Your SlideShare is downloading. ×
INTERNAL MEDICINE CLERKSHIP COURSEBOOK.doc.doc
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

INTERNAL MEDICINE CLERKSHIP COURSEBOOK.doc.doc

1,526

Published on

Published in: Health & Medicine, Education
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,526
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
49
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc INTERNAL MEDICINE CLERKSHIP COURSEBOOK I. INTRODUCTION The internal medicine clerkship is one of the seminal clinical experiences for medical students. In this clerkship, students are expected to begin developing many of the basic competencies of doctoring. The third year clerkship is meant to compliment the experiences in the fourth-year clerkship and in the primary care clerkship. Those problems and medical conditions in Internal Medicine that every physician should be able to manage, regardless of chosen specialty, will be emphasized. We will provide you with clinical and didactic experiences that should stimulate learning. This curriculum detailed below specifies and prioritizes course objectives in terms of the basic generalist competencies, the specific learning objectives (knowledge, skills, and attitudes) pertinent to these competencies, and includes the clinical experiences and evaluation methods. The goal in Medicine 7-500 is to have you identify clinical problems in your patients through the integration of information derived from the history and physical examination. You will use knowledge of pathophysiology and clinical epidemiology in order to develop a reasoned differential diagnosis. Finally, you will plan a logical and practical diagnostic evaluation, using the principles of evidence-based medicine. Your resident, attending physician, and tutors have also been provided with this booklet. The information included is to assist in setting expectations for these courses, for you, and for the faculty. Each course is to be viewed as a successive part of the educational continuum; those medical problems and skills that you do not learn in Medicine 7-500 should be mastered in Medicine 7-501 or in the Primary Care Clerkship. Course Objectives for the Externships in Medicine are intended to help you set your own goals. The ability to learn independently is an essential trait for every physician to have and very important for your success in these externships. You will have opportunities to evaluate and take care of patients, discuss cases with your resident and attending physician, present cases to both teachers and student colleagues at Case Presentations, and participate in Tutorials addressing common clinical problems. Each of these experiences should stimulate you to ask questions and to seek answers using the medical literature where appropriate. In particular, the student conferences will present opportunities for you to actively participate in clinical problem-solving. The degree to which all students are prepared to do so will largely determine how successful the Externships in Medicine will be as educational experiences for you and your colleagues. This curriculum is based in large part on the collaborative efforts of the Society of General Internal Medicine and the Clerkship Directors in Internal Medicine, please see http://www.im.org/CDIM/ResourcesFor/CDIMeducationaltools.htm for details of this collaboration.
  • 2. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc OUTLINE 1. Course Committee 2. Sites 3. General Information 4. Core Lectures a. MED I b. MED II 2. Grading/Evaluation 3. Portfolio 4. Course Objectives 5. Core Competencies Curriculum 6. General Competencies 7. Core Topics COURSE COMMITTEE The course committee coordinates activities on MED I and MED II across all of the clinical sites. The committee is involved in evaluation of students with borderline grades and resolution of disputed grades. The committee consists of the Clerkship Director and the Hospital Coordinators from each of the clinical sites. Internal Medicine Clerkship Director: James Nixon, M.D. Fairview University Medical Center 420 Delaware St SE MMC 741 Minneapolis, MN 55455 Phone: 612-626-5230 Email: nixon007@umn.edu Daneen Barnett-Johnston Coordinator for Undergraduate Medical Education Fairview University Medical Center 612-625-9975 Email: barne042@umn.edu Site Directors: Med I (Medicine 7500) Tom Stillman, M.D. (7500 & 7501) Hennepin County Medical Center Department of Medicine 612-873-8723 Course Contact: Lyneshia Robinson
  • 3. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc
  • 4. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc Laurel Drevlow, M.D. (7500) Abbott-Northwestern Medical Center Medical Education 612-863-4212 Course Contact: Jackie Wilczek Tom Yacovella, M.D. (7500 &7501) Regions Hospital Department of Internal Medicine 651-254-1886 Course Contact: Karen Lee James Nixon, M.D., (7500) Fairview University Medical Center Department of Medicine 612-625-9975 Course Contact: Daneen Barnett-Johnston Med II (Medicine 7501) Stacey Mollis, M.D. (7501) Veterans Affairs Medical Center Department of Medicine 612-725-2085 Course Contact: Donna Luck Tom Stillman, M.D. (7500&7501) Hennepin County Medical Center Department of Medicine 612-873-8723 Course Contact: Lyneshia Robinson Connie Manske, M.D. (7501) Fairview University Medical Center Department of Medicine 612-625-9975 Course Contact: Daneen Barnett-Johnston Tom Yacovella, M.D. (7500 &7501) Regions Hospital Department of Internal Medicine 651-254-1886 Course Contact: Karen Lee SITES Abbott Northwestern – MED I Abbott Northwestern Hospital is the largest not-for-profit hospital in the Twin Cities area. Abbott Northwestern Hospital is a part of Allina Hospitals & Clinics, a family of hospitals, clinics and care services in Minnesota and Western Wisconsin. Abbott Northwestern Hospital's services include: complete medical, surgical and critical care for patients and multi-specialty care and clinical expertise in behavioral health services, cardiovascular
  • 5. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc services, medical/surgical services, neuroscience, oncology, orthopedics, rehabilitation, spine care and women's health. Hennepin County Medical Center – MED I and MED II U.S. News and World Report has repeatedly named Hennepin County Medical Center (HCMC) one of America’s Best Hospitals. HCMC is a comprehensive academic medical center and public hospital located in the heart of the Twin Cities of Minneapolis and St. Paul, Minnesota. Our health care campus includes a 360-bed acute care hospital and primary care and specialty clinics Regions Hospital– MED I and MED II Regions Hospital is the major community hospital for Ramsey County (St. Paul) and referral center affiliated with HealthPartners, a major Twin Cities health care maintenance organization. Regions provides general and subspecialty medical care to HealthPartners™ patients, which includes a large population of new Americans. It offers critical care experience as well as toxicology training and has a level 1 trauma center. University of Minnesota Medical Center – Med I and II Rated in the top 100 hospitals nationally, Fairview-University Medical Center ´s highly specialized care is a major national and regional referral center. Fairview-University provides primary, secondary and tertiary care on general medicine (4), cardiology (2), critical care (2), heme/onc (1), and bone marrow transplant (1) inpatient teams. This hospital offers state-of-the-art critical care and transplantation medicine affiliated with Fairview Health System, a large provider of primary care services in the Twin Cities. Minneapolis VA Medical Center– MED II The Minneapolis VA is a teaching hospital which serves as a tertiary referral center for the Upper Midwest. It has 237 acute care diagnostic and treatment beds, as well as a 104-bed extended care unit. The medical center provides primary, specialty, mental and behavioral health, and extended care and rehabilitative care to over 45,000 veteran patients. It has one of the largest education and training programs in the VA system. Annually, approximately 1,000 students and residents and 1,500 other trainees are involved in education and training programs at the facility. GENERAL INFORMATION Supervision: The site directors at each teaching site bear the primary responsibility for the development and maintenance of a program to fulfill the learning objectives of the Externships in Medicine. The coordinator is responsible for organizing the tutorials and seminars and encouraging faculty members to take the expected approach toward student involvement in seminars and tutorials. Since there are differences in student responsibilities for Medicine 7-500 and 7-501, directors will also reinforce at the beginning of each period, with the attending physician and resident, the objectives to be met by the students assigned to their ward team. Each student is part of a medical team usually consisting of one or two first-year residents, a senior resident, and an attending physician. Some teams may pair students (subinterns) with an attending physician without residents. Students in both
  • 6. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc Medicine 7-500 and 7-501 attend morning work rounds each day and participate in attending rounds as scheduled. The attending physician has the primary responsibility for educating students assigned to the ward team. The immediate day-to-day supervisor for students is the senior resident. All of the physician-teachers with whom the student has contact are expected to serve as positive role models. Conferences: Each site has developed student-specific seminars. Most topics are common to all of the sites, but the presentation has been developed at the site. These are mandatory conferences and students are expected to attend and participate. Each site has a student specific schedule. Departmental conferences are routinely held at each of the hospitals. These conferences include medical grand rounds, morning report, clinicopathological conferences, resident teaching conferences, and subspecialty conferences. Students are welcome at departmental conferences, although, if student-specific conferences are scheduled at the same time you are expected to attend those instead. Textbooks: Students are expected to do some reading in a general medicine textbook as relates to conference topics and to their patients. General Concise Textbooks 1. Medical Knowledge Self-Assessment Program, MKSAP for Students 3, American College of Physicians, (Suggested) 2. Internal Medicine Essentials for Clerkship Students, American College of Physicians (Required) Work-ups and Write-ups: Medicine 7-500 students are expected to work-up a minimum of twelve patients during the rotation. Medicine 7-501 students are expected to work-up a minimum of fifteen patients. Students, who, through no fault of their own, do not reach the required minimum, will not be considered deficient. More cases may be assigned. Students should attempt to complete their history and physical examinations within 60 minutes. Cases will be presented to the attending physician during attending rounds. It is at this time, or previously in review with the senior resident, that factual historical items should be substantiated and physical findings corroborated. Valued Student Performance Behaviors: The course committee has had many discussions about what makes an outstanding student and resident. Medical knowledge, skills in gathering and organizing data, and excellent judgment are all essential components. Perhaps most important is attitude. Students who are self- starters, who create opportunities for their own learning, who take obvious pleasure in the learning opportunities on the ward are students who will stand out for us. Look at the evaluation forms. If you are always bringing in new information for the team, you will be highly regarded. Accept constructive criticism as a help to your improvement (don’t be defensive). If you don’t know, don’t make something up. If you complain about reading and do it only grudgingly, if you complain about learning value of patients admitted to you, these are red flags. Before you complain, be sure you have something to complain about. (See Troubleshooting below) Feedback: Since ongoing feedback is fundamental to a successful educational relationship, students should feel free to ask about their progress. Feedback from faculty and residents to students is extremely important in providing the opportunity
  • 7. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc to improve clinical performance. During the Externships in Medicine, students will be expected to initiate meetings at mid-rotation, first with their supervising resident (if assigned) and then with their attending physician, to discuss both strengths and areas needing improvement. The content of this feedback is outlined in the Evaluation forms for this course. A similar process should occur at the end of the rotation so that the student, resident and faculty can discuss the student’s progress relative to the mid-rotation assessment and the Course Objectives. These student-initiated sessions should make the feedback process more efficient, effective, and palatable for the faculty and residents; and equally important, promote student self-assessment through analysis of specific examples of their own performance. Absence: Each student is assigned to a team and is expected to function as a responsible member of that team. Any unexcused absence may result in a failing grade. Absence for any reason but illness or emergency must be approved ahead of time by the hospital coordinator. An opportunity to make up required work will be provided when such absences are cumulatively less than one week in length. Absence for more than two weeks for any reason will automatically result in the student having to repeat the entire externship. Absences of one to two weeks will be handled on an individual basis by the hospital coordinator and course director. During the six weeks of Medicine 7-501, if students need time off for interviewing they should try to minimize the time taken from any clerkship (please see the medical school guidelines for interviewing days off). Prior approval from the hospital site coordinator is required. Students are expected to receive on average, one day off per week, arranged with the team. This may be on a weekday, if that best fits with the schedule. This time off does not count as an absent day from the rotation. If you, for some reason, miss the NBME Shelf Exam, the only option for taking this will be to wait for the next administration 6 weeks later at the conclusion of the next clerkship. LECTURES Medicine 7-500 Required Seminars Seminars: Nine general topics have been selected for tutorials. This does not represent the entirety of the information you are expected to know after completion of this clerkship. See Objectives, General Competencies and Core Topics later in this course book for a more detailed description of the expectations for this course. Additional topics are assigned, at the discretion of the hospital coordinators. Emphasis in the tutorials is on the definition of basic problems and a general approach to understanding and solving these problems. Additional special student conferences (physical examination, medical decision-making, fluids and electrolytes, PFTs, blood gases, etc) may be offered at individual hospital sites. Tutorial objectives are provided as a guide for students when preparing tutorials. In order to effectively discuss the cases presented during the tutorials, students should prepare in advance. Some of the material outlined in the tutorial objectives will not be directly covered during the tutorial session. A variety of cases may be used as examples to cover the objectives outlined.
  • 8. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc Core Content Seminars 1. Anemia Students should be able to define and describe: a. Classification and morphologic definition of anemia as normocytic, microcytic, or macrocytic. b. Morphological and laboratory characteristics of iron deficiency anemia, megalobalistic anemia, hemolytic anemia including microangiopathic, and congenital disorder (sickle cell, thalessemias). c. Indications, contraindications, and complications of blood transfusion. 2. Hypertension Students should be able to define and describe: a. Classification and prevalence of primary and secondary hypertension and the most common causes of secondary hypertension. b. Hypertensive urgency and emergency and their initial management. c. Pathophysiology, presentation, and diagnostic approach for Cushing’s disease, renovascular hypertension, pheochromocytoma, and hyperaldosteronism. d. Manifestations of target-organ damage from hypertension. 2. Jaundice Students should be able to: a. Outline a differential diagnosis for yellow skin, including important features from the history, physical examination, and laboratory data. b. Outline a differential diagnosis for jaundice (differentiating obstructive from non-obstructive) and identify distinguishing clinical features from the history, physical examination, and laboratory data of each major etiology. c. Outline diagnostic and management strategies for: (1) Obstructive jaundice (2) Non-obstructive jaundice 3. Dyspnea Students should be able to: a. Discuss the differential diagnosis of a patient presenting with (1) Acute dyspnea (2) Chronic dyspnea b. Discuss the signs, symptoms, and initial evaluation of:
  • 9. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc (1) Left ventricular failure * (2) Right ventricular failure (3) Pulmonary embolism (4) Asthma/COPD exacerbation (5) Interstitial lung disease c. Discuss the diagnostic and therapeutic management of the case presented. 4. Venous Thromboembolism Students should be able to: a. Discuss risk factors for developing thrombophlebitis b. Discuss presenting symptoms of thrombophlebitis and pulmonary embolus/infarction c. Discuss the long term sequelae of DVT 5. Fever Students should be able to: a. Describe normal characteristics of thermal regulation, such as diurnal variations in temperature. b. Describe methods of obtaining temperatures and their limitations. c. Describe the significance of accompaniments of fever, such as chills, seizures, tachycardia. d. List seven general disease categories, which are often accompanied by fever. e. Outline the differential diagnosis for fever in a hospitalized patient, in an immunocompromised patient, in a patient with a fever and pulmonary infiltrates (pneumonia*). f. Describe the therapeutic management of fever for patients, defined in e above, including the indications for antibiotics or other specific therapy. g. Define fever of unknown origin and plan, in general terms, the evaluation of a patient with this disorder. 6. Chest pain Students should be able to describe and define: a. Signs and symptoms associated with ischemic cardiac pain (stable and unstable angina), non-ischemic cardiovascular pain (dissecting aortic aneurysm, acute pericardial pain), valvular heart disease (aortic stenosis and mitral valve prolapse), GI disorder (gastroesophageal reflux and esophageal spasm), pulmonary disorders (pneumothorax, pulmonary embolism, inflammation of the
  • 10. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc pleura), and musculoskeletal disorders (costochondritis and muscular strain). b. Factors that exacerbate angina pectoris. c. Cardiac risk factors. 7. Gastrointestinal Hemorrhage Students should be able to: a. Outline and describe clinical features that distinguish upper from lower gastrointestinal bleeding. b. Describe how to determine the magnitude of blood loss. c. Describe the approach for hemodynamic resuscitation of clinically important blood loss, including indications for transfusion of blood products. d. Outline a differential diagnosis for: (1) Upper gastrointestinal bleeding (2) Lower gastrointestinal bleeding e. Describe the indications for and utility of various investigative procedures for delineating the source of bleeding (e.g., endoscopy, angiography, barium studies). 8. Diabetes Students should be able to describe and define: a. Diagnostic criteria for, and pathogenesis, genetics, epidemiology, major causes of morbidity and mortality, and presenting sign and symptoms of type I and type II diabetes mellitus. b. Signs and symptoms of diabetic ketoacidosis and nonketotic hyperglycemic coma. Medicine 7501 Required Seminars Management of Medical Emergencies (1 seminar per week). These seminars focus on the recognition and management of common medical emergencies. Students are expected to be prepared to participate actively in the discussions. Topics which will be covered include: 1. Shock Students should be able to: a. Describe the hemodynamic and metabolic events that occur in the shock state b. Describe the clinical findings of shock. c. Discuss the major categories of shock (e.g., hypovolemia, cardiogenic, sepsis) and the clinical differentiation of these states.
