Yr 3B CCD Student Guide 2017

Problem-based Learning
Student Guide
Year 3B
2017
Year 3B Problem-Based Learning (PBL) Student Guide
YEAR 3B MED, 2017
ATTENDANCE AT PBL TUTORIALS
Key to Success in Problem-Based Learning

Attendance at PBL sessions is mandatory. Students must attend and participate in all PBL
sessions. This is because the PBL group function depends on the unique collaboration of each
student. Each PBL group member is responsible for his/her own learning as well as for contributing to
the learning of his/her peers. The absence of a member changes the dynamics in the group. The
student must therefore be present at every session in order for the PBL group to function optimally.
Excused absences are limited to extenuating circumstances such as the death of an immediate family
member, wedding of an immediate family member or students health problem.
Discussion should take place in the PBL group in the case of an anticipated absence to arrange for
the management of learning responsibilities. An absence does not excuse learning
responsibilities.
In the case of a students health problem, he/she must contact the Clinical Site Administrator (CSA)
Office at their site, the PBL tutor and the group spokesperson(s), if possible, in the morning of the
session or within 24 hours of the absence.
CONTENTS
Problem-based Learning (PBL) Student Guide .................................................................... 1
Introduction ............................................................................................................................ 1
What is Problem-Based Learning? ............................................................................................. 1
Problem-Based Learning in MED at Monash University ................................................................ 1
Paper Cases for Problem Based Learning ................................................................................... 2
Real Patient Cases for Problem Based Learning .......................................................................... 3
Problem-based Learning Cases List 2017 ................................................................................... 4
Tutor Role in Problem Based Learning ....................................................................................... 6
Other Roles in Problem Based Learning Groups .......................................................................... 9
Further Reading..................................................................................................................... 10
Problem-based learning Paper Cases .............................................................................. 11
Title: Mr Lance Patrick - swollen legs ................................................................................. 13
Title: Ms Ghelani Singh - breathless on exertion ................................................................. 15
Title: Mrs Jessie Johnson - calf pain................................................................................... 17
Title: Ms Sophie Panopoulos - tired and out of sorts ........................................................... 19
Title: Mr Peter Hood - cough and loss of breath.................................................................. 21
Title: Mr Michael Todd - jaundiced .................................................................................... 23
Title: Mr Stephen Tsagakis - severe stomach pain .............................................................. 25
Title: Mr Maxwell Jacobs - fever and night sweats .............................................................. 27
Title: Mr Tony Spencer - severe headache and flu symptoms ............................................... 29
Title: Ms Jenny Randall - muscle aches, fever and cough .................................................... 31
Title: Mr Josh Felix - extreme lethargy ............................................................................... 34
Title: Mr Simon Smith cannot get out of bed ................................................................... 38
Title: Ms Siu Jung - rash ................................................................................................... 40
Title: Mr Peter Paunch - knee pain and swelling.................................................................. 41
Title: Mr Jules Brady - health check ................................................................................... 42
Title: Ms Anne Smith - history of headache ........................................................................ 44
Title: Mr Branco Vladic motor vehicle accident ................................................................. 46
Problem-based learning Patient Cases ........................................................................... 49
CASE 1: Chest Pain........................................................................................................... 51
CASE 2: Acute Glomerulonephritis (GN) .............................................................................. 54
CASE 3: Breathlessness .................................................................................................... 56
CASE 4: Cough and weight loss ......................................................................................... 59
CASE 5: Deep Venous Thrombosis/Pulmonary Embolus ....................................................... 61
CASE 6: Abdominal Pain.................................................................................................... 63
CASE 7: Diarrhoea ............................................................................................................ 65
CASE 8: GI Bleeding ......................................................................................................... 68
CASE 9: Obstructive Jaundice ............................................................................................ 71

CASE 10: Anaemia ............................................................................................................. 73
CASE 11: Breast Cancer ...................................................................................................... 75
CASE 12: Splenomegaly and lymphadenopathy ..................................................................... 77
CASE 13: Pneumonia .......................................................................................................... 80
CASE 14: Thyroid Disease ................................................................................................... 83
CASE 15: Osteoporosis ....................................................................................................... 86
CASE 16: Type 2 diabetes ................................................................................................... 90
CASE 17: Delirium .............................................................................................................. 93
CASE 18: Stroke................................................................................................................. 95
CASE 19: Peripheral Neuropathy.......................................................................................... 98
CASE 20: Seizure ............................................................................................................. 100
CASE 21: Movement Disorder/Parkinsons Disease .............................................................. 102
CASE 22: Peripheral Vascular Disease ................................................................................ 104
CASE 23: Urinary Obstruction ............................................................................................ 107
CASE 24: Skin rash/ulcer .................................................................................................. 109
Problem-based Learning (PBL) Student Guide

Introduction
This Handbook is intended to support students in PBL tutorials. The essence of PBL is about students
finding out information for themselves and sharing information with group members and PBL tutors.
PBL is a student-led process. These notes aim to clarify the varied roles in the PBL process. The
Handbook is designed to help you adapt to what may be different ways of working where the
emphasis in PBL is on learning rather than being taught. If you have any questions on any aspect
of the PBL curriculum, please contact Liz Molloy, Liz.Molloy@monash.edu.
What is Problem-Based Learning?

In Problem-based learning (PBL), students learn in small groups supported by a tutor. They initially
explore a predetermined problem (Case). The problem contains triggers designed to evoke
objectives or concepts which are used to set the agenda for individual or group investigation and
learning after the initial session. Subsequent group meetings permit students to monitor their
achievements and to set further learning goals as required. The tutor's role is to offer support for
learning and to help reach the expected outcomes.
Problem-based learning (PBL) enables students to develop the ability to translate knowledge into
practice at an early stage, encourages individual participation in learning and also allows the
development of teamwork skills.
Students in PBL courses have been found to place more emphasis on "meaning" (understanding) than
"reproduction" (memorisation). Students must engage in a significant amount of self-directed learning;
lectures are kept to a minimum. PBL originated at McMaster University in Canada, and then at
Maastricht University, and is now widely adopted in medical schools in many countries.
Source: (http://www.iime.org/glossary).
Problem-Based Learning in MED at Monash University

Students will work in groups of up to eight and meet weekly for PBLs. Sixty PBLs will be completed in
Year 3B. Tutors will be required for each session although the time commitment varies between
tutorials. There are two types of PBLs in Year 3B of the Monash MED:
1. Paper cases are PBLs that are presented to the students on paper. These problems are
often based on real patients but patients are not essential to the learning process. However,
students are strongly encouraged to see real patients that have similar problems to those that
the PBLs outline.
2. Real patient cases are PBLs that always include real patients in the learning process. At
Monash University this has been previously referred to as Case based learning (CBL).
1
Paper Cases for Problem Based Learning

A number of the content areas previously delivered as PBL may be delivered at your site in an
alternative format, such as a short didactic lecture/tutorial or incorporated into your own learning
objectives. The faculty has recommended that a number of PBL areas from 2011 and prior have
objectives that could be better met in bedside, procedural skills teaching or other formats. Please refer
to the online curriculum guide to check the learning objectives for these areas. Be prepared for
variation in group size and delivery format at your site.
There are 17 paper-based PBLs in Year 3B. These PBLs require one meeting weekly (two hours). The
session will be divided between two cases finishing one case and beginning the next.
The first Tutorial in PBLs involves students reading the scenario, defining terms, exploring possible
issues surrounding the problem, setting priorities for issues, considering possible explanations,
exploring the problem/s thematically, developing learning objectives and setting tasks for the second
tutorial.
The range of learning activities that can be generated between tutorials is diverse and includes library
study, clinical skills work, ward observations, community activity and much more. The content may
include any range of topics - pharmacology, pathology, evidence-based clinical practice, ethics and
procedural skills. Students are expected to use their recommended references to investigate
problems. It is also important for students to refer to their Study Guides from Years 1 and 2 as they
build on what has already been learned.
In the second tutorial, students present the findings of their work to their group members.
Students are encouraged to consider each problem in the broader context of their medical education
and respond to the four themes that underpin our MED curriculum. This educational process is shown
below:
Tutorial 1
Read PBL case
Clarify unfamiliar terms
Define the problem(s)
Brainstorm possible explanations
Arrange explanations into a tentative solution
Define learning objectives and requisite clinical experience
Allocate tasks
Interim
Study and gain clinical experience.
Tutorial 2
Review the case
Share results of private study
Apply clinical reasoning
Discuss clinical experience in the light of that understanding
Synthesis information for the PBL case
2
Real Patient Cases for Problem Based Learning

There are 24 patient PBLs in Year 3B. Patient PBLs require two tutorials weekly (one hour and two
hours respectively). The same eight steps described above are worked through sequentially.
In the first tutorial, nominated students (usually two) make a case presentation to their group. This is
the equivalent of the paper PBL in which students read the case. The patient/s who are presented in
the first tutorial are identified by tutors in advance, enabling nominated students to meet the patient,
take a history and conduct a physical examination.
The tutorial group explores possible explanations for the presentation, investigations and treatment etc
and identifies areas for further study. It is very important to help students make links between what
they already know and new information. This includes basic, medical and social sciences, evidence-
based clinical practice, epidemiology and clinical skills etc.
PBLs provide a unique opportunity for the development of clinical reasoning skills.
Between tutorials all students are encouraged to see patients who have similar problems to those
being studied, identifying similarities and differences in presentation (eg. gender, age, ethnicity),
response to treatment and prognosis.
Note that the format of delivery Patient Cases will vary from site to site depending on availability of
patients, and the tutors expertise. Most Cases will be delivered using a PBL format, and some will be
provided in the form of a student-led seminar. Students are asked to take a flexible approach to Real
Patient Cases for Problem based learning, and remember that the quality of the reasoning and content
raised are the key determinants of a productive learning session.
Tutorial 1
Brief discussion of pre-session questions
Students make their patient presentation
Issues from presentation
Issues from scenario
Relationship to themes
Set learning objectives
Allocate tasks
Plan to see patient/s
Plan to see procedures
Plan to practice clinical skills.
Tutorial 2
Student report findings
Students compare and contrast patient presentations
Further review of pre-session questions
Outstanding issues and plan to address
Complete the review questions below.
Learning objectives are thematically based and reflect our integrated curriculum.
We are very interested in receiving feedback on any aspect of the curriculum. In addition to structured
evaluation of each case, please email any feedback that you have to liz.molloy@monash.edu that it
can be incorporated into future documents.
The cases are listed below. Although students know the medical conditions of patient PBLs, they do
not know the name of the condition in the paper PBL. Instead they are usually given a patients name
and written cues to their presentation. Part of the process in the paper PBL includes clinical
reasoning to try and reach a diagnosis and subsequently construct an evidence-based management
plan.
3
Problem-based Learning Cases List 2017
Problem Based Learning Cases
Real Patient Paper
Cardiovascular disease Cardiovascular disease
1 Chest pain 1. Congestive heart failure
2 Ischaemic heart disease
Renal disease Renal disease
2 Acute glomerulonephritis 3 Acute renal failure
4 Chronic renal failure
Pulmonary disease Pulmonary disease
3 Breathlessness 5 Asthma
4 Cough / Weight loss
5 DVT / PE
GIT/Hepatobiliary disease GIT/Hepatobiliary disease
6 Abdominal pain (acute / chronic) * 6 Acute liver failure/chronic liver disease
7 Diarrhoea 7 Pancreatitis *
8 GI bleeding (upper / lower) *
9 Obstructive jaundice *
10 Anaemia
Haematology/Oncology
11 Breast cancer *
12 Splenomegaly/LAD
Infectious diseases Infectious diseases
13 Pneumonia 8 Infectious endocarditis *
9 Meningitis
10 Pyrexia of unknown origin
11 Tuberculosis
12 HIV infection
4
Problem Based Learning Cases
Real Patient Paper
Endocrinology Rheumatology / Clinical immunology
14 Thyroid disease * 13 Connective tissue disease
15 Osteoporosis 14 Mono-arthritis
16 Type II diabetes
General
15 Health Check
Neurology Neurology
17 Delirium 16 Headache
18 Stroke
19 Peripheral Neuropathy
20 Seizure
21 Movement disorder
General surgery Surgery
22 Peripheral vascular diseases 17 Multi-trauma/ lower limb fracture
23 Urinary Obstruction
Dermatology * Signifies significant surgical content
24 Skin rash / Ulcer
5
Tutor Role in Problem Based Learning

This information is provided so that you understand the tutors role in PBL. The PBL tutors role is to
ensure that students move through each PBL in a rigorous, logical manner using a step-wise
approach. Although the descriptions of the roles below appear to have demarcations, some overlap
will occur and reflect the ways in which your group functions. It is CRITICAL that the PBL steps are
followed. Ideas that relate to preparation and facilitating discussion are relevant to all roles.
Being a tutor for PBLs requires knowledge of:
the overall curriculum
specific PBLs and how they fit within the semester
educational methodologies (eg. formative assessment, evaluation)
usefulness of different learning resources
PBL steps
the rationale and strategies to stimulate self-directed learning
group dynamics.
Personal attributes of tutors that support PBL include:
acceptance of the PBL approach as a means of promoting knowledge acquisition, critical
thinking, self-directedness and the tutorial forum of the PBL for integration, direction and
feedback
valuing attendance at sessions
undertaking staff development.
Skills required for tutors include:
facilitation for learning
promoting group problem-solving and critical thinking
promoting effective group functioning
encouraging individual learning.
Tutor Preparation
1. Read the PBL case before the session.
2. If you are tutoring a Patient PBL then you will need to identify a suitable patient for the pair of
student to see in advance of the tutorial.
3. Be familiar with the learning objectives that the case writers expect students will meet by
working through the PBL.
4. Be familiar with the paper PBL trigger materials within each link (segment) and how they relate
to the learning objectives.
5. Be familiar with resources (eg. references, clinical skills sessions, clinico-pathology tutorials etc)
that students may want or are directed to use.
6. Read any feedback from other groups (students and tutors). Students in Year 3B will be working
through the cases in different sequences. By semester 6 we should have information available
that informs you how other groups have experienced each case. In addition, students will
remain in their PBL group for the entire year. It is important that you are familiar with how a
particular PBL group is functioning. Ask other tutors and ask the students.
7. Check the room and time.
8. Ensure that the room has the equipment needed (eg. overhead projector and pens, flip chart
with pens, viewing box for radiographs, computer etc).
9. Ensure you have all the case material (eg. ECGs, radiographs, laboratory results, pictures,
video). Some cases will use trigger material other than that in the text. This will be indicated for
each case and will provided at your site.
6
Tutorial 1
1. Introductions (Tutor and students).
2. Consider the seating arrangements to ensure flow of communication.
3. Briefly go over the steps of the PBL process (Review any outstanding content or process issues
from the last tutorial).
4. Clarify roles: chair, scribe (Students must rotate through roles over the semester) If the PBL is
paper PBL, then nominate a student to read the case aloud stopping at the discussion
questions. From this point students clarify terms, brainstorm and work through the PBL
process).
5. As tutor, monitor how the group are working through the steps towards learning objectives. You
may need to ask questions that help the students make sense of their discussions. It can also
be helpful to ask students to summarise what they have achieved so far.
6. Make sure that the learning objectives are recorded (and you have a copy).
7. Record attendance at the tutorial and forward to your site administrator.
Tutorial 2
1. The chair and scribe should be the same people as in the first tutorial.
2. Ask the chair to list the learning objectives.
3. Discussion should be around these. It is okay for some deviation because students learn by
going off on tangents but be conscious of time constraints if learning objectives are not being
met.
4. Encourage students to identify their resources and cite the source(s) of information used.
Learning how to use resources and being aware of strengths and limitations are important
general aims of PBL learning.
5. Encourage the students to think how their clinical experience fits with their knowledge and
understanding of the problem.
6. Record attendance at the tutorial and forward to your site administrator.
Post Tutorials
1. Make notes on the group process and contributions of individual members.
2. Give feedback on group functioning.
3. Record the learning objectives set by the group since this is one way we can evaluate the PBL
and return to your site administrator.
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Guide to Facilitating Discussion in Problem Based Learning

Accept silence; students may need time to think.
Before making any comments, ask yourself whether what you are about to say will help
students in learning how to learn.
When you do ask questions try to ensure that they are open-ended as these questions promote
discussion.
Ask probing questions:
What aspects of the case need to be discussed further?
How does that comment explain this part of the problem?
Based on what you know about ..., how can you explain this scenario?
Elicit students reasoning. If students request more information, ask them why they want that
information:
What are you hoping to find out?
Why are you asking that question?
How would knowing the answer to that question make a difference in your
understanding of the patients problem?
Ask questions that make connections between concepts:
What is the association between and ?
Ask students to explain their use of medical terminology:
Can you tell me what you mean by ?
Encourage students to explain mechanisms and causes of patients problems and
pharmacological and surgical interventions:
What physiological processes could have caused this problem?
What is the mechanism for the action of that drug?
What is the evidence that treatment makes any difference?
How do you decide which investigations to do?
What anatomical structures do you need to consider for this surgery?
Ask questions that show that you have been listening. Refer to individual students comments
throughout the tutorial:
I was interested to hear that earlier Anne stated and now Lee has expressed a
different viewpoint. What do the rest of you think?
Do not dominate the group.
Contribute as though you are a participant.
Periodically remind students how much they are learning by making a specific summary and
use their examples.
8
Other Roles in Problem Based Learning Groups

Students should rotate through these roles over the semester. In each PBL, the chair and the scribe
should stay in the same role. For example, one person acts as scribe for tutorials one and two of the
same PBL.
Chair
Tasks of the chair are to:
promote discussion and keep it focussed
be aware of students who are over and under participating and take measures to moderate
participation
offer guidance in group decisions for example, allocation of tasks
clarify and summarise as this can help to keep the discussion progressing as well as providing
status reports
ask questions of group members
supervise and offer assistance to the scribe
act as time keeper
at the end of the first tutorial, the chair should review with all group members the tasks for each
person. Some topics can be researched by all students while others can be divided
invite feedback from the tutor on the group dynamics (as well as content)
review the learning objectives at the beginning of the second tutorial
request that group members cite sources of information when they are presenting their
information in the second tutorial
make a summary at the end of the second tutorial highlighting any aspects of the problem that
have not been resolved and consider ways of meeting unmet learning objectives
gather information required for the evaluation of the PBL.
Scribe
Tasks of the scribe are to:
record ideas as presented by students during brainstorming
make short notes throughout the PBL
listen carefully and avoid interpreting or judging contributions made by group members in the
process of scribing
record learning resources used by the group this informs the evaluation of the PBL as well as
raise students awareness of the quality of data sources
work with the Chair to:
make interim summaries
help the group order their thoughts
identify issues and concepts requiring investigation
identify possible explanations
formulate learning goals
ask clarifying questions
Students
Tasks of the students in the group are to:
follow the steps of PBL
share information
ask questions of each other especially open-ended questions
make notes
listen
respect contributions of others even though all ideas can be challenged
research learning objectives they have been allocated
9
Further Reading
Albanese M. Problem-based learning: why curricula are likely to show little effect on knowledge and
clinical skills. Medical Education. 2000; 34: 729-738.
Dammers J, Spencer J, Thomas M. Using real patients in problem-based learning: students
comments on the value of using real, as opposed to paper cases in a problem-based learning module
in general practice. Medical Education. 2001; 35: 27-34.
Davis MH & Harden RM. AMEE Education Guide Number 15. Problem-based learning: a practical
guide. Medical Teacher. 1998;21 (2): 130-140.
Dolmans DH, Snellen-Balendong H, Wolfhagen IH, Van der Vleuten PM. Seven principles of effective
case design for a problem-based curriculum. Medical Teacher. 1997; 19 (3): 185-189.
Harden RM & Davis MH. The continuum of problem-based learning. Medical Teacher. 1999; 20 (2):
317-322.
Washington ET, Tysinger JW, Snell LM, Palmer LR. Developing and evaluating ambulatory care:
problem-based learning cases. Medical Teacher. 2003; 25 (2): 136-141.
Maudsley G. Roles and responsibilities of the problem-based learning tutor in the undergraduate
medical curriculum. British Medical Journal. 1999; 318: 657-661.
Norman GR, Schmidt HG. Effectiveness of problem-based learning curricula: theory, practice and
paper darts. Medical Education. 2000; 34: 721-728.
Schmidt HG. Problem-based learning: rationale and description. Medical Education. 1983; 17: 11-16.
Wood D. Problem based learning. British Medical Journal. 2003; 326: 328-330.
The following websites provide introductory information on problem-based learning in the context of
medical education.
http://www.unimaas.nl/pbl/
Maastricht University, Netherlands
http://www.pbli.org/core.htm and http://www.siumed.edu/oec/
Southern Illinois University School of Medicine, USA
http://www.queensu.ca/ctl/goodpractice/problem/index.html
Queens University, Canada pp 22-25 provides an example
http://pbl.cqu.edu.au/content/online_resources.htm
McMaster University, Canada
10
Problem-based learning
Paper Cases
11
12
Year 3B Problem-Based Learning (PBL) Student Guide PBL Paper 1
Title: Mr Lance Patrick - swollen legs

