of head management of head injured
injuries patient
Suture scalp laceration 3
The Glasgow Coma 4 Use GCS for monitoring head 4
Scale and its use injured patients
Role of CT in head injury 4 Interprate brain CT 2
Indications for surgery 3 Craniotomy for head injury 2
following head injury
Critical care for head 2 Ongoing care for patient with 2
injury head injury
Complications of head 4 Determine rehabilitation 1
injury potential and needs following
head injury
Pathophysiology, 3 History and examination of 2
epidemiology and patient with suspected intra-
presentation of central cranial infection
nervous infections
Initiate treatment for patient 3
with suspected intra-cranial
infection
Pathophysiology, 2 History and clinical 2
epidemiology and examination of patient with
presentation of brain suspected brain tumour
tumours
Pathophysiology, 2 Management of patient with 2
epidemiology and hydrocephalus
presentation of
hydrocephalus
Pathophysiology, 4 Identification, clinical 4
epidemiology and examination and initial
presentation of spinal management of spine injured
injuries patient
Identify spinal cord injury 3
Interpretate radiographs of 3
spine
Ongoing care for patient with 2
spinal cord injury

128
Trauma Care Optimal organization for 3 Initial assessment of the 4
trauma care: pre- injured patient. Carry out
hospital, in-hospital, & primary survey initiate
trauma systems resuscitation and carry out
secondary survey
Trauma performance 3 Management of shock in an 3
improvement injured patient
Injury prevention 2 Surgery for control of 2
bleeding following injury
Organise on-going care for 2
the multiply injured

Cardiothoracic Principles of surgery for 2

surgery ischeamic heart disese
Principles of surgery for 2
valvular heart disease
Pathophysiology and 4 Identify patient wtth cardiac 3
clinical features of tamponade
traumatic cardiac
tamponade
Surgery for cardiac laceration 1
pathology, epidemiology 4 History and examination of 4
and clinical features of patient with bronchial
bronchogenic malignancy
malignancy
pathology, epidemiology 4 Interpretation of CXR 4
and clinical features of
secondary bronchial
malignancy
Preparation of patient for 3
thoracic surgery
Lung resection 1
Post operative care for 3
thoracic surgery
Mechanism of injury, 4 Identify and treat simple 4
pathophysiology- and pneumothorax, tension
clinical features of pneumothorax, haemothorax
thoracic injuries
Indications for insertion 4 Needle thoracostomy for 4
of tube thoracostomy tension pneumothorax
Indications for urgent 3 Interpretation of CXR in 3
thoracotomy following trauma
injury
Insertion of tube 3
thoracostomy
Identify flail chest and 3
multiple rib fractures
Initiate treatment for rib 3
fractures and flail chest
129
 Recognise patient who 3
require urgent thoracotomy
Causes, 4 History and clinical findings of 4
Pathophysiology and pleural effusion
clinical features of
pleural effusions
Pathology and clinical 3 History and clinical findings of 3
features of empyema empyema
Interpretation of CXR findings 4
for pleural effusions and
empyema

Urology Causes, pathology and 4 History and clinical findings of 4

clinical features of patient with haematuria
patient with haematuria
Appropriate investigations for 4
haematuria
Causes, pathology and 4 History and clinical findings of 4
clinical features of patient with acute retention of
patient with acute urine
retention of urine
Appropriate investigations for 4
acute retention of urine
Insert urethral catheter 4
Perform examination of 4
prostate
Fluid management of patient 3
with treated obstructive
uropathy
Staging and Treatment 3
options for prostate
cancer
Causes, pathology and 4 History and clinical findings of 4
clinical features of patient with difficulty passing
patient with difficulty urine
passing urine
Urethral dilatation 2
Causes, pathology and 4 History and clinical findings of 4
clinical features of patient with renal tract calculi
urinary tract calculi
Investigations urinary tract 4
calculi
Causes, pathology and 4 History and examination of 4
clinical features of patient with painful testicle
painful testicle
Immediate management of 4
patient with suspected torsion
of the testicle
Scrotal exploration 2
130
 Causes, pathology and 4 History and clinical 4
clinical features of lump examination of patient with a
in the testicle lump in the testicle
Testicular carcinoma 3 Drainage of hydrocele 4
Surgery for hydrocele 2

Paediatric Anatomical and 4 Prescribing fluids and drugs 3

surgery physiological differences for children
in children compared to
adults
Clinical presentation and 3 Resuscitation and surgery for 1
pathophysiology of neonates
neonatal surgical
problems including
congenital diaphragmatic
hernia,tracheoesophage
al malformations,
Gastroschisis and
Necrotising enterocolitis
Clinical presentation and 3 History and clinical findings in 3
pathophysiology of child presenting with a tumour
Paediatric Tumours
Clinical presentation and 4 History and clinical findings in 4
pathophysiology of child with pyloric stenosis
pyloric stenosis
Fluid resuscitation of child 3
with pyloric stenosis
Surgery for pyloric stenosis 1
Clinical presentation and 3
pathophysiology of
Hirschprungs disease
Clinical presentation and 3 History and clinical findings of 3
pathophysiology of child with intussuception
Intussusception
Management of child with 2
intussuception
History and examination of 4
child who has
ingested/inhaled a foreign
body
Management of an Aspirated 3
or Ingested foreign body
Clinical presentations 4 History and clinical findings in 4
and pathophysiology of child with hernia, hydrocele or
herniae, hydrocele and undescended testicle
undescended testicle in
children
Surgery for herniae, 2
hydrocele and undescended
131
 testicle
Orthopaedics Mechanism of injury and 4
types of fracture
and dislocations
Principles of fracture and 4 History and clinical features 4
dislocations of limb fractures and
management dislocations
Principles of fracture 4 Identification of injuries 4
healing associated with fractures and
dislocations
Use of X-rays to identify 4
fractures and dislocations
Identification of compartment 3
syndrome
Fasciotomy 2
Manipulation of fractures and 3
dislocation under anaesthetic
Application of plaster of Paris 3
Application of limb traction 3
Open reduction and internal 2
fixation of fractures
On going care of patients with 3
fractures