  • 11. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc d. Discuss the differential diagnoses of each of the major categories of shock. e. Discuss the clinical management of each type of shock state. Discuss the role of hemodynamic monitoring in the management of shock. 2. Acute Respiratory Failure Students should be able to: a. Define respiratory failure. b. Discuss the clinical signs of respiratory failure. c. Give three examples of patient diagnoses, which may present with respiratory failure. d. Differentiate cardiogenic pulmonary edema from adult respiratory distress syndrome (ARDS), with respect to pathophysiology. e. Discuss the pathophysiology of hypoxemia in asthma vs. ARDS; include reasons for differences in treatment of hypoxemia in each case. f. Describe how to determine when the patient requires mechanical ventilation for each of the following etiologies: (1) COPD exacerbation (2) Asthma (3)ARDS (3) Bellows failure (e.g., Guillian-Barre, ALS) g. Discuss the complications of mechanical ventilation and of PEEP. h. Discuss the therapeutic management of acute respiratory failure of the case presented. 3. Electrolyte Disorders Students should be able to describe and define: a. The pathophysiology, presenting signs and symptoms, differential diagnosis (most common causes), and an approach to a patient with: elevated or decreased blood volume, elevated or decreased serum sodium, potassium, calcium, phosphorous, magnesium; simple acid- based disorders. b. How to calculate total body water and understand its distribution. c. How to determine the etiology hyponatremia and hypernatremia. d. The risks of too rapid or delayed therapy for hyponatremia. e. How to calculate the anion gap and explain its relevance to determining the cause of a metabolic acidosis. f. The types of fluid preparations and methods of administration to treat fluid and electrolyte disorders. g. Causes and treatment of hyperkalemia. 4. Acute Renal Failure Student should be able to describe and define: a. Acute Renal Failure (ARF) as a rapid decline in glomerular filtration rate (GFR) and retention of nitrogenous waste products and discuss
  • 12. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc and distinguish between the three major pathophysiologic etiologies for ARF: (1) decreased renal perfusion (pre-renal) (2) intrinsic renal disease (renal) (3) acute renal obstruction (post-renal) b. The difference between and the major pathophysiologic etiologies of “pre-renal” ARF including: (1) hypovolemia (2) decreased cardiac output (3)systemic vasodilatation (4)renal vasoconstriction c. The difference between and the major pathophysiologic and etiologies of intrinsic “renal” ARF including: (1) vascular lesions (2)glomerular lesions (3)acute tubular necrosis (ATN) (4)interstitial nephritis (5)intra-tubule deposition/obstruction d. The difference between the two major etiologies of ATN – ischemic and nephrotoxic. Discuss the common offending agents involved with nephrotoxic induced ATN. e. The natural history, initial and supportive treatment modalities and complications of acute renal failure. 5. Acute MI Student should be able to: a. Recognize electrocardiographic changes indicative of myocardial ischemia and infarction. b. Interpret cardiac enzymes. c. Describe a typical patient presentation for Acute MI. d. Describe the major complications of Acute MI and how to recognize and treat them. e. Describe major therapeutic management options and their risks and benefits.
  • 13. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc GRADING AND EVALUATION Information from a variety of sources will be compiled in the evaluation and grading of each student. The hospital coordinator at each site is responsible for compiling the evaluations and using these evaluations along with the scores on the examination(s) to assign the final grade. In the event of a disputed grade, failing grade on any exam or any area of performance that was judged as “below expectations”, a final grade will only be assigned after thorough review of student performance by the Course Committee. Grades will be Outstanding, Excellent, Satisfactory and Fail. The targeted grade distribution will be 25% Outstanding, 50% Excellent and 25% Satisfactory and Fail less than 2%. Medicine 7-500 Final Grade • 50% of the grade will be based upon clinical activities as evaluated by attending and senior resident. (25% from attendings and 25% from residents) • 20% of the grade based upon participation and performance as evaluated by site coordinator. • 30% of the grade based on exam scores. 1. National Board of Medical Examiner, Shelf Exam (20%) 2. Lab/EKG Exam (10%) Medicine 7-501 Final Grade • 70% of the grade will be based upon clinical activities as evaluated by attending and senior resident. (35% from attendings and 35% from residents) • 30% of the grade is based on the exam score. Failure Failing grades can be assigned based on: 1) Professionalism, 2) Unsatisfactory Clinical Performance or 3) Failure of the written exam(s). In the event a student fails the NBME Shelf Exam, the student will be allowed to repeat the exam without repeating the course (assuming clinical performance was acceptable). A second failure will require remediation of the entire clerkship. If a student fails both of the exams for MED I this will be reviewed on an individual basis and the student may be asked to remediate the entire clerkship. If your performance is judged “below expectations” in any area on any final evaluation, all your evaluations and any other pertinent information about your performance will be carefully reviewed by the Medicine Clerkship Committee who will
  • 14. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc then determine your grade. If you are assigned a grade of Fail you must follow the procedures outlined by the Medical School. If a student’s performance on the clerkship was passing but marginal, further review of the students overall medical school performance may be recommended. COURSE OBJECTIVES General Overview For MED I the student will be able to:  Elicit a record an appropriately complete, cogent, and organized medical history.  Conduct and record an appropriately complete and accurate physical examination  Communicate in a facilitative, effective, efficient, and educational manner with patients and their families.  Identify the social and psychological components of patients’ medical problems.  Use knowledge of the pathophysiology of signs and symptoms to establish clinical correlation’s with disease processes.  Develop an accurate and complete problem list.  Formulate a reasoned differential diagnosis for each problem.  Formulate an appropriate plan for confirming the diagnosis.  Use knowledge of the indications and limitations of clinical sources such as laboratory and roentgenographic studies, consults, family input and old records to request and interpret data pertinent to problem solving.  Use information from texts, syllabi, and journals to study general topics related to patient’s problems.  Observe, review, reassess, and revise clinical management daily, record patient progress in the medical record, and make a verbal report to the health care team.  Communicate clearly and succinctly to colleagues and other members of the health care team. For MED II the student will (in addition to above objectives):  Apply those technical skills commonly employed on a medical service.  Formulate an appropriate initial treatment program taking into account the urgency of the patient’s problems.  Formulate an appropriate ongoing health care plan for patients within their socio-economic situation.
  • 15. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc  Assume independent responsibility for the primary care of patients with appropriate supervision.  Recognize and respond appropriately to common medical emergencies.  Demonstrate independent learning in response to questions raised in the clinical setting by using textbooks, journal articles, media, computer-based tools and other resources.  Demonstrate an expanded fund of knowledge by active participation in tutorial sessions. Technical and Interpretation Skills: Students are expected to acquire certain technical skills and interpretation that are commonly employed in medical care. Wherever possible and appropriate students are encouraged to participate in procedures under adequate supervision. Since the opportunities for participation will be limited, the acquisition of technical expertise should occur throughout both Externships in Medicine. The student should be able to:  Record and interpret an ECG.  Perform venipuncture for blood specimens or intravenous therapy.  Test for the presence of blood (e.g. by hemoccult) in stool.  Interpret cardiac enzymes.  Interpret a complete blood count.  Interpret results of a urine analysis.  Interpret gram stain results of body fluids.  Interpret bedside tests of pulmonary function.  Interpret chest x-ray findings.  Interpret arterial blood gas measurements.  Interpret serum electrolyte measurements.  Interpret results of body fluid analysis including joint, pleural, peritoneal, spinal Each objective follows a standard sequence of steps appropriate to effective design of a clinical course: 1) specifying and prioritizing course objectives in behavioral terms as the competencies to be mastered; 2) identifying the specific learning objectives pertinent to each of these competencies and stating them in terms of requisite knowledge, skills, and attitudes; 3) formulating clinical and classroom experiences appropriate for the learning objectives; and 4) establishing evaluation methods for measuring the desired competencies.
  • 16. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc DETAILED GENERAL CLINICAL CORE COMPETENCIES Learning objectives for each competency Diagnostic Decision-Making Case Presentation Skills History Taking and Physical Examination Communication and Relations with Patients and Colleagues Test Interpretation Therapeutic Decision Making Bioethics of Care Self Directed Learning Prevention Coordination of Care Basic Procedures Geriatric Care Community Health Care Nutrition Advanced Procedures Occupational Health Care Continuous Improvement in Systems of Medical Practice DIAGNOSTIC DECISION-MAKING Rationale Physicians are responsible for directing and conducting the diagnostic evaluation of a broad range of patients, including acutely and chronically ill patients. In a time of rapidly proliferating tests, internists must design safe, expeditious, and cost-effective diagnostic evaluations. This requires well-developed diagnostic decision-making skills that incorporate probability-based thinking. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. key history and physical examination findings pertinent to the differential diagnosis. 2. information resources for determining diagnostic options for patients with common and uncommon medical problems. 3. key factors to consider when selecting from among diagnostic tests, including pretest probabilities, performance characteristics of tests (sensitivity, specificity, likelihood ratios), cost, risk, and patient preferences. 4. the relative cost of diagnostic tests. 5. how critical pathways or practice guidelines can be used to guide diagnostic test ordering. 6. the method of deductive reasoning. B.Skills: Each student should be able to: 1. formulate a differential diagnosis based on the findings from the history and physical examination. 2. use probability-based thinking to identify the most likely diagnoses. 3. use the differential diagnosis to help guide diagnostic test ordering and sequence.
  • 17. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 4. use pretest probabilities and scientific evidence about performance characteristics of tests (sensitivity, specificity, likelihood ratios) to determine post-test probabilities according to the predictive value paradigm. 5. participate in selecting the diagnostic studies with the greatest likelihood of providing useful results at a reasonable cost. C.Attitudes: Each student should: 1. incorporate the patient’s perspective into diagnostic decision-making. 2. limit the chances of false positive/false negative results by demonstrating thoughtful test selection. CASE PRESENTATION SKILLS Rationale Communicating patient care information to colleagues and other health professionals is an essential skill regardless of specialty. Internists have traditionally given special attention to case presentation skills because of the comprehensive nature of patient evaluations and the various settings in which internal medicine is practiced. Students should develop facility with different types of case presentation: written and oral, new patient and follow-up, inpatient and outpatient. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. components of comprehensive and abbreviated case presentations (oral and written) and the settings appropriate for each. B. Skills: Each student should be able to: 1. prepare legible, comprehensive, and focused new patient workups that include the following features as clinically appropriate: • present illness organized chronologically, without repetition, omission, or extraneous information. • a comprehensive physical examination with detail pertinent to the patient’s problem. • a succinct and, where appropriate, unified list of all problems identified in the history and physical examination. • a differential diagnosis for each problem (appropriate to level of training). • a diagnosis/treatment plan for each problem (appropriate to level of training). 2. orally present a new patient’s case in a logical manner, chronologically developing the present illness, summarizing the pertinent positive and negative findings as well as the differential diagnosis and plans for further testing and treatment. 3. orally present a follow-up patient’s case, in a focused, problem-based manner that includes pertinent new findings and diagnostic and treatment plans
  • 18. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 4. select the appropriate mode of presentation that is pertinent to the clinical situation. C. Attitudes: Each student should: 1. demonstrate a commitment to improving case presentation skills by regularly seeking feedback on presentations. 2. accurately and objectively record and present data. HISTORY-TAKING AND PHYSICAL EXAMINATION Rationale The ability to obtain an accurate medical history and carefully perform a physical examination is fundamental to providing comprehensive care to adult patients. In particular, the internist must be thorough and efficient in obtaining a history and performing a physical exam with a wide variety of patients, including healthy adults (both young and old), adults with acute and chronic medical problems, and adults with complex life-threatening diseases. The optimal selection of diagnostic tests, choice of treatment, and use of subspecialists, as well as the physician’s relationship and rapport with patients, all depend on well developed history-taking and physical- diagnosis skills. These skills, which are fundamental to effective patient care should be a primary focus of the student’s work during the core clerkship in general internal medicine. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. the significant attributes of a symptom, including location and radiation, intensity, quality, temporal sequence (onset, duration, frequency), alleviating factors, aggravating factors, setting, associated symptoms, functional impairment, and patient’s interpretation of symptom. 2. the four methods of physical examination (inspection, palpation, percussion, and auscultation), including where and when to use them, their purposes, and the findings they elicit. 3. the physiologic mechanisms that explain key findings in the history and physical exam. 4. the diagnostic value of history and physical exam information. B. Skills: Each student should be able to: 1. use language appropriate for each patient. 2. use non-verbal techniques to facilitate communication and pursue relevant inquiry. 3. elicit the patient’s chief complaint as well as a complete list of the patient’s concerns. 4. obtain a patient’s history in a logical, organized, and thorough manner, covering the history of present illness; past medical history (including usual source of and access to health care, childhood and adult illnesses, injuries, surgical procedures, obstetrical history, psychiatric problems, hospitalizations, transfusions, medications, tobacco and alcohol use, and
  • 19. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc drug allergies); preventive health measures; social, family, and occupational history; and review of systems. 5. obtain, whenever necessary, supplemental historical information from other sources, such as significant others or previous physicians. 6. demonstrate proper hygienic practices whenever examining a patient. 7. position the patient and self properly for each part of the physical examination. 8. perform a physical examination for a patient in a logical, organized, respectful, and thorough manner, giving attention to the patient’s general appearance, vital signs, and pertinent body regions. 9. adapt the scope and focus of the history and physical exam appropriately to the medical situation and the time available. C. Attitudes: Each student should: 1. recognize the essential contribution of a pertinent history and physical examination to the patient’s care by continuously working to improve these skills. 2. establish a habit of updating historical information and repeating important parts of the physical exam during follow-up visits. 3. demonstrate consideration for the patient’s feelings, limitations, and cultural and social background whenever taking a history and performing a physical exam. COMMUNICATION AND RELATIONSHIPS WITH PATIENTS AND COLLEAGUES Rationale The physician-patient relationship forms the core of the practice of internal medicine. Many physicians view it as the most satisfying aspect of their work. The medical interview and the relationship between physician and patient are important diagnostic and therapeutic tools. Effective communication skills are needed for a physician to serve as an effective patient advocate. Communication skills also are needed to address patient concerns and requests. Proficiency in communicating with patients results in increased patient and physician satisfaction, increased adherence to therapy, and reduced risk of malpractice claims. The student on the internal medicine clerkship interacts with a diverse array of patients, physicians, and other health team members, necessitating proficiency in communication and interpersonal skills. Students also witness how diversities of age, gender, race, culture, socioeconomic class, personality, and intellect require sensitivity and flexibility. The result of proficiency in communication and interpersonal skills is increased satisfaction for both doctor and patient. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. how patients’ and physicians’ perceptions, preferences, and actions are affected by cultural and psychosocial factors and how these factors affect the doctor-patient relationship. 2. the role and contribution of each team member to the care of the patient. 3. the role of psychosocial factors in team interactions. 4. the role of the physician as patient advocate.