Author: Professor David Kaye
Scenario
Mr Lance Patrick presents during your rotation as a medical student in a busy inner western general
practice. He is aged 57 and has not visited the practice before, although his wife and children have
attended the practice. He only presented this time after continued pressure from his wife (Janine) to
seek advice and assistance for very swollen legs and breathlessness.
Further Information
History
Mr Patrick has never visited a doctor before, apart from 8 years ago when he attended the emergency
department after cutting his hand on a glass at the pub. He works as a forklift driver at a local factory.
While the work is generally light he has recently found it hard to catch his breath when lifting 10-20kg
boxes off the forklift. He has never paid much attention to his health. As described above, Janine has
also noticed his shortness of breath and remarked on his swollen ankles. She has also noticed that he
is snoring a lot more at night than in previous years.
Past History
Mr Patrick has never been to a general practitioner. He has generally ignored coughs and colds, but
has been aware of headaches from time to time.
Family History
Lances mother has hypertension and diabetes. His father left home when Lance was 8 years old.
Social History
Lance usually goes to the pub after work and has 4 pots of beer. At the weekend he drinks a little
more. He smoked until 6 months ago after he developed a cold and was very short of breath. His wife
works part-time in a local convenience store. They have two boys aged 8 and 11. Neither is very
active and both are already on the borderline for obesity. Lance and Janine have a mortgage on their
house.
Medications
Nil.
Further Information
Physical Examination
Lance is fairly comfortable at rest, although he did seem a bit short of breath when he walked in from
the waiting room.
Vital Signs
Heart rate 98/min (irregular)
Blood pressure 160/105
Respiratory rate 18/min
Temperature 36.8oC
Weight 118 kg
Cardiovascular Examination
JVP is elevated 2 cm above the clavicle. The apex beat is hard to feel, but seems to be down towards
the 6th intercostal space in the anterior axillary line. The heart sounds are normal, with no murmurs.
The ankles and lower legs are very swollen, up to the mid-tibia.
Respiratory Examination
There is normal chest expansion, with widespread fine and coarse crackles throughout both lung
fields. The left lung base is dull to percussion.
13
Abdominal Examination
Lance is quite obese and it is hard to feel any masses.
Neurological Examination
Normal power, but the level of sensation in his toes seems reduced.
Further Information
Investigations
ECG: atrial fibrillation, LVH, old anterior infarct
CXR: cardiomegaly, upper lobe diversion, left pleural effusion
U+Es, glucose: Na 129, K 4.1, Ur 12.2, Cr 0.14, gluc 10.5
Further Information
Progress
You review Lance one week later. His breathing is better and the amount of ankle swelling has
subsided a little. His weight is now 115 kg. He is worried about his finances and asks about return to
work.
References
AHA Guidelines for Heart Failure
ACC Measures for Heart Failure
NHF Guidelines for Heart Failure
Learning Resources
Chest x-ray - cardiomegaly / pulmonary oedema
PRIOR LEARNING FOR THEME III OBJECTIVES
Sem Activity Title
3 PCL Rita's not feeling so good ......
3 PCL Andrew is tired
3 Lecture Sleep disorders and non-invasive ventilation
3 PCL Anna's out of breath
3 PCL Hoping for the best
3 PCL The Ballet Dancer
3 Lecture Inotropic agents
3 Lecture Vasodilator agents
3 Lecture Diuretics
14
Title: Ms Ghelani Singh - breathless on exertion

Author: Professor Ian T. Meredith
Scenario
Ms Ghelani Singh, a 56 year old mother of 4 children and former Primary School Teacher. She
presents after an episode of distressing exertional dyspnoea, which occurred while walking briskly with
her dog along the beach.
Her exertional breathlessness is associated with mild chest tightness but the latter is neither painful
nor particularly concerning to her.
The breathlessness has been present for 4-6 months and occurs 2-3 times per week. It has been
getting worse gradually but she does not describe breathlessness at rest or while lying down.
Her past medical history is significant for Type II Diabetes Mellitus for 8 years but no overt diabetic
complications, post menopause 6 yrs, previous cholecystectomy age 44 and renal calculi age 40. She
does not have a history of asthma.
Further Information
Cardiovascular Risk Factors
ex-smoker (3 yrs)
mild hypertension
BMI 29
lipid status not known to patient
T2 DM 8 years on oral hypoglycaemic agents
Family History
father died at age 66 from an AMI
mother, alive 79 yrs old, Systolic Hypertension
brother, 54 yrs old CABG 12 months ago
General Inspection: Moderately overweight, otherwise well
Cardiac and Vascular Examination:
BP 148/84, repeat 150/84
PR 80, All pulses intact
Otherwise normal cardiovascular examination
Basic Investigations
ECG: Voltage criteria for LVH
CXR: Normal
U & Es: Normal
HbA1c: 8.7%
Clotting Profile: Normal
Lipid Profile: Total Chol 5.7mmol/L, LDL Chol 3.8mmol/L,
HDL Chol 1.0mmol/L, TG 2.6mmol/L
Subsequent Investigations
Echocardiography: Mild Left Ventricular Hypertrophy
Old posterolateral MI
15
Standard Exercise Stress Test:

No chest pain but significant dyspnoea
Moderate workload completed (6 minutes)
Hypertensive response to exercise
Widespread minor non-diagnostic ST depression
Exercise Nuclear Stress Test:
Multiple reversible perfusion defects with exercise
Further Information
Ms Singh proceeds to coronary angiography and is found to have severe multivessel CAD.
Learning Resources
Chest X-ray
ECG
Biochemistry
Echocardiography
Stress Test
Sem Activity Title
3 Practical History taking for the Cardiovascular System
3 Lecture The respiratory system: neoplasms of the lung
3 Practical History taking and physical examination for the Respiratory System
3 Lecture Coronary circulation in health and disease
3 PCL Tom in the garden
3 Lecture Cardiovascular System history and examination
4 Lecture Insulin and Oral Antidiabetic Agents
4 Lecture Overview of Diabetes Mellitus
4 Lecture Diabetes
4 Lecture Introduction to Diabetes and Metabolism CD-ROM
3 Lecture Vasodilator agents
16
Title: Mrs Jessie Johnson - calf pain

Authors: Professor N Thomson
Mr A Saunder
Scenario
Mrs Jessie Johnson is a 78-year-old woman living independently with her husband. She has a hiatus
hernia, chronic osteoarthritis, hypertension and diet-controlled type II diabetes. She is on multiple
drugs including Indapamide, Simvastatin, Celecoxib, Trandolapril and Pantoprazole.
Over the last 3 months she has noticed calf pain on walking 60 metres, which is relieved by rest. Last
week she noticed that her left second toe has become cold and looks dark. She is referred to hospital
for investigation including a femoral angiogram. The result showed mild narrowing of major vessels
and she is reassured and discharged.
Over the next 48 hours she became nauseated and short of breath and returns to the Emergency
Department of the hospital where you see her.
Further information
A full history did not detect known renal disease prior to the angiogram. The patient had felt dizzy
when standing, soon after the angiogram, suggesting intravascular volume depletion around this time
and this may have been due to her fasting for 12 hours before the procedure and still taking her
Indapamide. However, she subsequently continued to drink although noticing reduced urine output,
and by the time she presented to the Emergency Department she noticed some swelling of her lower
legs.
On examination, her blood pressure was 160/90 lying and standing, pulse was 80 and regular,
oedema was detected in her lower legs, JVP was elevated 6cm, and chest examination revealed
crackles in lower zones. The rash of livido reticularis was not detected. Urinalysis showed protein ++
and blood +. The patient did not show signs of chronic renal failure (anaemia, leukonychia, skin
pigmentation).
Investigations revealed a serum creatinine of 550m/L (n < 110), urea 40mmol/L (n<6), serum sodium
135mmol/L (normal), potassium 6.8mmol/L (n 3.5-4.5), bicarbonate 11mmol/L (n 20-26). Random
blood glucose was 6.9mmol/L (n 4-8). Microurine showed 120 red cells / mm3 (n < 10) and hyaline
casts. FBE was normal. ECG was normal. Chest x-ray showed an enlarged heart and pulmonary
congestion. Renal ultrasound showed both kidneys to be of normal size.
References
Acute Renal Failure: in Textbook of Medicine, Edited by RL Souhami, J Moxham; 4th ed.
Churchill Livingstone, 2002, pg 1047-1051.
Renal Toxicity of Non-Steroidal Anti-Inflammatory Drugs. Murray MD, Braser DC. 1993; Ann.
Review Pharmacol. Toxicol. 33: 435-465.
Learning Resources
General texts on internal medicine
Texts on renal disease (nephrology)
Journal review articles using following key words/phrases: acute renal failure, acute tubular
necrosis, drug nephrotoxicity, the kidney in the elderly
17
Sem Activity Title
3 Lecture Acute Renal Failure
3 Lecture Introduction to the renal system and body fluids
3 Lecture Renal transport mechanisms
3 Lecture Renal filtration and clearance
3 Lecture Renal and Urinary System History, Examination and Clinical Reasoning
3 Practical Assessment and Clinical Reasoning for the Renal and Urinary System
4 Practical Gross Anatomy - posterior abdominal wall, renal, ureters, adrenal, spleen, vessels
and nerves
3 Lecture Regulation of body fluid osmolality and water balance
3 Lecture Infection and immunity in the urinary system
3 Practical Respiratory and Urinary systems - revision of Clinical Skills
3 Lecture Acid/base regulation the role of the renal and respiratory systems
3 Lecture Renal handling of bicarbonate
3 PCL Hot summers night
3 PCL Complications
3 Lecture The Role of the Kidney in Pharmacokinetics
2 PCL An Unwelcome Guest
18
Title: Ms Sophie Panopoulos - tired and out of sorts

Author: Dr Richard Kitching
Scenario
Ms Sophie Panopoulos is a 47 year old woman process worker with four children (aged 6, 12, 14 and
20 years) who migrated from Greece to Australia at the age of 16. Her father died at 49 with
hypertension and a cerebral haemorrhage, and her cousin (fathers nephew) aged 61 is on
haemodialysis in Germany. Sophie developed hypertension during her last pregnancy which did not
resolve but was controlled with amlodipine 5mg per day. Over the last 6 months Sophie has become
tired, lost her appetite and developed mild swelling of her ankles at the end of the day.
She was finding it increasingly difficult to work and look after the children and was increasingly grumpy
with them. She went to Dr Sarah Black, her GP, who ordered a full blood count, found her Hb was 103
g/l (n 110-160) and prescribed a course of ferrous gluconate. Her BP was 140/88 so the dose of
amlodipine was increased to 10 mg per day. Two weeks later she developed left loin pain and noticed
macroscopic haematuria, Dr Black suspected a urinary tract infection and ordered an MSU with further
blood tests. Haematuria, and + proteinuria was confirmed but the urine culture was negative for
bacteria. Her blood tests showed creatinine 480 mol/l (40-120), urea 35 mmol/l (2.5-7.8). A renal
ultrasound scan showed larger kidneys (left 16.5 cm and right 16 cm) with multiple cysts in each.
Note: There are likely to be a number of patients in the hospital with significant renal
impairment (especially if the hospital has a renal unit or a dialysis unit). Many of them
will be interested in telling you their stories (including details of their symptoms and
treatments). You are advised to seek out real patients with chronic renal failure
during your study of this case.
Further information
Over the next 3 months, Sophie learnt more about her condition. She discussed her illness with her
husband and children. Despite her BP falling to 120/80, her tiredness did not improve, nor did her mild
oedema and she developed a generalised itch. Her creatinine clearance was measured at 12ml/min. A
nephrology team became involved in her care. She saw a number of health professionals on several
occasions, including a nephrologist, renal education nurses, a dietician, a social worker and a vascular
surgeon as well Dr Black on a regular basis. She commenced recombinant erythropoietin injections
weekly (darbepoetin) subcutaneously for her anaemia. She chose haemodialysis as her means of
renal replacement therapy; a forearm fistula was formed and after a further six week commenced
three times a week haemodialysis.
References
Davies et al: Human Physiology Ch 89, pg 789-797
Kumar and Clark, Clinical Medicine 5th ed. pg 642-660
In addition, the text The Renal System: basic science and clinical conditions (Field, Pollock,
Harris) has good coverage of chronic renal failure (pg 98-105) and has been written by
Australian nephrologists.
Patient information
http://www.kidney.org.au/
http://www.pkdcure.org/home.htm
Evidence based guidelines for management of chronic renal failure in Australia
http://www.kidney.org.au/
19
Sem Activity Title
3 PCL Complications
3 Lecture Chronic renal failure
3 Lecture Renal transport mechanisms
4 Practical Gross Anatomy - posterior abdominal wall, renal, ureters, adrenal, spleen,
vessels and nerves
3 Lecture Regulation of body fluid osmolality and water balance
3 Lecture Acid/base regulation the role of the renal and respiratory systems
3 Lecture Renal handling of bicarbonate
1 PCL Sisters
3 Lecture Acute Renal Failure
20
Title: Mr Peter Hood - cough and loss of breath

Authors: Associate Professor Frank Thien
Associate Professor Michael Abramson
Scenario
Mr Peter Hood is a 42 year old electronics engineer and a lifelong non-smoker. He has had asthma
since the age of 35, without any background history of childhood asthma. He describes having had
chronic persistent nasal obstruction with rhinorrhoea since his early 30s with some loss of a sense of
smell, and has required 2 nasal polypectomy operations. He often has heartburn, particularly after
meals and in the evenings, for which he takes over the counter antacids. Over the last few months, he
has developed increasingly frequent asthma symptoms, requiring inhaled reliever medications 2-3
times a day, including nocturnal waking with breathlessness 1-2 times per week. He also finds that he
is unable to complete his early morning run due to cough and shortness of breath.
Further information
Occupational history reveals 20 years in the electronics industry. He commenced as a junior
technician whose work frequently involved soldering printed circuit boards in confined spaces. For the
last 10 years, he has been a manager and spends most of his time in an air conditioned office well
away from the workshop. He is not on any other medications. Allergy skin prick tests to inhaled
allergens are negative. Spirometry shows moderate airflow obstruction, with a 15% bronchodilator
response in force expiratory volume in 1 second (FEV1). Home peak flow charts show a diurnal
variability of 20%.
Further information
Recently he had a severe attack of asthma which occurred after he took naproxen 500 mg for a knee
injury. Within 30 minutes, he developed nasal congestion with profuse rhinorrhoea, followed by chest
tightness shortness of breath and wheeze. His inhaler provided minimal relief and he attended a
hospital Emergency Department where he was given nebulised bronchodilators and followed by a
seven day course of oral steroids. He recalls he had taken naproxen for back pain 3 years ago,
without adverse reaction.
Further information
After the weeks course of oral steroids, he recovers from the severe acute attack, but is still relying on
his reliever inhaler once or twice a day. His peak flows have improved to near his best, but still with
10-15% variability. He goes to see his GP for advice regarding other inhaled medications, and an
action plan for unstable asthma or acute exacerbations.
References
Clinical Medicine, Kumar & Clark, pg 785 ff
National Asthma Campaign Asthma Management Handbook (2002)
Powell H, Gibson PG. Options for self-management education for adults with asthma (Cochrane
Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd.
Learning Resources
CD ROM of Asthma Cases developed by Melbourne University Dept of General Practice,
N Sulaiman et al
21
Sem Activity Title
3 Readings The epidemiology of respiratory disease
3 Lecture Respiratory immunology, allergy and host defences
3 Practical Interpretation of chest Xrays, Peak Flow measurement, and use of Asthma
devices
3 Practical Respiratory, Urinary and Neurological Systems - Revision of Clinical Skills
3 PCL Georgias Bad Cough
3 Lecture Evidence based medicine and Complementary Medicine (1)
3 Lecture Complementary Medicine in Clinical Practice
3 Lecture Pulmonary pharmacology
22
Title: Mr Michael Todd - jaundiced

Author: Associate Professor Bill Sievert
Scenario
Mr Michael Todd, a sixty year old man with known alcoholic liver disease, is seen in the Emergency
Department because his partner thought he looked a bit jaundiced. He has been seen in the same
hospital previously for treatment of gastrointestinal bleeding from oesophageal varices. He attends the
Liver Clinic irregularly for treatment of mild ascites. About two months ago he went to Thailand for a
three week holiday. A few days before admission he began to feel lethargic with nausea and anorexia;
yesterday he noticed that his urine had become tea coloured.
On physical examination he was afebrile; the blood pressure was 110/70, the pulse 85 and regular,
respiratory rate 16 bpm. He looked unwell but was alert and oriented to time, place and person; there
was no asterixis. He was noted by the ED registrar to have mild scleral icterus and numerous spider
angiomata over the upper chest and arms. Abdominal examination revealed that the liver edge was
firm and easily palpable below the right costal margin, the spleen tip was palpable on deep inspiration
and there was bilateral flank dullness. There was 2+ pitting oedema of the ankles.
Further information
Laboratory investigations:
Haemoglobin 95 g/L (110 -160 g/L)
9
Total white cell count 4.0 X 10 /L (4.0 - 11.0 X 109/L)
Neutrophil count 1.7 X 109/L (2.0 - 7.5 X 109/L)
Platelet count 95 X 109/L (150 - 450 X 109/L)
Total bilirubin 110 mol/L (2 - 20 mol/L)

Alkaline phosphatase 230 U/L (30 - 120 U/L)
Glutamyl transpeptidase 300 U/L (5 - 45 U/L)
Alanine aminotransferase 800 U/L (5 - 40 U/L)
Aspartate aminotransferase 730 U/L (5 - 40 U/L)
Albumin 30 g/L (35 - 50 g/L)
INR 1.3 (1.0 - 1.2)

(International normalised ratio)
Creatinine 0.076 mmol/L (0.040 - 0.110 mmol/L)

Urea 9.3 mmol/L (3.0 - 8.0 mmol/L)
Serum sodium 133 mmol/L (135 - 145 mmol/L)
Serum potassium 4.4 mmol/L (3.5 - 5.0 mmol/L)
Serum bicarbonate 34 mmol/L (22 - 32 mmol/L)
Serum chloride 95 mmol/L (95 - 110 mmol/L)
Abdominal ultrasound shows an irregular liver edge, consistent with Mr Todds known cirrhosis, but a
focal liver lesion is not identified. Moderate ascites is demonstrated.
23
References
Gastrointestinal and Liver Disease, 7th ed M Feldman, LS Freidman and M: a Sleisenger (eds),
WB Saunders, 2002
Hepatology - a textbook of liver disease, 4th ed D Zakim and TD Boyer (eds), WB Saunders,
2003
Australian Immunisation Guidelines; 8th ed 2003 Available from the NHMRC website
http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook-home
American Liver Foundation website (http://www.liverfoundation.org)
Sem Activity Title
3 Practical Anatomy of the anterior abdominal wall & gross anatomy of the gastro-intestinal tract
4 Lecture Formulation and functions of bile and the enterohepatic circulation
4 Lecture Digestion and Absorption of Carbohydrates, Fats and Protein; Intrinsic Factor,
Vitamin B12
1 Practical Tissue responses to cellular injury
1 Tutorial How does alcohol disrupt the liver?
1 Practical The histology of cancer cells
2 Lecture Pharmacokinetics
4 Lecture Role of the liver in metabolism and detoxification (1)
4 Lecture Role of the liver in metabolism and detoxification (2)
4 Lecture Integrative tissue metabolism
24
Title: Mr Stephen Tsagakis - severe stomach pain

Author: Dr Stuart Roberts
Scenario
Mr Stephen Tsagakis is a 48 year old alcoholic who is divorced and lives by himself. He has a history
of chronic epigastric pain associated with mild-chronic diarrhoea with passage of bulky stools that are
sometimes difficult to flush. His GP has advised him on a number of occasions to reduce his alcohol
intake without success. He has been taking codeine phosphate intermittently over the past two months
for relief of symptoms.
He presented to hospital acutely unwell with severe epigastric pain associated with nausea and
vomiting. He rated the pain 9 out of 10 in severity and found it was partially relieved by sitting up. He
had had no previous episodes of pain this severe. In addition, he felt mildly short of breath and had
some tingling in his hands.
In the Emergency Department he appeared unwell with a tachycardia of 120bpm, tachypnoea with a
respiratory rate of 28, a blood pressure of 90/50 and temperature of 38oC. His abdomen was tender in
the epigastric region and there was a purplish discolouration in his flanks.
Laboratory Investigations (on admission)
Haemoglobin: 110 gm/L
WCC: 18 x 109/L with neutrophilia and left shift
Platelets: 320,000
U&E: Urea 12 mmol/L, Creatinine 0.15 mmol/L
LFTs: Albumin 28 gm/L, alkaline phosphatase 300 U/L,
GGT 350 U/L, bilirubin 28 mol/L
Serum calcium: 1.85 mmol/L (corrected 2.09 mmol/L)
Serum amylase: 1800 U/L
Serum lipase: 600 U/L
Pulse oximetry: Oxygen saturation 85%
Arterial blood gases: pa O2 54 mm Hg, pH 7.18
Chest x-ray: Mild diffuse pulmonary opacification
Ultrasound: oedematous-looking head of pancreas with multiple
gallstones in gall bladder but common bile duct of
normal size
Further information
Mr Tsagakis has presented with acute abdominal pain in an alcoholic with chronic epigastric pain and
diarrhoea. The diagnosis arrived at by Emergency Room staff is Acute Pancreatitis.
25
References
Baron TH, Morgan DE. Acute necrotizing pancreatitis. New England Journal of Medicine 1999;
340 (18): 1412-7
Fagel FL, Sherman S. Acute biliary pancreatitis: when should the endoscopist intervene?
Gastroenterology 2003; 125 (1): 229-35
Somogyi L, Martin SP, Venkatesan T & Ulrich CD, Recurrent acute pancreatitis: an algorithmic
approach to identification and elimination of inciting factors. Gastroenterology 2001; 120 (3):
708-17.
Etemad B, Whitcomb DC. Chronic pancreatitis: diagnosis, classification and new genetic
developments. Gastroenterology 2001; 120 (3): 682-707
Yamada, Takataka (ed) Textbook of Gastroenterology. Publisher Lippincott Williams & Wilkins,
2003
Sem Activity Title
3 Practical Anatomy of the anterior abdominal wall & gross anatomy of the gastro-
intestinal tract
Vitamin B12
4 Lecture History and examination of the Gastrointestinal system 2; symptoms and signs
suggesting an acute abdomen/management of vomiting
4 Practical Clinical Reasoning - Gastrointestinal Tract Findings
1 Lecture Tissue responses to injury and infection: Acute and chronic inflammation
26
Title: Mr Maxwell Jacobs - fever and night sweats