Causes, patho- History and clinical 4

physiology and clinical examination of major joints
features of Joint pain &
swelling
Interpretation of Joint x-rays 4
Joint replacement surgery 2
Arthroscopic surgery 2
Causes, History and clinical signs of a 4
pathophysiology and child with a limp
clinical features of
limping in children
Investigation of a child with 3
limp
Management of child with 3
limp
Causes, patho-
physiology and clinical
features of soft tissue
disorders

Otorhinolaryngolo Causes and clinical 4 Initial assessment and 4

gy (ENT) features of nose bleed management of nose bleeds
Causes, History and clinical signs of 4
132
 pathophysiology and nasal obstruction
clinical features of nasal
obstruction
Management of nasal 3
obstruction
Causes, 4 History and clinical features 4
pathophysiology of oral of oral and pharyngeal
and pharyngeal infections
infections
Causes of upper airway 4 Management of airway 3
obstruction obstruction
Management of upper 4
respiratory tract infections
Causes, 4 History and clinical signs of
pathophysiology and deafness 4
clinical features of
deafness
Role of screening for 3 Distinguish conductive from 4
childhood hearing sensory neural deafness
difficulties
Investigation of deafness and 3
role audiometry
Recognise tympanic 4
perforation

History, clinical signs and 4

management of glue ear
Role of hearing aids 3 Explain use of hearing aids to 3
patients
Causes, 4 Management of tinnitus 3
pathophysiology and
clinical features of
tinnitus
Advise patients on preventing 4
deafness
Causes, 4 History, clinical signs and 4
pathophysiology and initial management of vertigo
clinical features of
vertigo
Perform otoscopy 4

Perform rhinoscopy 4
Management of impacted ear 3
wax

Opthalmology Causes, 4 Clinical history and 4

pathophysiology and examination of the eyes
133
 clinical features of
common causes of
blindness including
diabetes, cataract,
glaucoma, trachoma,
macular degeneration,
retinal detachment
The effects of systemic 4 Clinical history and 4
diseases on the eyes examination of the eyes in
relation to systemic disease
Understand the role of 3 Tests for visual acuity 3
optometrists and
ophthalmic nurses
Tests for colour vision 3
Use of opthalmoscope 4
Recognise normal and 4
abnormal findings on
fundoscopy
Test for red reflex 4
Causes, 4 Clinical history, and 4
pathophysiology and examination for extra retinal
Clinical features of extra- eye diseases
retinall disease including
conjunctivitis, corneal
abrasion, dendritic ulcer,
corneal foreign body
orbital cellulitis
Management of diabetic 2
retinopathy
Management of trachoma 3
Occular complications of 4
HIV
Causes, 4 Recognise the different types 3
Pathophysiology of of occular trauma
ocular trauma
Causes, 4 Assessments of visual fields 4
pathophysiology and
clinical features of visual
field defects
Causes, 4 History and clinical findings of 4
pathophysiology and leukocor ia
clinical features of
leukocoria in children
Management of leukocoria in 3
children

Anaesthesia Pharmacology and side 4

effects of common
anaesthetic drugs
134
Rationale for pre 4 Perform pre-operative 4
operative assessment assessment
Understand the role and 4 Interperate findings from 3
physiological basis of monitoring equipment
intra-operative
monitoring
Post operative recovery 4
Pharmacology and side 4 Prescribe and instill local 3
effects of local anaesthetic drugs
anaesthetic drugs
Pharmacology, uses, 4 Prescribe post operative 4
and side effects of pain analgesia
relieving drugs
Understand the role of 4 Perform basic airway 4
the various airway manouveres
techniques
Perform advanced airway 3
manouveres
Understand the role of 3
critical care in the
managerment of surgical
patients
Perform Basic Life Support 4
Perform Advanced Life 3
support

135
Acknowledgement

On behalf of the Phase II curriculum committee, I would like to acknowledge and appreciate the
following persons for their immense contribution in modifying and putting together this curriculum for
the clinical years of the MBBS program:

1. Professor John Cookson who supported and guided us accordingly in developing this curriculum.

2. Members of the phase II curriculum committee: Prof Yohana Mashalla, Prof Sandro Vento, Dr
Oathokwa Nkomzana, Dr George Mokone, Prof Amos Masele, Dr Michael Walsh, Dr Shiang-ju
Kung, Dr Francesca Cainelli, Dr Negussie Bekel, Dr Tadele Benti, Dr Loeto Mazhani, Dr Julius
Mwita, Dr Habte Dereje, Dr Ganiyu Adewale who worked tirelessly over the last 6 months
making this document a reality.

3. The Botswana Health Professions Council who offered guidance on standards of practice and
critiqued the document in all its stages of development.

4. The School of Medicine Advisory Board who met on two occasions to discuss the document and
made useful inputs to it.

5. The Acting Dean, FHS who provided supported and facilitated the phase II curriculum workshop
in the early stages of developing this document.

6. Our students who also gave their own input into how the logistics of implementation was going
to affect them.

Among the many documents and curricula that were consulted, the following documents are
particularly worth mentioning:

1. The Hull & York Medical School Undergraduate curriculum

2. The University of Liverpool Undergraduate Medical curriculum

3. The University of the Free State Undergraduate Medical curriculum

4. The University of Namibia Undergraduate Medical curriculum

Prof M N Tanko

Phase II Coordinator

136