  • 20. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc B. Skills: Each student should be able to: 1. demonstrate appropriate listening skills, including verbal and non-verbal techniques (e.g., restating, probing, clarifying, silence, eye contact, posture, touch) to demonstrate empathy and help educate the patient. 2. demonstrate effective verbal skills including appropriate use of open- and closed-ended questions, repetition, facilitation, explanation, and interpretation. 3. determine the information that a patient has independently obtained about his/her problems. 4. identify patient’s emotional needs. 5. seek the patient’s point of view and concerns about his/her illness and the medical care he/she is receiving. 6. determine the extent to which a patient wants to be involved in making decisions about his/her care. 7. assess patient commitment and adherence to a treatment plan taking into account personal and economic circumstances. 8. work with a variety of patients, including multiproblem patients, angry patients, somatizing patients, and substance abuse patients. 9. work as an effective member of the patient care team, incorporating skills in interprofessional collaboration. 11. give and receive constructive feedback. C. Attitudes: Each student should: 1. work hard to develop effective doctor-patient communication skills. 2. take into consideration in each case the patient’s psychosocial status. 3. demonstrate respect for patients. 4. demonstrate actively involving the patient in his/her health care whenever possible. 5. demonstrate teamwork and respect toward all members of the health care team, as manifested by reliability, responsibility, honesty, helpfulness, selflessness, and initiative in working with the team. 6. respond pertinently to patient concerns. 7. attend to or advocate for the patient’s interests and needs in a manner appropriate to the student’s role. TEST INTERPRETATION Rationale Physicians, in particular general internists, order a wide variety of medical tests in the course of their clinical practice. They must be able to interpret the results of such tests accurately and properly determine how the results should influence patient management. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. the various components of a complete blood count, blood smear, electrolyte panel, general chemistry panel, electrocardiogram, urinalysis, pulmonary function tests, and body fluid cell counts and chemistries. 2. range of normal variation in the results of a complete blood count, blood smear, electrolyte panel, general chemistry panel, electrocardiogram,
  • 21. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc chest x-ray, urinalysis, pulmonary function tests, and body fluid cell counts and chemistries. 3. results of the above tests in terms of the related pathophysiology. 4. test sensitivity, test specificity, pre-test probability, and predictive value. 5. how errors in test interpretation can affect clinical outcomes and costs. B. Skills: Each student should be able to: 1. interpret a blood smear, gram stain, electrocardiogram, chest X-ray, and urinalysis. 2. record the results of laboratory tests in an organized manner, using flow sheets when appropriate. 3. estimate post-test probability based on test results and state the clinical significance of these findings. C. Attitudes: Each student should: 1. demonstrate estimating the implications of test results before ordering tests and after test results are available. 2. personally review X-ray films, blood smears, etc., to assess the accuracy and significance of the results. THERAPEUTIC DECISION-MAKING Rationale Internists are responsible for directing and coordinating the therapeutic management of patients with a wide variety of problems, including critically ill patients with complex medical problems and the chronically ill. To manage patients effectively, physicians need basic therapeutic decision-making skills that incorporate both pathophysiologic reasoning and evidence-based knowledge. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. information resources for determining medical and surgical treatment options for patients with common and uncommon medical problems. 2. key factors to consider in choosing among treatment options, including risk, cost, evidence about efficacy, and consistency with pathophysiologic reasoning. 3. how to use critical pathways and clinical practice guidelines to help guide therapeutic decision making. 4. factors that frequently alter the effects of medications, including drug interactions and compliance problems. 5. factors to consider in selecting a medication from within a class of medication. 6. factors to consider in monitoring a patient’s response to treatment, including potential adverse effects. 7. various ways that evidence about clinical effectiveness is presented to clinicians and the potential biases of using absolute or relative risk or number of patients needed to treat. 8. methods of monitoring therapy and how to communicate them in both written and oral form.
  • 22. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc B. Skills: Each student should be able to: 1. formulate an initial therapeutic plan. 2. access and utilize, when appropriate, information resources to help develop an appropriate and timely therapeutic plan. 3. explain the extent to which the therapeutic plan is based on pathophysiologic reasoning and scientific evidence of effectiveness. 4. begin to estimate the probability that a therapeutic plan will produce the desired outcome. 5. write prescriptions accurately. 6. counsel patients about how to take their medications and what to expect when they take their medications, including beneficial outcomes and potential adverse effects. 7. monitor response to therapy. C. Attitudes: Each student should: 1. incorporate the patient in therapeutic decision-making, explaining the risks and benefits of treatment. 2. respect patient’s informed choices, including the right to refuse treatment. 3. incorporate the elements of patient autonomy, treatment efficacy, quality of life, and societal demands into decision-making. 4. provide close follow-up of patients under care. BIOETHICS OF CARE Rationale A basic understanding of ethical principles and their application to patient care is essential for all physicians. During the internal medicine core clerkship, the student can put into practice some of the ethical principles learned in the preclinical years, especially by participating in discussions of informed consent and advance directives. Additionally, the student learns to recognize ethical dilemmas and respect different perceptions of health, illness, and health care held by patients of various religious and cultural backgrounds. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. basic elements of informed consent. 2. circumstances under which informed consent is necessary and unnecessary. 3. basic concepts of autonomy, treatment efficacy, quality of life, and societal demands. 4. potential conflicts between individual patient preferences and societal demands. 5. the role of the physician in making decisions about the use of expensive or controversial tests and treatments. B. Skills: Each student should be able to: 1. participate in a discussion about advance directives with a patient. 2. participate in informed consent for a procedure.
  • 23. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 3. participate in the care of a consent-requiring terminally ill patient. 4. participate in a preceptor’s discussion with a patient about a requested treatment that may not be considered appropriate (e.g., notcost- effective). C. Attitudes: Each student should: 1. take into account the individual patient’s perspective and perceptions regarding health and illness. 2. demonstrate a commitment to caring for all patients, regardless of gender, race, socioeconomic status, intellect, sexual orientation, ability to pay, or cultural background. 3. recognize the importance of allowing terminally ill patients to die with comfort and dignity when that is consistent with the wishes of the patient and/or the patient’s family. 4. recognize the potential conflicts between patient expectations and medically appropriate care. PRACTICE BASED LEARNING AND IMPROVEMENT Rationale Because of the breadth of the problems encountered in clinical practice, internists face an extraordinary challenge to keep up with the burgeoning amount of new information relevant to providing high quality care. Therefore, they must master and practice self-directed life-long learning, including the ability to access and utilize information systems and resources efficiently. Prerequisites Basic library skills, including the ability to perform an electronic literature search. Critical appraisal skills. Understanding of basic concepts of biostatistics and clinical epidemiology. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. key sources for obtaining updated information on issues relevant to the medical management of adult patients. 2. a system for managing information from a variety of sources. 3. key questions to ask when critically appraising articles on diagnostic tests or therapies. B. Skills: Each student should be able to: 1. perform a computerized literature search to find articles pertinent to a clinical question. 2. demonstrate critical review skills. 3. read critically about issues pertinent to their patients. 4. assess the limits of medical knowledge in relation to patient problems. 5. use information from consultants critically. 6. recognize when he or she needs additional information to care for the patient. 7. ask colleagues (students, residents, nurses, faculty) for help when needed. 8. make use of available instruments to assess one’s own knowledge base.
  • 24. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc C. Attitudes: Each student should be able to: 1. demonstrate self-directed learning in every case. 2. acknowledge gaps in knowledge to both colleagues and patients and request help. COORDINATION OF CARE Rationale The task of coordinating a patient’s care is central to the general internist’s role and involves communication with the patient and his/her family; colleagues; consultants; nurses; social workers; and community-based agencies. It is essential for the student to learn that the physician’s responsibility toward the patient does not stop at the end of the office visit or hospitalization, but continues in collaboration with other professionals to ensure that the patient receives optimal care. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. the role of consultants and their limits in the care of a patient. 2. key personnel and programs in and out of the hospital that may be able to contribute to the ongoing care of an individual patient for whom the student has responsibility. 3. the role of the primary care physician in coordinating the comprehensive and longitudinal patient care plan, including communicating with the patient and family through telecommunications and evaluating patient well-being through home health and other care providers. 4. the role of the primary care physician in the coordination of care during key transitions (e.g., outpatient to inpatient, inpatient to hospice, etc.). B. Skills: Each student should be able to: 1. discuss with the patient (and family as appropriate) ongoing health care needs, using appropriate language, avoiding jargon and medical terminology. 2. participate in requesting a consultation and identifying the specific question(s) to be addressed. 3. participate in the discussion of the consultant’s recommendations. 4. participate in developing a coordinated, ongoing care plan in the community. 5. obtain a social history that identifies potential limitations in the home setting which may require an alteration in the medical care plan to protect the patient’s welfare. C. Attitudes: Each student should: 1. demonstrate teamwork and respect toward all members of the health care team. 2. demonstrate responsibility for patients’ overall welfare. 3. participate, whenever possible, in coordination of care and in provision of continuity.
  • 25. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc BASIC PROCEDURES Rationale For many students, the internal medicine clerkship is where the basic procedural skills required in other clerkships, subinternships, and residencies are learned. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. key indications, contraindications, risks, and benefits of each of the following basic procedures: • venipuncture. • blood culture. • arterial blood gas. • electrocardiogram. • nasogastric tube. • urethral catheterization. • peripheral intravenous catheter insertion. • throat culture. • PAP smear. • digital rectal examination. • place and interpret a tuberculin skin test (PPD). 2. alternatives to a given procedure. 3. what the patient’s experience of the procedure will be. B. Skills: Each student should be able to: 1. demonstrate obtaining informed consent, when necessary, for basic procedures, including the explanation of the purpose, possible complications, alternative approaches, and conditions necessary to make the procedure as comfortable, safe, and interpretable as possible. 2. demonstrate step-by-step performance of basic procedures with technical proficiency. 3. observe precautions and contraindications for the procedures used. C. Attitudes: Each student should: 1. always participate in obtaining informed consent for basic procedures they perform or in which they participate. 2. explain what the patient’s experience is likely to be in understandable terms. 3. communicate risks and benefits to patients. 4. always make efforts to maximize patient comfort during a procedure. GERIATRIC CARE Rationale Care of the elderly is one of the traditional functions of the general internist, and with the “greying” of the population, geriatrics will become a larger part of the practice of all physicians who care for adults. The student should understand the unique health care needs and presentation of the elderly, key management strategies, and the importance of an interdisciplinary approach to care.
  • 26. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. functional implications of aging organ systems. 2. special nutritional needs of the elderly. 3. key illnesses in the elderly, focusing on their often atypical presentation (e.g., urinary tract infection, pneumonia, tuberculosis, depression, thyroid disease, myocardial infarction, acute abdomen). B. Skills: Each student should be able to: 1. take a history from a geriatric patient with special emphasis on physical and mental functioning. 2. perform a physical examination and functional assessment on an elderly patient, adapting it to possible conditions of frailty, immobility, hearing loss, memory loss, and other impairments. 3. perform a mental status examination to evaluate confusion and/or memory loss in an elderly patient. 4. identify patients at high risk for falling. 5. practice an interdisciplinary approach to management and rehabilitation of elderly patients. C. Attitudes: Each student should: 1. always obtain historical information from significant others, whenever possible. 2. respect the increased risk for iatrogenic complications among elderly patients by always taking into account risks and monitoring closely for complications. 3. demonstrate respect to older patients by making efforts to preserve their dignity. NUTRITION Rationale Despite the importance of nutritional factors in health and illness, physicians frequently have been criticized for giving these factors inadequate attention. Internists, by virtue of their dedication to providing comprehensive care to their patients, should assess nutritional factors on a routine basis. Physicians, particularly general internists, also should be prepared to provide patients with basic advice regarding ways to optimize their nutritional status. All physicians also need to have at least a basic working knowledge of the principles of nutritional assessment and intervention. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. key symptoms and signs that may indicate a nutritional problem. 2. nutritional problems that occur most commonly in adults. 3. common medical problems that can cause nutritional deficiencies. 4. contributions of dietary indiscretion to hyperlipidemia, diabetes, hypertension, etc.
