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  • MEDEX Seattle 37 MEDEX Seattle 36 Projected objectives of Spring 37 Items covered in Winter 37: None Respiratory Readings Objectives Cardiovascular Readings Objectives Oral Health Readings Objectives Endocrinology Readings Objectives Genitourinary Readings Objectives Alcoholism Readings Objectives Dermatology Readings Objectives Obesity Readings Objectives Nutrition Readings Objectives Neurology
  • Readings Objectives Respiratory Respiratory Required Readings I. Respiratory Lab Tests Mosby’s Manual (see appropriate topic) Current Chp. 9 Mosby’s Manual (See individual topics) B. Pulmonary Function Tests: Review the basic definitions for pulmonary volumes and capacities in whatever anatomy and physiology text you own. Current Chp. 9 Enright, Paul L. Overview of pulmonary function testing. Wellesley, MA: UpToDate. Available at: file=misclung/14150 Accessed: 2/6/03. II. Smoking Cessation Current Chp. 1 Noble Chp. 57 p.47 III. COPD Current Chp. 9 IV. Asthma Current Chp. 9 Noble Chp. 72 V. Acute Bronchitis Bartlett, John G. Acute Bronchitis Wellesley, MA: UpToDate. Available at :http// file=pulm_inf/4399&type=A&selectedTitle=1~9 VI. Respiratory Infections (Pneumonia) Current Chp. 9 Noble Chp. 73, (Pneumonia) VII. Tuberculosis Current Chp. 9 Noble Chp. Ch. 74 VII. Arterial Blood Gases
  • Mosby’s Manual If you need more background information try Ravel Chp. 24 (Acid-Base and pH) VIII. Lung Cancer Current Chp. 9 Noble Chp. 81 Respiratory Respiratory Objectives I. A. Sputum Culture & Gram Stain 1. Identify several reasons why sputum Gram stains and cultures may be unreliable. 2. Identify helpful criteria on the laboratory report form that would help you distinguish sputum from spit. 3. Identify other clinical situations besides sputum in which Gram staining is considered a routine procedure. 4. Recognize the microorganism known as Streptococcus pneumoniae by any of its three common names. 5. Describe the role of this organism in causing bacterial pneumonia, otitis media, and meningitis. 6. Describe the clinical picture of respiratory infection caused by Mycoplasma pneumoniae. 7. Briefly identify the lab tests available for diagnosing pneumonia caused by Mycoplasma. 8. Identify Pneumocystis carinii as a frequent infection of AIDS patients, and the necessity of invasive techniques to obtain material for diagnosis. B. Pulmonary Function Tests 1. Identify spirometry as the most common pulmonary function test (PFT) required for screening, assessing and managing most patients with respiratory disease seen in primary care. 2. Define the following terms: tidal volume residual volume vital capacity total lung capacity forced vital capacity (FVC) View slide
  • FEV1 FEF25-75% (a.k.a.: maximal mid-expiratory flow rate) 3. Describe the effect of obstructive pulmonary disease on flow rates, residual volume, and vital capacity.* 4. . Define restrictive lung disease. 5. Identify the subjective patient complaints that would make you include restrictive lung disease in your differential diagnosis. 6. Be able to describe and identify the spirometry values and patterns that are consistent with restrictive lung disease. 7. Identify the different groups of disorders that can cause restrictive lung disease. According to Overview of pulmonary function testing 8. Explain why the diffusion of carbon monoxide test (DLCO) will help differentiate between the different classes of restrictive disease. 9. Given a patient's history and PFT results that are consistent with a restrictive lung disease formulate: a. a differential diagnosis b. an appropriate physical examination c. any further work-up or referral d. a plan for treatment or follow-up (*Note: The following explanation from another book may help clarify these objectives. "In obstructive pulmonary disorders—chronic bronchitis, emphysema, and asthma—the resistance to airflow increases and flow rates decrease. As obstruction to airflow increases, hyperinflation occurs and both residual volume, and to a lesser extent, total lung capacity increase. With the increase in residual volume, vital capacity decreases. In restrictive pulmonary disease—pulmonary fibrosis—the lungs shrink and flow rates are maintained in proportion to the decrease in lung size.") 10. List several indications for obtaining pulmonary function tests. 11. List several indications for bronchoscopy. II. Smoking Cessation 1. Describe what you would do as a primary care PA to assist a patient in your practice to quit smoking. 2. Discuss techniques for smoking cessation to include pharmacologic and behavioral methods. View slide