Author: Dr Denis Spelman
Scenario
Mr Maxwell Jacobs is a 39-year-old male who works full-time as a social worker. He is married with
two primary school aged children. He presents to the Emergency Department with fevers and
uncontrollable shivers, which had commenced 3 days earlier. On further questioning, he had been so
unwell during this time that he was forced to stop working. He had had severe night sweats and had
recorded his temperature to be 39C on 2 occasions. He had also vomited twice and has lost his
appetite. His previous health had generally been good.
He was not taking any regular medications. He had a past history of allergy to penicillin. He smoked
up to 10 cigarettes per day and had moderate alcohol intake. His most recent visit to his local medical
officer was 10 days previously, when he had cut his hand with a kitchen knife whilst attempting to peel
an apple. He received 2 sutures and a tetanus booster.
He gave a history of recent occasional intravenous drug use although had used more frequently when
in his early 20s.
Further Information
Examination reveals a mildly overweight man (weight 87kg). He is lying on the Emergency
Department trolley and is unshaven and looks unwell. His oral temperature is 37.8C, his pulse rate is
106/min (regular), his respiratory rate is 20/minute and his blood pressure is 100/70.
There are 2 subconjunctival haemorrhages in his right eye. His jugular venous pulse pressure is not
elevated. There is no cervical lymphadenopathy.
Examination of his chest reveals clear lung fields. Two heart sounds are heard as well as a
3/6-pansystolic-murmur audible at the apex and radiating into the axilla. No diastolic murmur is
audible.
Abdominal examination reveals a slightly tender liver, which is palpable at 3 finger breaths below his
right costal margin on inspiration. The spleen is not palpable. There is no rash and no joint swelling.
The remainder of the examination is normal.
Further Information
On further questioning Max remembered that as a child he was told that he had a heart murmur and
that he should have a regular medical check-up. He also reported that his intravenous drug use was
more frequent than previously reported and that he had occasionally shared needles. There was no
history of clinical hepatitis and no history of his having received vaccination against hepatitis B or
hepatitis A.
Investigations in the Emergency Department
Ward test of urine: Glucose++
Blood ++
Protein ++
FBE: Hb 110g/l,
WCC 17.0 x 10 9 with neutrophilia and L) shift,
platelets 160 x 10 9/L.
U&Es Creatinine 0.12 umol/L
LFTs Bilirubin 30, AST 125, ALP 190
ESR 65
CRP 225
Blood cultures 2 sets taken
ECG Sinus tachycardia with large P waves seen in chest leads
CXR Normal lung fields. Normal heart size with enlarged left atrium
Urine for microscopy and urine glomerular red cells, culture pending
27
Further Information
On the following day, the laboratory rings to tell you that the blood cultures are positive and Gram
positive cocci have been seen on all blood culture bottles. The isolate from the blood cultures is
confirmed to be a Staphylococcus aureus that is resistant to penicillin, but sensitive to methicillin,
cephalosporin and erythromycin.
A cardiac echocardiogram has been performed and demonstrated moderately severe mitral
regurgitation, an enlarged left atrium and a 1 cm vegetation on the mural leaflet of the mitral valve.
Also a Hepatitis B surface antigen test returns as positive.
References
Spelman D and McDonald M. Endocarditis and Intravascular infection. In Yung A, McDonald
M, Spelman D, Street A and Johnson P. Infectious Diseases: A Clinical Approach 2001, pg
177-187. The University of Melbourne Press and Monash University Press
Therapeutic Guidelines Antibiotics. Version 2. 2003
Sem Activity Title
3 Lecture An introduction to the cardiovascular system
3 Lecture Cardiovascular System biology/structure & histology
3 Lecture The cardiac cycle
1 Lecture Bacteria and antibiotics: social perspectives on magic bullets
1 Tutorial Bacteria and antibiotics: social perspectives on magic bullets
1 Tutorial Bacteria and antibiotics: social perspectives on magic bullets
1 Tutorial Bacteria and antibiotics: social perspectives on magic bullets. Hypothetical
28
Title: Mr Tony Spencer - severe headache and flu symptoms

Authors: Dr Edwina Wright
Dr Olga Vujovic
Scenario
Mr Tony Spencer is a 32-year-old volunteer ambulance driver. Yesterday he woke with a severe
headache, myalgia and fever and spent the day in bed. Last night his flatmate called a locum doctor,
who examined Mr Spencer and made a provisional diagnosis of influenza and recommended bed rest
and paracetamol.
This morning Mr Spencer nearly collapsed after getting out of the shower. He is taken by ambulance
to hospital. On arrival at the hospital a clinical examination of Mr Spencer reveals that he is
normotensive, his temperature is 39.20C and he has a purpuric rash over his limbs and trunk.
Mr Spencer is drowsy but is able to talk and complains of a severe headache and of light hurting his
eyes.
Further Information
The RMO at the Emergency Department does a lumbar puncture and the results are:
Full blood examination: Normal range
Hb 142 g/L (125 175)
WCC 10.1 x 109/L (4.0 11)
Plt 460 x 109/L (150 450)
CSF examination:
CSF is macroscopically turbid
CSF pressure is 30 mmHg (<15)
Glucose 2.0 mmol/L (2.5 4.5)
Protein 0.60 g/L (< 0.40)
Microscopy:
Polymorphs x 106/L 2500
Erythrocytes x 106/L100
Gram negative diplococci seen on gram stain
The patient is admitted to hospital and intravenous penicillin and ceftriaxone are commenced.
References
Attia J, Hatala R, Cook DJ & Wong JG, Does this adult patient have meningitis? JAMA 1999;
281: 175-181.
De Gans & Van De Beek D, for the European Dexamethasone in Adulthood Bacterial Meningitis
Study Investigators. NEJM 2002; 347: 1549-1556
Yung A & Sasadeusz J, Fever and acute neurological symptoms. In, Infectious Diseases: A
Clinical Approach. Yung A et al Cherry Press, Melbourne 2001 pg 111-118
Tunkel AR & Scheld WM, Acute meningitis. In Mandell, Douglas and Bennetts Principles and
Practice of Infectious Diseases 5th ed Churchill Livingstone, Pennsylvania 2000
Meningococcal Disease Home Page. http://www.health.vic.gov.au/ideas/diseases/mening_facts
Therapeutic Guidelines. Antibiotic. Version 12, 2003 Publisher: Therapeutic Guidelines Limited
(http://www.tg.org.au/)
The Australian Immunisation Handbook 8th ed 2003 NHMRC
29
Sem Activity Title
3 Practical Skull, Scalp and Cranial Cavity
3 Lecture Neuro anatomy 1
3 Lecture Neuro Anatomy 2
2 PCL Janet has a sore foot
1 Tutorial Diagnosis and prevention of infection
3 Practical Haematology
3 Tutorial Diagnosis of Anaemia and White Blood Cell Abnormalities
3 Lecture Haematological System History, Examination and Clinical Reasoning
30
Title: Ms Jenny Randall - muscle aches, fever and cough

Author: Dr Alex Padiglione
Scenario
Ms Jenny Randall is a 23 year old student who presents to her local doctor with cough and fever.
Ms Randall started to feel unwell 3 days prior with a shiver and muscle aches, though she did not
take her temperature at that time. The following day she also developed a mild non-productive cough.
She missed her classes and stayed home, drinking fluids and taking regular paracetamol, which
seemed to improve her fever. On the day prior to presenting she felt a little better in the morning and
returned to university, but had to go home at lunchtime because of malaise and a mild headache.
When she got home she again had the shivers and felt she had a temperature, but was again unable
to measure it (there was no thermometer at her boyfriends house). Ms Randall has been previously
well but admits to smoking 10-20 cigarettes a day, which she stopped the day she became unwell.
She has a regular sexual partner. Her only regular medication is a combined oral contraceptive pill.
She has no allergies. Her boyfriend, with whom she lives, has recently had a cold. There is a family
history of heart disease (her father died of an AMI aged 58).
Ms Randall has recently returned from a 3 week holiday.
On examination she appears a little tired but not unwell. Her vital signs are P72 BP 120/65 R 16 T
36.2 Chest appeared clear. The doctor diagnosed a probable viral URTI and advised symptomatic
treatment alone, though she also provided a prescription for roxithramycin to be filled out if her chest
worsened.
Further Information
Ms Randall returns the next day because her fever did not seem to settle overnight despite regular
paracetamol. She bought a thermometer this morning: her temperature at 10 am was 36.9, though by
then she was feeling a little better. Her cough is still not severe and she is unwilling to fill out the script
for roxithromycin, as she knows she gets thrush whenever she takes antibiotics.
The doctor takes a more detailed history. The current illness started with mild shakes, but the episode
of shivers on the day prior to presentation lasted 10 minutes, was associated with chattering teeth and
could not be voluntarily controlled. Two further episodes of fever were similarly severe.
It appears Ms Randall was in Vietnam for 3 weeks during term break, during which time she travelled
from Australia to Hanoi (via Bangkok), then down to Ho Chi Minh city, then via Phnom Penh and Siem
Riep to Bangkok. She returned to Australia 2 weeks before becoming unwell. She received Hepatitis A
and typhoid shots from a University health service before her trip, and took doxycycline as malarial
prophylaxis. (Hep B had been administered on admission to medical school). She stayed in budget
accommodation throughout.
She travelled with a fellow student and admits to a one night stand with a fellow traveller.
On examination she looked tired.
Her vital signs were P72 BP 120/65 R 16 T 36.9
Full CVS, respiratory and abdominal examinations were unremarkable.
There was no rash, and joints appeared normal.
The doctor suspects an atypical chest infection, but is also concerned about the possibility of a travel
related infection. She takes blood for a FBE, electrolytes, serology (for atypical pneumonia, HIV and
Hep A+B) and Malarial thick and thin film. She also thinks a CXR needs to be done. However, she is
unsure about whether Ms Randall needs to go to hospital. She decides to speak to a colleague in the
practice for advice. You are that colleague.
31
Further Information
The doctors decide that, because it is 8pm on a Friday night and the clinic closes at 9 pm, there is no
scope to keep Ms Randall there until results of a malarial screen are available. In addition they think
she looks sick enough to possibly warrant empiric treatment for typhoid or other bacterial sepsis, and
would like a second opinion. They ring the local hospital and speak to the admitting officer, to advise
that they are sending Ms Randall in for assessment. On arrival to the department Ms Randall looks
unwell. Her vital signs are P72 BP 120/65 R 16 T 38.5. The rest of the examination is unremarkable.
Ms Randall admits that, although she was prescribed Doxycycline as malarial prophylaxis, she only
took it intermittently after the first week because she developed vaginal itch that she was certain was
thrush.
She feels her risk of STDs is low, as she has only had protected intercourse, both with her boyfriend
and her casual contact.
Further Information
Some results are faxed through from the large private laboratory:
FBE: Hb 11 WCC 7.0 Plt 110
Malarial Thick and thin film: negative
U + Es: Na 140 K 4.0 Ur 7.0 Cr 110
LFTs: Mildly elevated ALT and Bilirubin, otherwise normal
Serology
Hepatitis A: Total Ab positive, IgM pending
Hepatitis B: Surface Antibody POSITIVE, Surface pending
Arbovirus (Dengue): Pending
HIV: Eliza negative
Atypical pneumonia:
Please specify which tests are required. Convalescent serology should be sent in 2-4 weeks to
confirm.
A CXR at your hospital appears normal.
Further Information
Ms Randall is admitted overnight for observation, and the decision is made not to start any empiric
treatment. The night medical registrar is asked to check on the patients condition overnight, and feels
that she is quite stable, and there is still no need for urgent antibiotics.
A FBE/Malarial blood film is requested urgently 8 hours after the first one was taken. This now shows:
FBE: Hb 10 WCC 7.3 Plt 90
Malarial Thick and thin film: Positive for Plasmodium falciparum, parasite count 0.2%
Ms Randall is started on oral quinine, in consultation with an Infectious Diseases Physician. She
continues to have erratic fevers. Over the next few days her blood results are as follows:
FBE: Hb 9 WCC 7.2 Plt 96; Parasite count 0.1%
FBE: Hb 9.5 WCC 7.2 Plt 115; Parasite count 0%
Her doctor orders a pregnancy test.
References
Brown G, 2001 Malaria & Yung A & Ruff T 2001 Infections in returned travellers and
Immigrants Ch 27 & 38 in Infectious Diseases: A clinical approach. Yung, McDonald, Spelman,
Street & Johnson, eds 2001 University of Melbourne & Monash University, Co-publishers
32
Sem Activity Title
1 Tutorial Diagnosis and prevention of infection
33
Title: Mr Josh Felix - extreme lethargy

Authors: Dr Malcolm McDonald
Dr Chris Drummond
Scenario
Mr Josh Felix is a roadie for the grunge band, Warped Spasm. He is 25 years old and grew up just
outside Wagga Wagga before moving down to live with his cousin, Pearl, in Glen Waverley 5 years
ago. Pearl is an urologist at Dandenong Hospital.
Late one evening, Josh goes to a nearby 24-hour medical clinic for a repeat prescription of his asthma
medication; hes been on tour lately and, over the last 6 weeks, has noticed increasing lethargy
together with a productive cough. He says he has had to borrow another pair of jeans from a friend
because his own kept slipping down.
Further Information
The doctor gives Josh a prescription for salmeterol and fluticasone inhalers, plus prednisolone tablets
5mg (x 100) to take according to his Asthma Management Plan if he gets an attack whilst on the road.
He also gives him a 5-day course of amoxycillin 500mg tds for his cough and asks him to come back if
it doesnt settle down quickly.
Further information
Josh returns to the clinic 5 days later; he feels worse and is unable to sleep properly because of night
sweats, despite taking the amoxycillin as directed. He has not taken any of the prednisolone, but
wondered if it might help his symptoms. You are the new doctor on duty; you look at his file and
decide to go into matters in more detail.
Apart from the productive cough, there are no new respiratory symptoms: he has mild dyspnoea
on exertion (carrying speakers); but no chest pain or haemoptysis.
The sputum is thick & light brown in colour; he is coughing up about a table-spoonful each
morning.
He thinks he may have a fever, although he hasnt taken his temperature. Each evening for the
last month he has felt unwell with slight chills and aching in the muscles. This is followed by
profuse sweating in the early hours of the morning and he has to get up to change his pyjamas.
Josh has had mild asthma since the age of 5 years; he has 3-4 attacks each year, but has
never been hospitalised. He uses the inhalers intermittently, when symptomatic, and rarely
takes oral prednisolone. He is on no other medication.
He smokes about 25 cigarettes per day and has done so for the last 7 years.
Overall, his general health has been reasonable and systematic questioning was otherwise
unhelpful. He doesnt inject illicit drugs, but he does binge drink 2-3 times each month, in
addition to about 4 bourbon and cokes each day.
34
Further History
Family history - Joshs mother went into Wagga Wagga hospital when he was 7 years old and was
treated for spitting blood. His brother, Zack, has severe asthma.
Contact history - Some members of the band have a cold.
Sexual history - He has had many different female sexual partners; sex has often been unprotected.
On one occasion last year he had sex with a man, but cant remember much about it.
Travel history - Josh has never been outside Australia. He recently spent 2 months in Darwin and the
Top End (from early December to late January) with the band. Several of the roadies sleep in the one
motel room whilst on tour.
Animal contact - Pearl has a terrapin at home. No other contact.
Immunisation history - He cant recall what vaccinations he had as a child.
Dietary history - Joshs appetite is usually good. His diet is erratic and consists mainly of junk food; he
eats almost no fresh fruit or vegetables.
Rather gaunt white male, not acutely ill, with pulse rate 98/minute, blood pressure 130/75 mmHg (lying
and sitting), respiratory rate 16/minute & oral temperature 37.6oC.
There are tattoos on his knuckles and he has multiple piercings with rings and studs.
Deltoid cuboma noted (cigarette pack in the T-shirt sleeve). No lymphadenopathy.
Respiratory: hyper-expanded chest, soft rhonchi bilaterally; no other focal signs.
Cardiovascular system is normal & there is no hepatosplenomegaly.
Periphery: no clubbing; no BCG scar. Weight is 58 kg.
Further Information
Initial Results
Full blood film: Hb 109 g/L, WBC 14.5 X 109/L, platelets 140 X 109/L
HIV serology (ELISA): negative
LFTs: bilirubin 19 mol/l (N <17), ALP 110 IU/L (N<120),
ALT 240 IU/L (N<56), GGT 150 IU/L (N<75),
total protein 68 g/L, albumin 26 g/L (N 35 - 45)
CXR: lungs fields hyper-expanded, opacity in the right apex
with a 2 x 2 cm cavity (no fluid level); no cardiomegaly;
mediastinum & hilar regions normal
Sputum Gram stain: WBC +++, mixed Gram-positive and
Gram-negative organisms
Sputum bacterial culture: normal oral flora
Special sputum cultures for
Burkholderia pseudomallei: pending.
Sputum AFB stain: positive ++ (first specimen)
Sputum AFB culture: in progress
35
Further Information
Contacting the patient
In the light of the results, you immediately try to contact Josh only to discover that he was just
admitted to hospital. He was apparently attending the launch of the bands new album, Lambada in
Traction, when he started coughing blood over the drummer. You call the hospitals Admitting Officer
with Joshs test results but he is horrified that you hadnt ordered a Mantoux test. Somewhat
chastened, you then call the Department of Human Services to notify the case.
Further information
Josh has no further haemoptysis but is miserable in the hospitals isolation room and most of his
mates in the band are too frightened to call in. Pearl despairs that she didnt notice Joshs failing
health sooner.
The next two sputum specimens are also reported as positive and the consultant elects to start anti-
TB treatment immediately. Josh is told that he probably has tuberculosis (TB) and his doctor spends
an hour or so detailing the ramifications of the diagnosis. HBV & HCV serology are negative; repeat
liver function tests show a similar picture.
Further information
Management & Progress
The bands manager calls into your clinic to ask you how TB is spread. He is feeling quite well, but is
worried that he might have taken the infection home to his children.
Josh is started on 4 anti-TB drugs (rifampicin, isoniazid, ethambutol & pyrazinamide) plus pyridoxine.
He tolerates the medication well but wants to leave hospital as soon as possible. The nursing staff
notices that a bottle of bourbon has been smuggled into his bedside locker. Meanwhile, the medical
team refers Josh to the Social Work Department and the dietician. The TB cultures subsequently
come back as positive and M. tuberculosis is confirmed by PCR; the organism is then sent for TB drug
susceptibility testing. Cultures for Burkholderia pseudomallei are negative.
Further Information
TB facts for student discussion
It is estimated that 1.9 billion people are now infected with M. tuberculosis.
About 10% of people infected with M. tuberculosis will get the disease of tuberculosis sometime
in their life, about half in the first 2 years after infection.
There are 8 million documented new cases of disease each year; of course, the number of
undocumented case (for the most part) remains a mystery. WHO has recently declared a Global
Tuberculosis Emergency.
Worldwide, about 50% of people with active disease get treated & only half of those finish the
course of treatment. Failure to complete a course of treatment is the major cause of drug
resistance.
Multiple drug resistance is an increasing worldwide problem, especially in Asia and Eastern
Europe (former Soviet bloc counties).
The incidence of tuberculosis in Australia is low, about 6 cases per 100,000 people per year.
Risk groups include immigrants, indigenous communities, the homeless, the elderly and people
with HIV.
Nosocomial tuberculosis is an important problem: health care workers and other patients are at
risk. Delay in diagnosis is a critical factor. Note that there was a well-publicised outbreak of TB
at Dandenong Hospital about a decade ago.
M. tuberculosis and HIV were made for each other by the devil. The risk of developing
(tuberculosis) disease in someone infected with both M. tuberculosis and HIV is 10-15% per
year (more than a lifetimes risk each year). The disease is more aggressive and people with
open disease are more infective.
Worldwide, tuberculosis is the major cause of death in people with HIV.
36
Tuberculosis is primarily a disease of the poor. Thus, it is unlikely to generate substantial profits
for the pharmaceutical industry (and shareholders). There have been no significant new anti-TB
drugs on the market in more than 20 years.
The current budget of the WHO Tuberculosis Program is about the cost of a stealth bomber.
References
Street A, Tuberculosis. Ch 29 in Infectious Diseases: A Clinical Approach Ed. Yung,
McDonald, Spelman, Street & Johnson 1st ed 2001
Learning Resources
None Listed
Sem Activity Title
1 Lecture Tissue responses to injury and infection: Acute and chronic

inflammation
3 Directed learning The epidemiology of respiratory disease
1 PCL Alans dilemma
37
Title: Mr Simon Smith cannot get out of bed

Author: Anne Mijch
Scenario
You are working as a trainee General Practitioner in a Victorian regional city when a regular patient of
Dr Strongs, Mrs Bella Smith comes in with her 18 year old son Simon.
Simon states, I am too sick to work because of this flu which has got me down over the last two
weeks. Can you give me a certificate?
Mrs Smith interrupts with I am worried because he hasnt got out of bed for 10 days, he just lies there
in the dark complaining of bad headache, and fever and shivers, he wont eat anything and yesterday I
saw he had a rash all over his back and he has lumps in his neck. No one else in our community has
this. I think he caught it in Melbourne on his last trip.
Image: Diffuse Maculopapular rash

Further Information
Simon is previously well, works as an apprentice trainee chef in local restaurant, lives with his Koori
family (mother older sister and three younger brothers) in small community at edge of town, goes to
Melbourne each weekend. He has recently started experimenting with party drugs ice and hammer,
using his own fit obtained from NSP (needle and syringe program) and he drinks 14 beers each
Saturday night. Simon has visited a sauna for gay men, had 2 sexual partners in the past month; one
a local girl and one a man he met at the sauna. His mother knows nothing of his Melbourne activities.
He has no other travel history and has a pet dog and no other animal contacts. He knows no other
person with a similar illness. Family history reveals his grandmother had TB treatment when he was
four years old. He has no allergies and is not taking any prescribed medication.
Examination reveals Simon as an anxious young man looking mildly unwell. He has lymph nodes in
the cervical, axillary, inguinal areas, a just palpable spleen and a small painful healing ulcer on the
foreskin of his penis. There is a purulent discharge from the urethral meatus. Scrotal, perirectal
examination is normal. His rash is diffuse maculopapular and his mouth examination is normal. Neck
stiffness is absent; Kernigs sign is negative.
His height 170 cm, body weight 58 kg. BMI =20.1
38
References
Clinical Trials & Treatments Advisory Committee of the Australian National Council on AIDS,
Hepatitis C & Related Diseases (ANCAHRD) Model of care for HIV infection in adults Adelaide,
2000
Venereology Society of Victoria & the Australasian College of Sexual Health Medicine National
Management Guidelines for Sexually Transmissible Infections. Melbourne, 2002
http://www.mshc.org.au
Spicer J, Clinical Bacteriology, Mycology and Parasitology: an Illustrated Text. Churchill
Livingstone, Edinburgh 2000 pg 154-5
Australian Society for HIV Medicine. HIV/Viral hepatitis: a guide for primary care. Eds: Gore G
et al Canberra 2001 http://www.ashm.org.au
Australian Society for HIV Medicine. HIV Management in Australasia a guide for clinical care.
Eds: Jennifer Hoy & Sharon Lewin, Canberra 2003 http://www.ashm.org.au
National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and
sexually transmissible infections in Australia Annual Surveillance Report 2002. National Centre
in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, NSW
2002. http://www.nchecr.unsw.edu.au/
First Year MBBS Study Guide (2002)
Sem Activity Title
1 PCL Alans dilemma
1 Tutorial HIV/AIDS Across Nations
1 Lecture HIV/AIDS Across Nations
1 Tutorial HIV/AIDS Across Nations
39
Title: Ms Siu Jung - rash