  • 27. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc B. Skills: Each student should be able to: 1. obtain a nutritional history for patients with obesity, hyperlipidemia, diabetes mellitus, hypertension, alcoholism, cancer, COPD, CHF, and GI diseases, giving attention to weight change, appetite, eating habits, digestive problems, dental problems, physical handicaps, psychiatric problems, socioeconomic factors, alcohol use, medications, and physical activity. 2. identify physical findings relevant to the nutritional assessment of patients including: truncal distribution, abdominal striae, cachexia, decubitus ulcers, temporal wasting, glossitis, peripheral neuropathy, peripheral edema, ascites, depression, and weakness. 3. order appropriate initial tests for evaluating a patient’s nutritional status. C. Attitudes: Each student should: 1. assess the nutritional status of each patient. 2. consult a dietitian for patients with significant nutritional problems. ADVANCED PROCEDURES Rationale A number of advanced procedures may be performed by general internists but usually not third-year clerks. However, a knowledge of th key indications, contraindications, risks, and benefits of these procedures is essential for high quality patient care. Physicians, regardless of specialty, must be able to explain to their patients, in understandable terms, what will be experienced during a procedure. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. key indications, contraindications, risks, and benefits of each of the following advanced procedures: • arthrocentesis. • central venous catheterization. • flexible sigmoidoscopy. • lumbar puncture. • thoracentesis. • paracentesis. • Swan Ganz catheterization. • bone marrow aspiration. • skin biopsy. 2. alternatives to a given procedure. 3. what the patient’s experience of the procedure will be. B. Skills: Each student should be able to: 1. participate in obtaining informed consent for advanced procedures, including the explanation of the purpose, possible complications, alternative approaches, and conditions necessary to make the procedure as comfortable, safe, and interpretable as possible.
  • 28. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc C. Attitudes: Each student should: 1. demonstrate responsibility for helping to provide informed consent. 2. demonstrate a commitment to explaining the patient’s experience in understandable terms. 3. communicate risks and benefits of procedures to patients regularly. 4. maximize patient comfort during a procedure. CONTINUOUS IMPROVEMENT IN SYSTEMS OF MEDICAL PRACTICE Rationale Clinical education has emphasized the role of the physician as an individual decision maker. Problems with cost and quality of care have usually been attributed to errors in individual decision making. In recent years, it has become clear that systems, from simple to complex, are also critical in achieving high quality patient care. Furthermore, we have begun to think of quality from the patient’s perspective as well as that of the profession. The physician, both as an individual and as a member of the health care community, must make use of systems thinking and participate in the process of assessing current practice and testing new methods to improve patient care. Specific Learning Objectives A. Knowledge: Each student should be able to describe: 1. the principles of clinical quality improvement, including the notion of variation in practice as a quality issue and the concept of medical care as a process which can be studied and improved. 2. the analysis and improvement of systems to address common quality problems (treatment delays, medication errors, failure to give preventive care). 3. principles of medical record organization in both inpatient and ambulatory settings. 4. the need for a multidimensional approach to the assessment of quality, including the patient’s perspective of quality. 5. the relationship of quality and cost in health care. B. Skills: Each student should be able to: 1. use hospital-based support systems to assist in making clinical decisions (e.g., antibiotic control program). 2. recognize systems flaws in the provision of care at the clerkship site (e.g., inability to arrange a post-discharge appointment within a needed time frame, delays in obtaining test results). 3. use patient education materials (e.g., pamphlets for patients started on warfarin) which help patients participate in their care. 4. use the medical records system efficiently and write legible notes. 5. work collaboratively with other health professionals in the delivery of care. C. Attitudes: Each student should: 1. recognize the importance of systems—especially interprofessional collaboration—in delivering high quality patient care.
  • 29. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 2. strive to improve the timeliness of their diagnostic and therapeutic decision making to improve quality of care, increase patient satisfaction, and reduce cost. THE CORE TOPICS A content-based curriculum A review of the core competencies underscores the fact that internal medicine is a very broad, content-driven field that places a premium on cognitive work and interpersonal skills. Some argue that any patient will suffice to teach internal medicine’s basic approach to clinical problem solving, but most faculty agree that mastery of a substantial fund of knowledge and the ability to function effectively across a wide spectrum of problems are important hallmarks of the general internist and should be emphasized in the core clerkship. Consequently, this curricular model specifies a set of high-priority “training problems” that help to define the core knowledge base, encourage mastery of basic skills, and advance the attitudinal agenda. Utilizing both the inpatient (Medicine I and Medicine II) and outpatient services (Primary Care Clerkship) for clinical experiences (see the section “Learning Experiences”) and limiting the training problem list to common clinical conditions helps to ease the burden of case selection. The training problems listed below and detailed in the following pages were those receiving the highest scores from internal medicine faculty in a national survey of Clerkship Directors. Each is presented with a statement regarding its rationale and associated learning objectives (knowledge, skills, and attitudes). This content is based on curriculum that was presented at the 1994 Annual Meeting of CDIM and also sent to faculty for review and critique. LEARNING OBJECTIVES FOR EACH TRAINING PROBLEM Patients with a Symptom, Sign, or Lab Abnormality Abdominal Pain Altered Mental Status Anemia Back Pain Chest Pain Cough Dysuria Fluid, Electrolyte, and Acid-Base Disorders Joint Pain Patients with a Known Disease Condition Congestive Heart Failure COPD Depression Diabetes Mellitus Dyslipidemia HIV Infection Hypertension Smoking Cessation Substance Abuse Common Cancers
  • 30. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc TRAINING PROBLEM: ABDOMINAL PAIN Rationale Abdominal pain is a common problem that can be caused by a wide variety of acute and chronic disease processes, many of which can be life threatening. Mastery of the approach to patients with abdominal pain is important to general internists because they often are the first physicians to see such patients. Specific Learning Objectives A. Knowledge: Students should be able to: 1. describe and define principal types of pathophysiologic mechanisms of abdominal pain (i.e., obstruction, peritoneal irritation, vascular insufficiency, abnormal motility, mucosal irritation, metabolic aberrations, nerve injury, referred pain, psychopathology) 2. describe the relative likelihood of common causes of abdominal pain according to the quadrant in which the pain is located 3. list symptoms and signs indicative of an acute abdomen 4. describe the key diagnostic criteria for common causes of abdominal pain, based on a history, physical exam and laboratory testing 5. identify the indications and the limitations of the following principal diagnostic studies necessary to differentiate among common causes of abdominal pain, including: • fecal leukocytes • stool culture • stool guaiac • stool fat • hepatitis serology • liver enzymes • amylase and lipase • paracentesis • upper endoscopy • sigmoidoscopy • colonoscopy • barium studies • abdominal ultrasound • CT scan • radionuclide scan of hepatobiliary system 6. identify indications for dietary intervention, drug therapy and therapeutic procedures in patients with common causes of abdominal pain, and describe the physiological basis and/or scientific evidence supporting each type of intervention 7. identify indications for empiric therapy in patients with abdominal pain 8. describe steps in a critical pathway for patients with an acute abdomen B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of
  • 31. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc disease, including: elicit features of a patient’s abdominal pain, including location, radiation, duration, associated symptoms, weight change, exacerbating and remitting factors, surgery, medications, and family history. 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including: • demonstrate correct order and technique for examining the abdomen. • perform an adequate rectal and pelvic exam (under supervision). • identify relevant scars, abnormal bowel sounds and signs of peritoneal inflammation. 3. differential diagnosis: students should be able to generate a list of the most important and likely causes of a patient’s abdominal pain, recognizing specific history and physical exam findings that distinguish between: • peptic ulcer disease • dyspepsia • gastroparesis • pancreatitis • irritable bowel syndrome • diverticulitis • pseudomembranous colitis • acute and chronic hepatitis • inflammatory bowel disease 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences laboratory and diagnostic tests should include studies necessary to determine the cause of a patient’s abdominal pain 5. communication skills: Students should be able to: • explain the results of the evaluation to the patient, taking into consideration the patient’s knowledge about his/her condition 6. basic and advanced procedure skills: Students should be able to: • insert a nasogastric tube after explaining the procedure to the patient 7. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients, including: • selecting an appropriate medical regimen for patients with peptic ulcer disease, dyspepsia, gastroparesis, pancreatitis, irritable bowel syndrome, diverticulitis, and pseudomembranous colitis • determining when to prescribe medical therapy for patients with chronic hepatitis • determining when to involve a surgeon in the management of patients with peptic ulcer disease, inflammatory bowel disease, cholecystitis, and pancreatitis recognizing the value of psychotherapy in the management of chronic abdominal pain • accessing and utilize appropriate information systems and resources to help delineate issues related to abdominal pain C. Attitudes and Professional Behaviors: Students should be able to:
  • 32. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 1. recognize the importance of involving a surgeon as soon as possible when a patient is identified as having an acute abdomen 2. recognize the importance of patient preferences when selecting among treatment options TRAINING PROBLEM: ALTERED MENTAL STATUS Rationale The diagnosis and management of altered mental status requires a knowledge of all areas of internal medicine, so varied are the etiologies and corresponding treatment strategies. Internists must master an approach to the problem as they are often the first physicians to see these patients. Specific Learning Objectives A. Knowledge: Students should be able to describe and define: 1. the pathophysiology, signs, and symptoms of the most common and most serious causes of altered mental status including: • metabolic causes (i.e., hyper/hyponatremia, hyper/hypoglycemia, hypercalcemia, hyper/hypothyroidism, hypoxia/hypercapnea, hepaticencephalopathy, uremic encephalopathy, drug intoxication/withdrawal, Wernicke encephalopathy) • structural lesions (primary or metastatic tumor, intracranial hemorrhage, infection) • cerebrovascular accident • transient ischemic attack • meningitis • encephalitis • seizures • postictal state • hypertensive encephalopathy • vasculitis • arrhythmias • heart failure • endocarditis. 2. the differential diagnosis of altered mental status based on historical and physical findings, specifically being able to distinguish delirium from dementia 3. the key diagnostic criteria of altered mental status 4. the essential diagnostic tests to differentiate among possible causes of altered mental status with their indications and contraindications including: • lumbar puncture • CT scan • MRI scan • EEG • drug screen • CBC with differential • electrolytes • serum chemzyme screen (glucose, renal/hepatic function tests)
  • 33. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc • VDRL • arterial blood gas • vitamin B12 and thiamine • thyroid function tests 5. principles of management of common causes of altered mental status 6. describe steps in a critical pathway for altered mental status B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, including eliciting appropriate information from patients with altered mental status, and/or their families, including the onset, progression, associated symptoms, potential causes (including medications), and level of physical and mental disability 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including: neurologic exam and construct a differential diagnosis based on historical and physical findings 3. differential diagnosis: Students should be able to generate a differential list of the most important and most likely causes of a patient’s altered mental status, recognizing specific history and physical exam findings that confirm or refute a diagnosis of: • metabolic causes: • hyper/hyponatremia • hyper/hypoglycemia • hypercalcemia • hyper/hypothyroidism • hypoxia/hyperpnea • hepatic encephalopathy • uremic encephalopathy • drug intoxication/withdrawal • Wernicke encephalopathy • structural lesions: • primary or metastatic tumor • intracranial hemorrhage • infection • cerebrovascular accident • transient ischemic attack • meningitis • encephalitis • seizures • postictal state • hypertensive encephalopathy • vasculitis • arrhythmias • heart failure • endocarditis 3. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory and be able to interpret them, both prior to
  • 34. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc and after initiation treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Laboratory and diagnostic tests should include, when appropriate: • lumbar puncture (color, opening pressure, glucose, protein, cell counts, cytology, Gram’s and India ink stains, cultures, cryptococcal • antigen, VDRL) • CT scan and MRI scan • EEG • drug screen • electrolytes • serum chemistries • arterial blood gas • vitamin B12 and thiamine • thyroid function tests 4. communication skills: Students should be able to: explain the results of the evaluation to the patient, taking into consideration the patient’s knowledge and ability to comprehend new information 5. basic and advanced procedure skills: Students should be able to: • perform a venipuncture for collection of blood specimens • insert a peripheral venous catheter • obtain an arterial blood gas • assist in performing a lumbar puncture after explaining the procedure to the patient 6. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients with altered metal status including: • writing appropriate fluid orders for the treatment of hyper/hyponatremia, hyper/hypoglycemia, and hypercalcemia • writing appropriate insulin and glucose orders for the treatment of hyper/hypoglycemia • writing appropriate antibiotic orders for the treatment of meningitis, encephalitis, and endocarditis • determining when to involve a neurosurgeon or neurologist in the management of patients with altered mental status • eliciting questions from the patient and/or family regarding the management plan • accessing and utilizing appropriate information systems and resources to help delineate issues related to altered mental status. C. Attitudes and Professional Behaviors: Students should be able to: 1. appreciate the family’s concern and at times despair arising from the development in an individual of altered mental status
  • 35. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc TRAINING PROBLEM: ANEMIA Rationale Anemia is a common condition, often identified incidentally in asymptomatic patients. It can be “benign” or a manifestation of a serious underlying disease. Distinguishing among the many disorders that cause anemia, not all of which are treatable, is an important training problem for third year medical students. Specific Learning Objectives A. Knowledge: Students should be able to describe and define the:classification of anemias 1. morphological characteristics, pathophysiology, and relative prevalence of: a. iron deficiency and other microcytic anemias (i.e., b. sideroblastic) c. macrocytic anemias d. anemia of chronic disease e. congenital disorders (sickle cell, thalessemias) f. hemolytic anemias 2. available laboratory tests and normal values 3. indications, contraindications, complications of blood transfusion 4. steps in a critical pathway for anemia B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including: a. constitutional symptoms (fatigue, weight loss) b. GI bleeding c. abdominal pain d. drugs e. diet f. menstrual history g. family history 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including inspection of: a. skin b. eyes (sclera, conjunctiva, fundi) c. mouth d. heart e. abdomen f. rectum g. lymph nodes h. nervous syste 3. differential diagnosis: Students should be able to generate a list of the most importance and most common causes of anemia, recognizing specific history and physical exam findings that suggest a specific etiology of anemia. 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Laboratory and diagnostic tests should include, when appropriate:
  • 36. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. hemoglobin & hematocrit b. red cell indices c. reticulocyte count d. iron studies (serum iron, TIBC, ferritin, transferrin) e. serum B12 & folate f. haptoglobin g. LDH h. Schilling test i. hemoglobin electrophoresis 2. communication skills: Students should be able to: explain the results of an initial evaluation to patients and their families, taking into consideration their knowledge about the condition and counsel with regard to a. possible causes b. appropriate further evaluation to establish the diagnosis of an underlying disease, and c. the impact on the family (genetic counseling) 3. basic procedural skills: Students should be able to perform and interpret: a. peripheral blood smear 4. advanced procedural skills: Students should be able to assist in perfoming: a. bone marrow aspiration 5. management skills: Students should be able to develop an evaluation plan to obtain appropriate diagnostic studies useful in establishing a specific diagnosis including: a. GI blood loss b. hemolytic anemia c. pernicious anemia d. chronic disease (renal, thyroid, HIV, malignancy, inflammation) e. Students should be able to develop a treatment plan for a specific diagnosis including: a. iron therapy b. vitamin B12 c. folic acid f. accessing and utilizing appropriate information systems and resources to help delineate issues related to anemia C. Attitudes: Students should be able to: 1. recognize that constitutional symptoms, such as fatigue or malaise, may be caused by depression, rather than any underlying anemia or dietary deficiency TRAINING PROBLEM: CHEST PAIN Rationale Chest pain is an important presenting symptom for a variety of disorders, many of which represent serious medical disorders. Angina pectoris is the most common cardiac source of chest pain which may present classically or in a variant form such as Prinzmetal angina or atypical angina. Distinguishing chest pain of cardiac origin from that occurring as a result of chest wall disorders, pleuropulmonary disorders, aortic dissection, gastrointestinal disorders, and psychogenic states is an important training problem for third-year medical students.