  • 3. Know the role of Bupropion, an antidepressant in the management of patients who wish to stop smoking. 4. Know the nicotine withdrawal symptoms. (Try the DSM-IV if you have trouble finding this information elsewhere). 5. Know when to refer your smoker patient to formal treatment programs. III. Chronic Obstructive Pulmonary Disease (COPD) 1. Define chronic bronchitis. 2. Identify cigarette smoking as the most important factor responsible for the high incidence of chronic bronchitis and emphysema. 3. Describe the typical symptoms of cough, sputum, dyspnea, wheezing, and recurrent bronchopulmonary infections seen in chronic bronchitis; contrast these with the typical symptoms of a patient with emphysema. (Note: there can be some overlap between these two conditions, but we want you to learn what would be typical for a relatively "pure" presentation of either. ) 4. Identify chronic cor pulmonale, carbon dioxide retention, and hypoxemia as manifestations of severe COPD. 5. Describe how you would differentiate chronic bronchitis from other diseases with a similar presentation: asthma bronchiectasis cystic fibrosis 6. Describe the typical picture of chronic bronchitis and emphysema seen on history, physical exam, and diagnostic testing results. (Note: we want you to learn the typical changes seen in the chest x-ray of an emphysema patient. The signs we want you to remember are low flat diaphragms, and increased radiolucency —"blackness" —of the lung fields.) 7. Describe a general plan for following and treating a patient with COPD as an outpatient, addressing issues of: pharmacologic therapy prevention of influenza and pneumococcal pneumonia supplemental oxygen therapy nonpharmacologic therapy pulmonary rehabilitation IV. Asthma
  • 1. Identify hyperresponsiveness and reversibility of airway obstruction as the key factors that set asthma apart from other disorders of airways obstruction (e.g., fixed airways obstruction). 2. List several common precipitating factors for asthma attacks. 3. Describe (briefly, not in detail) the role of antigens, IgE antibodies, mast cells, and histamine in allergic asthma. 4 Identify helpful items on the history, physical examination, and laboratory workup in the initial clinical assessment of the asthmatic patient. Recognize the increasing importance of ABG data as asthma progresses in severity (staging). 5. Identify several clinical disorders that can mimic bronchial asthma. 6. Describe in general terms (i.e., very general terms—not detailed) the role of each of the following in asthma therapy: avoidance of environmental factors bronchodilators corticosteroids (systemic and inhaled) theophylline cromolyn sodium 7. Given a patient with asthma, be able to classify the patient’s disease severity and prescribe a suitable step-wise treatment program based on that assessment (According to the National Asthma Education and Prevention Program -NAEPP). 8. Material on acute, severe asthma and status asthmaticus will be covered in the Emergency Medicine course. Details on the indications, contraindications, and side effects of asthma medications will be covered in the Patient Management course. V. Acute bronchitis 1. Describe the airway pathology associated with “Acute Bronchitis”. 2. Describe the pathogens associated with acute bronchitis. 3. Be able to construct a differential diagnosis for the cough associated with acute Bronchitis ( including infectious and non-infectious causes) 4. Compare and contrast the different reasons to have a cough and design an efficient method to work-up and establish a definitive cause. 5. Given a patient with the appropriate symptoms be able to establish the diagnosis of “Acute Bronchitis” and formulate an appropriate treatment plan.