Author: Professor Geoff Littlejohn
Scenario
Ms Sui Jung is a 22 year old student who presents with a rash on her face and chest. It has been
made worse following a recent vacation in Queensland. She has had some months of aching and
stiffness in the joints of her hands but she reports no joint swelling. She has been feeling vaguely
unwell and has had some mouth ulcers in recent times but reports no other symptoms.
Examination shows she is pale but she is not unwell. She has patchy alopecia, a rash and axillary
lymphadenopathy. Initial investigations show mild anaemia, leukopenia, elevated erythrocyte
sedimentation rate, negative rheumatoid factor, positive antinuclear antibody and elevated
anticardiolipin antibodies. Renal function is normal.
References
Key references from scientific journals
American College of Rheumatology Classification Criteria for lupus, scleroderma, myositis, Sjogrens
syndrome
Selected text book reference articles
Sem Activity Title
1 Lecture Primary tissue types and function I
1 Lecture Blood components
1 Lecture Blood clotting
1 Lecture Introduction to the immune system: self and non-self
1 Lecture Cellular and molecular basis of the adaptive immune system
1 Tutorial T Cells
1 Lecture How the immune system works and how it defends the body against infection
1 Lecture How the immune system deals with invading organisms
3 Lecture Susceptibility to infection resulting from white cell abnormalities
40
Title: Mr Peter Paunch - knee pain and swelling

Authors: Professor Geoff Littlejohn
Associate Professor Michelle Leech
Scenario
Mr Peter Paunch a mildly obese exVFL footballer, aged 41, presents with acute pain and swelling of
the right knee after a minor injury at work. The injury was not severe but examination reveals marked
swelling and some redness of the right knee joint. The joint is very warm. No other joints are involved
and he is otherwise well. There is a past history of a similar onset of pain, swelling and redness in the
first metatarsophalangeal joint on two occasions over the past year each lasting up to one week and
subsequently resolving completely.
Further Information
Investigations show, normal full blood examination, erythrocyte sedimentation rate is 52 (normal < 20),
uric acid is 0.5 micromole per litre (normal 0.15 to 0.47). X-ray shows mild medial compartment joint
space loss, mild subchondral sclerosis and a small osteophyte at the medial joint margin. There are no
erosions and no calcification of articular cartilage. Joint aspiration showed a white cell count of 30,000
white cells per cubic millimetre and numerous monosodium urate crystals were identified under
polarised-light microscopy. There are no organisms seen on gram stain and no growth on culture of
joint fluid. What are all the possible causes of peters knee swelling? How would you rule each one
out? How would you prevent this attack from occurring and how would you manage his background
knee problems in the long term?
References
None provided
Sem Activity Title
2 Tutorial Framework for focussed history taking and examination of the musculoskeletal
system
3 Lecture Diuretics
41
Title: Mr Jules Brady - health check

Authors: Professor Harvey Newnham
Dr Roger Peveril
Professor Boyd Strauss
Scenario
Jules Brady, an overweight 29 year old teacher you have seen infrequently with minor problems in the
past, presents to your general practice for follow-up of his lipid status. He initially attended for a health
check at the insistence of his wife, Brenda, who is concerned because Juless father has recently had
coronary surgery at the age of 59. You had insufficient time at the previous visit to do a formal
assessment but did ask him to have a fasting lipid profile which has now come back showing
hyperlipidaemia (fasting cholesterol 7.8 mmol/l, triglyceride 1.7 mmol/l, HDL 1.1 mmol/l).
Further information
History
Sedentary teacher, concerned about weight but otherwise no previous health problems.
No symptoms to suggest coronary, cerebrovascular or peripheral vascular disease.
Jules is a non-smoker and drinks 1-2 glasses of wine daily.
He does not take any herbal or other medications and has no known drug allergies.
Family History
Father had first AMI age 51 with subsequent coronary angioplasty. Recently had coronary grafts after
developing unstable angina and noted to be hyperlipidaemic.
Fathers elder brother had AMI and died age 54.
Jules has two children, a son age 5 and daughter age 3.
Juless mother and wife are both well.
Diet
Jules takes sandwiches to school, made by Brenda who is quite health conscious. He has take-away
twice a week, eats fish twice weekly and has only occasional between-meal snacks. He is enjoys a
Friday evening barbecue after work.
Examination
Increased BMI, cheerful man
Pulse 70 reg, BP 140/75. Afebrile
CVS: Corneal arcus. Thickened Achilles tendons bilaterally. Peripheral pulses all present and no
vascular or cardiac bruits.
Chest, abdo NAD. No signs of chronic liver disease.
Clinically euthyroid with brisk ankle jerks and no goitre.
Full ward test urine negative for glucose & protein.
Pre-meeting questions
1. What are the major cardiovascular risk factors for the development of atherosclerosis?
2. How should patients be targeted and investigated regarding possible cardiovascular risk
factors?
3. What are the major treatment options (pharmacological and non-pharmacological) for the
treatment of hypertension, obesity and hyperlipidaemia?
42
Learning Resources
General textbook of medicine eg Harrisons Textbook of Medicine (Up-To-Date CD-rom based
reference)
Obesity: preventing and managing the global epidemic Report of WHO Consultation on
Obesity, WHO Geneva 1997.
National Heart Foundation (Australian) Web Site:
http://www.heartfoundation.org.au/Professional_Information/General_Practice/Pages/Managing
bloodpressureandlipids.aspx
Australian Institute of Health and Welfare Website:
http://www.aihw.gov.au/cvd/risk_factors.cfm
Coronary risk calculators:
http://www.nzgg.org.nz/guidelines/0035/CVD_Risk_Chart.pdf and http://www.riskscore.org.uk/

Sem Activity Title
1 Lecture The chemical components of cells
2 Lecture Introduction to Epidemiology & Biostatistics
3 Correlation Coronary circulation in health and disease
4 SPC Briefing Student Project Case briefing

Topic 6: Risk factors for heart disease
4 Lecture Lipid metabolism
1 Tutorial Health Enhancement 3 Nutrition
2 Lecture Motivation

Topic 5: Growth, Nutrition & Critical Periods
4 Lecture Peripheral actions of thyroid hormones
4 PCL The Wedding
4 Lecture Nutritional Fuels and Energy Balance: Major Food Substrates and their
Basic Structures
4 Lecture Micronutrients structure, function and relationship to disease
4 Lecture Digestion and Absorption of Carbohydrates, Fats and Protein; Intrinsic

Factor, Vitamin B12
4 PCL Why Am I So Overweight?
43
Title: Ms Anne Smith - history of headache

Author: Dr Richard Stark
Scenario
Ms Anne Smith is a 40 year old woman who presents to you with a long history of headache. She
suffered headaches about once a month from age 15. These occurred mostly with her period, but
sometimes at other times. Her VCE year was worse, with headaches sometimes once a week. In her
20s, they occurred on average every 2-3 weeks. These headaches were all quite disabling.
Sometimes they would be preceded by a visual disturbance of shimmering in the right or left visual
field. This would move gradually to the periphery over 20-30 minutes, then settle and the headache
would follow. Sometimes the headache came without any warning.
It was severe, usually in one or other temple and over the forehead. Within an hour or two she would
be confined to bed with nausea and vomiting. She had to get away from light and noise. If she could
get to sleep quickly, she would usually wake with only a mild headache, but would feel hung-over;
otherwise the headache might linger for 24 hours or so. She tried a lot of over-the-counter medications
and found Panadeine and similar agents to be slightly helpful. Her mother had also had severe
headaches and had always taken a lot of over-the-counter medications for them. While in her 20s,
Anne had once called her GP at night because of an unusually severe headache. A locum service was
on call; the locum seemed reluctant to treat her but eventually gave her an injection (she thinks it was
Pethidine) which helped her to sleep. Once or twice she attended the GP to get a work certificate and
once the GP gave her a prescription for some Panadeine Forte. She found this more effective than
Panadeine. After that, whenever her headaches flared up, she would visit the GP and get another
prescription.
Over the past 10 years the headaches have become more frequent, with usually 1-2 headaches/week.
However in the last 6 months the headaches have been present virtually daily, with only rarely 1-2
days without headache. Most of the headaches are moderately severe but about once a week a
severe one occurs. The current severe headaches are bilateral, severe - reported by the patient as
11/10 on a scale of 0 (no pain), to 10 (worst imaginable) with nausea & vomiting, and last 2-3 days.
She often presents to her GP for treatment of these. Nothing short of Pethidine seems to help them
and this worries her GP. Several have required admission and rehydration. The background daily
headaches are 7/10 in severity and she takes 2-4 Panadeine Forte per day.
On review of her current treatment, she is taking Panadeine Forte 2-8/day (average 30/week) and is
receiving Pethidine 100mg about once a week. During the last six months she has tried Imigran,
Sandomigran and Inderal without benefit. She describes herself as emotional, a worrier, perfectionist,
dreadful sleeper. She has had several family stresses in the past few years: she and her husband
were on the verge of separating 2 years ago and her teenage daughter is causing concern with
rebellious behaviour. She works as a legal clerk and has missed about 4-5 days work per month with
headache in the past 3 months. Her boss was initially sympathetic but is now becoming less tolerant.
References
Headache classification committee of the IHS. Classification and diagnostic criteria for
headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988 8: 1-96. NB There has
been a substantial revision in October 2003, definitive reference not yet available.
Standard neurology reference text, chapter on headache for an overview. Any text will do,
eg Neurology in Clinical Practice 2nd ed Bradley et al (eds) 1996 Butterworth-Heinemann
Monograph: Mechanism and Management of Headache 6th ed Lance & Goadsby 2000
Goadsby PJ Migraine: diagnosis and management Intern Med J 2003 Sep-Oct; 33 (9-10):
436-42. Nice summary of the state of the art in migraine.
44
Sem Activity Title
2 Lecture Antimigraine
3 Lecture Treatment of Hypertension 1 & 2
45
Title: Mr Branco Vladic motor vehicle accident

Authors: Dr Sarah Kemp
Mr Shay Zayontz
Scenario
You look at your watch. It is 3 oclock in the morning. You wonder if you will have time for a coffee
before seeing another patient and, as you are wondering this, you are called to the phone.
Dr Nguyen, it is the Ambulance Service. The ambulance dispatch tells you that they are bringing in a
24 year old man, who has been involved in a car accident. They report that he was the driver of a car
that hit a power pole on the wrong side of the road. They go on to say that he was not wearing a seat
belt.
The patient, Mr Branco Vladic, arrives 10 minutes later. He is confused, looking around and asking
where he is but he is not answering your questions. He is combative with staff, smells of alcohol and
complains of lower chest pain on his left side and bilateral leg pain with severe pain in the left leg. The
ambulance officer hands the patient over to you and informs you of her observations - pulse rate 104,
blood pressure 110 on 60, respiratory rate 26, oxygen saturation 98% and he is currently on
supplemental oxygen therapy. You thank the ambulance officer and take over the management of the
patient.
Thirty minutes later the patients condition starts to decline. You note that is his pulse rate and
respiratory rate are increasing and his blood pressure and oxygen saturation are falling. When you re-
examine the patient his trachea is deviated to the right and he has absent breath sounds over the left
chest.
You insert an intercostals catheter with immediate bubbling through the under water seal and minimal
fluid / blood drainage and the patients condition starts to stabilise. However, you are concerned
because he remains confused, cannot answer questions about the accident and does not know where
he is or what day it is.
You order an IV infusion of saline, a trauma series of x-rays, a CT scan of his head. His Chest x-ray
shows fractured ribs on the patients lower left side and a well positioned left ICC, lateral c-spine x-ray
is normal as is the x-ray of the pelvis and lower limbs shows bilateral fractures of the shaft of femur.
The CT scan of the brain is normal. After an hour and a half in the Emergency Department the
patients pulse rate is now 110, blood pressure is 90/50 and oxygen saturation is 97%.
What associated injuries must be excluded immediately (primary survey)? What other
associated injuries must be sought (secondary survey)?
What is the difference between a compound fracture and an open fracture?
What are the possible causes for the severe pain in the left leg?
Which of these causes needs urgent attention and what are the clinical signs?
What test can be used to confirm this diagnosis?
What are the signs of common peroneal nerve or tibial nerve injury?
What are the anatomical relations of these nerves and where are they prone to injury?
What are the anatomical relations of the branches of the popliteal artery and how would you
assess the source of bleeding from the right leg wound?
What are the potential complications of the right leg wound and what steps would you take to
prevent them?
What are the most common potential infecting organisms?
What is the likely management for the left and right limbs, and when is the patient likely to
commence mobilisation?
What are the musculoskeletal consequences of prolonged immobilisation?
Each group member will thoroughly research at least one aspect of fractured limb.
All students should attempt to see at least one patient with fractured limbs before the second
tutorial.
46
Learning Resources
Section on multiple injury / multiple trauma in surgical textbook
EMST/ ATLS manual
Chest X-rays showing pneumothorax and rib fractures
CT scans showing extradural haematoma, subdural haematoma, diffuse cerebral swelling
(these films should be available in radiology department libraries)
If possible students should observe a trauma resuscitation in their hospitals emergency
department.
Sem Activity Title
3 PCL Hot summers night
1 Practical First Aid Program: Basic Life Support Level 1
3 Lecture Tranfusion
3 Practical Blood Transfusion
3 Practical Basic First Aid - Part A - The Patient with a Medical Emergency
3 PCL Josh under pressure
47
48
Problem-based learning
Patient Cases
49
50
Year 3B Problem-Based Learning (PBL) Student Guide PBL Patient Case 1
CASE 1: Chest Pain

Author: Professor Ian T. Meredith
Aim: Students will explore the aetiology, pathophysiology, clinical manifestations (including
ECG findings of a patient with chest pain) and management of ischaemic heart
disease.
Preparation
Before the first tutorial one pair of students should see a patient with coronary artery disease
(CAD).
The common admitting unit is the cardiac unit.
The students should take a thorough history and perform a complete physical examination.
Focus particularly on the presenting symptoms, the presence or absence of complications and
potential risk factors.
Bring along the results of relevant investigations to the tutorial and be prepared to make a
patient presentation to your group members.
All group members should discuss the scenario below. Discuss the similarities and differences
between the presenting signs and symptoms of your patient compared to the presentation of the
patient described in the case scenario and whether this is different for male and female patients.
All group members should review typical 12 lead ECG changes associated with inferior,
inferolateral, posterior and anterior myocardial infarction.
1. What is the pathophysiology of acute myocardial infarction?
2. How is this different in men and women?
3. What is the fundamental objective of reperfusion therapy and what are the options?
4. What is meant by secondary prevention? What are the options and how do they work?
Tutorial 1
Brief discussion of answers to pre-session questions.
Students make their patient presentation.
What questions emerge as a consequence of the students presentation?
What issues emerge from the scenario?
How does each theme relate to the patient presentation and the scenario?
Each group member will thoroughly research at least one aspect of chest pain/IHD.
All students should attempt to see at least one patient with chest pain/IHD before the second
tutorial.
All students should attempt to see a coronary angiogram and angioplasty before the second
tutorial.
Scenario
Clinical History:
It is 7.45am on a Sunday in the Accident & Emergency Department when Mr John Hopkins, 41 year
old married male with 3 children (aged 3, 5, and 7 years) is brought in. He is a self-employed builder
and amateur triathlete. He was awoken at 4.30am with dull, heavy, central indigestion-like chest
discomfort. The discomfort is associated with tightness in the neck and throat and a heavy woody
feeling in both arms. He gives a history of 2 vaguely similar episodes while riding his training bike to
work on cold mornings.
Past Medical History
Appendicectomy at 14yrs
Vasectomy at 40yrs
Mild Hypertension at 35 yrs
51
Cardiovascular Risk Factors

Smoked 30 cigarettes per day for 15 yrs. Stopped smoking 1 year ago.
Blood pressure apparently mildly elevated. First noted 6yrs ago.
Lipids Never had it checked
No history of diabetes
Family History
Father died at 58 AMI (known Type II Diabetes Mellitus, Smoker)
Mother CVA at 61
2 Older sisters, 1 younger brother, 1 older sister has T2 DM and Hypertension.
General Inspection:
Pale, sweaty, distressed and unwell looking
Not centrally cyanosed
Vital Signs
BP 90/58 lying
PR 102 sinus rhythm
RR 20
Temp 37o
CVS, Respiratory & Vascular Examination
All pulses intact, L = R
No carotid bruits
Apex beat not displaced
Auscultation, Normal heart sounds, no murmurs but clear 4th heart sound
Lung fields clear
Basic Investigations
ECG: Marked ST elevation in leads, II, III, AVF, V5, V6
CXR: Upper lobe diversion, mild pulmonary venous congestion
Cardiac Enzymes: CK, CKMB, cTnI Minor cTnI rise 2.0
U & Es: Normal
FBE: Normal
Clotting Profile: Normal
Lipid Profile: Total Chol 7.0mmol/L,
LDL Chol 4.9mmol/L,
HDL Chol 1.2mmol/L, TG 2.6mmol/L
52
Tutorial 2
Report your findings to the group.
Compare and contrast the patient presentation from the first tutorial with other patients you have
seen with chest pain/IHD.
Review the pre-session questions.
Are there any outstanding issues? If so, what are they and how will you answer them?
References
Charney P (ed) Coronary Artery Disease in Women: What all Physicians Need to Know.
Philadelphia, American College of Physicians 1999
Vaccarino V, Parsons L, Every NR, Barron HV & Krumholz HM, Sex-Based Differences in Early
Mortality after Myocardial Infarction. N Engl J Med 1999; 341 (4): 217-25
Hochman JS, Tamis JE, Thompson TD et al Sex, Clinical Presentation, and Outcome in
Patients with Acute Coronary Syndromes. N Engl J Med 1999; 341 (4): 226-32
Learning Resources
ECG
Cardiac Enzymes
Echocardiography
Angiographic Images
Pathology Specimens
Lipid Profile
Review Questions
1. What are the typical ECG features of an inferior MI?
2. Has reperfusion therapy been shown to be of benefit?
3. What secondary prevention strategies have been shown to be of benefit?
Sem Activity Title
1 PCL Fred goes to the doctor
3 Lecture Principles underlying clinical reasoning in medical history taking
3 Lecture Arrhythmias and their pharmacological treatment
3 Lecture Sex, Gender and Medicine
3 Lecture Thrombosis
53
CASE 2: Acute Glomerulonephritis (GN)