  • 37. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. the signs and symptoms of: a. right- and left-sided congestive heart failure b. ischemic heart disease c. valvular heart disease (aortic stenosis, aortic insufficiency, mitral stenosis, mitral regurgitation) 1. the signs and symptoms of the following common causes of cardiac chest pain a. angina pectoris (typical and atypical) b. prinzmetal angina (variant angina) c. acute myocardial infarction d. unstable angina e. non-ischemic cardiovascular pain f. mitral valve prolapse g. dissecting aortic aneurysm h. pericardial pain (acute) i. cardiomyopathy 2. signs and symptoms associated with chest pain due to GI disorders: a. gastroesophogeal reflux b. peptic ulcer disease c. biliary colic d. pancreatitis 3. signs and symptoms associated with chest pain due to pulmonary disorders: a. pneumonia b. spontaneous pneumothorax c. pulmonary embolism d. pulmonary hypertension e. inflammation of the pleura 4. signs and symptoms associated with chest pain due to musculoskeletal causes: a. costochondritis (Tietze’s syndrome) b. muscular strain 5. reasons why the following factors are associated with exacerbating chest pain: a. anemia
  • 38. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc b. hypoxemia c. hypertension d. tachyarrhythmia e. hyperthyroidism 6. typical blood pressure values that occur with a. aortic stenosis, b. aortic insufficiency, c. and pulsus paradoxicus 7. common abnormalities that can cause paradoxical and fixed splitting of the S2; factors that increase or diminish the intensity of S1the consequences of the following risk factors and their association with heart disease: a. hypertension b. smoking c. lipid abnormalities d. age and gender e. diabetes mellitus f. family history of heart disease g. obesity h. dietary intake of saturated fat and cholesterol i. sedentary lifestyle 8. role of a critical pathway or practice guideline in delivering high quality care for patients hospitalized with ischemic chest pain 9. role of a critical pathway or practice guideline in delivery high quality, cost effective care for outpatients presenting with non-ischemic chest pain B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease, including: a. the presence of chest pain (typical, atypical) b. dyspnea (resting, exertional, nocturnal) c. history of hypertension, valvular heart disease, mitral valve prolapse, rheumatic fever, cardiac murmurs, family history of heart disease and cardiovascular risk factors 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: a. obtaining an arterial blood pressure b. identifying major arterial and venous pulses for abnormalities and the presence of any bruits c. examination of the fundus
  • 39. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc d. examining the extremities, to ascertain skin condition, including color and temperature; presence of edema; cyanosis and presence of clubbing e. examining the lungs for crackles, rhonchi, and decreased breath sounds f. inspection and palpation of the anterior chest to identify right- and left heaves and thrills g. examining the heart, including rhythm; intensity of heart sounds; presence of murmurs, rubs, gallops, or extra sounds (e.g., clicks). h. Recognizes the following heart sounds: i. S1, S2, and normal splitting of the S2 ii. abnormal sounds, S3, S4, summation gallop, abnormal splitting of the S2 and mitral valve clicks iii. distinguishes ejection from regurgitant systolic murmurs. i. examining the abdomen, to determine the presence of epigastric or RUQ tenderness, hepatomegaly 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest ischemic chest pain from nonischemic causes of chest pain, (GI, pulmonary, musculoskeletal, or undetermined) 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics, as well as patient preferences. a. Laboratory and diagnostic tests should include, when appropriate: i. blood count ii. specific enzyme tests to determine the presence of cardiac damage iii. electrocardiogram iv. chest x-ray v. ABG b. students should be able to define the indications for and interpret (with consultation) the significance of the results of: i. echocardiogram ii. exercise stress test and the use of the pretest probability of CAD to interpret results iii. stress thallium (myocardial perfusion radionuclide scan) iv. cardiac catheterization v. pulmonary angiography vi. V/Q scan 5. communication skills:
  • 40. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. Students should be able to facilitate the provision of counseling to patients about the following: i. smoking cessation ii. dietary saturated fat and cholesterol reduction iii. dietary sodium reduction iv. weight reduction v. increased physical activity b. students should be able to communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families, and when appropriate, identify and educate patients about cardiovascular risk factors for disease relative to their age and gender 6. basic procedural skills: Students should be able to perform: a. EKG 7. management skills: For each treatment listed below, students should be able to identify indications, action, mechanism, side effects, adverse reactions, and significant interactions of: a. medications: students should be able to locate information on the cost of various agents within each class of medications i. digoxin ii. calcium channel blockers iii. beta blockers iv. angiotensin-converting enzyme inhibitors v. nitrates vi. nitroglycerine vii. aspirin viii. heparin ix. warfarin b. other therapies: i. thrombolytic therapy ii. PTCA c. surgical therapy: i. CABG 8. students should be able to access and utilize appropriate information systems and resources to help delineate issues related to chest pain C. Attitudes and Professional Behaviors: 1. Students should be able to: understand the emotional impact of a diagnosis of coronary artery disease and its potential effect on lifestyle (work performance, sexual functioning, etc.)
  • 41. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc TRAINING PROBLEM: COUGH Rationale Cough is a very common presenting complaint of patients. It is also an important presenting symptom for a variety of disorders, some of which are serious and life threatening. The most common causes of chronic cough are benign or self-limiting problems, yet large resources may be expended to exclude life-threatening disease. Recognizing the benign causes of cough and how they can be distinguished in a cost effective way from serious causes, such as cancer and pneumonia, are important training problems for third year medical students. Specific Learning Objectives A. Knowledge: Student should be able to define and describe: 1. the criteria used to classify a cough as chronic and a cough as productive 2. signs and symptoms associated with the most common causes of acute cough: a. viral tracheitis b. bronchitis c. pneumonia 2. signs and symptoms associated with the most common causes of chronic cough: a. post nasal drip b. asthma c. gastroesophageal reflux d. cigarette smoking e. lung cancer f. TB g. CHF 3. signs and symptoms of variant asthma and its precipitants a. the pathogenic, epidemiologic, and pathophysiologic differences between: b. community-acquired vs. hospital-acquired pneumonia c. lobar vs. interstitial pneumonia d. normal host vs. immunocompromised pneumonia e. aspiration pneumonia vs. viral/bacterial pneumonia 4. the effect of old age on the pathogenic, epidemiologic and pathophysiologic factors for each of the pneumonias listed above 5. the differences in pathogens and clinical presentation for chronic and acute pneumonia 6. the pathophysiology of lung abscess, post-obstructive pneumonia, and pseudotumor
  • 42. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 7. the indications for pneumococcal and influenza immunization 8. the severe complications of acute bacterial pneumonia (bacteremia, sepsis, emphysema, meningitis, metastatic microabscesses) 9. patients who are at risk for impaired or deficient immunity 10. the community health risks of undetected or inadequately treated tuberculosis 11. the role of antibiotic control programs and other hospital basic support systems in the case of patient’s pneumonia B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiology of disease, to: a. obtain a thorough history of environmental/occupational allergies and determine the likelihood of atopic disease b. assess a patient for symptoms of gastroesphageal reflux disease 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including: a. respiratory rate, effect of breathing, level of respiratory distress b. examination of the nasal cavity when possible c. recognize the pharyngeal signs of post-nasal drip syndrome d. distinguish crackles from rhonchi and wheezes e. distinguish pleural effusion from pulmonary consolidation f. identify the following by physical exam: i. pleural effusion ii. consolidation iii. acute bronchitis iv. interstitial lung disease v. chronic obstructive diseases 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis including: 4. recognizing specific history and physical exam findings that both suggest chronic rather than acute cough, and suggest a specific etiology of acute cough 5. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Laboratory and diagnostic tests, when appropriate, tests should include: a. sinus CT examination b. chest x-ray examination
  • 43. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc c. barium swallow d. cinesophagogram e. gram stain of sputum f. sputum culture and susceptibility reports g. arterial blood gases h. sputum cytology i. acid fast stain of sputum (Zieht-Neelsen) j. pulmonary function testing k. cell count and chemistries of pleural fluid 6. communication skills: Students should be able to: explain specific treatment plans for the individual patient’s situation, counsel and educate patients about: a. environmental contributors to their disease b. allergen skin testing c. pneumococcal and influenza immunizations d. smoking cessation e. over the counter nasal decongestants sprays 7. basic procedural skills: Students should be able to perform: a. arterial blood gas b. sputum gram stain 8. management skills: Students should be able to design an appropriate evaluation and treatment plan for patients including: a. the treatment of post-nasal drip, allergic rhinitis, gastroesophageal reflux, and variant asthma b. suppressing cough, identifying the benefit and risks of cough suppressant therapy c. assessing atopic disease, including the indications for allergen skin testing d. identifying the presence of potential complications of bacterial and viral pneumonias including: i. respiratory failure ii. meningitis iii. bacteremia/sepsis iv. empyema v. pericarditis vi. selecting appropriate antimicrobial therapy for: vii. pneumococcal pneumonia viii. hemophillus pneumonia
  • 44. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc ix. aspiration/post-obstructive pneumonia x. staphylococcal pneumonia xi. mycoplasma pneumonia xii. acute bronchitis xiii. acute sinusitis xiv. legionella e. including locating information about the cost of alternative regimens 9. accessing and utilizing appropriate information systems and resources to help delineate issues related to cough C. Attitudes and Professional Behaviors: Students should be able to: a. demonstrate commitment to using cost-benefit considerations in the selection of drug therapies for chronic cough, including over the counter medications b. appreciate the functional disruption of a patient’s life caused by these illnesses TRAINING PROBLEM: DYSURIA Rationale Dysuria is a very common symptom that is associated with significant morbidity and is sometimes associated with serious medical disorders. Diagnosing the etiology of dysuria is an important training problem for third year medical students because accurate diagnosis requires prudent selection and interpretation of common diagnostic studies. Also, learning the proper use of antibiotic therapy for dysuria is important because of its impact on health care cost, on selection pressure for antimicrobial resistance in the microbial pool of the community, and on patient morbidity. Specific Learning Objectives A. Knowledge: Student should be able to define and describe: 1. the signs and symptoms, in women, of the following: a. cystitis b. urethral syndrome c. estrogen deficiency changes d. genital herpes e. vaginitis 2. the signs and symptoms, in men, of the following: a. urethritis b. cystitis c. genital herpes
  • 45. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc d. balanitis 3. the signs and symptoms of the following: a. urinary tract infection associated with Dysuria b. pyelonephritis c. prostatitis d. asymptomatic bacteruria 4. the signs and symptoms of the following: a. cystitis b. urethritis c. urethral syndrome 5. the typical presenting features that distinguish cystitis, pyelonephritis, and urethritis from each other 6. the signs and symptoms of bacteremia and sepsis 7. factors that may predispose a patient to cystitis, pyelonephritis, urethritis, and asymptomatic bacteruria including a. sexual activity b. pregnancy c. barrier contraceptives (diaphragm) d. prior urinary tract instrumentation e. urinary catheterization (in-dwelling and intermittent) f. anatomic anomalies (congenital and acquired) g. bladder dysfunction 2. reasons why the following signs differentiate the causes of urinary tract infection: a. flank tenderness b. enlarged kidney c. palpable bladder d. post-void residual urine e. urethral discharge 3. the indications for the diagnostic tests for urinary tract infection including: a. intravenous pyelogram b. voiding cystourethrogram c. urodynamic determination d. renal ultrasound 4. the rationale for different durations of antimicrobial therapy for cystitis and pyelonephritis 5. the commonly used antimicrobial drugs used for urinary tract infections by:
  • 46. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. naming six drugs and the class to which each belongs b. describing the antimicrobial spectrum for each, and their effectiveness c. designating the cost of each d. toxicity/side effects of each B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history: a. that differentiates among etiology of disease including eliciting a full description of symptoms which considers both cystitis and non-cystitis causes of Dysuria b. determining if dysuria is associated with sexual activity, menstruation, or pregnancy c. determining the patient’s risk for venereal disease. d. obtaining a description of all prior episodes of dysuria and how they were treated e. determining the presence or absence of predisposing causes, such as prior instrumentation, catheterization, and anatomic anomalies 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including: a. palpating the bladder for distention and tenderness b. palpating and massaging the urethra to express a discharge c. recognizing atrophic perineal changes, perineal inflammation, balanitis d. determining the presence or absence of flank tenderness e. performing prostatic massage 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology: a. In women: 1. cystitis 2. urethral syndrome 3. estrogen deficiency atrophic changes 4. genital herpes 5. vaginitis b. In men: 1. Urethritis 2. cystitis 3. genital herpes
  • 47. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 4. balanitis 4. laboratory interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests should include, when appropriate: a. urinalysis, with recognition of pyuria, bacteria, white cell casts, hematuria, renal tubular epithelial cells, and transitional cells in the urine sediment b. gram stain of urethral discharge c. urethral swab culture d. vaginal/cervical swab culture e. KOH preparation of genital mucosal scrapings f. urinary catheterization to assess for post-void residual 6. communication skills: Students should be able to: a. counsel and educate patients about sexual activity. b. communicate the diagnosis, treatment plan and subsequent follow-up to patients. 7. basic procedural skills: Students should be able to perform: a. urinalysis b. gram stain of urethral discharge c. urethal swab culture d. KOH preps e. urinary catheterization 8. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patient including: a. select appropriate antibiotic therapy prior to culture results b. select the appropriate duration of therapy for cystitis and pyelonephritis c. identify information about costs of alternative treatment regimens d. access and utilize appropriate information systems and resources to help delineate issues related to dysuria C. Attitudes and Professional Behaviors: Each student should be able to: appreciate the discomfort and concern associated with dysuria
  • 48. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc TRAINING PROBLEM:FLUID, ELECTROLYTE & ACID-BASE DISORDERS Rationale Many disease processes can cause serious disturbances in the fluid, electrolyte and acid-base status of patients. The general internist must be prepared to identify and correct these disturbances as efficiently as possible. Specific Learning Objective A. Knowledge: Students should be able to define and describe: 1. pathophysiology of hypo- and hypervolemia, hypo- and hypernatremia, hypo- and hyperkalemia, hypo- and hypercalcemia, simple and mixed acid-base disorders, hypo- and hyperphosphatemia, hypo- and hyper-magnesemia (respiratory acidosis & alkalosis, and metabolic acidosis & alkalosis) 2. presenting symptoms and signs of the above disorders 3. the importance of total body water and its distribution 4. the differential diagnosis of hypo- and hypernatremia in the setting of volume depletion, euvolemia and hypervolemia 5. how to identify spurious hyperkalemia or acidosis-related hyperkalemia 6. risks of too rapid or delayed therapy for hyponatremia 7. the most common causes of respiratory acidosis, respiratory alkalosis, metabolic acidosis and metabolic alkalosis 8. calculate the anion gap and explain its relevance to determining the cause of a metabolic acidosis 9. how to differentiate saline responsive from saline resistant metabolic alkalosis 10. changes in total body water distribution that occur with aging 11. how altered mental status can contribute to electrolyte disorders 12. tests to use in the evaluation of fluid, electrolyte and acid-base disorders 13. indications for obtaining an arterial blood gas 14. the types of fluid preparations to use in the treatment of fluid and electrolyte disorders B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including: a. eliciting appropriate information from patients with volume overload, including recent weight gain, edema or ascites, symptoms of heart failure, dietary sodium intake, changes in medications, noncompliance and intravenous fluid regimens.