  • VI. Pneumonia 1. Identify common predisposing factors for pneumonia. 2. Identify the most common diagnostic studies obtained in patients with suspected pneumonia. 3. Describe how you might distinguish the following on clinical evaluation*: upper from lower respiratory tract infection acute bronchitis from pneumonia bacterial versus "atypical" pneumonia community-acquired vs. nosocomial infection 4. Describe the classic clinical presentation and basics of treatment for a patient with community-acquired pneumonia due to the following agents: Streptococcus pneumoniae Mycoplasma pneumoniae 6. Learn the association of host factors with particular pathogens . For example: Alcoholism is associated with a higher incidense of Streptococcus pneumoniae, Klebsiella pneumoniae and Staphylococcus aureus. Injection drug use is associated with a higher incidense of Staphylococcus aureus etc. (One source of this information is in the “Pneumonia” chapter of Noble) 7. Describe a general approach to antibiotic therapy for community- acquired pneumonia in the immunocompetent adult; identify macrolides as the recommended drugs of first choice and the reason why. 8. Describe aspects of pneumonia diagnosis and therapy that deserve special attention in the elderly population, especially if the patient is a resident of a nursing home. 9. Describe aspects of pneumonia diagnosis and therapy that deserve special attention in patients with altered immunity 10. List indications for hospitalization in the treatment of pneumonia. VII. Tuberculosis 1. Identify airborne transmission as the most common route of TB infection in humans. 2. Describe the natural history of primary tuberculosis. 3. Describe the typical signs and symptoms of pulmonary tuberculosis in adults. (Recognize that pyuria (with a negative urine culture) and microscopic hematuria can be the presenting findings in renal tuberculosis.)
  • 4. Identify high-risk groups for tuberculosis in the USA. in whom screening and a careful diagnostic approach are justified. 5. Recognize that extrapulmonary tuberculosis occurs, and list several common sites. 6. Describe the role of acid-fast staining, cultures, genetic techniques, and drug susceptibility studies in diagnosing TB. 7. Identify the following as classic chest x-ray findings of tuberculosis: nodular infiltrates and cavities, especially in the upper lobes; hilar adenopathy, pleural thickening, and miliary pattern. 8. Identify different standards of induration for a positive PPD test, depending on a patient's risk group (e.g., 5 mm is considered positive for an HIV-infected person). 9. List or recognize common causes of a false negative PPD test. 10. Recognize that the local health department must be notified whenever a case of tuberculosis is diagnosed. 11. Briefly describe current issues in TB management—e.g., the need for multiple drug treatment, the problem of increasing antibiotic resistance, indications for preventive treatment, etc. 12. Describe some of the special problems associated with TB in HIV- infected persons. VIII. Acid-Base and pH) 1. Define pH as the hydrogen ion concentration of blood. 2. Recognize the normal pH of arterial blood as 7.4, with a normal range of 7.35 - 7.45. 3. Identify bicarbonate (HCO3-) as the body's most important buffer substance for hydrogen ion concentration. 4. Identify the kidneys as the main regulator of bicarbonate (HCO3-) production and the lungs as the organ that primarily controls CO2 excretion. 5. Define alkalosis as an increase in normal plasma pH. 6. Define acidosis as a decrease in normal plasma pH.
  • 7. Identify PCO2 and PO2 as the measurements of the partial pressure of carbon dioxide and oxygen in blood. 8. Recognize the following as common causes of metabolic acidosis: acid-gaining acidosis: salicylate poisoning (later stage) diabetic ketoacidosis starvation severe dehydration base-losing acidosis: severe intestinal diarrhea uremia 9. Identify pulmonary CO2 retention as the common mechanism producing respiratory acidosis. 10. Recognize the following as potential causes of respiratory acidosis: respiratory muscle paralysis (e.g., polio) respiratory brain center depression (e.g., morphine overdose) primary lung disease (e.g., pulmonary fibrosis or severe emphysema) chronic CHF 11. Recognize the following as common causes of metabolic alkalosis: excessive sodium bicarbonate intake severe or protracted vomiting potassium ion loss from diuretics 12. Identify excessive blowing off of CO2 by the respiratory center (hyperventilation) as the cause of respiratory alkalosis. 13. Recognize the following causes of hyperventilation that can lead to respiratory alkalosis: hyperventilation syndrome (hysteria or anxiety) high fever drug stimulation aspirin overdose (early stage) 14. Identify the changes in pH and PCO2 that happen in classic acid-base syndromes of: metabolic acidosis metabolic alkalosis respiratory alkalosis respiratory acidosis.