Authors: Professors Stephen Holdsworth
Napier Thomson
Aim(s): Students will recognise the clinical features and diagnostic processes that define
glomerular dysfunction and the different diseases that may cause it as well as the
indications for, and principles of, treatment.
Preparation
Before the first tutorial, one pair of students should see a patient with primary or secondary
glomerulonephritis.
Patients will be found in the renal unit. Several patients are admitted each week for renal
biopsy (the vast majority have this biopsy to investigate glomerulonephritis). Many of the
patients in the dialysis unit will have developed renal failure because of glomerulonephritis.
Students should take a thorough history and perform a complete physical examination and urine
analysis focussing on the symptoms and signs of glomerular injury and the presence of any
underlying disease that may have led to glomerulonephritis.
Bring the results of relevant investigations to the tutorial and be prepared to make a patient
presentation to the group members.
between the presenting signs and symptoms of your patient compared to the patient described
in the scenario below.
1. What is the role of the glomerulus and what would be the clinical consequences of damage to
these filtering organs?
2. What are the major extra renal diseases that may secondarily cause glomerulonephritis?
3. What major clinical and laboratory indicators would suggest the presence of one of these
diseases?
4. How would laboratory tests (including urine analysis) assess the consequences of glomerular
injury?
5. When should a renal biopsy be performed and what information will it provide?
6. How does glomerular filtration rate vary between males and female and what impact will that
have on their management?
Tutorial 1
Brief discussion of answers to pre-sessions questions.
What questions emerge as a consequence of this presentation?
Discuss the clinical features of the patient that result from glomerular injury.
Discuss the extra-renal features that (in association with the presence of glomerulo-nephritis)
comprise the primary disease.
How does each theme relate to glomerulonephritis?
Each group member will thoroughly research at least one aspect of glomerulonephritis.
All patients should attempt to see at least one patient with glomerulonephritis before the second
tutorial.
All students should view a renal biopsy and the CD Glomerulonephritis - from renal biopsy to
diagnosis.
Role-play giving information to patients presenting with glomerulonephritis about diagnostic
procedures, likely diagnoses, outcomes and treatment options.
54
Scenario
Mr Kevin Jacobs is a 66 year old retired carpenter who has been in excellent health and is planning for
an active retirement. He and his wife have 8 grandchildren whom they see frequently. Over the last
3 months Kevin has developed recurrent sinusitis. Despite antibiotics and decongestants he has felt
generally unwell with increasing tiredness, weight loss of 8 kg, occasional night sweats and increased
aches and pains. For 3 weeks he has noticed a rash on his legs below the knees consisting of fine red
spots. Two days ago he became short of breath and today developed a productive cough with blood
stained sputum.
On physical examination he is pale and dyspnoeic (respiratory rate 18). His blood pressure is 150/100.
His chest has scattered coarse crepitations throughout both lung fields and he has tenderness over
both maxillary sinuses. His palpable red non-tender rash below the knees is confirmed and mild ankle
oedema is detected.
His GP ordered a CXR which showed 2 upper lobe infiltrates bilaterally, one possibly
cavitating. His screening blood tests showed a creatine of 350 umol/l (n<100),
anaemia hb90 g/l (n>120) and a raised CRP 110 (n<5) and ESR 60. He is referred to
hospital for urgent further assessment.
Tutorial 2
Compare and contrast the patient presentation/case scenario from the first tutorial with other
patients you have seen with glomerulonephritis.
Are there any outstanding issues in relation to glomerulonephritis? If so, what are they and how
may they be resolved.
Review Questions
1. Outline how serological screening can exclude the presence of secondary glomerulonephritis.
2. In which forms of glomerulonephritis is a renal biopsy important?
3. When confronted by a patient with oedema, how would nephrotic syndrome be excluded?
4. What approach should be taken to elucidate the cause of nephrotic syndrome?
5. Outline how renal disease could be excluded in an asymptotic normotensive patient with no
family history of renal disease.
6. How would this case be different if the patient were female?
Sem Activity Title
3 Lecture The Role of the Kidney in Pharmacokinetics
3 Lecture Psychosocial factors and Mind-Body Medicine in Health promotion
55
CASE 3: Breathlessness
Authors: Dr Rob Stirling
Dr Frank Thien
Aim(s): To understand the pathophysiology of breathlessness and its aetiology
To consider the various determinants of breathlessness, how they interact and how
they may be clinically differentiated
To identify the clues of medical history in breathlessness
Preparation
Before the first tutorial one pair of students should see a patient with breathlessness.
The common admitting unit is the cardiac unit.
between the presenting signs and symptoms of your patient compared with the presentation of
the patient described in the case scenario.
1. What is breathlessness?
2. What is the pathophysiology of breathlessness?
3. Which organ systems may contribute to breathlessness?
4. Consider the aetiologies of breathlessness when the pattern of onset is rapid (hours or days),
progressive (weeks) or insidious/slowly progressive.
Scenario
Ronald Biggs has been feeling increasingly worse over the last 3 days. He had bad chest pain on his
left side and was feeling breathless despite using his puffer throughout the night. He has lost his taste
for cigarettes and his appetite is poor.
Maureen, Ronalds wife was worried about his chest pain. She was no expert but maybe it was a heart
attack. Ronald was 60 and had smoked about 1 pack a day for the last 40 years. Maureen had finally
scared Ronald into giving up about a month ago, after his hospital admission with pneumonia. The
inhalers he had been given after his last admission had been forgotten - left in a drawer until 2 days
ago. Maureen remembered 10 years ago when he was able to run for half an hour but since then he
had gradually declined until now, when he was lucky to walk 100 meters without having to stop for a
breather.
Maureen decided if he wasnt any better by tea time she was taking him to the hospital.
Several hours later Ronalds breathing was worse, he was sweaty and talking less. Maureen took him
to the hospital.
Further Information
Examination revealed an overweight man in some respiratory distress, respiratory rate was 26, heart
rate 106, temperature 37.6C and BP 158/82. Pulse oximetry showed Sp02 88% on room air. Lips were
darkened and the mouth dry. The chest was barrel shaped and the neck muscles tensed with
inspiratory effort. The heart sounds were soft and distant. Breath sounds were soft and there were
coarse wheezes throughout, with crackles at the left base posteriorly.
56
Further information
Six weeks after his hospital admission, Mr Biggs returned for review, denying that he had been
smoking but smelling strongly of cigarette smoke. His chest pain had completely resolved and his
cough had regressed so that he was clearing his throat each morning without visible sputum. Walking
up an incline or with shopping bags remained difficult. He has discontinued his inhaled medications
since discharge. Spirometry on discharge had revealed an FEV1 of just 58% predicted with Forced
Expiratory Ratio (FEV1/FVC) 52%.
Tutorial 1
Each group member will thoroughly research at least one aspect of breathlessness.
All students should attempt to see at least one patient with breathlessness before the second
tutorial ensuring to take a thorough history.
All students should attempt to visit the lung function laboratory to observe.
The students should try to attend the Respiratory outpatient clinics and try to familiarise
themselves with investigations including visits to lung function testing, radiology, CT scanning
and the bronchoscopy suite.
Tutorial 2
seen.
References
Clinical Medicine, Kumar & Clark pg 755-757
Oxford Textbook of Medicine, Weatherall pg 1285-1287
COPDX Guidelines eMJA
http://www.mja.com.au/public/issues/178_06_170303/tho10508_all.html and
http://www.copdx.org.au/
Quitline Ph: 131848, http://www.quit.org.au
The Cancer Council Victoria http://www.accv.org.au
57
Sem Activity Title
3 Practical Histopathology of the respiratory system
3 Lecture Respiratory system - History and Examination
3 Lecture Infectious diseases of the respiratory system
3 Lecture Pulmonary Pharmacology - Antimicrobials
3 PCL Tom in the garden
58
CASE 4: Cough and weight loss

Authors: Dr Phil Bardin
Dr Xun Li
Aim: Students will explore cough as a symptom associated with weight loss. Causes, key
investigations and surgical management of lung cancer will be incorporated.
Preparation
Before the first tutorial one pair of students should see a patient with cough.
The common admitting unit is the Respiratory Unit (44N MMC).
The students should take a thorough history. Focus particularly on the presenting symptoms,
the presence or absence of complications and potential risk factors.
1. How is cough generated and in response to which stimuli? What nerve supply is involved?
2. What are the most common causes of cough?
3. Why is cough such a key yet under-rated symptom?
4. Why may weight-loss be important in this context?
Tutorial 1
How does each theme relate to the patients presentation?
Each group member will thoroughly research at least one aspect of cough.
All students should attempt to see at least one patient with cough before the second tutorial.
Scenario
Ian wishes he could be out having a cigarette rather than sitting in a waiting room of a doctors surgery
waiting to be told to give up his favourite hobby. Today he is seeing Dr McDonald, who is new at the
practice he has been going to for the last 20 years. Hope he doesnt nag too much, is Ians last
thought before entering the surgery. Dr McDonald asks Ian, What has brought you here today, Mr
McNamara?. Ian replies, Call me Ian. I am here because I am a bit worried because I have noticed
some blood in my phlegm the last few weeks. My wife keeps nagging me to give up the cigarettes
because they are to blame but you arent going to make me give them up, are you, Doc?
Dr McDonald asks Ian a few questions and finds out that he smokes 1 pack a day and has done so for
the last 20 years since he was about 30 years old. Dr McDonald has a quick look at Ians file and sees
that he had been hospitalised with pneumonia as a child and ever since has had some cough and
sputum production. He also feels lethargic and has not much appetite and appears to have lost
weight. On strenuous exertion Ian feels somewhat breathless without impact on his daily activities. He
denies any chest pain. Dr McDonald does a physical examine on Ian and notices clubbing of the finger
nails and, on chest auscultation, decreased breath sounds on the left side. Enlarged lymph nodes are
palpable on the left supraclavicular area.
59
Tutorial 2
seen with cough.
Review Questions
1. What special investigations can be done to investigate cough? What is a reasonable approach
given that not all patients with cough can be extensively investigated (or need to be)?
2. What determines operability of lung cancer?
3. How effective is treatment for lung cancer?
References
Clinical Medicine, Kumar & Clark 759-782
Oxford Textbook of Medicine (2003) Weatherall 1283-1285
Sem Activity Title
1 Lecture Natural barriers, innate defense mechanisms and introduction to host-parasite

relationship
1 Lecture Principles of diagnosis of infectious diseases
1 PCL Immunisation
3 Lecture Respiratory immunology, allergy and host defences
3 PCL Georgias Bad Cough
60
CASE 5: Deep Venous Thrombosis/Pulmonary Embolus

Authors: Paul King
Michael Farmer
Aim(s): Students will recognise the clinical presentation of deep venous thrombosis (DVT) and
pulmonary embolism (PE), and understand the appropriate laboratory investigations,
underlying pathophysiology and treatment.
Preparation
Before the first tutorial one pair of students should see a patient with a DVT and one pair of
students should see a patient with a PE.
The common admitting units are the haematology unit, the respiratory unit and the general
medical unit.
The students should take a thorough history and perform a complete examination. Focus
particularly on the presenting symptoms, the presence or absence of complications and
between the patient presentation and this scenario.
Pre-meeting Questions
1. What are the definitions of a deep venous thrombosis and a pulmonary embolus?
2. What are the main clinical (symptoms and signs) features of a DVT and a PE?
3. What are the tests needed to assess patients with DVT and PE (with specific reference to full
blood examination, ECG, oxygen saturation, Chest X-ray, leg ultrasound, V/Q scan and CT
angiography)?
Scenario
Mrs Jones is a 55 year old woman with a history of chronic congestive heart failure who has returned
to Australia last week after a holiday in Europe. She notes the acute onset of sharp right-sided chest
pain. She also feels mildly short of breath and coughs up a small amount of blood. Alarmed, she
phones her daughter who takes her to a hospital emergency department.
In the emergency room Mrs Jones is examined by the intern who finds that her chest is clear on
auscultation, but notices some swelling of her left calf.
Tutorial 1
Presentation of patients with DVT/PE and comparison with scenario
Discussion of presenting symptoms and signs of patients with a DVT and a PE
Discussion of the tests needed to assess patients with DVT and PE (with specific reference to
full blood examination, ECG, oxygen saturation, Chest X-ray, leg ultrasound, V/Q scan and CT
angiography).
All students should attempt to see at least one patient with DVT/PE before the second tutorial.
One pair of students should research the predisposing factors for thrombo-embolic disease and
one pair of students should research the treatment of acute thrombo-embolic disease
61
Tutorial 2
seen with DVT/PE.
One pair of students should give a presentation on the predisposing factors for thrombo-embolic
disease.
One pair of students should give a presentation on the treatment of acute thrombo-embolic
disease with a discussion of the use of heparin and warfarin, the side effects of these drugs, the
type of monitoring required (eg. INR and APTT) and the associated drug interactions.
References
Harrisons Textbook of Internal Medicine or the Oxford Textbook of Internal Medicine
New England Journal of Medicine (http://content.nejm.org/), available in all hospital libraries On
the website log into Collections then select Anticoagulants/Thromboembolism. An outstanding
and current source of articles on this changing area of medical practice
Washington Manual of Medical Therapeutics. Chapter on Disorders of Haemostasis: a concise
and practical summary

Describe the risk factors for development of deep venous thrombosis and pulmonary embolus
Recognise the clinical presentations of DVT and PE
Describe immediate and longer term treatments for DVT and PE
Sem Activity Title
3 Lecture Mechanisms of haemostasis
3 Tutorial Hemostasis and Thrombosis
3 PCL The Ballet Dancer
3 Lecture Lipid lowering drugs and anticoagulants
62
CASE 6: Abdominal Pain

Author: Dr Wendy Brown
Aim(s): To recognise the various causes of abdominal pain and be able to formulate a
management plan for a patient with acute or chronic abdominal pain
Preparation
Before the first tutorial one pair of students should see a patient with abdominal pain. The common
admitting units are one of the general surgical units or the gastroenterology unit. You should take a
thorough history and perform a complete examination. You should focus particularly on the presenting
symptoms, the presence or absence of complications and potential risk factors. You should bring
along the results of relevant investigations to the tutorial.
In the first tutorial the case will be discussed. You should have made an attempt to answer the pre-test
questions. This will enable the group to formulate a series of questions. Each group member will be
assigned one question to research thoroughly using the latest available evidence base.
In the second tutorial each group member will report back on their assigned questions and the group
will discuss these as a whole. By the end of the second tutorial you should have a clear answer for
each of the pre-test questions.
1. Describe the anatomy of the gastrointestinal (GI) tract, the renal tract, the abdominal aorta, the
pancreas and hepato-biliary tree.
2. Where are pain receptors found in the GI tract? What kind of pain do patients describe and what
is the physiological basis for this experience when they have problems of the:
stomach
small intestine
large intestine
abdominal aorta
hepato-biliary tree
renal tract
pancreas
Tutorial 1
How does each theme relate to a patient presenting with abdominal pain?
Each group member will thoroughly research at least one aspect of abdominal pain.
All students should attempt to see at least one patient with abdominal pain before the second
tutorial.
All students should attempt to see a colonoscopy before the second tutorial.
Tutorial 2
seen with abdominal pain.
63
Review questions
1. What non-abdominal pathology may be experienced as abdominal pain? Please explain these
phenomena?
2. What it the definition of the phrase acute abdomen? What is the definition of chronic abdominal
pain?
3. What investigations may help you determine the cause of a patients abdominal pain? What are
the relative advantages, disadvantages and costs of each procedure?
4. Make a table of the common causes of acute abdominal pain. List alongside each the
presenting clinical features, most important investigations and immediate management.
5. Make a table of the common causes of chronic abdominal pain. List alongside each the
presenting clinical features, the most important investigation and management.
6. Discuss the use of narcotics in acute and chronic abdominal pain.
References
Kelso LA & Kugelmas M, Nontraumatic abdominal pain. AACN Clinical Issues 8 (3): 437-48,
1997 Aug
Guthrie E & Thompson D, Abdominal pain and functional gastrointestinal disorders BMJ 325
(7366): 701-3, 2002 Sep 28
Johnson CD, ABC of the upper gastrointestinal tract. Upper abdominal pain: Gall bladder BMJ.
323 (7322): 1170-3, 2001 Nov 17
David V, Radiology of abdominal pain. Lippincott's Primary Care Practice 3 (5): 498-513, 1999
Sep-Oct
Bagshaw EJ, Abdominal pain protocol: right upper quadrant pain. Lippincott's Primary Care
Practice 3 (5): 486-92, 1999 Sep-Oct
Robertson C, Differential diagnosis of lower abdominal pain in women of childbearing age.
Lippincott's Primary Care Practice 2 (3): 210-29, 1998 May-Jun
Sem Activity Title
3 Practical Anatomy of the anterior abdominal wall & gross anatomy of the gastro-intestinal
tract
vessels and nerves
1 Lecture Primary tissue types and function II
2 Lecture The Autonomic Nervous System Periphery (2)
4 Lecture Gastrointestinal motility
4 Lecture Dismotility Disorders; Diarrhoea, gastroparesis, pseudo-obstruction, constipation

and achalasia
4 Lecture History and examination of the Gastrointestinal system 2; symptoms and signs
suggesting an acute abdomen/management of vomiting
4 Practical Clinical Reasoning - Gastrointestinal Tract Findings
64
CASE 7: Diarrhoea
Author: Associate Professor Bill Sievert
Aim(s): Students will recognise the clinical presentation of diarrhoea, its complications,
management and underlying pathophysiology.
Preparation
Before the first tutorial one pair of students should see a patient with diarrhoea.
The common admitting units are the gastroenterology unit and the infectious diseases unit.
patient described in the case scenario.
1. What is the definition of diarrhoea?
2. What are the most common pathogens causing acute bacterial diarrhoea and what are the risk
factors for acquiring these pathogens?
3. What features of the patients history would suggest different causes for diarrhoea (for example,
intestinal parasites)?
4. What features from the history and physical examination suggest severe or potentially life-
threatening diarrhoea?
5. What initial investigations would help to determine a cause for the diarrhoea?
6. What features suggest infective gastroenteritis as opposed to inflammatory bowel disease?
Scenario
John is a 21-year-old medical student who has taken a year off from school to travel; recently he has
been in the southern United States and Mexico. His general health has previously been good with no
significant medical or surgical illnesses. He has been home in Australia for three days and presents to
his family doctor because of the recent onset of loose bowel actions with some blood mixed in with the
stools. He first experienced mild lower abdominal cramping just before getting on the plane back to
Melbourne and used an antidiarrheal medication that he obtained over the counter in Tijuana so that
he could make the flight back home. On his return, the pain has been worse; he feels feverish and
fatigued and is having frequent loose stools, around 5 over a 24-hour period, now with obvious blood
mixed in with the stool. His past medical and family history is otherwise not contributory. He is due to
start his next clinical rotation and is anxious not to miss the first week.
On physical examination he has a temperature of 37.5C, pulse 90 and regular, respiratory rate 16
and blood pressure of 110/70. There is no icterus; the thyroid gland is normal. There is no peripheral
lymphadenopathy and the liver and spleen are normal in size. The abdomen is mildly tender to
examination in both lower quadrants. Digital rectal examination is normal.
Laboratory Investigations
Full blood examination:
Hgb 110 g/L (normal red cell indices)
WCC 10 X 109/L (neutrophils 6,000)
Platelets 490,000
ESR 25
65
Creatinine and urea are normal; serum electrolytes are normal except for a serum potassium of 2.9
mmol/L (normal range 3.5 to 5.0 mmol/L).
Liver function tests normal aside from serum albumin 33 g/L
Faecal microscopy shows numerous leucocytes.
Faecal cultures grow Campylobacter jejuni
Tutorial 1
Discuss the possible causes of diarrhoea.
How does each theme relate to diarrhoea?
Each group member will thoroughly research at least one aspect of diarrhoea.
All students should attempt to see at least one patient with diarrhoea before the second tutorial.
All students should attempt to see a sigmoidoscopy or colonoscopy before the second tutorial.
Role-play giving information to patients undergoing these procedures.
Tutorial 2
seen with diarrhoea.
Are there any outstanding issues in relation to diarrhoea? If so, what are they and how will you
answer them?
References
Field M, Intestinal ion transport and the pathophysiology of diarrhoea. The Journal of Clinical
Investigation 2003 111: 931-943
Schiller L & Sellin J, Diarrhoea (Ch 9 pg 131-153) in Gastrointestinal and Liver Disease 7th ed M
Feldman, LS Freidman & M Sleisenger (eds) Saunders 2002
Review Questions
1. What features of a colonic mucosal biopsy help to differentiate between acute and chronic
colitis?
2. What are the pathophysiological implications and clinical utility of finding faecal leukocytes?
3. Describe differences in clinical presentation and microbiological findings in immunosuppressed
patients (for example, a patient with HIV infection and a low CD4 cell count [<100/l]) compared
to patients with a normal immune system.
4. Which organisms are implicated in nosocomial diarrhoea and how are they spread?
5. What is the role of non-specific (supportive) pharmacological therapy in treating patients with
severe diarrhoea? How does a clinician decide on specific pharmacological therapeutic
agents?
66
Sem Activity Title
3 Practical Anatomy of the anterior abdominal wall & gross anatomy of the gastro-
intestinal tract
4 Practical Histology & histopathology; GIT structure, epithelium, specialised structures,

muscles and sphincters, colonic polyps and cancers
2 Lecture The Autonomic Nervous System Periphery (2)
4 Lecture Gastrointestinal motility
1 Lecture Extracellular environment, body fluids and gradients
1 Tutorial Body fluid composition, osmolarity and ion balance
4 Lecture Digestion and Absorption of Carbohydrates, Fats and Protein; Intrinsic

Factor, Vitamin B12
1 Lecture Interactions between bacteria and the human host
1 Lecture Microbial organisms of medical importance
1 PCL Jacks feeling sick
4 Lecture Dismotility Disorders; Diarrhoea, gastroparesis, pseudo-obstruction,

constipation and achalasia
4 PCL The Wedding
2 Lecture Drugs acting at the ANS synapses
2 Lecture Analgesia
67
CASE 8: GI Bleeding
Author: Dr Stuart Roberts
Aim: Students will explore acute upper and lower GI bleeding and chronic GI bleeding,
including relevant causes, clinical manifestations, initial and diagnostic approaches to
treatment, and secondary prevention.
Preparation
Before the first tutorial one pair of students should see a patient with gastro-intestinal bleeding.
1. What is acute upper GI and lower GI bleeding and what are the clinical features?
2. What are the common causes for acute upper and lower GI bleeding?
3. What are the major risk factors for acute upper GI bleeding?
4. What are gastroscopy and colonoscopy?
5. What role do they have in acute GI bleeding?
6. What are the priorities in the management of the shocked patient?
7. What are pharmacotherapeutic agents used in management of peptic ulceration and GI
bleeding?
Tutorial 1
Brief discussion of answers to pre-meeting questions.
Discuss the possible causes of this condition.
How does each theme relate to this condition?
Each group member will thoroughly research at least one aspect of this condition.
All students should attempt to see at least one patient with this condition before the second
tutorial.
All students should attempt to see procedures relevant to this condition before the second
tutorial.
68
Scenario
David is a 54 year old Plumber who has osteoarthritis of his fingers, for which he takes Voltaren
intermittently. For the past three weeks he has had intermittent upper abdominal pain which he notices
is better after eating and is improved with antacids. Three days ago while at work, he noticed his
stools were loose and black. While he thought this was unusual, his work was busy and he could not
take time off to see the doctor. Two days later when he got up at night to go to the toilet he felt light
and dizzy, and then passed a large amount of dark blood per rectum. His wife called an ambulance
who took him to the Hospital Emergency Department. He had no other relevant past medical history
but his father had a history of peptic ulcer disease. He was a smoker of 20 cigarettes per day and
consumed social quantities of alcohol.
On presentation to hospital, he appeared pale and unwell with a pulse of 110 and regular, respiratory
rate of 18 and blood pressure of 100/60 with a 20 mm postural drop on sitting. There were no signs of
chronic liver disease. The abdomen was lax and non-tender, and the liver and spleen were normal in
size. Rectal examination revealed burgundy coloured stool.
Laboratory investigations
Haemoglobin: 105 gm/L

WCC: 11 x 109/L
Platelets: 350,000
Blood film: Reticulocytosis
U&E: Urea 18.5 mmol/L, Creatinine normal
LFTs: normal
Coagulation profile: normal
Chest x-ray & ECG: normal
Tutorial 2
seen with this condition.
Review the pre-meeting questions.
Are there any outstanding issues in relation to this condition? If so, what are they and how will
you answer them?
References
Acute Gastrointestinal Bleeding: Diagnosis and Treatment. Kim, Karen E (ed) Publisher
Humana 2003
Janssen DM, Machicada. Diagnosis and treatment of severe haematochezia, Gastroenterology
1988; 95: 1569-1574
Textbook of Gastroenterology, Yamada, Takataka (ed) Publisher Lippincott Williams & Wil,
2003
69
Review Questions
1. What is the definition of upper GI bleeding?
2. What are the common causes of acute upper GI bleeding?
3. What are the clinical features of acute upper GI bleeding?
4. What is the definition of lower GI bleeding?
5. What are the common causes of lower GI bleeding?
6. What are the differences between acute and chronic GI bleeding?
7. What is the pharmacological management of peptic ulceration and GI bleeding?
8. What are the clinical features of hypovolaemic shock?
9. What is resuscitation and why is it important?
10. What are the priorities after initial assessment and resuscitation?
11. Why is early investigation with gastroscopy important in upper GI bleeding?
12. What is the role of H.pylori in peptic ulcer disease?
Sem Activity Title
tract
3 PCL Josh under pressure
3 Lecture Anaemia
3 Lecture Transfusion
3 Practical Blood Transfusion
70
CASE 9: Obstructive Jaundice