  • 49. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc b. eliciting appropriate information from patients with volume depletion, including recent weight loss, thirst, gastrointestinal losses, urinary losses, oral intake, insensible losses and intravenous fluid regimens. c. eliciting appropriate information from patients with electrolyte problems, including use of diuretics and other medications, gastrointestinal losses, and history of relevant medical conditions (e.g., heart failure, liver disease, renal disease, pulmonary disease, central nervous system disease and malignancy). 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including: a. measurement of orthostatic vital signs b. identify signs of volume overload including peripheral edema, pulmonary edema, ascites c. identify signs of volume depletion including tachycardia, orthostatic hypotension, dry mucous membranes, poor skin turgor d. identify signs of sodium disorders including lethargy, weakness, encephalopathy, delirium, seizures e. identify signs of potassium disorders including weakness, fatigue, constipation, ileus, cramping, tetany, hypo- or hyperreflexia f. identify signs of calcium disorders including cramping, tetany, Chvostek’s & Trousseau’s sign, seizures, anorexia, constipation, polyuria, hypo- or hyperreflexia, stupor, coma 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that distinguish between: a. hypo- and hypervolemia b. hypo- and hypernatremia c. hypo- and hyperkalemia d. hypo- and hypercalcemia e. hypo- and hyperphosphatemia f. hypo- and hypermagnesemia g. respiratory acidosis & alkalosis h. metabolic acidosis & alkalosis 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic, when appropriate, tests should include: a. serum osmolality
  • 50. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc b. urinary sodium c. fractional excretion of sodium d. anion gaps e. ECG findings in hyper- and hypokalemia 6. communication skills: Students should be able to: a. explain the results of the evaluation to the patient 7. basic and advanced procedure skills: Students should be able to: a. insert a peripheral intravenous catheter b. obtain an arterial blood gas c. assist in the insertion of a central venous catheter 8. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients including: a. write appropriate fluid orders for the treatment of hypo- and hypervolemia, hypo- and hypernatremia, hypo- and hyperkalemia, hypo- and hypercalcemia b. write appropriate orders for replacing sodium, potassium, calcium, phosphates, and magnesium c. write appropriate orders for correcting hyperkalemia, hypercalcemia, hyperphosphatemia and hypermagnesemia d. calculate the water deficit that needs to be corrected to treat hypernatremia e. identify indications for administration of bicarbonate f. explain to a patient why intravenous fluids are needed g. access and utilize appropriate information systems and resources to help delineate issues related to fluid, electrolyte and acid-base disorders TRAINING PROBLEM: JOINT PAIN Rationale Joint pain is a common problem that can cause considerable dysfunction and disability. To properly evaluate and treat patients with joint pain, the general internist must use a systematic approach. Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. common presenting symptoms and signs of: a. osteoarthritis b. rheumatoid arthritis c. systemic lupus erythematosus d. polymyositis
  • 51. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc e. crystalline arthropathies f. scleroderma g. carpal tunnel syndrome h. herniated disc i. aseptic necrosis of the hip j. septic arthritis k. sarcoidosis 2. the difference between arthralgia and arthritis 3. a systematic approach based on an understanding of pathophysiology to classify potential causes of joint pain 4. key diagnostic criteria for common causes of joint pain 5. pathophysiology of joint stiffness and pain 6. immunologic tests to use in the evaluation of patients with joint pain 7. indications for performing an arthrocentesis 8. basic types of therapy to use in the treatment of joint pain and side effects associated with each B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease including: a. eliciting features of a patient’s joint pain, including duration, location, severity, timing, debility, exacerbating and remitting factors, associated neurologic symptoms, impact on daily activities, and prior or family history of related problems b. determine when in the course of acute arthritis it is necessary to obtain a sexual history and perform a genital exam with appropriate cultures c. determining the impact of joint pain on a patient’s activities of daily living 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including: a. performing a systematic examination of all joints, and identifying the following abnormal findings: i. erythema ii. swelling iii. tenderness iv. effusion v. crepitus vi. decreased or excessive range of motion vii. Heberden’s nodes
  • 52. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc viii. Dupuytren’s contracture ix. ulnar deviation x. tophi xi. synovial thickening 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology: a. osteoarthritis b. rhematoid arthritis c. systemic lupus erythematosus d. polymyositis e. crystalline arthropathies f. scleroderma g. carpal tunnel syndrome h. herniated disc i. aseptic necrosis of the hip j. septic arthritis k. sarcoidosis 4. laboratory interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests should include, when appropriate: a. joint fluid results (Gram’s stain, crystal exam, cell count & differential, and glucose) b. sedimentation rate c. rheumatoid factor d. complement levels e. antinuclear antibodies f. uric acid g. complete blood count h. plain x-rays i. radionuclide bone scan 6. communication skills: Students should be able to explain the results of the evaluation to the patient. 7. basic and advanced procedure skills: Students should be able to assist in:
  • 53. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. performing arthrocentesis of the knee after explaining the procedure to the patient 8. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patient including: a. select appropriate medications to use for the relief of joint pain b. locate information about the cost of alternative medications c. determine when to recommend joint immobilization, rest, nonsteroidal antiinflammatory drugs, corticosteroids, antibiotics, assistive devices (cane, walker), and physical therapy d. determine when to involve a rheumatologist or surgeon in the management of patients with joint pain e. elicit questions from the patient about the management plans f. access and utilize appropriate information systems and resources to help delineate issues related to joint pain C. Attitudes and Professional Behaviors: Students should be able to: demonstrate sensitivity to the impact of chronic joint pain on a patient’s quality of life and well-being TRAINING PROBLEM: CONGESTIVE HEART FAILURE Rationale Chronic congestive heart failure ranks among the most common of cardiac problems. Identification and correction of treatable underlying causes, elimination of precipitating factors and judicious use of multidrug regiment for individuals with CHF are important issues for third year medical students. Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. types of processes (i.e. ischemic, valvular, cardiomyopathy, infiltrative, inflammatory) and most common disease entities that cause CHF 2. types of processes that cause systolic vs. diastolic dysfunction 3. signs and symptoms of left-sided vs. right sided heart failure 4. compensatory mechanisms in heart failure 5. factors leading to exacerbation of CHF including hypoxemia, anemia, fever, hypertension, tachyarrhythmia, and hyperthyroidism B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease, including the presence or absence of the following:
  • 54. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. dyspnea b. orthpnea c. paroxysmal nocturnal dyspnea (PND) d. peripheral edema e. fatigue and decreased exercise tolerance 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including: a. measurement of arterial blood pressure b. assessment of major arterial pulses for abnormalities, including bruits c. assessment of eye ground changes, specifically of the conjunctiva and retina d. assessment of the extremities, to ascertain skin condition, including color and temperature; presence of edema; cyanosis and presence of clubbing e. assessment of the lungs for crackles, rhonchi and decreased breath sounds f. inspection and palpatation of the anterior chest to identify right- and left-sided heaves and thrills g. assessment of the heart, including rhythm, intensity of heart sounds, splitting of S2, and presence of murmurs, rubs, gallops, or extra sounds (e.g., clicks) h. assess abdomen, to determine the presence of hepatomegaly, splenomegaly, hepatojugular reflux, ascites, abnormal masses, pulsations, and bruits 3. differential diagnosis: students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that confirm or refute CHF distinguishing between: a. pericardial b. endocardial c. valvular (congenital, acquired) d. endocarditis e. myocardial f. hypertrophic g. restrictive h. congestive 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests, when appropriate, should include:
  • 55. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. chest x-ray b. ECG baseline and during exercise testing c. exercise testing (for functional capacity) d. echocardiography (2D, TEE) e. radionuclide gated blood pool scintigraphy (LVEF) 6. laboratory and diagnostic tests that one should be able to define the indications for and interpret the results of include: a. ECG baseline and during exercise testing b. exercise testing (for functional capacity) c. echocardiography (2D, TEE) d. radionuclide gated blood pool scintigraphy (LVEF) 7. communication skills: Students should be able to: a. communicate the diagnosis, prognosis and treatment plan of the disease to patients and their families b. educate patients about cardiovascular risk factors including: i. hypertension ii. smoking iii. lipid abnormalities iv. age and gender v. diabetes mellitus vi. family history of heart disease vii. obesity viii. dietary intake of saturated fat and cholesterol ix. sedentary life style x. alcohol xi. Endocarditis prophylaxis 8. basic procedural skills: Students should be able to perform: a. EKG b. arterial blood gases 9. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients including: a. non-pharmacological management: b. sodium restriction c. physical activity d. coronary revascularization e. heart transplantation f. pharmacologic management:
  • 56. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc g. diuretics h. vasodilators i. positive inotropic agents j. ACE inhibitors/ calcium channel blockers k. antiarrhythmic agents l. anticoagulants/antithrombotic agents 10. how critical pathways or practice guidelines in ambulatory patients or patients hospitalized with CHF can be used to guide diagnostic test ordering 11. accessing and utilizing appropriate information systems and resources to help delineate issues related to CHF C. Attitudes and Professional Behaviors: Students should be able to: recognize the importance of lifestyle limitations caused by CHF (and counsel patients appropriately) TRAINING PROBLEM: COPD Rationale The chronic obstructive pulmonary diseases (chronic bronchitis/emphysema) are important causes of morbidity and mortality and are a major cause of total disability, second only to coronary artery disease. Cigarette smoking plays a major role in the progression of the disease, with survival rates lower among patients who continue to smoke cigarettes. The severity and debilitation of these particular disorders make them an important training problem for all third year medical students. Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. disease entities and pathophysiologic processes of common, serious, or prototypical respiratory diseases that can result in COPD a. asthma b. chronic bronchitis c. emphysema d. genetic predisposition—alpha 1 antitrypsin deficiency 2. other disease entities that may cause symptoms or signs similar to those caused by COPD a. allergic and non-allergic factors that may precipitate bronchospasm and asthma 3. the risks for developing COPD in various patients and correlate risk factors associated with each respiratory tract diseases with occupational and environmental hazards 4. basic principles of O2, antibiotic, bronchodilator and corticosteroid therapy
  • 57. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 5. the scientific evidence supporting use of influenza vaccine/pneumovax in COPD patients B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease including: a. existence, duration, and severity of the following symptoms: i. shortness of breath ii. sputum production iii. cough iv. wheezing v. hemoptysis vi. fever vii. abnormal nocturnal/diurnal sleep patterns b. patient’s occupational history, including current and past exposures, environmental, smoking (active and passive), travel, and family respiratory tract history, including: c. a history of allergies, previous respiratory tract diseases, and previous PPD, TB, and BCG status d. the risk for alpha 1 antitrypsin deficiency 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: a. assessing the use of accessory muscles for breathing b. inspection, palpation, percussion and auscultation of the chest to: i. recognize and differentiating abnormal lung sounds, such as wheezing, rales, and rhonchi from normal breath sounds. ii. differentiate between a normal, dull and hyperresonant chest by percussion. iii. differentiate between areas of consolidation and pleural fluid by assessing the quality of the breath sounds and ancillary findings such as egophony and whispered pectoriloquoy iv. assess the presence of pleural friction rub. 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis, recognizing specific history and physical exam findings that confirm or refute a diagnosis of asthma, chronic bronchitis, or emphysema 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and interpret them, both prior to and after initiating treatment based on the differential diagnosis,
  • 58. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests, when appropriate, should include: a. chest x-ray to recognize x-ray patterns that suggest asthma, bronchitis, and emphysema b. basic pulmonary function tests (such as ABG, pulmonary function tests, and spirometry) used to evaluate respiratory tract diseases c. interpretation of a gram stain of sputum d. pulse oximetry 6. communication skills: Students should be able to: a. communicate the diagnosis, prognosis and treatment plan of the disease to patients and their families, taking into consideration their knowledge of the disease and their treatment preferences 7. basic procedural skills: Students should be able to perform: a. arterial blood gases 8. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients including: a. the basic principles of oxygen, antibiotic, bronchodialator, and corticosteroid therapy b. the basic bronchodialator and corticosteroid management when appropriate c. the steps in a critical pathway for patients hospitalized with COPD exacerbations d. smoking cessation strategies e. accessing and utilizing appropriate information systems and resources to help delineate issues related to COPD C. Attitudes and Professional Behaviors: 1. Students should be able to: recognize that poor working, living, and environmental conditions can contribute to respiratory tract disease TRAINING PROBLEM: DEPRESSION Rationale Depression is a very common problem in adults that results in significant morbidity and mortality. Often the internist is the first health professional to see a depressed patient. Frequently, the initial presentation is associated with somatoform complaints that bring the patient to the internist or with serious underlying medical illness. There is significant evidence that primary care physicians commonly fail to diagnose major depression. With recent improvements in available treatment, it is even more important for internists to screen for depression and to know the common presenting symptoms. The internist should also be familiar with available therapeutic options
  • 59. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc and be prepared to treat selected patients including those who decline consultation with a mental health professional. Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. the prevalence of depression in the general population and the impact of major illness on the prevalence of depression 2. the impact of depression on the outcome of medical illness 3. the nine symptoms of major depression, and name the minimum number of them (five) that makes a diagnosis of major depression likely 4. common somatic symptoms associated with major depression (insomnia, restlessness, anhedonia, decreased cognition, memory loss, weight gain, weight loss, fatigue) 5. basic principles of brief psychotherapy and its application to dysthymia, depressive reactions, and major depression 6. the sedative, anticholinergic, and cardiac effects of the major classes of anti-depressant drugs, and common interactions with other medications 7. the medical indications and contraindications to electroconvulsive therapy B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, in order to: a. determine an individual patient’s potential risk for subsequent depression b. determine the presence or absence of underlying dementia, anxiety disorder, adverse drug effect, and grief in any patient suspected of having depression c. determine a patient’s risk for suicide d. obtain a complete drug history (including illicit drugs) 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: a. a complete screening neurologic examination b. a screening mental status examination c. a complete mental status examination 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest depression more than grief reaction, dementia, anxiety disorder and adverse drug effect
  • 60. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests, when appropriate, should include: a. blood and urine drug screening b. screening for syphilis c. interpretation of a lumbar puncture d. thyroid function tests 6. communication skills: Students should be able to: a. effectively communicate the diagnosis to the patient and their families, using sensitive, non-judgmental language b. recruit the patient into treatment c. advise the patient of the delay in therapeutic benefit from anti- depressant drugs d. communicate to the patient the need for psychiatric consultation when necessary 7. basic procedural skills: Students should be able to: perform lumbar puncture 8. management and treatment: Students should be able to develop an appropriate evaluation and treatment plan for patients including: a. selecting appropriate anti-depressive drugs with understanding of dosing and the complexities of each b. recommending psychotherapy for individuals with anxiety disorders suffering from grief c. accessing and utilizing appropriate information systems and resources to help delineate issues related to depression C. Attitudes and Professional Behaviors: Students should be able to: 1. understand that complaints of depression may be symptoms of potentially life-threatening disease 2. understand the confidentiality requirements of psychiatric diagnoses 3. understand that uncomplicated depression can be diagnosed and treated by non-psychiatrists. TRAINING PROBLEM: DIABETES MELLITUS Rationale Diabetes mellitus is, after obesity, the most common endocrinologic problem seen in primary care practice. All physicians must identify those at risk and institute appropriate management to ameliorate the potentially fatal complications of this disease.