  • 15. Describe the information that is provided by either high or low PCO2 on pulmonary alveolar gas exchange (ventilation). 16. Learn an approach to interpreting acid-base data based on either first examining the PCO2 or first inspecting the pH. 17. Identify three reasons for PO2 measurement. 18. Identify transcutaneous electrode systems and pulse oximetry as noninvasive methods of measuring CO2 and O2 in blood; list several clinical situations where noninvasive continuos oxygen monitors are especially useful. 19. Note: The ultimate objective for this unit is to able to take a clinical case presentation, plus arterial blood gas data, and identify the acidosis or alkalosis conditions of the patient. IX. Carcinoma of the Lung 1. Identify lung cancer as the most common cause of cancer death in both men and women. 2. List typical complaints on the history that might suggest lung cancer. 3. Describe typical findings on the physical exam of a patient with lung cancer. 4. Describe or recognize classic signs of bronchogenic carcinoma on the chest x-ray. 5. Identify the most common sites of metastasis of lung cancer. (Lung CA frequently metastasizes to the brain, liver, bone, and adrenals.) 6. Identify sputum cytology, fiberoptic bronchoscopy (FOB), and transthoracic needle aspiration (TNA) as the most common methods of obtaining material for a histological diagnosis of lung cancer. 7. Describe the general significance of solitary pulmonary nodules (SPN; a.k.a.: coin lesions) on chest x-rays. 8. Identify surgical resection as the form of therapy that offers the greatest possibility of long-term survival in non-small-cell lung cancer. 9. Identify small-cell (oat cell) carcinoma as the only form of lung cancer which is clearly benefited by the use of chemotherapy.
  • Cardiovascular Cardiovascular Required Readings I. Chest Pain Current Chp. 10 Noble Chp. 16, Chp. 63. and Pgs. 1005-1006 II. Cardiac Diseases Current Chp. 10 Noble Chp. 63 III. Congestive Heart Failure Current Chp. 10 Noble Chp. 65 IV. Hypertension Current Chp. 11 Noble Chp. 60 The Sixth Report of the Joint National Commission on Detection, Education, and Treatment of High Blood Pressure will be useful in answering some of the hypertension objectives. A copy is in your patient management syllabus. V. Valvular Heart Disease Current Chp. 10 Noble Chps. 66 VI. Venous Disease of the Lower Extremity Current Chp. 12 Noble Chps. 80, 93, 115 and: Pgs. 630-633, 1048-1049, 1030 Bates Chp. 14 Cardiovascular Cardiovascular Objectives I. Chest Pain 1. Explain why the history is the most important diagnostic information in the approach to a patient with chest pain. 2. Specify several symptoms that would exclude angina from consideration in a person with chest pain. 3. Distinguish typical angina pectoris from other causes of chest pain by characteristics related to: onset and precipitating factors, duration, location, relief,
  • quality. 4. Compare and contrast the typical presentation of each of the following: variant (Prinzmetal's angina), unstable angina. 5. Differentiate by symptoms other diseases besides coronary artery disease which may cause chest pain. In particular know common pulmonary, esophageal, musculoskeletal, and neurologic causes. 6. Compare and contrast causes of chest pain which will have normal physical examinations, against those which will demonstrate important physical findings. 7. Be able to differentiate several common chest-wall syndromes. 8. Summarize common tests ordered for patients with chest pain, their possible indications, and their limitations. 9. Explain the general role of each of the following in the management of angina pectoris. (Note: you do not have to know the indications and protocols for angiography and surgery in detail —just have the general concepts down. Similarly, you don't have to know specific drug names or dosages, just the general reasons for using each class.) coronary angiography coronary artery surgery sublingual nitroglycerin long-acting nitrates beta blockers calcium channel blockers aspirin risk factor modification exercise 10. Differentiate between common important causes of acute nonpleuritic chest pain. 11. Differentiate between common important causes of acute pleuritic chest pain. II. Cardiac Diseases 1. Explain the role and limitations of the following enzymes in making the diagnosis of acute myocardial infarction, including recognition of their initial and peak elevation times. LDH CK and CK-MB Troponin-I & T 2. Explain the general use and limitations of radionuclide heart scanning.