Author: Dr Wendy Brown
Aim(s): Students will recognise the various clinical presentations of gallstones, their
complications, management and underlying pathophysiology
Preparation
Before the first tutorial one pair of students should see a patient with gallstones - preferably
jaundiced.
The common admitting units are one of the general surgical units or the gastroenterology unit.
The students should take a thorough history and perform a complete examination. Focus
particularly on the presenting symptoms, the presence or absence of complications and
All group members should attempt the pre-meeting questions.
1. Draw a cartoon of the anatomy of the gallbladder, hepatic and common bile ducts.
2. What is the role of bile in digestion? How is bile produced? How is it circulated through the
body?
3. What types of gallstones are there? Which ones are common in our community?
4. Identify the sites where gallstones may lodge and cause obstruction. What would be the
consequence of the stones lodging in each site?
5. Jaundice is due to an elevation in the serum bilirubin. How can liver function tests help us
determine the cause of the jaundice?
Tutorial 1
Brief discussion of answers to pre-test questions.
What questions emerge as a consequence of the presentation?
How does each theme relate to obstructive jaundice?
Each group member will thoroughly research at least one aspect of obstructive jaundice.
All students should attempt to see an ERCP and a cholecystectomy before the second tutorial.
Tutorial 2
seen with obstructive jaundice.
Review the pre-test questions.
Are there any outstanding issues in relation to obstructive jaundice? If so, what are they and
how will you answer them?
Complete the test questions below.
71
References
Well-annotated descriptions of the approach to jaundiced patients can be found in standard
textbooks of gastroenterology, hepatology and internal medicine:
Gastrointestinal and Liver Disease 7th ed M Feldman, LS Freidman & M Sleisenger (eds)
Saunders 2002
Harrisons Principles of Internal Medicine 15th ed E Braunwald, A Fauci, D Kasper, S Hauser, D
Longo & J Jameson (eds) McGraw Hill 2001
Review Questions
1. What tests are available to image the biliary tree? What are the relative merits and
disadvantages of each one? What is the cost of each one? How do patients rate the
procedures?
2. Infection is important sequelae to an obstructed biliary system. What organisms cause this
infection? What antibiotics can be used to treat this infection? How do they work?
3. What techniques are there for removing stones from the biliary tree? What are the relative
merits of each technique?
4. Cholecystectomy is a common operation. Who should be offered cholecystectomy? What
physiological consequences follow its removal? What might a patient notice? What risks do
patients need to be aware of?
Sem Activity Title
tract
Vitamin B12
4 Lecture Abnormalities of gastrointestinal secretion, consequences and management
4 Lecture Investigations of Jaundice
72
CASE 10: Anaemia

Author: Professor Hatem Salem
Aim: Students will explore the causes, risk factors, investigations and management of
anaemia
Preparation:
Before the first tutorial one pair of students should see a patient with anaemia.
All group members should discuss the scenarios and blood reports below. Discuss the
similarities and differences between the presenting signs and symptoms of your patient
compared to the presentation of the patient described in the case scenario and whether this is
different for male and female patients.
Pre-meeting Questions:
1. What is the definition of anaemia?
2. What are the most common causes of and risk factors for anaemia?
3. What initial investigations would help to determine a cause for the anaemia?
Scenario:
Stavros Papadopoulos is a 75-year-old widower who lives alone. He is visited on Sundays by his son.
He is retired and has enjoyed reasonably good health except for progressively increasing shortness of
breath on exertion and tiredness. Initially he ascribed his symptoms to his age, but with the passage of
time he found it increasingly difficult to carry out his day-to-day activities. In addition he noted
exertional chest discomfort, which he described a dull ache that settles rapidly with rest. With
worsening symptoms, his son insisted that he visits his medical practitioner Dr Alan Michaels. After
taking a history, Dr Michaels asked for a full blood count.
Further information:
Examination showed Mr Papadopoulos to look pale. He had a sinus tachycardia of 92/minute and his
blood pressure was 160/70 mm of Hg. The cardiovascular examination was normal except for an
ejection systolic murmur at the left sternal edge and the aortic area. The murmur did no radiate to the
neck. His abdomen was soft and non-tender. There were no signs of bruising or bleeding.
Further information:
Scenario 1: Full Blood Count:
Hb 56 g/L (120-155)
9
WBC 7.55 x 10 /L (4.50 11.50)
Platelets 630 x 109/L (150-400)
MCV 70 fl (80-97)
Film: Marked anisocytosis, moderate polychromasia and hypochromasia, mild microcytosis
with a small number of elongated cells, target cells, tear drop cells and occasional nucleated
red cells
WBC: normal morphology
Platelets: large platelets present
73

Hb 64 g/L (120-155)
9
WBC 14.3 x 10 /L (4.50 11.50)
Platelets 395 x 109/L (150-400)
MCV 94 fl (80-97)
Film: Marked anisocytosis, moderate polychromasia , a large number of spherocytes and a
small number of nucleated red cells
WBC: Neutrophilia with a left shift including myelocytes. Normal morphology otherwise.
Platelets: normal
Hb 102 g/L (120-155)
9
WBC 4.77 x 10 /L (4.50 11.50)
Platelets 132 x 109/L (150-400)
MCV 125 fl (80-97)
Film: Marked anisocytosis, rouleaux, mild macrocytosis, polychromasia and hypochromasia, a
small number of elongated cells, tear drop cells and occasional nucleated red cells
WBC: Hypersegmented neutrophils present
Platelets: large platelets present
Tutorial 2:
Report your findings to the group
seen with anaemia
Keywords
anaemia, full blood count, haemoglobin, MCV, white cell count, platelet count, red cells, microcytic
hypochromic, elliptocytes, macrocytic anaema, normochromic haemolytic anaemia
74
CASE 11: Breast Cancer

Author: Dr Jane Fox
Aim: Students will explore the diagnosis and treatment options for breast cancer
Preparation
Pre-reading: http://www.wesclark.com/jw/mastectomy.html
Please read the account of a mastectomy, written from the patients perspective. This operation
took place in 1811.
Tutorial 1
Discuss the issues raised in the pre-reading which you think might be applicable to the
management of breast cancer in 2006. How does each theme relate to this case?
Each group member should research at least one aspect of breast cancer
All students should attempt to see at least one patient with breast cancer before the second
tutorial
Tutorial 2
seen with breast cancer
Review issues from Tutorial 1
Complete the Review Questions below.
References
Clinical practice Guidelines Management of Breast Cancer NHMRC National Breast Cancer
Centre
Psychosocial clinical practice guidelines NHMRC National Breast Cancer Centre
ABC of Breast Disease by Dixon
Breast/Breast oncology clinics, Surgical and oncology wards and radiation oncology clinics
Review Questions
1. Discuss those features of the diagnosis and treatment of breast cancer which you think still
apply and highlight those which differ.
2. What choices do patients and practitioners have and how do they make those choices?
3. What are the roles of the available treatment modalities?
4. What are the available systemic treatments and what are their modes of action? Are they all
freely available? If not, should this change?
75

Sem Activity Title
1 PCL A Family History
1 Tutorial Medical Interview skills: breaking the bad news
1 Lecture Disordered growth and differentiation:Introduction to cancer biology
1 Lecture Biology of cancer: What effect does cancer have on the patient?
1 Lecture Biology of cancer: What is the molecular basis of cancer? (Part 1)
1 Lecture Biology of cancer: What is the molecular basis of cancer? (Part 2)
1 Practical The histology of cancer cells
1 Tutorial The nature of cancer and its relationship to normal growth and differentiation
1 PCL Aidans Mole
2 Practical The axilla walls and the breast
76
CASE 12: Splenomegaly and lymphadenopathy

Author: Professor Gordon Whyte
Aim: Students will develop an approach to diagnosing the cause of lymphadenopathy
and/or splenomegaly in a patient.
Preparation
Prior to seeing the patient, review the anatomy and physiology of the reticuloendothelial system
and the definitions of lymphadenopathy and splenomegaly.
Before the first tutorial one pair of students should see a patient with lymphadenopathy or
splenomegaly.
The students should take a thorough history and perform a complete physical examination,
especially of the haemopoietic system. Focus particularly on the presenting symptoms, physical
examination and the laboratory work up.
Propose a series of hypotheses about the aetiology and pathophysiology of their findings.
Review the critical diagnostic features of their investigations and be prepared to present to the
group.
All group members should discuss the scenarios below. Discuss the similarities and differences
patient described in the case scenarios and whether this is different for male and female
patients.
1. What are the characteristics of infectious and of malignant lymphadenopathy?
2. What are the predisposing factors and demographics of the causes of generalised and local
lymphadenopathy?
3. What are the common causes of splenomegaly in Australia and world wide?
4. What are the key investigations and critical findings for investigating isolated splenomegaly?
5. Develop, as a group, a table of differential diagnosis with a pathophysiological basis, and one
based on clinical features.
6. What is the definition of lymphoma?
7. What are the predisposing factors and demographics of the various types of lymphoma?
8. What are the key investigations and critical findings for staging a lymphoma?
9. What is the process for deciding on the initial management of a patient diagnosed with a
lymphoma?
10. What features distinguish aggressive disease from low grade malignancy?
77
Scenarios
1. David, a 21 year old male student presents as unwell for four days after returning from a trip to
Hanoi and rural Vietnam. He has had a remitting fever for four days with no specific symptoms
except for a sore throat and a sudden dislike for alcohol. On examination he has generalised
lymphadenopathy and a just palpable and slightly tender spleen. Explain your differential
diagnosis and approach to management.
2. Joan, a 50 year old female advertising executive, presents to her doctor with a bloated feeling in
her abdomen. She has been feeling a bit tired recently, but has put it down to increased work
and a recent promotion. On examination she has minor pallor and marked non-tender
splenomegaly of 6cm in the right lateral position. Explain your differential diagnosis and
approach to management.
3. John, a 60 year old male farmer, has been quite well apart from a slight loss of weight (5%) over
the last month. His appetite has been good but he does not have quite his usual energy. On
examination the only abnormality that you find is a hard node of 1.5 cm at the root of his neck
on the right. Explain your differential diagnosis and approach to management.
Tutorial 1
Brief discussion of answers to pre-session questions
What issues emerge from the scenarios?
Discuss the possible causes of splenomegaly/ lymphadenopathy in the scenarios
How does each theme relate to lymphadenopathy / splenomegaly?
Each group member will thoroughly research at least one aspect of splenomegaly or
lymphadenopathy
All students should attempt to see at least one patient with splenomegaly or lymphadenopathy
before the second tutorial
Tutorial 2
Compare and contrast the patient presentation from the first tutorial with other patients. Review
the pre-session questions
Are there any outstanding issues in relation to lymphadenopathy? If so, what are they and how
will you answer them?
Complete the review questions below
References
Robbins, Cottran, Kumar & Collins, Robbins Pathologic Basis of Disease. 6th ed. (1999)
Roitt, Essential Immunology (latest edition)
Kumar, P. & Clark, M. (2002). Clinical Medicine: A Textbook for Medical Students and Doctors
5th ed. Philadelphia: Saunders.
Review Questions
1. Describe the functional anatomy of the immune system at the molecular, cellular and organ
level, sufficient to demonstrate a sound knowledge of the normal response to a viral infection.
This is a review of Week 11 in Semester 1 and see Roitt, Essential Immunology
2. Describe the natural history of Epstein Barr Virus infection, including long term effects on
tumorigenesis in developed countries and in southern China and tropical Africa. See Robbins
Pathological Basis of Disease 6th ed.: Infectious Mononucleosis (pg 371) and Viral and Microbial
Carcinogenesis (pg 311) and Origin of Reed Sternberg Cells in Hodgkins Disease (pg 670)
3. Provide a differential diagnosis of isolated splenomegaly and its investigation. See Kumar &
Clark Ch 8
78
4. Develop a differential diagnosis of enlarged lymph nodes in a group such as the right side of the
neck and outline appropriate investigations to reach a firm diagnosis. See Kumar and Clark
Table 9.16
Sem Activity Title
vessels and nerves
1 Lecture Cellular and molecular basis of the adaptive immune system
1 Tutorial T Cells
1 Lecture How the immune system works and how it defends the body against infection
3 Lecture Susceptibility to infection resulting from white cell abnormalities
3 PCL Andrew is tired
79
CASE 13: Pneumonia

Author: Dr Olga Vujovic
Aim(s): Community-acquired pneumonia is a common cause of admission to hospital. This
case focuses on development of a thorough understanding of the epidemiology,
clinical and laboratory features of community-acquired pneumonia and an approach to
management and prevention.
Preparation
Before the first tutorial one pair of students should see a patient who has been admitted to
hospital with a provisional diagnosis of pneumonia.
between the presenting symptoms and signs of your patient compared to the presentation of the
1. What is pneumonia?
2. What is the pathogenesis of pneumonia?
3. What are the clinical patterns of community acquired pneumonia?
4. What are the causative (aetiological) agents of community-acquired pneumonia?
5. How is the diagnosis of pneumonia made, and how is the specific aetiological agent identified?
Tutorial 1
What appear to be the major problems of the patient? Of the patient in the scenario?
How will you determine whether the patient has pneumonia?
What features on history provide clues as to the aetiology of pneumonia?
How would you rate the severity of the illness in both the real patient and the patient in the
scenario? Refer to references below
How would you investigate this patient?
Scenario
Elaine is a 60 year old woman who is brought to hospital by her daughter. She had been well until two
days earlier at which time she developed fevers and chills. The next day she developed a cough with
production of green phlegm and associated difficulty breathing. Her daughter also noted her to be
somewhat confused at night. Elaines medical history includes diabetes mellitus and hypertension.
She is a current smoker. She has not travelled recently and has not had contact with anyone with a
similar illness. She is on tablets for her diabetes and blood pressure. It is unclear whether she has
received influenza vaccination this year.
On examination she has a fever of 39.50 C, pulse 110 and regular, respiratory rate of 24 per minute
and blood pressure of 130/80. She is disoriented in time and place. Chest examination reveals
dullness to percussion at the right lung base; on auscultation of this area bronchial breathing is heard.
Cardiovascular and abdominal examination is unremarkable.
CXR reveals right lower lobe consolidation
Hb 105 g/L (115 - 155), WCC 16.4 x 109/L (4.5 - 11.5), Plt 350 x 109/L (150 - 396)
80
Urea and electrolytes:

urea 11.2 mmol/L (2.0 - 8.5), otherwise normal
Serum glucose:
15mmol/L (4.0 - 7.0)
Liver function tests normal
Arterial blood gases:
pH 7.48 (7.38 - 7.43), pO2 60 mmHg (> 75), pCO2 30 mmHg (35 - 45)
Sputum microscopy reveals epithelial cells, occasional pus cells with growth of oral flora only.
Streptococcus pneumoniae is isolated from blood cultures.
Before the second tutorial, students should:
Follow-up patients progress, treatment, etc. (students who originally saw patient).
All students should see another patient with pneumonia.
Private study - treatment of pneumonia, complications of pneumonia, etc. - all students to
research one aspect.
All students (as a group) to visit the hospital microbiology laboratory to discuss the following
steps in processing sputum samples
assessing the quality of the sample - is it sputum or saliva?
look at sputum Gram stain
identification of common pathogens of community acquired pneumonia
look at Gram stain and culture of Strep pneumoniae if available
Visits to the laboratory can be arranged by contacting either the Infectious Diseases or Microbiology
Registrar or, in hospitals without registrars in these disciplines, by contacting the senior scientist in the
laboratory to arrange a suitable time.
Tutorial 2
The patients progress and treatment are reported back to the group. If possible, the CXR should be
reviewed by the whole group and the findings discussed.
you answer them?
References
Yung A & Street A, Fever and lower respiratory tract symptoms in Infectious Diseases. A
Clinical Approach. Ed. Yung, McDonald, Street & Johnson 1st ed 2001
Johnson PDR, Irving LB & Turnidge JD, Community-acquired pneumonia. Med J Aust 2002;
176: 341-7
Therapeutic Guidelines. Antibiotic. Version 12, 2003. Publisher: Therapeutic Guidelines Limited
http://www.tg.org.au/
The Australian Immunisation Handbook 8th ed 2003 NHMRC
Review Questions
1. Discuss the utility of sputum examination in pneumonia. What are the limitations of the test?
2. What are the treatment recommendations for community acquired pneumonia?
3. What factors may be associated with slow resolution of pneumonia?
81
4. How would you approach the problem of an increasing pleural effusion in an individual who has
received 5 days of antibiotic therapy for pneumonia?
5. What preventive strategies may be employed to reduce the risk of community acquired
pneumonia in a given individual?
6. How might your approach to hospital acquired pneumonia differ?
Sem Activity Title
3 Practical Introduction to thorax, heart and great vessels
3 Practical Surface anatomy of the lungs and pleura
3 Lecture Pulmonary Circulation
3 Lecture Biomechanics of breathing
3 Practical Lung volumes, performance and interpretation
3 Practical Histopathology of the respiratory system
1 Lecture Natural barriers, innate defense mechanisms and introduction to host-

parasite relationship
1 Lecture Interactions between bacteria and the human host
1 Practical Lobar pneumonia
1 Lecture Principles of diagnosis of infectious diseases
1 Lecture Microbial organisms of medical importance
3 Lecture Pneumonia with complications including pleural effusion
82
CASE 14: Thyroid Disease

Author: Mr Jonathan Serpell
Aim(s): Goitre and thyroid diseases are common and may present in a variety of ways.
Students will become familiar with the diagnosis of the common causes of goitre,
hyperthyroidism, hypothyroidism, the diagnosis of these conditions and their
treatment.
Preparation
Before the first tutorial one pair of students should see a patient with thyroid disease.
1. How is thyroid hormone produced and what are its normal physiological effects? What are the
clinical consequences of excess thyroid hormone and deficiency of thyroid hormone?
2. Describe in detail the differing types of goitre, including diffuse goitres, both simple and nodular
and solitary nodular goitres.
3. What are the common causes of thyrotoxicosis and how would you distinguish these,
investigate them and treat them?
4. How common is thyroid cancer? How does it usually present, how is it usually managed and
what is the usual prognosis?
5. What are the potential complications of thyroid surgery?
Scenario
Mrs Smith is a 35 year old, with a history of a swelling in the neck dating back to her early teenage
years. She has always been aware of a somewhat full neck, but over the last five years has been
increasingly aware of pressure in the neck, associated with some difficulty in swallowing and
occasionally a feeling of choking, particularly when she lies in bed, flat on her back. Recently,
however, she has noted that she has lost weight and has sweaty hands and prefers cooler rather than
warm rooms. Earlier in the year she had a CT scan of her brain in the course of investigation of severe
headaches. Her doctor finds on examining her that she has a pulse rate of 120 and a goitre in the
neck which is multinodular in nature. It clinically appears to extend retrosternally and Pembertons sign
is positive. There were no abnormal eye changes. Her general examination was otherwise normal.
83
Tutorial 1
The group is required to produce a case report summarising the clinical presentation, key
symptoms and signs, diagnostic tests, management strategies concerning their patient with
thyroid disease
The case report should include positive and negative responses to a detailed problem-oriented
history and problem-oriented examination for the patient with thyroid disease
There should be particular emphasis on the clinical assessment of thyroid function and
examination of the thyroid gland.
How does each theme relate to thyroid disease?
Each group member will thoroughly research at least one aspect of thyroid disease
All students should attempt to see at least one patient with thyroid disease before the second
tutorial.
All students should attempt to see imaging of the thyroid and fine needle aspiration cytology
before the second tutorial.
Tutorial 2
Report your findings to the group. Emphasis will be on understanding the interpretation of
thyroid function tests, and imaging of the thyroid and fine needle aspiration cytology if
performed.
Detailed discussion of the management strategy adopted for the patient should follow
seen with thyroid disease
References
Harrisons Textbook of Internal Medicine. Braunwald E et al (eds) McGraw Hill Ch 330
Disorders of the Thyroid Jameson & Weetman
Sherman SI. Thyroid Carcinoma. Lancet 2003 Feb 8; 361 (9356): 501-11
Welker MJ & Orlov D, Thyroid Nodules. Am Fam Physician 2003 Feb 1; 67 (3): 559-66
Felz MW & Stein PP, The Many Faces of Graves Disease. Part 1. Eyes, Pulse, Skin and
Neck Provide Important Clues to Diagnosis. Postgrad Med. 1999 Oct 1; 106 (4): 57-64
Felz MW & Stein PP, The Many Faces of Graves Disease. Part 2. Practical Diagnostic
Testing and Management Options. Postgrad. Med. 1999 Oct 15; 106 (5): 45-52; quiz 158
Pearce EN, Farwell AP & Braverman LE, Thyroiditis. N Eng J Med. 2003 Jun 26; 348 (26):
2646-55
Review Questions
1. Describe in detail the differing types of goitre including diffuse goitres, both simple and nodular
and solitary nodular goitres.
2. What are the common causes of thyrotoxicosis and how would you distinguish these,
investigate them and treat them?
3. How is thyroid hormone produced and what are its normal physiological effects?
4. How common is thyroid cancer, how does it usually present and how is it usually managed and
what is the usual prognosis?
5. What are the potential complications of thyroid surgery?
84
Sem Activity Title
4 PCL The Wedding
4 Lecture Pituitary, thyroid and adrenal pathology
4 Lecture Components of an endocrine system
4 Lecture Thyroid structure and function
4 Lecture Peripheral actions of thyroid hormones
4 Lecture Drugs in the Treatment of Thyroid Disease
4 Practical History and examination of the endocrine system - 1
4 Practical Pituitary, thyroid and adrenal histology
85
CASE 15: Osteoporosis

Author: Dr Christopher Gilfillan
Aim(s): Osteoporosis is the most common metabolic bone disease and resulting fractures are
a major cause of death and disability, and a significant burden on the health care
system in Australia. This module will review the definition of osteoporosis, the
contributing causes, the clinical presentation, the investigation and management of
this common disorder.
Preparation
Before the first tutorial one pair of students should see a patient with a fragility fracture
The common admitting units are the orthopaedic unit and the general medical unit (vertebral
and pelvic fractures).
Focus particularly on the circumstances of the fracture, the presence or absence of clinical risk
factors for fracture and osteoporosis.
between your patient compared to the presentation of the patient described in the case
scenario.
1. How would you define osteoporosis?
2. What are the clinical risk factors and disease states associated with osteoporosis?
3. What are the common osteoporotic fractures?
4. What is the interpretation of your patients DEXA scan?
5. What treatments are available with proven ability to prevent fracture in patients with
osteoporosis?
6. In the population, who should be treated for osteoporosis and what determines the form of
therapy?
Scenario
Annie Winter, a 65 year old woman and a retired school teacher, presents with acute mid-thoracic
back pain that developed spontaneously without obvious trauma. The pain radiates around the chest
bilaterally and is exacerbated by coughing. An X-ray is performed (see attachment 1).
The pain subsides over a 6 week period with rest and analgesia. Further history is obtained. Annie is
unmarried and has no children. She had a normal menstrual history with menopause at the age of 52.
She has never used hormone replacement therapy. She has gastroscopy-proven oesphageal reflux
and takes regular ranitidine. She had a DVT following knee surgery aged 50 and there is a positive
family history of pulmonary embolism in her mother. There is no personal or family history of breast
cancer. She is a non-smoker and consumes only occasional alcohol. She consumes approximately 2
glasses of milk daily and ice-cream twice weekly, but little cheese and no yoghurt. She does not use
calcium supplements.
1. What is the diagnosis?
2. What is the grade of the fracture?
3. Is her presentation typical?
4. What does this do to her risk of subsequent fracture?
5. Comment on each aspect of the history with respect to Annies bone health.
6. What is Annies approximate calcium intake and does she require supplements?
7. What important negatives should we establish when taking the history?
86
8. What investigations should we now perform if any?

