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MEDICINE AND THERAPEUTICS

The Department of Medicine and Therapeutics is the second largest department in the University of Ghana Medical

School comprising the clinical and academic/research sub-specialties units of cardiology, clinical pharmacology, dermatology, endocrinology, gastroenterology, infectious diseases, nephrology, neurology, nuclear medicine, and respiratory medicine.

Aside from running undergraduate courses in internal medicine, the Department organizes programmes for  other academic and higher professional qualifications at the masters level and for membership and fellowship diplomas for the Ghana College of Physicians and Surgeons and the West African College of Physicians.

The department is additionally responsible for the provision of clinical services to the Korle-Bu Teaching Hospital in Accra covering the areas of chest diseases, drug addiction, infectious diseases, kidney dialysis, adult medical emergency, general medical and sub-specialty in-patient and out-patient services.

Mission

The mission of the Department is to produce highly disciplined, scientifically knowledgeable and skilled clinicians capable of functioning effectively in any rural or urban medical set up in Ghana, and working at a standard acceptable in the international community of medicine.

Courses

The Department organizes and runs the following courses:

1. Introduction to Nursing (Level 500): Duration – 1 week

This course introduces pre-clinical students to common nursing procedures and practices. It is run by senior nursing practitioners and tutors.

1. Introductory Course in Clinical Medicine (Level 500): Duration – 4 weeks

This course is intended to help the 1^st clinical year student acquire skills in gathering of clinical information from history taking and physical examination. It consists of clinical demonstrations on the ward and lectures as well as an introduction to medical ethics. The course is evaluated towards the end by a written examination and a feedback session with tutors.

1. Junior Clerkship (Level 500): Duration – 24 weeks

This is a coordinated course undertaken in conjunction with the Department of Surgery.  The course consists of daily lectures covering all the internal medicine sub-specialty areas together with bedside teaching and tutorials on the wards for two groups of continuing 1^st clinical year students, each spending 12 weeks in medicine or surgery, followed by the other discipline for another 12 weeks. The course emphasizes the application of clinical techniques and laboratory/radiological investigations in making a diagnosis in different clinical scenarios. It is evaluated in the 12^th week by both a written and clinical examination as well as a feedback session with tutors.

1. Dermatology Course (Level 600): Duration – 24 weeks

This course for 2^nd clinical year students consists of weekly lectures and clinical out-patient sessions for three small groups, each spending 8 weeks in dermatology and two other specialty areas (psychiatry and otolaryngology). The course is evaluated by a written examination.

1. Senior Clerkship (Level 700): Duration – 40 weeks

This course is provided for students in their final year coming to the Department in four separate groups for

10 weeks each.  Other rotations during this period include general, orthopaedic and urological surgery and community health. It is a more concentrated and detailed course in internal medicine covering all aspects of diagnosis and patient management. The focus is to prepare the student for the housemanship or internship after graduation. There are no formal lectures, however, numerous teaching and learning opportunities exist at all times during ward rounds, bedside teaching, emergency room and out-patient reviews and at weekly Friday clinical meetings. Students are also required to organize weekly student-led clinical presentations which are supervised by a tutor. Students are additionally encouraged to develop the ability to acquire knowledge and information from recommended reference books, journals, other library material and reliable internet sources. Two weeks of this rotation are spent in a hospital outside Korle Bu Teaching Hospital and another two at the mortuary. At the mortuary students learn to carry out a basic autopsy examination and to appreciate the correlation between ante-mortem diagnosis and post-mortem findings. The course is evaluated by a written and clinical examination which forms part of the continuous assessment for the final MB ChB examination.

Basic Requirements for the Courses

Students must acquire the following for all clinical courses in internal medicine; white coat, approved name tag, wrist watch with a ‘seconds’ hand, stethoscope, pocket torch, tendon hammer, measuring tape and pocket-size diagnostic set.

Expectations

Students would be expected to have mastered the following procedures and/or be certified by a tutor or clinical assistant to have repeatedly performed the following by the end of the sub-internship; veni-puncture for blood samples, insertion of intravenous lines, preparing of thick and thin films for malaria parasites, staining blood film for malaria parasites, Gram’s and Zeihl Neilson staining of sputum, urinalysis, blood glucose testing with a glucose meter, lumbar puncture, thoracocentesis, abdominal paracentesis, electrocardiogram lead placement and recording.

They would also be expected to have observed the following; liver and renal biopsy, haemodialysis, pleural biopsy, bronchoscopy, colonoscopy and gastroesophagoduodenoscopy.