  • III. Congestive Heart Failure 1. Define "congestive heart failure." 2. Describe the basic pathologic mechanisms which may result in heart failure and list one or two common examples of each. 3. Compare and contrast the following terms as they relate to CHF: preload, afterload, contractile (inotropic) state of the myocardium, ejection fraction, cardiac output and stroke volume. 4. Determine the role of each of the following as compensatory mechanisms in CHF. Frank-Starling relationship ventricular dilitation ventricular hypertrophy increased sympathetic nervous system activity excess salt and water retention 5. Distinguish between the following forms of heart failure, and give examples of each. acute vs. chronic heart failure left-sided vs. right-sided heart failure low-output vs. high-output heart failure 6. Compare and contrast a number of common precipitating or aggravating factors in heart failure. 7. Summarize the symptoms and physical findings of CHF. 8. Review, discuss and explain the role of each of the following laboratory studies and diagnostic procedures in CHF. CBC electrolyte levels BUN and creatinine levels liver function tests arterial blood gases EKG chest X-ray echocardiography radionuclide angiography cardiac catheterization
  • 9. Compare and contrast in general terms the role of each of the following in the treatment of CHF: rest diet diuretics digitalis vasodilators (especially ACE inhibitors) 10. Examine and explain the syndrome of acute pulmonary edema. IV. Hypertension The 6th Report of the Joint National Commission on Detection, Education, and Treatment of High Blood Pressure came out in 1997. I would recommend utilizing this as a source for answering some of your objectives. I would pay particular attention to "Chapter 4: Special Populations and Situations". Since knowledge of specific antihypertensive medications is part of the Patient Management course, you are not responsible for that information here. The following objectives do not appear in this exact order in the reading, so you may have to hunt around for them a bit. They should also be addressed in class; some of them are answered for you. 1. Define and distinguish between the following: essential (primary) hypertension, secondary hypertension, resistant hypertension isolated systolic hypertension, hypertensive emergencies and urgencies. 2. Identify and explain the effects of prolonged uncontrolled hypertension on the four "target organs" or sites of end-organ damage, which are: heart, brain, kidneys, and retina. 3. List diseases that can result from hypertension. 4. Compare and contrast the most common causes of secondary hypertension by their characteristic signs and symptoms, or lab values uncovered on routine tests. 5. Specify the items that should be covered in taking the medical history of a patient with newly discovered hypertension. 6. Determine and describe the physical exam that should be performed on a patient with newly discovered hypertension. 7. List the four stages of hypertensive retinopathy. (Answer: Stage I = narrowing; II = AV nicking; III = hemorrhages and exudates; IV = all of the above plus papilledema. Stages I & II are more chronic, and Stages III & IV reflect more acute changes.)