Tutorial 1
Discuss questions 1-8 raised in the scenario.
How does each theme relate to the evaluation of the patient with osteoporosis?
Each group member (or in pairs depending on group size) will thoroughly research at least one
aspect of calcium metabolism before the second tutorial. Suggested topics:
Vitamin D supplementation and fracture prevention
Primary hyperparathyroidism and effects on bone
The bone remodelling cycle
Corticosteroid-induced osteoporosis
Oestrogens and SERMs in the treatment of osteoporosis
Bisphosphonates in the treatment of osteoporosis
All students should attempt to visit the body composition laboratory to view a DEXA scan being
performed before the second tutorial.
Tutorial 2
Students should present their research topics for 5 minutes each (or each group)
Annie returns following her investigations and asks what is her risk of further fractures and what
can be done to prevent further fractures.
Answer the following questions regarding the treatment of osteoporosis and the prevention of
fractures.
References
Brown SA & Rosen CJ, Osteoporosis. Med Clin North Am 2003 Sep; 87 (5): 1039-63. Review.
Christodoulou C & Cooper C, What is osteoporosis? Postgrad Med J. 2003 Mar; 79 (929):
133-8. Review
Hauselmann HJ & Rizzoli R, A comprehensive review of treatments for postmenopausal
osteoporosis. Osteoporos Int. 2003 Jan;14 (1): 2-12. Review
French L, Smith M & Shimp L, Prevention and treatment of osteoporosis in postmenopausal
women. J Fam Pract. 2002 Oct;51(10):875-82. Review. No abstract available. Erratum in:
J Fam Pract 2002 Nov;51 (11): 968. PMID: 12401161 [PubMed - indexed for MEDLINE]
Review Questions
1. What would your advice be to Annie?
2. What non-pharmacological measures would you suggest?
3. What drug therapy could be prescribed? What are the risks and benefits of available
treatments?
4. How long treatment should be continued?
5. Discuss the societal costs of osteoporotic fractures and the cost effectiveness of therapy.
6. Are there any outstanding issues? If so, what are they and how will you answer them?
7. Finally devise a management plan for Annie.
87
Sem Activity Title
1 Lecture Construction of organs from cells and tissues
2 Lecture Microstructure bone
4 Practical Neck, Median Visceral Column and Laterovisceral Space
4 Lecture Key signs and symptoms suggesting an endocrinopathy: investigations required
4 Briefing Endocrinology Learning Package Preview
Fracture risk index calculator

What is your current age?
<65 0
65-69 1
70-74 2
75-79 3
80-84 4
>85 5
Have you broken any bones after age 50?
Yes 1
No/Dont know 0
Did your mother have a hip fracture after age 50?
Yes 1
No/Dont know 0
Do you weigh less than 57 kg?
Yes 1
No 0
Are you currently a smoker?
Yes 1
No 0
Can you get out of a chair without using your arms?
No 2
Yes 0
BMD T score
>-1.0 0
-1.0 to -2.0 2
-2.0 to -2.5 3
<-2.5 4
88
Reference
Black DM, Steinbuch M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni MS & Johnell O, An
assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int. 2001;
12 (7): 519-28.
A score of 5 is a useful intervention threshold
5 year risk of any fracture by Fracture Index
45
40 38.7
5 year risk of fracture
35 NNT
30 26.9
25 21.8
20
20
15.6
15 13
9.8 9
10 7
5
5
0
1-2 3-4 5 6-7 8-13
Fracture Index
89
CASE 16: Type 2 diabetes

Author: Richard OBrien
Preparation
Before the first tutorial all students should see at least one patient with Type 2 diabetes.
The Diabetes/Endocrinology Registrar will be able to provide names of patients; however, patients
with diabetes are also commonly seen on General Medical and Surgical Units.
The students should take a thorough history focussing on presenting symptoms and method of
diagnosis. The presence of risk factors for diabetes, presence or absence of complications, current
self-care practices (eg. home blood glucose monitoring), dietary habits and pharmacological therapy.
One pair of students should present their case. All group members should briefly discuss the
similarities and differences between their cases.
1. What are the common symptoms and signs of diabetes?
2. What are the common risk factors for Type 2 diabetes?
3. How is a diagnosis of diabetes usually made?
4. What dietary advice should be given to a patient with newly diagnosed diabetes?
5. What is the role of the Diabetes Educator for a patient with newly diagnosed diabetes?
6. Why is good glycaemic control important and how is it monitored?
7. What are the principles of pharmacological treatment for Type 2 diabetes?
Tutorial 1
What appear to be the major problems of the patient? Of the patient in the scenario?
How will you determine whether the patient has diabetes?
What features on history provide clues as to the aetiology of diabetes?
How would you rate the severity of the illness in both the real patient and the patient in the
scenario? Refer to references below
How would you investigate this patient?
Scenario
Mrs Mary Jackson is a 62 year old woman with a five year history of Type 2 diabetes who presents for
the first time to her new GP, having moved from interstate. Apart from her diabetes she has been well.
She complains of some numbness in the feet but has no other symptoms of diabetes complications.
She tests her blood glucose every second morning before breakfast and the reading is usually 8-10
mmol/L. She is taking gliclazide 160 mg bd (the maximum dose) and metformin 500 mg bd. She has
not been able to tolerate higher doses of metformin because of diarrhoea. She is not on any other
medication.
On examination Mrs Jackson is overweight with a BMI of 29.5. Her blood pressure is 155/95 with no
change after 10 minutes of resting. There is no postural blood pressure drop. There is evidence of
decreased sensation in the stocking distribution in both feet but the pulses are normal. Cardiovascular
examination is normal. Fundoscopy shows some dot and blot haemorrhages in both fundi.
90
Investigations:
Electrolytes normal
Urea and creatinine normal
Fasting blood glucose 9.8 mmol/L
HbA1c 8.9%
Cholesterol 5.8
Triglycerides 2.8
HDL 0.9
LDL 3.6
Urine albumin excretion 85 g/min (normal <20).
The details of this case will be discussed at the next tutorial. In preparation for the tutorial the group
should work in pairs or individually to answer the following questions, using the suggested references
or other material suggested by the tutor.
1. Explain in a step-wise manner the basic principles involved in improving Mrs Jacksons
glycaemic control.
2. Discuss the link between diabetes and cardiovascular disease and comment on potential
mechanisms to reduce Mrs Jacksons risk.
3. Discuss the stages of diabetic nephropathy, the significance of an elevated urine albumin, and
potential treatment to reduce the progression of diabetic nephropathy.
4. Briefly discuss the pathogenesis of diabetic neuropathy and the clinical presentation of the
different forms of diabetic neuropathy. Briefly outline the foot care advice to a patient with
peripheral neuropathy.
5. Mrs Jacksons fundi show some dot and blot haemorrhages. Discuss the significance of this
abnormality, the various stages of diabetic retinopathy, and the principles of screening for
retinopathy.
6. Discuss this case with a diabetes educator. How could a diabetes educator assist with Mrs
Jacksons management? Sit in with a diabetes educator during a session with a patient with
Type 2 diabetes, and discuss your experience with the group.
Tutorial 2
Each student or pair of students should spend about 5 minutes presenting their findings to the group.
The case of Mrs Jackson should then be discussed again, with each significant issue being examined
in the light of the students research. The group should collectively formulate a management plan for
Mrs Jackson.
The pre-meeting questions should be reviewed. Are there any outstanding issues? Can these be
addressed from the reference material?
you answer them?
91
References
Campaigne BN & Wishner KL 2000 Gender-Specific Health Care in Diabetes Mellitus. The
Journal of Gender-Specific Medicine 2000 3 [1]: 51-58
Laws A, 1999 Diabetes and Insulin Resistance: Ch 3 in Charney P (ed) Coronary Artery
Disease in Women: What all Physicians Need to Know. Philadelphia, American College of
Physicians 1999
Sem Activity Title
3 PCL Complications

Topic 4: Diabetes Mellitus Type 2 and Metabolic Syndrome
4 Lecture Overview of Diabetes Mellitus
4 Lecture Diabetes
4 Lecture Insulin and Oral Antidiabetic Agents
92
CASE 17: Delirium

Author: Professor Elsdon Storey
Aim(s): Students will be able to recognise the clinical presentation of delirium and formulate a
reasonable approach to diagnosis and management.
Preparation
Before the first tutorial one pair of students should see a patient with delirium.
1. What is consciousness?
2. What brain structures and body functions are important in consciousness?
3. How does one assess level of consciousness?
4. What factors may impair consciousness?
5. What features from the history and physical examination suggest the presence of delirium?
6. What initial investigations would help to determine a cause of delirium?
Scenario
Mr Michael Reilly is a 57 year old car salesman. He falls from a ladder while cleaning his roof gutters
and is admitted to hospital with a fractured femur. The fracture is internally fixed at operation and he
initially appears to be doing well, but on the third hospital day, begins to become agitated, reporting
visual hallucinations, odd sensations like ants crawling on my skin, and a generalised feeling of
anxiety. His symptoms fluctuate, and his degree of agitation changes rapidly from hour to hour. At his
worst, his behaviour is barely controllable, he is in danger of falling out of bed, and he is verbally and
physically aggressive towards the nursing and medical staff. At times, he requires sedation to control
his behaviour and stop him harming himself or others.
On examination late one night, he is sweaty, tachycardic, mildly febrile and hypertensive. He has
irregular jerking movements of his limbs and is seen to pluck at his skin and bedclothes. Auscultation
of the chest reveals bronchial breath sounds at the right base. He repeatedly asserts that there is
nothing wrong with me, I want to go home. He accuses the staff of restraining him against his will and
planning him harm. On repeat examination the next morning, he is much less agitated and more
reasonable and has no memory of his prior behaviour.
Corroborative history from his wife is at first unhelpful. With persistent tactful enquiry, however, it
emerges that he has been under stress at work and has been drinking a bottle of Scotch every two or
three days in the evenings, as well as a few beers at lunchtime.
Investigations show: low haemoglobin, raised white cell count, elevated liver enzymes, low sodium
and potassium. Blood gas measurement shows borderline low oxygen and low carbon dioxide and a
respiratory alkalosis. Chest X-Ray shows right basal consolidation.
93
Tutorial 1
Discuss
How does each theme relate to the current case?
Each group member will thoroughly research at least one aspect of delirium.
All students should attempt to see at least one patient with delirium before the second tutorial.
All students should attempt to perform two mental state examinations (one normal, one
abnormal) before the second tutorial.
Tutorial 2
seen with delirium
References
Standard neurology reference text, chapter on delirium for an overview. Any text will do, eg:
Bradley et al (ed) Neurology in Clinical Practice 2nd ed Butterworth-Heinemann 1996
Accompanying monograph on delirium by Dr Storey
The students may search for and critically appraise information sources available on the
internet
Review Questions
What are the clinical characteristics of delirium?
How common is it? What are the predisposing causes? (ie who is at risk?)
How may it be staged and followed at the bedside?
What are the usual precipitants (direct causes)?
What investigational strategies are most efficient of both time and resources?
How is delirium best managed on the ward?
What should the relatives be told?
Sem Activity Title
2 Lecture The cognitive aspects of the mental state examination

2 Tutorial Mental State Examination - Cognition, Insight, Judgement and Informed Consent
2 Lecture Consciousness and the mind
Formulate a differential diagnosis of delirium

Suggest and interpret appropriate investigations
Explain its epidemiology and prognosis
Identify the reasons for assessing cognitive domains in a particular order
94
CASE 18: Stroke

Author: Dr Victor Gordon
Aim(s): On completion of this case, students will be able to assess and formulate a differential
diagnosis and plan of management of a patient with stroke.
Preparation
Before the first tutorial one pair of students should see a patient with a stroke.
Patients may be found in the stroke unit (if available) or in the general medical ward. A patient
with a past history of stroke will suffice if there are no patients with acute stroke; best if there are
persisting clinical signs.
The students will take a detailed medical history, supplemented from the medical notes and
corroborative history from the family if the patient is aphasic.
The students will bring along the results of relevant investigations to the tutorial and be
prepared to make a patient presentation to the group.
1. What is the definition of stroke?
2. What are some epidemiologic features of stroke?
3. What determines the clinical presentation of stroke?
4. What are some common stroke syndromes?
5. What are the risk factors for stroke?
6. What are the principles of management of stroke?
Scenario
Mr George Foreman is a 75 year old retired cook who lives with his wife. Over the last few months
prior to his presentation to the emergency room, he had been having episodes where he experienced
a few minutes of loss of vision like a black curtain coming down of his left eye. On the day of
presentation, his wife found him slumped over the breakfast table. He was unable to speak, but
seemed to understand what she was saying. The right side of his face was drooping and his right arm
was weak. He arrived at the emergency room 2 hours after the onset of his symptoms.
On examination, he is unable to speak but obeys simple commands. There is a right facial droop,
more pronounced in the lower part of the face. Vision and visual fields are intact. Power is reduced in
the right arm, with only weak elevation of the shoulder and shoulder adduction. There is mild
weakness of right hip flexion. Plantar responses are flexor. There is a soft bruit on auscultation of the
left carotid artery. Vital signs show a blood pressure of 165/100.
His medical history includes hypertension, for which he has been on treatment with an ACE inhibitor.
He is an ex-smoker, having smoked 20 cigarettes a day for 40 years; he last smoked 10 years ago.
His father, who was also a smoker, died of a stroke at the age of 65.
Haematological and biochemical screen are normal, including a blood sugar. Coagulation screen is
normal. CT scan of the brain performed shortly after arrival at the hospital is reported as normal. MRI
scan shows an area of diffusion restriction in the anterior portion of the left middle cerebral artery
territory, and a repeat CT scan done 48 hours later shows an area of low attenuation in the same
region.
He is admitted to the stroke unit and given aspirin. Speech therapy assessment shows dysphagia with
uncoordinated swallowing, so he is made nil by mouth and a feeding nasogastric tube is placed.
Physiotherapy is commenced the next day. He becomes febrile, right lower lobe consolidation is
detected clinically and seen on a chest X-Ray; antibiotic and chest physiotherapy treatment is
instituted promptly. Over the next week, there is good return of speech and his right arm weakness
partially improves. He is referred to rehabilitation.
Carotid Doppler study shows an 80-90% occlusion of the left carotid artery. Vascular surgery is
consulted; a left carotid endarterectomy is planned in 6 weeks time.
95
Tutorial 1
His amaurosis fugax should have been investigated
Should he have received intravenous thrombolysis?
Management of blood pressure in acute stroke in general, leave mild to moderate
hypertension alone.
How does each theme relate to the patient presented and/or the scenario?
Each group member will thoroughly research at least one aspect of stroke including the
difference between men and women in stroke.
All students should attempt to see at least one patient with stroke before the second tutorial.
All students should attempt to see a feeding nasogastric tube insertion before the second
tutorial.
Tutorial 2
seen with
References
Standard neurology reference text, chapter on stroke for an overview. Any text will do,
eg Neurology in Clinical Practice 2nd ed Bradley et al (eds) 1996 Butterworth-Heinemann
Ch 58
Literature search there is a considerable literature on stroke
The students may search for and critically appraise information sources available on the internet
An excellent comprehensive site on this and many other neurologic topics, with a US bias, of
course: http://www.strokecenter.org/prof/basics.htm
Review questions
As per pre-meeting questions
96
Sem Activity Title
2 Lecture Overview of the mental state examination
2 Briefing Briefing for two geriatric medical unit site visits
2 Tutorial Framework for focussed history taking and examination of the motor elements of
the peripheral nervous system
2 Lecture Walking and Normal and Abnormal Gait
2 Tutorial Framework for the assessment and examination of the sensory elements of the
peripheral nervous system
2 Lecture Introduction to the CNS and anatomy of cranial nerves and pathways
3 Practical Skull, Scalp and Cranial Cavity
3 Practical Face, Muscles of Facial Expression and Parotid
3 Lecture Neurological history and examination of Cranial Nerves
3 Practical Neurological history and examination of Cranial Nerves
1 Lecture Gene and protein engineering in clinical medicine: production of proteins for use
in treatment of disease
97
CASE 19: Peripheral Neuropathy

Aim(s): On completion of this case, students will be able to demonstrate an organised
approach to the clinical assessment and investigation of a patient with peripheral
neuropathy. Be familiar with the common clinical patterns and causes of peripheral
neuropathy.
Preparation
Before the first tutorial one pair of students should see a patient with symptomatic peripheral
neuropathy.
Patients may be found in the general medicine unit (diabetes, renal failure),
haematology/oncology units (chemotherapy, paraneoplastic), AIDS patients (HIV neuropathy,
drug-induced neuropathy from AIDS treatment).
The students should take a full history of the patient, to include the history of the neuropathic
symptoms, history of other illness (eg. diabetes), medication history, family history (inherited
neuropathy), travel history (leprosy, other infections).
1. What is a peripheral nerve?
2. How are peripheral nerves classified?
3. What is a peripheral neuropathy?
4. How are peripheral neuropathies classified?
5. How do the symptoms and examination of a neuropathy classically differ from those of a
myopathy?
6. What are some important aetiologies of peripheral neuropathy?
7. How to investigate a peripheral neuropathy
8. How are the symptoms of a neuropathy managed?
Pain
Maintenance of function
Scenario
Mr Milton Friedman is a 67 year old man, retired accountant. He has had Type II diabetes for
10 years. His diabetic control has been adequate at best. Over the last three years, he has noticed the
gradual onset of decreased sensitivity of his feet. For example, he can no longer feel the texture of
carpet when he walks barefoot at home. Despite the numbness, he also has an unpleasant burning
sensation in his feet and toes, which keeps him awake at night. He has also noticed difficulty walking
on uneven ground, especially in the dark, and frequently stumbles on the poorly maintained footpath
on his street. He is aware of no family members with similar symptoms, but he promises to call his
sister and ask her if she is aware of any.
Cranial nerve examination is normal, although he has mild to moderate diabetic retinopathy on
fundoscopy. Upper limbs show normal power, tone, reflexes, sensation (light touch, pinprick,
proprioception, vibration) and co-ordination. In the lower limbs, however, there is symmetrical
decreased sensitivity to pinprick to the mid-shin level and diminished proprioception and vibration
sensation of the toes. Ankle tendon reflexes are absent. Power is relatively normal.
Indices of diabetic control show moderate to poor values. He has microalbuminuria. Serum
protein studies are normal. His syphilis, Hep B, C and HIV serology are negative. CSF protein is
not elevated. Nerve conduction studies show low amplitude or absent sensory responses in
the lower limbs with relatively normal findings in the upper limbs. EMG shows mildly long
duration high amplitude polyphasic motor unit potentials in distal but not proximal lower limb
muscles.
98
Tutorial 1
How does each theme relate to the patient presented and/or the scenario?
Each group member will thoroughly research at least one aspect of neuropathy
All students should attempt to see at least one patient with neuropathy before the second
tutorial
All students should attempt to see a nerve conduction study performed before the second
tutorial
The adventurous student could try having a nerve or two studied on themselves (median
motor and sensory, Ulnar motor and sensory)
The stoic student could try having a muscle needled on themselves (first dorsal interosseus
usually hurts the least)
Tutorial 2
seen with neuropathy
Would the presentation be different in a patient other than an elderly white male?
References
Standard neurology reference text, chapter on peripheral neuropathy for an overview. Any text
will do, eg Neurology in Clinical Practice 2nd ed Bradley et al (ed) 1996 Butterworth-
Heinemann Ch 81 A caveat peripheral neuropathy is poorly handled in many general
neurology texts
The students may search for and critically appraise information sources available on the internet
An excellent comprehensive site on this and many other neurologic topics is
http://www.neuro.wustl.edu/neuromuscular/naltbrain.html
Review questions
As per pre-meeting questions
Sem Activity Title
2 Lecture Propagating the action potential
2 Briefing Practical Briefing Session
2 Practical Nerve Conduction
2 PCL Angela has a pain in the hand
99
CASE 20: Seizure