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY Objectives

The objective of the course is to produce a student

1. Who is equipped with the attitude, knowledge and skills he/she will need to develop into a competent doctor after completion of his/her housemanship (internship) training
2. Who will have a sound foundation for specialist training in Obstetrics and Gynaecology if he/she so desires.

LEVEL 600 – SENIOR CLERKSHIP

OBSTETRICS AND GYNAECOLOGY WORKSHOP

Tuesdays/Fridays

2.00 – 4.00 p.m.

Student                 Subject                  

Team

E                         – The Bony Pelvis.  Landmarks and Diameters.  Features of Gynaecoid,

• Android pelves, anthropoid, platypeloid. –  Value of adult gynaecoid pelvis.                          –  Assessment of pelvic capacity;
• Clinical and radiological. The fetal skull.

D                        – Fetal Distress in Labour.  Clinical

• Fetal Distress, Bio-chemical Fetal
• Distress, Diagnosis, monitoring cord presentation and cord prolapse. –  Resuscitation of   the newborn

B                     –    Normal and Abnormal Labour

–  The Partograph

A                   –         Adolescent Pregnancy

C                      –     P.P.H.

E                      –    A.P.H.

C – Face, Brow, Shoulder and Compound        – Presentations.  Incidence, aetiological

• Factors, diagnosis, Management.
• Maternal and Fetal Complications.

LEVEL 600 – SENIOR CLERKSHIP

WORKSHOP SCHEDULE

LECTURES:                                        Tuesdays              8.30 a.m.  to 9.30 a.m.

Thursdays 4.00 p.m. to 5.00 p.m. CLASS WORKSHOPS:  Tuesdays 2.00 p.m. to 4.00 p.m.

Fridays                  2.00 p.m. to 4.00 p.m.

Guidelines for Class Workshops

The Residents shall prepare a comprehensive outline of the subject.  He shall first discuss the outline with his Consultant and then with the students of the Team who are to present the subject.

The Residents shall moderate the presentation and discussion.  At the end the Consultant shall summarise, emphasizing the core points of the subject.

Clerkship Hand-Out

You are all welcome into the Department of Obs/Gynae.  I will like you to appreciate that in this department you deal with the most personal and intimate parts of the females and hence your approach to the patient should be very tactful and polite.

For the first time in your training you have the opportunity to do a lot for the patient yourself and it is our wish that you take the opportunity to get involved in the work of the Department.

The Clerkships are combined ones and hence you must pay equal attention to both Obstetrics and Gynaecology.

Students in each group starting the Junior Clerkship period will be allocated to one of the 5 firms within the department.  Each student should follow the weekly timetable of the firm to which he or she is attached, as far as ward work, clinics and operating sessions are concerned.  Such a timetable should be obtained from the Consultantin-charge working in the firm.  Over and above this work, students must devote as much of their time during this Clerking period to the labour suite, and they should follow their Unit Doctors on emergency duty.

The duties in the labour suite should include history taking and admission of patients, routine observations normally carried out in the first stage room eg. fetal heart monitoring, pulse and blood pressure readings, testing of urine, setting up and monitoring intravenous infusion, vaginal examinations to assess progress of labour, normal vaginal deliveries under supervision and repair of episiotomies  or perineal tears.  Students must try as much as possible to follow up cases from the time of admission into the labour suite to the time of discharge from the postnatal ward, so that they will be able to record their observations.

You will be expected to complete a partograph for each patient that you follow up in the labour suite and deliver.

This must be signed for you by the supervision midwife/Doctor soon after the delivery and submitted at the end of the Clerkship.  Students should take every opportunity to examine patients, observe and assist in operative vaginal deliveries, and also Caesarean sections.  Suturing Episiotomies is a Must and All Students Should Learn, Perform and Repair Episiotomies.

In the labour suite the students must conduct themselves well.  They must realise that the Sister or Midwife is incharge of the patients in the labour suite.  They must therefore carry out routine procedures as instructed by her and also not to undertake any other procedures on patients without her knowledge or that of the doctor.  Students, while working in the labour suite, must change into proper labour suite attire, which is obtainable from the Sister.

There will be several routine rounds in the labour suite, both by Junior and Senior member of staff and you are advised to avail yourself for them.

Students must be present in the Department especially the labour suite when on call as much as possible throughout the duty period in order to be present when the cases are being managed.

Needless to say, if a student is unwell, has a sore throat, cold, septic finger and infection, he or she should not attend the labour suite or operating theatres.  The student should inform a member of the senior staff in their firm.