  • 8. Establish which laboratory tests should be obtained on a patient with newly discovered hypertension, and explain the reason why each one is necessary. 9. Outline general principles of non-pharmacologic treatment of hypertension. V. Valvular Heart Disease 1. Describe and distinguish the typical presentation of each of the following: aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, mitral valve prolapse. 2. Describe the typical presentation, complications, most common causative organisms, and diagnostic studies for infective endocarditis. 6. Determine who is at increased risk for developing infective endocarditis and explain the importance of antibiotic prophylaxis before certain medical or dental procedures in this population. VI. Venous Disease of the Lower Extremity 1. Define and explain the typical causes, presentation, diagnostic studies, and basic principles of treatment of each of the following: varicose veins, thrombophlebitis (deep and superficial), chronic venous insufficiency, stasis ulcers. Raynaud’s Phenomenon or Disease 2. Identify and recognize the following platelet disorders: • Thrombocytopenia (ITP, HIT, TTP and qualitative disorders) • Platelet Dysfunction 3. Describe typical signs or symptoms and general approach for each of the following bleeding disorders: 4. Factor VIII deficiency 5. Vitamin K deficiency 6. Liver disease 7. DIC 8. Identify the following treatment modalities for DVTs: • Heparin • Low molecular Weight Heparin • Warfarin • Fibrinolytics • Antiplatelet agents
  • Life Long Oral Health/Adult Medicine Required Readings Life Long Oral Health /Adult Medicine Required Readings Tintinalli (the Emergency Medicine book) Chp. 234 Life Long Oral Health/Adult Medicine Objectives Life Long Oral Health/Adult Medicine Objectives 1. Be able to discuss periodontitis, including the structures involved, the signs and symptoms, as well as the management. 2. Be able to identify and describe the management of these dental injuries as they pertain to secondary teeth: -Coronal fracture -Root fracture -Luxation -Intrusion -Avulsion 3. Be able to identify and describe the signs and symptoms of peridontal abscess and acute necrotizing ulcerative gingivitis. Discuss their treatment. 4. Be able to explain the disease process of tooth decay from the simple destruction of the enamel (caries) to facial abscess/cellulitis. Describe triage and initial treatment. 5. Identify the most common oral precancerous lesion and the three common sites of involvement. 6. Identify the four most common types of oral cancers. 7. Be able to identify and describe the following soft tissue lesions in the oral cavity: -oral candidiasis -aphthous stomatitis -HSV I/II -Coxsackievirus, (herpangina and hand-foot-mouth disease) 8. Compare and contrast the oral manisfestations of these conditions: -vitamin deficiency -anemia
  • 9. Know the possible adverse effects of medications on the teeth and gums. (Specifically associated with gum hyperplasia and tooth discoloration.) Endocrinology Endocrinology Required Readings I. Thyroid Disorders Current Chp. 26 Noble Chp. 97 II. Diabetes Mellitus Current Chp. 27 Noble Chp. 96 III. Endocrine Roundup Current Chp. 26 Noble Chp. 98, 99, 100. Endocrinology Endocrinology Objectives I. Thyroid Gland Disorders 1. Identify iodine as necessary for the synthesis of thyroid hormones. 2. Identify TRH and TSH and describe their role in regulating thyroid hormone levels. 3. Identify thyroxine (T4) and triiodothyronine (T3) as the two major thyroid hormones. 4. Describe the difference between free vs. protein-bound thyroid hormone (TBG). 5. Identify and describe the role of each of the following diagnostic tests in evaluating thyroid disease. T4 RAI Free T4 T3 resin uptake T3 RAI (total serum T3) free thyroid index (FTI) TSH antithyroid antibodies thyroglobulin thyroid radioiodine uptake (RAI uptake) thyroid scanning
  • thyroid ultrasound fine needle aspiration and cytology 6. Identify autoimmune processess and treatment for hyperthyroidism as the most common causes of hypothyroidism in the USA; identify iodine deficiency as the most common cause worldwide. 7. Identify Hashimoto's thyroiditis as an autoimmune disease that often results in hypothyroidism with goiter. 8. Define "cretinism." Identify the relationship between thyroid hormone deficiency at birth and mental retardation. 9. Describe the typical signs and symptoms of hypothyroidism. 10. Describe the clinical picture of severe hypothyroidism with myxedema. 11. Describe basic principles of thyroid replacement therapy for hypothyroidism (choice of drug, schedule for increasing dosages, cautions in elderly or cardiac patients). 12. Identify Graves' disease as the most common cause of hyperthyroidism; distinguish between Graves' disease and other forms of hyperthyroidism. 13. Identify or describe the classic signs and symptoms of hyperthyroidism; identify infiltrative ophthalmopathy as specific for Graves' disease. 14. Briefly describe the pros and cons of treating hyperthyroidism with: antithyroid drugs (e.g., propylthiouracil and methimazole), radioactive iodine, surgery. 15. Describe the syndrome of toxic multinodular goiter. 16. Describe the syndrome of subacute thyroiditis. 17. Describe the syndrome of thyroid storm. 18. Describe the workup for a patient with a solitary thyroid nodule. 19. Describe the difference between, and clinical significance of, "hot" nodules versus "cold" nodules on radioisotope scanning. II. Diabetes Mellitus 1. Know the laboratory criteria for the diagnosis of diabetes mellitus in adults.