Aim(s): To provide students with an opportunity to explore presentation, investigations and
management of patients with seizure
Preparation
Before the first tutorial one pair of students should see a patient with epilepsy, preferably who
has had a recent seizure, or a patient presenting with their first seizure.
The common admitting units are the neurology or general medical units.
The students should take a thorough history from the patient and available witnesses to the
seizure (by telephone if necessary) and perform a neurologic examination. Focus particularly on
the nature of the seizure and potential precipitating factors.
1. What is the definition of a seizure?
2. What is the definition of epilepsy?
3. What are the potential precipitating factors for seizures?
4. What are the implications of a diagnosis of epilepsy for the patient?
5. What is the appropriate first-aid management of a seizure?
6. What is status epilepticus?
7. What is the management of epilepsy?
Scenario
Mary is a 17 year old high school student doing her VCE, studying late at nights, not getting her usual
amount of sleep, and eating irregularly. One night she goes to a post-exam party and has quite a few
drinks. She remembers having an unusual sensation in her abdomen, then the next thing she
remembers is waking up in the emergency room with sore muscles, a bitten tongue and doctors and
nurses fussing over her.
Marys friends describe that she fell over, made a peculiar groaning noise, her limbs went stiff for
20 seconds, and she then had rhythmic jerking movements of the body and limbs lasting 2 minutes.
Mary was incontinent of urine. She regained partial consciousness a few minutes later, but was
confused and a little aggressive.
Her mother remembers that as a child, she had convulsions during a high fever. She has been
knocked unconscious a few times in falls from horses during equestrian sports. Her mothers brother
has had seizures.
Her examination is normal. Routine laboratory tests are normal, including blood count, electrolytes,
calcium, and magnesium. A urine drug screen is positive for amphetamine derivatives.
EEG performed that afternoon shows non-specific generalised slowing. A repeat routine EEG a week
later is normal. A sleep-deprived EEG (no sleep the night before) shows focal slowing and spike-wave
complexes in early stages of sleep arising in the left anterior temporal region.
CT brain is normal. MRI scan with seizure protocol shows volume loss and signal abnormality of the
left medial temporal lobe and hippocampus.
100
Tutorial 1
Each group member will thoroughly research at least one aspect of epilepsy
All students should attempt to see at least one patient with epilepsy before the second tutorial.
All students should attempt to see an EEG before the second tutorial.
Tutorial 2
seen with epilepsy.
Are there any differences between male and female patients in presentation treatment or
outcomes of seizure?
References
Standard neurology reference texts, chapter on epilepsy for an overview.
Neurology in Clinical Practice 2nd ed Bradley et al (eds) 1996 Butterworth-Heinemann
Epilepsy Society publications, organise visit if appropriate
International League Against Epilepsy seizure classification criteria (available at website cited
below)
The students may search for and critically appraise information sources available on the
internet. For example,
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/epileptic-
syndrome/
Review Questions
1. What is the first aid management of a seizure?
2. What are some potential precipitants for a seizure?
3. What are the drugs available for the treatment of epilepsy? What are the difficulties of drug
therapy?
4. Are there any non-drug treatments for epilepsy?
Sem Activity Title
2 Lecture Consciousness and the mind
4 Lecture Adverse Drug Interactions
101
CASE 21: Movement Disorder/Parkinsons Disease

Author: Dr Mee Yoke Ling
Aim: Students will explore the aetiology, pathophsyiolgy, clinical presentation and
management plan for Parkinsons disease
Preparation
Review of anatomy/physiology with regard to the basal ganglia/extrapyramidal system and the control
of movement.
1. Identify the brain structures of the basal ganglia / extrapyramidal system
2. What is the function of this complex system?
3. What do you need to walk normally?
4. What are some patterns of gait abnormality?
5. What are the consequences of gait abnormality?
6. How do you examine gait?
7. What investigations may help in diagnosis?
8. What are the principles of management of gait disorder?
Scenario
Thelma Evans, aged 63, widow and long-time resident of a small town in Victoria, had been involved
in local government for several years. One Thursday evening, Thelma noticed that her left foot was
moving uncontrollably during a local council meeting. She hoped that no one would notice and went
home after the final agenda item. The left foot tremor continued on and off for several weeks then
spontaneously stopped, only to be replaced by involuntary movements in her right hand and right foot.
The tremor occurred mainly at rest and could be dampened or abolished by movement. During council
meetings over the ensuing months Thelma tried to hide the tremor by placing her left hand on top of
her right arm. However, Thelma realised that something had to be done when a fellow council
member asked her if she was nervous and why her hand was shaking so much.
When Dr Mark Sanders saw Thelma the next day he noticed, in addition to the tremor, that her face
didnt look as animated as it used to, she walked with small steps and there was a slight stooping in
her posture. Dr Sanders suspected a diagnosis of Parkinsons disease. This was subsequently
confirmed by the visiting neurologist.
What are the differential diagnoses and how would you distinguish these from Parkinsons disease?
What is Parkinsons disease (pathogenesis) and what are the cardinal features required in making the
clinical diagnosis?
Discuss the pharmacology of L-DOPA, DOPA agonists, anticholinergics, COMT inhibitors, other anti-
Parkinsonian medications.
10 years pass and Thelma, now 73 years old, is still living alone in Bendralgon. Thelma is taking
Sinemet 100/25 2 tablets at 7am, 11am, 3pm and 7pm. One Saturday afternoon, Thelma was
brought to the casualty of the local hospital after another fall. While walking on the footpath, Thelma
fell forward and grazed her hands and fractured the third metacarpal of her left hand. Dr Sanders, who
happened to be on call that weekend, noted that this is the fourth fall that Thelma has required
medical treatment for in the last 12 months. Dr Sanders got a splint for Thelmas hand and noted that
Thelma had lost weight and wondered how she was coping at home.
102
Tutorial 1
Each group member will thoroughly research at least one aspect of Parkinsons disease.
All students should attempt to see at least one patient with Parkinsons disease before the
second tutorial.
All students should revise the neurological history and examination (especially focussing on
movement) before the second tutorial.
Tutorial 2
seen with Parkinsons Disease
References
Jane E Rice & Philip D Thompson Movement disorders I: Parkinsonism and the akinetic-rigid
syndromes (Medical Journal of Australia 2001 174: 357-363)
Iansek R, Key points in the management of Parkinsons disease Australian Family Physician
1999; 28 (9) 897-901
Kumar & Clark Clinical Medicine: A Textbook for Medical Students and Doctors
Review Questions
1. Initially Thelma Evans found that levodopa/carbidopa (100mg/25mg three times a day)
improved all symptoms. Over the next 5 years, intermittent dosage increased to Sinemet 100/25
2 tablets at 7am, 11am, 3pm and 7pm. However, the duration of benefit from each dose
lessened. How can this be managed?
Sem Activity Title
2 Tutorial Framework for focussed history taking and examination of the motor elements of the
peripheral nervous system
2 Lecture Drugs acting at the ANS synapses
4 Lecture Adverse Drug Reactions and Poisoning
4 Practical History and examination of the endocrine system - 1
2 Lecture Transmitters
103
CASE 22: Peripheral Vascular Disease

Authors: Dr Peter Evans
Mr Alan Saunder
Aim(s): Peripheral Vascular Disease (PVD) is a common clinical problem and one
manifestation of the systemic condition of atherosclerosis. This problem based
learning module will explore the contributing factors, clinical manifestations and
principles of management of peripheral vascular disease.
Preparation
Before the first tutorial one pair of students should see a patient with peripheral vascular
disease
Nearly all patients with clinically significant PVD will be outpatients or inpatients of the Vascular
Surgery Unit, and the unit Registrar/Fellow should be able to provide you with an appropriate
patient to assess.
1. What is atheroma? Describe the pathophysiology of atherosclerosis and plaque development
2. What are the most common risk factors for PVD, and how can they be managed?
3. What are the usual presenting features of PVD? What is critical ischaemia and what features
from the history and physical examination suggest severe or potentially life-threatening
peripheral vascular disease?
4. What initial investigations would help to determine the severity and subsequent management of
peripheral vascular disease?
Scenario
Mr. Elliott is a 70 year old man who presents to his GP with a painful left foot. Over the past 4 years he
has been increasingly troubled by pain in his left calf when walking. Initially he could walk 100 to 200
metres before developing calf pain, and the pain would resolve with rest. Lately however, the pain has
developed after walking shorter distances and is also involving the thigh. He has been waking at night
with a pain in his left foot that is relieved by getting up to go to the toilet.
Mr. Elliott is on medication for hypertension and has been a diabetic for 5 years. For the past 6 months
he has required insulin to control his diabetes. He weighs approximately 85kg. He has had Coronary
Artery Bypass Surgery five years ago after a small heart attack.
Lately, the calf pain occurs while walking inside his house and involves the thigh. For the last two
weeks, he has been waking with a pain in the left foot that is relieved by hanging the foot out of bed.
For the last three evenings he has slept" in a chair to try to get some relief at night.
On examination his left foot is noted to be pale with poor capillary return. There is a 2cm diameter,
weeping area of black skin on the great toe. His femoral pulse is present with a thrill and bruit but
there are no pulses present distally in the left leg. Buergers test is positive.
His GP advises him to go straight to the local Emergency Department. He is admitted to hospital for
tests and undergoes surgery the next day.
104
Tutorial 1
The group should all go to see the patient, and the presenting student should demonstrate a full
vascular examination.
Discuss the possible causes of peripheral vascular disease.
All students should attempt to see at least one patient with peripheral vascular disease before
the second tutorial.
All students should attempt to see a procedure or test related to peripheral vascular disease
before the next tutorial. Angiography can be arranged through the Radiology Department and
Duplex scans are performed in either the Radiology Department or Vascular Laboratory.
Tutorial 2
seen with peripheral vascular disease.
References
Burkitt & Quick, Essential Surgery (Churchill Livingston) 3rd ed pp 437-468
Forrest, Carter & Macleod, Principles and Practice of Surgery (Churchill Livingston) 3rd ed
pp 270-287
Review Questions
1. What is the name given to the pain he has been experiencing over the last 4 years?
2. What are the main differential diagnoses of this pain, and what clinical features help you to
make a diagnosis?
3. What is the pathophysiology of this pain?
4. What is Buergers test? What is its significance and what is the mechanism of this effect?
5. What is the significance of the pain in his left foot and what is this called?
6. What are the risk factors for peripheral vascular disease in this patient?
7. What is the significance of the pain on movement of his foot, and ulcer in this case? Why has
his GP sent him straight to the Emergency Department?
8. What are the common sites of arterial occlusion in the peripheral vascular system? What is the
site of arterial occlusion in this mans left leg? How can this be confirmed? What investigations
are most commonly used?
9. Outline the risks of angiography? Why are angiograms often contra-indicated in diabetics? What
can be done to minimise these risks?
10. What is the likely surgical management of this patient? How would you manage his diabetes,
pre-, peri- and post-operatively?
105
Sem Activity Title
3 Practical Introduction to thorax, heart and great vessels
4 Practical Gross Anatomy - posterior abdominal wall, renal, ureters, adrenal,

spleen, vessels and nerves
2 Practical Anatomy of the anterior and medial thigh
2 Practical Anatomy of the posterior thigh
2 Practical The Leg
2 Practical The Ankle Joint
2 Practical The Foot
4 Lecture Lipid metabolism

Topic 6: Risk factors for heart disease
3 Lecture Coronary circulation in health and disease
3 Lecture Diuretics and Antihypertensives
3 Lecture Antihypertensives (2) and the role of the kidney in pharmacokinetics
1 Lecture Causes and mechanisms of tissue injury, cellular adaptations and

responses to injury
106
CASE 23: Urinary Obstruction

Author: Uri Hanegbi
Aim(s): To recognise the presentation of benign prostatic hypertrophy (BPH), its complications
and management options.
Preparation
Review the anatomy of the male urinary tract
Review the normal function of the prostate
See a male patient with lower urinary tract symptoms
Take a history and examine the prostate (ask the urology resident or registrar for guidance).
1. Draw a diagram of the male urinary tract
2. What is the relationship of the rectum to the prostate
3. At what sites may obstruction of the urinary tract occur
4. What type of pathology of the prostate may lead to lower urinary tract symptoms
Scenario
A fit 60-year old man presents to his GP with a 6 month history of urinary symptoms including a
deteriorating stream and nocturia. On examination the bladder is not distended and the prostate is
moderately enlarged and soft. The GP orders a renal function test, a urine culture, a PSA and a
urinary tract ultrasound. The blood and urine tests are normal and the ultrasound confirms prostatic
enlargement with no renal or bladder abnormality. The patient is referred to an urologist who assesses
the patient and discusses treatment options. The patient undergoes a transurethral resection of the
prostate (TURP).
Tutorial 1
Clarify any unfamiliar terms and acronyms
Students to present their patients
What are the possible causes of this mans symptoms?
What are other lower urinary tract symptoms and their significance?
What are the possible sequelae of prostatic enlargement?
What is the reason the investigations were ordered?
What are the treatment options for prostatic enlargement?
What are the possible complications of the above treatments?
Each group member to research thoroughly one aspect of this topic
All students should attempt to see a TURP before the second tutorial
107
Tutorial 2
seen with the condition.
Discuss potential complications and the long-term implications for patients in the event that they
experience these complications.
Review Questions
1. Describe how you would consent a patient for a TURP.
Sem Activity Title
vessels and nerves
4 Lecture History and examination of the reproductive system (2)
108
CASE 24: Skin rash/ulcer

Author: Associate Professor Rod Sinclair
Aim(s): This case provides stimulation for learning about skin lesions, particularly skin
cancers. Students need to discuss the risk factors, clinical features and management
of skin cancers, particularly facial lesions. Factors to consider in planning for surgical
excision include the local anatomy, assessment of the structures endangered by the
tumour and the procedure to remove it, the differential diagnosis and methods
available to confirm the diagnosis prior to definitive surgery, excision margins required
for tumour clearance, the likely resultant defect and surgical options for repair of
defects.
In addition, the options for anaesthesia (general anaesthesia and local anaesthesia
with or without sedation) and the venue for the procedure (in-office surgery, day
surgical facility, hospital operating theatre) should be considered in terms of infection
control, patient care and cost.
Skin cancer epidemiology and primary and secondary preventive strategies need to
be considered. Key discussion points are the incidence of skin cancers, the
distribution patterns in Australia, the contribution of occupational exposure and the
effectiveness of Australian skin health promotion programs. The case also provides
an opportunity to consider the skin lesions associated with HIV infection as Mr de
Vries is gay and is of unknown HIV-antibody status.
Scenario
Mr Johan de Vries, a 53 year old international airline pilot, is found on a routine health check to have a
skin lesion on the left lower eyelid/medial canthus region. The lesion is 1.8 cm in diameter with poorly
defined margins (figure 1). On general skin examination he also has an atypical pigmented lesion on
his back over his right scapula (figures 2a and 2b). He was unaware of this lesion. Mr de Vries is
concerned that UV radiation he is exposed to in the cockpit of the plane may have caused the lesion.
You are a medical officer with Qantas and are conducting a routine health examination on Mr Johan
de Vries, a 53 year old international pilot. You notice a skin lesion on his left lower eyelid/medial
canthus region.
109
1. Identify Mr de Vries presenting problem.
2. Using the key information provided and the biopsychosocial model, list the possible causes of
his problem (ie hypotheses).
3. Develop a causative mechanism for your working hypothesis.
4. What history questions would you wish to ask Mr de Vries if he were your patient? Explain your
reasoning.
History
Mr de Vries is well with no past medical history or relevant family history. He has not noticed the skin
lesion. He has no previous skin lesions.
Tobacco and alcohol
Non smoker. On the days that he is not flying, drinks 1-3 glasses of wine.
Medication
Nil
Allergies
Nil
Social History
Mr de Vries spends 10 days per month flying. The remainder of the time he spends at his home, a
hobby farm in the Yarra Valley. He grew up in Melbourne, although he lived in Queensland for eight
years while doing his flight training. He is the son of Dutch immigrants.
Sexual history
Mr de Vries is gay and has been in a stable relationship for 29 years with Adrian, a 51 year old wine
writer. He has unprotected anal sex with his partner (receptive and insertive) - although not that often.
They mostly engage in mutual masturbation and oral sex. He has never had an HIV test. As he has
not had unprotected anal intercourse since 1979 he thinks he must be HIV negative. Adrian is well and
has also never had a test.
Physical examination
Fit, lightly tanned, middle-aged man. No lymphadenopathy.
Facial lesion
left-lower eyelid/medial canthus region
1.8 cm diameter with poorly defined margin at 7 oclock
when skin is stretched between thumb and index finger the lesion takes on a pearly colour.
not particularly mobile due to surrounding structures
no associated pain or numbness in the area
Vital signs
Blood pressure 125/80
Pulse rate 68/min regular rhythm
Respiratory rate 12/min
Temperature 36.70C
Cardiovascular, respiratory, and abdominal examinations
Normal
110
Skin Examination
On general skin examination he has an atypical pigmented lesion on his back over his right scapula,
as well as multiple freckles and solar lentigines
Figure 2a Figure 2b
Finding on general skin examination Close up of lesion over right scapula
Use this information to refine your hypotheses. Give evidence.

What tests do you want to order to confirm your refined hypotheses? Explain your reasoning.
Discuss the alternatives for skin biopsy.
Discuss the importance of general skin examination in a patient deemed to be at high risk for
the development of skin cancer.
111
Investigations
Mr de Vries is referred to a plastic surgeon. At the initial consultation a full medical history and
examination is repeated. No lymphadenopathy or hepatomegaly is found. No relative contraindications
or potentially complicating factors to surgery are identified. He declines a HIV test.
In the office, local anaesthesia is infiltrated into the medial canthus and also the pigmented lesion on
the back. A shave biopsy is performed from the medial canthus. The lesion over the back is excised
with a 1 mm margin of normal skin all around.
Histology from lesion medial canthus
Histology from lesion back
Tutorial 1
Work through the scenario with the following information.
Each group member will thoroughly research at least one aspect of skin lesions.
All students should attempt to see at least one patient with skin lesions before the second
tutorial.
All students should attempt to see punch biopsy, shave biopsy, curettage and excisional biopsy
before the second tutorial.
112
Further Information
Mr de Vries is booked into a day surgery facility for removal of the lesion on the inner canthus and
wider and deeper excision of the lesion on the back. The patient is sedated with midazolam pre-
operatively. The areas are both infiltrated with 1 to 2 ml of 1% lignocaine and 1 in 200,000 adrenaline.
The lesion on the inner canthus is excised with a 3-4mm margin of normal skin down to periosteum.
The tear duct is visualised in the base of the wound. The defect is too large to close primarily. A full
thickness skin graft is taken from the ipsilateral post-auricular skin and sutured in place.
The lesion on the back is excised with a 2 cm margin of normal skin. Tissue mobility on the back is
sufficient to enable primary closure.
Post-operative recovery was uneventful. The histology showed that the lesion on the inner canthus
was completely excised. The re-excision specimen from the back showed only scar tissue.
The patient was followed up at six monthly intervals. No metastatic disease was identified. However 2
years later a basal cell carcinoma appeared on his forehead, and was treated by surgical excision.
Tutorial 2
seen with skin lesions.
References
Sinclair R & Marks R (1998) A guide to the treatment of common skin disorders. Skin and
Cancer Foundation, Victoria.
Sinclair R & Marks R (1998) A guide to the performance of diagnostic procedures used in the
management of common skin disease. Skin and Cancer Foundation, Victoria 1998
Sinclair R (2001) CD on pigmented skin lesions Minor Surgery Health Press
Sem Activity Title
1 Lecture Primary tissue types and function I
1 PCL Alans dilemma
1 PCL Aidans Mole
113

Yr 3B CCD Student Guide 2017

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Problem-based Learning

YEAR 3B MED, 2017

ATTENDANCE AT PBL TUTORIALS

Key to Success in Problem-Based Learning

CASE 9: Obstructive Jaundice ............................................................................................ 71

Problem-based Learning (PBL) Student Guide

What is Problem-Based Learning?

Problem-Based Learning in MED at Monash University

Paper Cases for Problem Based Learning

Real Patient Cases for Problem Based Learning

Problem-based Learning Cases List 2017

Problem Based Learning Cases

Real Patient Paper

Cardiovascular disease Cardiovascular disease

1 Chest pain 1. Congestive heart failure

2 Ischaemic heart disease

Renal disease Renal disease

2 Acute glomerulonephritis 3 Acute renal failure

4 Chronic renal failure

Pulmonary disease Pulmonary disease

4 Cough / Weight loss

GIT/Hepatobiliary disease GIT/Hepatobiliary disease

6 Abdominal pain (acute / chronic) * 6 Acute liver failure/chronic liver disease

8 GI bleeding (upper / lower) *

Infectious diseases Infectious diseases

13 Pneumonia 8 Infectious endocarditis *

10 Pyrexia of unknown origin

Problem Based Learning Cases

Real Patient Paper

Endocrinology Rheumatology / Clinical immunology

14 Thyroid disease * 13 Connective tissue disease

General surgery Surgery

22 Peripheral vascular diseases 17 Multi-trauma/ lower limb fracture

Dermatology * Signifies significant surgical content

24 Skin rash / Ulcer

Tutor Role in Problem Based Learning

Guide to Facilitating Discussion in Problem Based Learning

Other Roles in Problem Based Learning Groups

Title: Mr Lance Patrick - swollen legs

PRIOR LEARNING FOR THEME III OBJECTIVES

Sem Activity Title

3 PCL Rita's not feeling so good ......

3 PCL Andrew is tired

3 Lecture Sleep disorders and non-invasive ventilation

3 PCL Anna's out of breath

3 PCL Hoping for the best

3 PCL The Ballet Dancer

3 Lecture Inotropic agents

3 Lecture Vasodilator agents

Title: Ms Ghelani Singh - breathless on exertion

Standard Exercise Stress Test:

PRIOR LEARNING FOR THEME III OBJECTIVES

Sem Activity Title

3 Practical History taking for the Cardiovascular System

3 Lecture The respiratory system: neoplasms of the lung

3 PCL Anna's out of breath

3 Lecture Coronary circulation in health and disease

3 PCL Tom in the garden

3 Lecture Cardiovascular System history and examination

4 Lecture Insulin and Oral Antidiabetic Agents

4 Lecture Overview of Diabetes Mellitus

4 Lecture Introduction to Diabetes and Metabolism CD-ROM

3 Lecture Vasodilator agents

Title: Mrs Jessie Johnson - calf pain