  • 61. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. presenting symptoms and signs of type I and type II diabetes mellitus 2. presenting symptoms and signs of diabetic ketoacidosis and nonketotic hyperglycemic coma 3. major causes of morbidity and mortality in type I and type II diabetes mellitus (e.g., coronary artery disease, peripheral vascular disease, hypoglycemia, diabetic ketoacidosis, nonketotic hyperglycemic coma, retinopathy, neuropathy, nephropathy, foot disorders) 4. pathogenesis, genetics, and epidemiology of type I and type II diabetes mellitus 5. diagnostic criteria for type I and type II diabetes mellitus, based on a history, physical examination, and laboratory testing 6. key laboratory tests needed to diagnose type I and type II diabetes mellitus, diabetic ketoacidosis, nonketotic hyperglycemic coma, and hypoglycemic coma including: i. serum glucose ii. electrolytes iii. blood urea nitrogen iv. creatinine, ketones (serum) v. arterial blood gas vi. glycosylated hemoglobin or fructoseamine vii. urine glucose, ketones, albumin/protein 7. goals of treatment of diabetes mellitus (i.e, preventing complications, maintaining acceptable levels of glycemic control, and achieving weight reduction, if obese) 8. key indications for diet therapy, oral hypoglycemic agents, and insulin therapy in diabetes mellitus 9. management strategies for diabetic ketoacidosis and nonketotic hyperglycemic states, including the similarities and differences in fluid and electrolyte replacement 10. the American Diabetes Association (ADA) dietary recommendations for type I and type II diabetes mellitus 11. the Somogyi effect and the dawn phenomenon, and the implications of each in diabetes management 12. describe steps in the critical pathway for patients with diabetes mellitus B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among
  • 62. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc etiologies of disease, including: weight gain or loss, polyuria, polydypsia, polyphagia, weakness, fatigue, blurred vision, recent skin or other infection, vulvovaginitis/balanitis, abdominal pain, medication history (e.g., corticosteroids, medication compliance), family history of diabetes mellitus, and social history (e.g., cigarette use) disease complications (e.g., cardiac symptoms, autonomic postural hypotension, gastroparesis, diarrhea, constipation, urinary retention, impotence, lower extremity pain, numbness) diet history (i.e., total caloric intake, intake of sugar-containing foods, intake of saturated fat and cholesterol, physical activity level, alcohol intake, timing of meals in type I diabetes) 2. physical exam skills: Students should be able to perform, a physical examination on patients with type I or type II diabetes mellitus to establish the diagnosis and severity of disease focusing on altered mental status, stupor, coma, Kussmaul respirations, fruity breath, signs of autonomic insufficiency and/or volume depletion, skin examination for diabetic dermopathy, furuncles, carbuncles, candidiasis, and necrobiosis lipoidica diabeticorum, cataracts, retinopathy, glaucoma, peripheral pulses, peripheral neuropathy, corns and calluses, dermatophytosis, ulceration 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings, to diagnose type I versus type II diabetes 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and interpret them, both prior to and after initiating treatment, based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests should include, when appropriate: serum glucose, electrolytes, blood urea nitrogen, creatinine, ketones, arterial blood gas, glycosylated hemoglobin or fructosamine, urine glucose, ketones, albumin, creatinine clearance, CBC with differential and EKG 6. communication skills: Students should be able to: explain the results of the evaluation to the patient 7. basic and advanced procedure skills: Students should be able to: a. insert a peripheral venous catheter and obtain an arterial blood gas, after explaining each procedure to the patient b. perform fingerstick capillary blood glucose determination c. assist in the insertion of a central venous catheter 2. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients including: a. writing appropriate fluid and insulin orders and outline critical steps for the treatment of diabetic ketoacidosis and nonketotic hyperglycemic coma b. counseling a patient regarding basic features of ADA diabetic diet recommendations
  • 63. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc c. instructing a patient in home blood glucose monitoring d. counseling a patient on behavior changes (e.g., smoking, poor glycemic control, hypertension, hyperlipidemia and infection) to avoid the complications of diabetes e. determining when to institute diet therapy, oral hypoglycemic agents, and insulin therapy f. calculating an appropriate insulin dose for a diabetic patient g. determining when to involve an endocrinologist in the care of a diabetic patient h. determining when to involve an expert in foot care and the proper fitting of specially designed weight bearing shoes i. accessing and utilizing appropriate information systems and resources to help delineate issues related to diabetes C. Attitudes and Professional Behaviors: Students should be able to: a. appreciate the impact of diabetes mellitus on the individual and the family b. consider the individual’s social, socioeconomic, and cultural background when designing nutritional recommendations and making referrals TRAINING PROBLEM: EVALUATION AND MANAGEMENT OF DYSLIPIDEMIAS Rationale Hypercholesterolemia is a common, important, and treatable cardiovascular risk factor. Its pathophysiology is increasingly understood, diagnostic tests are readily available, and treatment modalities range from diet and exercise to a multitude of pharmacotherapies. Competency in the evaluation and management of this problem helps develop skills in rational test selection, patient education, and design of cost- effective treatment strategies. It also draws attention to the importance of community health education and nutrition Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. the contribution of hypercholesterolemia to coronary heart disease (CHD) risk, including the importance of elevations in total cholesterol, LDL cholesterol, HDL cholesterol, ratio of total to HDL cholesterol, and lipoprotein subfractions 2. the classification of dyslipidemias, including who to screen, and how often 3. the available diagnostic studies and their use, particularly determinations of HDL, LDL and total cholesterol, as well as the need to test for other cardiovascular risk factors (see the Training Problem: Healthy Patient) 4. the current National Cholesterol Education Program (NCEP) guidelines for treatment of hypercholesterolemia
  • 64. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 5. the therapeutic modalities for treatment of the common dyslipidemias, including diet, exercise, cessation of smoking, and use of statins, resins, and other agents; risks, benefits, expense, and how to choose a program B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, including obtaining pertinent history for diagnosis of lipid disorders and presence of other cardiovascular risk factors, including: a. family history of early cardiovascular disease b. dietary fat, saturated fat and cholesterol intake c. smoking d. alcohol use e. presence of other CAD risk factors f. presence of symptoms of angina and peripheral vascular disease g. past history of established CAD 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including assessing for: a. blood pressure elevation b. xanthomata c. atherosclerotic fundoscopic changes d. carotid bruits e. S4, single S2 f. femoral bruits g. diminished peripheral pulses 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest primary or secondary causes of dyslipidemia. 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment, based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests, when appropriate, should include a. lipoprotein fractions b. TSH c. serum glucose 6. communication skills: Students should be able to:
  • 65. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. communicate the diagnosis, treatment plan and prognosis of the disease to patients and their families. b. tailor to the patient’s life-style and preferences, with emphasis on the patient’s role in treatment and maximizing compliance. c. address the lipid and cardiovascular risk problems in patient’s family and community as well as on an individual basis. 7. management skills: Students should develop an appropriate evaluation and treatment plan for patients including: a. design a cost-effective treatment plan that incorporates the NCEP recommendations, includes a program of dietary modification, attends to cost considerations, and takes into account the patient’s life-style b. provide a detailed patient education regarding diagnosis, prognosis and treatment plan c. monitoring response to therapy and compliance, including liver function in patients taking statin drugs, GI side effects in those taking resins, and renal function and glucose in those using niacin d. outline a plan of exercise and weight reduction e. accessing and utilizing appropriate information systems and resources to help delineate issues related to Dyslipidemia C. Attitudes and Professional Behaviors: Students should be able to: a. appreciate the importance of encouraging patients to assume responsibility for modifying their diet and increasing their exercise level b. appreciate the importance of treating asymptomatic patients at high risk for CAD as aggressively as those with symptomatic disease TRAINING PROBLEM: HIV INFECTION Rationale AIDS (acquired immunodeficiency syndrome) represents one of the most difficult challenges in clinical medicine today. The majority of cases in the USA currently occur among members of three risk groups (homosexual men, intravenous drug users, and hemophiliacs who have received factory VIII concentrate in the past). The remaining cases occur in either sexual partners of high risk individuals, infants born of high risk mothers, or recipients of tainted blood products. Given there is not a proven cure for this disorder, AIDS remains an important training problem for third year medical students. Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. CDC AIDS case definition 2. symptoms and signs of HIV-related opportunistic infections a. P. carinii
  • 66. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc b. Candidiasis c. Cryptococcosis d. Cryptosporidiosis e. Cytomegalovirus f. Mycobacterium avium complex g. Mycobacterium tuberculosis h. Toxoplasmosis 2. symptoms and signs of the following HIV-related malignancies: a. Kaposi’s sarcoma b. Non-Hodgkin’s lymphoma c. Cervical carcinoma 3. what constitutes hospice care 4. relationship of CD4 count to opportunistic infections B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiology of disease including: a. HIV infection risk factors: i. sexual contacts ii. parenteral exposure to infected blood by needle sharing or transfusion iii. occupational exposures iv. other STDs that establish increased risk for HIV infection b. HIV serology results and CD4 lymphocyte counts c. HIV-related opportunistic infections. d. fever, sweats, weight loss, wasting, dyspnea, diarrhea or headache, neuropsychiatric complaints, vaginal candidiasis, cervical dysplasia and neoplasia, or pelvic inflammatory disease, travel e. demonstrate the ability to obtain a diet history to assess: i. number of meals eaten per day ii. use of supplements 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including assessing for: a. lesions of Kaposi’s sarcoma b. lymphadenopathy c. retinitis d. oral candidiasis
  • 67. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc e. sinusitis f. hairy leukoplakia g. gingivitis h. pulmonary infiltrates i. pelvic inflammatory disease j. mental status alterations k. cognitive function deficits l. focal neurologic deficits m. muscle wasting of extremities and temporal muscles 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings in an HIV-positive patient who presents with: a. fever b. dypsnea c. diarrhea d. headache e. altered mental status 4. laboratory interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests should include, when appropriate: a. specific tests for HIV (with appropriate application of sensitivity and specificity) b. hematologic abnormalities of HIV infection c. CD4 lymphocyte count as a predictor of disease d. induced sputum and LDH for the diagnosis of PCP e. chest x-ray for P. carinii f. serum and cerebral spinal fluid cryptococcal antigen 6. communication skills: Students should be able to: a. counsel and educate patients about HIV exposure prevention b. educate about HIV exposure and seroconversion rates c. council and educate patients about complications of HIV drug therapy 7. management skills: Students should be able to develop a treatment plan for patients with HIV infection including: a. prophylactic antiviral regimens for HIV positive persons b. P. carinii prophylaxis.