The periods spent in the clinic (both antenatal and gynaecological) should be utilized to the full.  The student should train himself in taking histories and seize every opportunity of examining patients.  Students should attach themselves to Members of the senior Staff.  These clinics should give the student a clear idea of the numbers, type of patients and abnormal conditions seen in our community.

In the ante-natal and postnatal wards students are responsible for clerking cases and also in helping the junior staff with the work-up of patients.  Students should as much as possible follow up cases that they have witnessed or managed in the labour suite.

Each student will be allocated a certain number of beds and the students will be responsible for clerking the patients that occupy these beds.  The students must be prepared to present such cases during ward rounds.

While in postnatal wards students should familiarise themselves with the care of babies especially of the ones they delivered.  Such care includes proper examination to exclude congenital abnormalities, bathing, preparation of feeds, observation of weight charts and breast feeding.  Students should also try and follow up babies being cared for in the

Neonatal Intensive Care Unit.

In Gynaecological wards the students would be allocated a number of beds for which they will be responsible.  Duties include clerking and work up of patients and assisting in the operating theatre.  They should be ready to present them during ward rounds.

No student will be allowed to appear for the final examination in Obstetrics and Gynaecology without completing the clerkship satisfactorily.  Students who fail such an assessment test will have to repeat part or all the clerkship period during the Vacation.

During the period of Junior Clerkship each student must prepare a Case-Record Book.  The purpose of this book is to give a clear idea of the work done and cases seen during the Clerkship period.  To facilitate the presentation of this work each student will be supplied with an empty book at the beginning of the Clerkship.  In it will be found detailed instructions of the number and type of cases you are expected to see or manage.

In summary these are:-

For Obstetrics

Details are per heading of 10 witnessed cases of normal deliveries.

Full details of 3 cases delivered personally.  Each case must be signed by the Supervising sister or midwife or

Medical Officer in the Labour Suite.

Summary of at least 20 more normal cases delivered personally by the student.  Signatures of supervising midwife must be obtained in each case.

See as many abnormal cases as you possibly can and write up as described under each section.

Give details about babies as asked.

For Gynaecology

Full details of 10 cases personally clerked and followed up during the period of clerkship.  The cases should be as varied as possible.

Details should include:

History

Examination

Laboratory

Diagnosis

Operation findings and procedures

Histological examination

Results and prognosis

Critical appraisal of the management

The empty pages at the end of this book are reserved for the gynaecological cases.

Each patient selected for write up must be certified by the Team’s Consultant as having been managed by/with the student.

OBSTETRICS & GYNAECOLOGY CLERKSHIP

Rationale

The Obstetrics and Gynaecology Clerkship should concentrate on the basic sciences as applied to obstetrics and gynaecology and on the common clinical conditions that the student is bound to see during the period of the Clerkship.

Objectives

By the end of the Junior and Senior Clerkships, the student will:

• Have a sound grasp of the basic sciences as applied to obstetrics and gynaecology
• Be able to perform the following clinical activities satisfactorily:
• History taking and history presentation
• Physical examination and presentation of findings
• Be able to describe/discuss with confidence the treatment and management of complications of the common clinical conditions listed below

Although both clerkships will cover all the course objectives, the Junior Clerkship will be more focussed on the first two objectives while the Senior Clerkship will put more emphasis on the discussion of treatment and management of complications.

Teaching Aids

• Bony Pelvis
• Fetal skull
• Surgical Instruments
• Pathology pots

Topics

Bony Pelvis

Bones, joints and ligaments of the pelvis

Pelvic inlet (brim), cavity and outlet

• Pelvic inclination
• Pelvic axis
• Definitions and normal values of the diameters of the adult gynaecoid (female) pelvis at:
  • Brim
  • Mid-pelvis
  • Outlet
• Features of adult gynaecoid pelvis, i.e. the features that make the bony pelvis suitable for parturition
• Major differences between the gynaecoid pelvis and each of the following pelvic types:
  • Anthropoid
  • Android
  • Platypelloid

Fetal Skull

• Description of the following:
  • Bones of the fetal skull
  • Sutures and fontanels
  • Vertex
  • Identification of the vertex presentation on vaginal examination  Description and normal values of diameters of the fetal skull at term  Presenting diameters in:
  • Well-flexed OA position
  • Deflexed OA position
  • OP position
• Moulding:
  • Definition and dynamics
  • Grading
  • Benefits and dangers

• Engagement:
  • Determination on abdominal examination and on vaginal examination
  • Prognostic significance

Pelvic Floor

• Levator ani muscles and their covering fasciae
• Functions of the levator ani
• The supports of the pelvic organs
• Blood supply
• Nerve supply

Perineum

• Muscles
• Fasciae
• Vascular supply
• Nerve supply

Maternal Adaptation to Pregnancy / Physiological changes in Pregnancy

• Cardiovascular system
• Haematological system
• Respiratory system
• Renal system
• Gastrointestinal system
• Uterus

PREGNANCY

Diagnosis

Antenatal Care

Estimation of Gestational Age – Pregnancy Dating

• Clinical methods
• Ultrasound scan

The booking scan: The variables reported on in the booking scan

Complications in Early Pregnancy

• Hyperemesis gravidarum
• Vaginal bleeding
  • Miscarriage (spontaneous abortion)
    • Threatened
    • Inevitable
    • Incomplete
    • Complete
    • Septic
    • Missed
  • Ectopic pregnancy
  • Molar pregnancy

Medical Conditions in Pregnancy

• Anaemia
• Malaria

Haemoglobinopathies (Sickle Cell Disease)

• Hypertensive Diseases in Pregnancy
• Diabetes in pregnancy

Non-medical Pregnancy Complications

Antepartum Haemorrhage

Multiple Pregnancy

Malpresentation (Breech presentation)

Premature rupture of membranes

Labour – Spontaneous

Mechanism of Labour in OA Position (Cardinal Movements)

Management of Labour and the Partograph

• Definitions of the 1^st and 2^nd Stages
• Historical basis of the partograph
  • Cervical dilatation curve: cervicograph
  • Latent and active phases of labour
  • Derivation of the alert and action lines
• Features of the partograph
• Normal partograph
• Using the partograph to diagnose abnormal labour delayed labour and the cause 3^rd Stage of Labour
• Definition
• Physiology
  • Mechanisms responsible for separation of the placenta
  • Mechanisms responsible for haemostasis at the placental site
• Complications of 3^rd stage
  • Primary postpartum haemorrhage
  • Retained placenta
• Management of 3^rd stage
  • Low-risk patient
  • High-risk patient

Active management of 3^rd Stage of labour

  Components:

Administration of uterotonic agents (drug of choice is oxytocin 10 units IM)

Controlled cord traction

Uterine massage after delivery of the placenta

Induced Labour

• Indications and contraindications
• Cervical assessment : Bishop’s score
• Methods

Episiotomy

• Definitions
• Muscles and nerves involved
• Types
• Advantages and disadvantages of each type
• Repair
• Complications

Perineal Tears

• Degrees: definitions
• Predisposing factors

Prevention

• Management of 4^th degree tear: operative, post-operative, subsequent deliveries Cephalo-Pelvic Disproportion (CPD)
• Definition
• Causes
• Complications
• Diagnosis: Antenatal, intrapartum

Primary Postpartum Haemorrhage (P.PPH)

• Definition
• Causes in order of their frequencies
• Determining the cause
• Differentiating uterine atony P.PPH from other causes (lower genital tract laceration P.PPH)
• Management of P.PPH from uterine atony
• Management of P.PPH from lower genital tract lacerations (technique of inspecting the lower genital tract) Secondary Postpartum Haemorrhage
• Definition
• Causes
• Management

Puerperium

• Definition
• Management of the normal puerperium including family planning
• Complications
  • Puerperal pyrexia: Causes and Investigations
  • Factors that predispose to puerperal sepsis (genital tract infection) Caesarean Section
• Indications
• Preoperative preparation
• Types: classical and lower segment
• Description of steps in lower segment caesarean section
• Advantages of the lower segment section
• Complications Breastfeeding
• Advantages of breast milk over cow milk
• Definitions of exclusive breastfeeding, replacement feeding, mixed feeding
• Disadvantages and dangers of replacement and mixed feeding  Physiology of suckling
• Benefits of breastfeeding:
  • Breast milk
  • Suckling HIV/AIDS in Obstetrics

Obstetric emergencies

Induced Abortion

Unsafe Abortion

• Definition and examples
• Importance
• Prevention

Post-Abortion Care

Activities in post-abortion care

Ectopic Pregnancy

• Definition
• Clinical types: acute and chronic
• Causes
• Diagnosis of ruptured tubal pregnancy: Leading symptoms and signs

Management

Other gynaecological emergencies

Vaginal Discharges

Differential diagnosis, complications and treatment of:

• Bacterial vaginosis
• Candida albicans
• Trichomonas vaginalis

Pelvic Inflammatory Disease

• Definition
• Causes
• Diagnosis: symptoms, signs, investigations
• Complications
• Management: outpatient and in-patient

Sexually Transmitted Infections

• Syndromic approach to STI management

Infertility

• Definitions: Primary & Secondary subfertility
• Causes
• History taking: To determine if infertility exists and to diagnose cause
• Physical examination: To determine if infertility exists and to diagnose cause
• Investigations
• Management/ Treatment (including assisted reproductive technology)

Uterine Fibroids

• Aetiological risk factors
• Histopathology
• Symptoms and signs
• Investigations
• Diagnosis
• Complications
• Management options

Pelvic Organ prolapse

Urinary Incontinence

• Vesico-vaginal fistula
• Other types of incontinence: Stress incontinence, Urge incontinence, Mixed incontinence Gynaecological Tumours
• Benign tumours
• Malignant tumours o Cervix o Endometrial o Ovary o Vulva o Choriocarcinoma

HIV/AIDS in Gynaecology

JUNIOR CLERKSHIP LECTURES

Lecture                                                                  

1. Overview of Obstetrics & Gynaecology              
2. Examination of Obst. & Gynae. Patients           
3. Review of anatomy of female pelvic organs and the breast
4. Maternal Mortality and Morbidity
5. Review of embryology of female genital organs and the urinary system
6. Prenatal diagnosis (SCD, sex linked disease etc) and Fetal Surveillance
7. Normal Labour and Partograph
8. Problems of Labour. Disproportion,

Deep Transverse Arrest occipito-Posterior

Position Trial of Labour

9. Obstetric analgesia and Anaesthesia
10. Mechanism of Labour – Normal and

Abnormal Presentation

11. The Puerperium
12. The Third Stage of Labour including Postpartum

Haemorrhage and Shock in Obstetrics

13. Anaemia in Pregnancy including Sickle cell disease in Pregnancy
14. Psychiatric and Psychosocial Aspects of O&G
15. Pelvic Inflammatory Disease
16. HIV/AIDS and other Sexually Transmitted Diseases
17. Menstruation and Menstrual disorders
18. Multiple Pregnancy
19. Pre-operative management and Post-operative complications in O & G
20. The Infertile Couple
21. Sex Chromosome Abnormalities and Intersex
22. Ante partum haemorrhage
23. Ultrasound in Obstetrics & Gynaecology
24. Obstetric operations
25. PROM & Preterm Labour & Postdate Pregnancy
26. Natural Family Planning. Contraception (Hormonal and Sterilisation)
27. Contraception (Barrier, IUCD) Emergency Contraception
28. Hypertension, Pre-eclampsia and Eclampsia
29. Utero-Vaginal Prolapse
30. Medical Disorders in Pregnancy (1)
31. Medical Disorders in Pregnancy (2)
32. Incontinence of Urine
33. Obstructed labour and Ruptured Uterus
34. Intra Uterine Growth Restriction
35. Endometriosis, Adenomyosis and Uterine fibroids
36. Abortion, Unsafe Abortion, Post-Abortion Care
37. Premalignant Lesions of the Female Genital Tract
38. Benign and Malignant tumours of the Vulva
39. Gestational Trophoblastic Disease
40. Carcinoma of the Cervix
41. Tumours of the corpus uterus (Benign and Malignant)
42. Tumours of the Ovary (Benign and Malignant)
43. Sexual and Reproductive Health and Rights.

(The Rights of Women and children)

Gender (Gender Equality, Gender Equity and Gender        Mainstreaming)

44. Ethical Issues in Obst & Gynae.
45. Course Review

OBS & GYNAE

Required skills

Taking an obstetrics history

Taking a gynaecological history

Abdominal examination

Examination of the pregnant uterus

Bimanual examination

Gaining intravenous access Setting up a IV line

Performing an episiotomy

Repairing an episiotomy

Suturing and trying of surgical knots

Cardiopulmonary resuscitation

Taking a Pap Smear

BP measurement

Vaginal deliveries

Bathing newborns

Breast feeding

Perform high vaginal and Endocervical Swab

Perform vaginal speculum examination

Required equipments/materials

Mannequins for abdominal, obstetrics and pelvic examinations

Instruments for suturing

Sutures

Pin cushions suturing practice

Mannequins for CPR procedures

Video/CDs on various skills

Sphygmomanometer

Plastic specula

Bony pelvis

Dummy babies

Cytobrushes, Ayre’s spatulae