  • 68. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc c. assessing PPD status and treatment for TB d. scheduling pneumococcal and H. influenza vaccines e. ordering nutritional supplements to manage and prevent malnutrition f. identify community health resources available for the care of AIDS patients g. students should also be able to access and utilize appropriate information systems and resources to help delineate issues related to HIV infection C. Attitudes: Students should be able to: 1. consider the bioethical and social issues concerning patient confidentiality of HIV infection 2. understand and have tolerance towards alternative life styles 3. maintain a non-judgmental attitude TRAINING PROBLEM: HYPERTENSION Rationale As many as 50 million Americans have elevated blood pressure (systolic pressure 140 mmHg or greater and/or diastolic blood pressure 90 mmHg or greater) or are taking antihypertensive medication. Nonfatal and fatal cardiovascular disease (CVD)- including coronary heart disease (CHD) and stroke- as well as renal disease, increase progressively with higher levels of both systolic (SBP) and diastolic (DBP) blood pressure levels. These relationships are strong, continuous, independent, predictive and etiologically significant, and indicate that reduction of blood pressure reduces these risks. Specific Learning Objectives A. Knowledge: Students should be able to: 1. identify the etiologies and relative prevalence of primary and secondary hypertension 2. define hypertensive urgency and emergency, citing examples of both 3. describe signs and symptoms of the following presenting disorders associated with secondary hypertension: a. polycystic kidneys b. renovascular hypertension c. Cushing’s disease or syndrome d. Pheochromocytoma 2. define and describe the manifestations of target-organ disease due to hypertension
  • 69. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 3. define the classification of blood pressure (systolic blood pressure (SBP), diastolic blood pressure (DBP)) for all age 18 or older (young adult, middle age, and the elderly) 4. describe basic approaches to the pharmacological management of acute and chronic hypertension, including the physiologic basis and scientific evidence supporting these approaches, and causes for lack of responsiveness to therapy 5. describe the prevention strategies for reducing hypertension (including lifestyle factors, dietary intake of sodium, weight, and exercise level), and explain the physiologic basis and/or scientific evidence supporting each strategy 6. describe steps in a critical pathway for management of patients with a hypertensive emergency B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease including: a. duration and levels of elevated blood pressure b. history of symptoms of cardiovascular, cerebrovascular, or renal disease; diabetes; dyslipidemia; or gout c. history of symptoms suggesting secondary hypertension (see knowledge section, A:3) d. history of weight gain, leisure-time physical activities, smoking or other tobacco use e. family history of high blood pressure, premature CHD, stroke, CVD, diabetes mellitus and Dyslipidemia f. psychosocial and environmental factors that may elevate blood pressure g. dietary assessment including sodium intake, alcohol use and intake of saturated fat and cholesterol results and side effects of previous antihypertensive therapy h. use of commonly prescribed, over-the -counter, and illicit medications that may raise blood pressure or interfere with the effectiveness of antihypertensive medications 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: a. blood pressure measurements to detect and confirm the presence of high blood pressure b. examination of the fundus for arteriolar narrowing, arteriovenous nicking, hemorrhages, exudates or papilledema c. neck for carotid bruits, distended veins or an enlarged thyroid gland d. heart for increased rate, increased size, precordial heave, clicks, murmurs, arrhythmias, and third(S3) and fourth (S4) sounds
  • 70. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc e. abdomen for bruits, enlarged kidneys, masses, and abnormal aortic pulsation f. extremities for diminished, delayed, or absent peripheral arterial pulsations, bruits, and edema g. peripheral pulses specifically femoral arterial pulses h. body habitus, looking for changes associated with secondary hypertension i. peripheral and central nervous system for ischemic changes 3. differential diagnosis: Generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology. 4. laboratory interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences 5. laboratory and diagnostic tests should include, when appropriate: a. urinalysis b. complete blood count c. blood glucose (fasting if possible) d. potassium e. calcium f. creatinine g. uric acid h. cholesterol, HDL, LDL, and triglycerides i. electrocardiography 6. communication skills: Students should be able to communicate the diagnosis, treatment plan and prognosis of the disease to patients and their families, taking into account the patient’s knowledge of hypertension and his/her preferences regarding treatment options educate patients about hypertension risk factors, taking into account: a. demographics b. concomitant diseases and therapies c. quality of life d. physiologic and biochemical measurements e. economic considerations 7. basic procedural skills: Skills that students should be able to perform: a. urinalysis (dipstick and microscopic) b. EKG 8. management skills: Students should develop an appropriate evaluation and treatment plan for patients with:
  • 71. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. acute and chronic hypertension b. primary hypertension c. secondary hypertension d. students should be able to access and utilize appropriate information systems and resources to help delineate issues related to hypertension. e. students should be able to prescribe preventive strategies to diminish hypertension, including: i. weight reduction ii. moderation of alcohol intake iii. regular physical activity iv. reduction of sodium intake v. increase in potassium intake vi. smoking cessation C. Attitudes and Professional Behaviors: Students should be able to: 1. appreciate the importance of patient preferences and compliance with management plans for those with hypertension 2. appreciate the importance of preventive strategies may diminish need for medications 3. appreciate the importance of complications secondary to drug administration, to which the geriatric population in particular may be more prone LEARNING OBJECTIVE: SMOKING CESSATION Rationale Smoking is a major public health issue because it causes or aggravates many serious illnesses. Effective intervention strategies for chronic smokers have been developed using principals of behavioral counseling. These principals are applicable to other risky health behaviors. Health behavior risk assessment and intervention is now an expected physician behavior for the comprehensive care of the adult. Selecting and performing an appropriate smoking cessation intervention is an important training problem for the third year medical student. Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. the pharmacological effects of nicotine 2. nicotine withdrawal symptoms 3. intervention strategies that physicians can use for their patients 4. symptoms indicating nicotine dependence 5. the common barriers preventing patients from undertaking smoking cessation
  • 72. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 6. the principles of at least one theory of behavior modification 7. the common medical diseases associated with chronic smoking and the effects of stopping on future risk. 8. the indications for nicotine replacement therapy 9. the association between smoking cessation and weight gain B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, in order to: a. determine if a patient has nicotine dependence b. assess a patient’s motivation for stopping c. assess the patient’s past experiences with smoking cessation d. review and determine patient’s barriers to stopping 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including: a. identifying nicotine stains on physical exam b. identifying lesions with malignant potential on the lips and in the oral cavity c. identifying the chest findings consistent with chronic obstructive lung disease 3. communication skills: Students should be able to: a. demonstrate a commitment to administer a non-judgmental “stop smoking” message to every patient who smokes b. respond positively and non-judgmentally to patient’s excuses or concerns about cessation c. counsel a patient on smoking cessation d. promote problem-solving by the patient 4. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patient including: a. design an intervention that matches the stage of behavior change demonstrated by the patient b. explain how to use nicotine patch therapy and nicotine gum therapy c. negotiate a follow-up plan with the patient d. encourage the patient to increase physical activity to lessen weight gain, if medically appropriate. e. access and utilize appropriate information systems and resources to help delineate issues related to smoking cessation C. Attitudes and Professional Behaviors: Student should be able to: administer a non-judgmental “stop smoking” message to every patient who smokes
  • 73. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc TRAINING PROBLEM: SUBSTANCE ABUSE Rationale Alcohol and drug abuse are associated with many of the interactions internists have with patients in a given day. The effects of substance abuse extend beyond the individual to include family, co-workers, and friends, yet can often be hidden from the observer who is unaware of their ubiquity. The physician who knows how to observe and ask about substance abuse can, through appropriate therapy, treatment, and/or referral, help the patient return to a healthy lifestyle. Specific Learning Objectives A. Knowledge: Students should be able to describe: 1. presenting signs and symptoms of abusing the following substances: alcohol, opiods, cocaine, amphetamines, hallucinogens, barbiturates, and other related medications and benzodiazipines. 2. presenting symptoms of alcohol and drug intoxication. 3. presenting symptoms of alcohol and drug overdose. 4. presenting symptoms of acute alcohol and drug withdrawal. 5. key risk factors for alcohol and drug abuse (social, genetic). 6. the major causes of morbidity and mortality associated with substance abuse (e.g., trauma, motor vehicle accidents, homicide, overdose, cirrhosis, endocarditis, HIV, hepatitis B, and suicide). 7. discuss the differences among substance abuse, dependency, and addiction. 8. the diagnostic criteria for alcohol and drug abuse, dependency, and addiction, based on a history, physical examination, and laboratory testing. 9. questions in the CAGE questionnaire (“Have you ever felt you should Cut down on your drinking?”, “Have people Annoyed you by criticizing your drinking?”, “Have you ever felt bad or Guilty about your drinking?”, “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang-over [Eye-Opener]?”)*. 10. list the key laboratory tests useful in evaluating substance abuse (e.g., blood alcohol level, liver function tests, complete blood count, amylase, urine and serum drug screens) 11. list available community referral sources (e.g., Alcoholics Anonymous, Narcotics Anonymous) and where to obtain telephone numbers. 12. list the key health benefits that accrue with cessation. 13. describe the management strategies for acute alcohol and drug withdrawal. B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease including:
  • 74. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. eliciting a social history in a nonjudgmental, supportive manner, using appropriate questioning (CAGE questions, etc.). b. evaluating a patient using the Diagnostic and Statistical Manual of Psychiatric Disease (DSM III-R) criteria for substance or alcoholic dependence. 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including assessing in a substance-abusing patient for: a. fever b. hypertension c. tachycardia d. skin for jaundice, needle tracks, manifestations of endocarditis, HIV infection, and cirrhosis e. eyes for pupil size and icterus, fundus exam (roth spots) f. nose for nasal septum perforation g. mouth for odor of alcohol and parotid enlargement h. breasts for gynecomastia i. lymph nodes for adenopathy j. heart for murmurs k. abdomen for hepatomegaly l. genital exam for testicular atrophy m. neurologic exam for tremor and cognitive impairment n. Dupuytren’s contractures 3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings to determine the diagnosis of substance abuse of drugs or alcohol. 4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment, based on the differential diagnosis, including consideration of test cost and performance characteristics, as well as patient preferences 5. laboratory and diagnostic tests should include, when appropriate: a. blood alcohol level b. urine and serum toxicology screens c. complete blood count d. liver enzymes e. amylase and lipase f. HIV 6. communication skills: Students should be able to explain the results of the evaluation to the patient.
  • 75. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 7. management skills: Students should be able to: a. assess a patient’s motivation for achieving sobriety/abstinence. b. deliver a directed, non-judgmental message to a substance- abusing patient urging him/her to quit. c. make an appropriate community referral for a substance- abusing patient d. write appropriate fluid and medication orders for the treatment of acute alcohol and/or drug withdrawal. e. access and utilize appropriate information systems and resources to help delineate issues related to substance abuse. C. Attitudes and Professional Behaviors: Students should be able to: 1. recognize the biopsychosocial etiology of addictions 2. appreciate the prevalence of addictions and the need to consistently include substance abuse in the history. 3. appreciate the power of simple directed messages in stimulating behavior change. 4. recognize that substance abuse affects the community and family, as well as the patient. 5. demonstrate a commitment to non-judgmental care of substance- abusing patients • [Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 252: 1905, 1984.] TRAINING PROBLEM: THE WORKUP OF COMMON CANCERS Rationale A skillful initial workup for suspected cancer is an essential part of effective primary care practice. Developing a logical and practical diagnostic approach to the more common cancers (e.g., breast, skin, colon, lung, prostate) is an excellent means of sharpening basic history-taking, physical examination, and communication skills and learning how to use diagnostic studies in a cost-effective manner. Encountering patients in whom cancer is a diagnostic possibility will stimulate learning the important clinical presentations and natural histories of these life-threatening conditions. Focusing on cancer diagnosis helps to concentrate the student’s learning and avoids premature immersion in the often very technical and specialized issues of treatment. Specific Learning Objectives A. Knowledge: Students should be able to define and describe: 1. principal clinical presentations, clinical courses, complications, and causes of death for the most common cancer
  • 76. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc 2. basic methods of initial evaluation, including the sensitivity and specificity of basic diagnostic studies and indications for their use, including: a. indications for skin biopsy in a patient with a suspicious skin lesion b. indications for breast biopsy in a person with a breast nodule or abnormal screening mammogram c. indications for a lymph node biopsy in a person with isolated lymphadenopathy d. initial cost-effective workups for: isolated pleural effusion, pulmonary nodule, liver nodule, prostate nodule, elevated PSA, testicular nodule, stool test positive for occult blood, abnormal PAP smear, testicular nodule, and other findings suggestive of gastrointestinal and urogenital cancers e. indications for sigmoidoscopy, barium enema, and colonoscopy in individuals at risk for colon cancer B. Skills: Students should demonstrate specific skills including: 1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, including: a. skin cancer b. breast nodules and secondary signs of breast cancer c. lymphadenopathy d. pulmonary nodule e. prostate cancer f. colon cancer 2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including assessing for: a. common skin cancers b. breast nodules and secondary signs of breast cancer c. lymphadenopathy d. pleural effusion e. liver nodularity and enlargement f. prostatic nodule g. testicular nodule h. pelvic mass i. cervical erosion 3. cost-effectively designs and carries out the initial diagnostic and staging workup, which includes ordering and interpreting, when appropriate:
  • 77. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc a. skin biopsy b. breast imaging and biopsy c. lymph node biopsy d. chest CT and pleural fluid analysis e. upper and lower GI imaging and endoscopy f. abdominal CT and ultrasound g. prostate and testicular ultrasounds and biopsy h. alkaline phosphatase/acid phosphatase/PSA i. liver biopsy j. bone scan k. Pap smear 4. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings to: a. provide prompt and critical review of the findings of the initial evaluation b. establish a tentative diagnosis and estimate severity and prognosis by use of staging criteria 5. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them ,both prior to and after initiating treatment, based on the differential diagnosis including consideration for test cost and performance characteristics, as well as patient preferences 6. laboratory and diagnostic tests should include, when appropriate: selecting tests carefully to minimize the risks of false-positive and false negative results 7. communication skills: Students should be able to: a. communicate the working plans, diagnosis, treatment plan and prognosis of the disease to patients and their families in a clear and supportive manner for bearing bad news b. provide a concise oral and written presentation of clinical findings, assessment, and initial diagnostic plan to faculty preceptor 8. basic procedural skills: Skills that students should be able to perform: a. chest tap for pleural fluid analysis* b. cervical PAP smear c. stool occult blood testing 9. management skills: Students should develop an appropriate evaluation and treatment plan for patients with cancer including: a. provision of support and information to patient, and coordination of care for work-up
  • 78. /mnt/temp/unoconv/20150130130229/internal-medicine-clerkship- coursebookdocdoc1887.doc b. timely arrangement of pertinent consultations c. accessing and utilizing appropriate information systems and resources to help delineate issues related to common cancers B. Attitudes and Professional Behavior: Students should appreciate the importance of: 1. keeping the patient well-informed and well-supported 2. maintaining close collaboration and coordination with specialty consultants 3. maintaining responsibility for coordinated care and support of the patient 4. being able to discuss DNR status with a patient and family III. CLINICAL EXPERIENCES AND OTHER TRAINING EXERCISES Proportioning Clerkship Time Between Inpatient and Outpatient Settings The internal medicine experience at the University of Minnesota consists of three core experiences: MED I MED II Primary Care Clerkship This results in a total of 12 weeks spent on inpatient internal medicine and another 8 weeks spent in ambulatory settings. Expectations for Clinical Sites Inpatient Sites MED I – General medical wards are utilized to present students a wide variety of inpatient clinical experiences. The student should be an integral member of the ward team, with direct responsibility for evaluation and management of patients, under the close supervision of housestaff and attendings. This active role in patient care has been the hallmark of the core medicine clerkship and its clinical sine qua non, irrespective of setting. Student made integral member of ward team. • Direct responsibility given for patient care, including new patient workups and management. • Access to a wide variety of medical patients with basic general medical problems (e.g., CHF, CAD, DM, HIV, Pneumonia, COPD). • Regular and detailed review of clinical work by housestaff and attending faculty. MED II – The expectation for MED II is that the student will spend the majority of time on subspecialty services. Most experiences will occur in the medical ICU, Hem/Onc service, BMT or Cardiac Service. The student should have an expanded role over the experience on MED I and should serve as a Sub-I.

×