  • 2. Describe the differences between type 1 and type 2 diabetes mellitus. 3. Recognize the typical symptoms of hyperglycemia which may cause the patient to present to the primary care practitioner. 4. Briefly describe the role that each of the following plays in the causation of diabetes mellitus: autoimmune processes, genetic inheritance, insulin resistance. 5. Identify diabetic ketoacidosis (DKA) and nonketotic hyperglycemic- hyperosmolar coma as the two major consequences of uncontrolled diabetes. 6. Recognize the signs and symptoms of DKA. 7. Recognize the signs and symptoms of nonketotic hyperglycemic-hyperosmolar coma. 8. Describe the symptoms of hypoglycemia that may be caused by insulin or sulfonylureas. 9. List or recognize the major chronic complications of diabetes mellitus, especially increased atherosclerosis (CAD, CVA, PVD), diabetic retinopathy, nephropathy, neuropathy, and foot ulcers. 10. Describe the characteristic clinical findings of diabetic retinopathy. 11. Describe the role that each of the following plays in management of diabetes. diet weight reduction for obesity exercise insulin* oral agents* self-monitoring of blood glucose glycosylated hemoglobin assay (Hb A1c) *Note: we will leave details of the insulins and oral agents to the Patient Management course. You should at least have an idea of which insulins are short-, intermediate-, or long- acting for this course. 12. Describe the management issues for each of the following special cases in diabetes mellitus. adolescents elderly pregnant patients
  • III. Endocrine Roundup: A. Parathyroid Disorders 1. Describe the role of each of the following in calcium homeostasis. parathyroid hormone (PTH) vitamin D calcitonin 2. Identify the problems caused in the body by hypercalcemia. 3. Identify hyperparathyroidism and malignancy as the two major causes of hypercalcemia. 4. Identify common causes of hypocalcemia. 5. Identify the problems caused in the body by hypocalcemia. 6. Describe the following signs associated with hypocalcemia. Chvostek's sign Trousseau's sign tetany B. Pituitary Gland Disorders 1. Describe the relationship between the hypothalamus and the anterior pituitary gland. 2. Recognize each of the following as anterior pituitary hormones, and state briefly what each of them does in the body. adrenocorticotropic hormone (ACTH) growth hormone (GH) prolactin thyroid stimulating hormone (TSH) follicle stimulating hormone (FSH) ltteinizing hormone (LH) 3. Recognize bilateral temporal field loss (homonymous hemianopsia) as a classic presenting sign in pituitary tumors. 4. Identify arginine vasopressin (AVP), also known as antidiuretic hormone (ADH), as a hormone produced by the posterior pituitary gland. 5. Define "diabetes insipidus" and identify how it would be recognized.
  • 6. Identify dwarfism, gigantism, and acromegaly as consequences of either under- or over-secretion of growth hormone. 7. Recognize the association of galactorrhea and amenorrhea in women with excessive prolactin secretion (hyperprolactinemia). C. Adrenal Gland Disorders 1. Identify cortisol, aldosterone, and androgens as adrenal hormones. 2. Describe the negative feedback relationship of ACTH secretion and cortisol levels. 3. Describe the clinical presentation of primary adrenal insufficiency (Addison's disease). 4. Describe the clinical presentation of adrenocortical hyperfunction (Cushing's syndrome). Distinguish between Cushing's syndrome and Cushing's disease. 5. Identify primary hyperaldosteronism as a cause of secondary hypertension; recognize the association with spontaneous hypokalemia. 6. Describe the clinical features of pheochromocytoma. D. Osteoporosis 1. Identify risk factors for development of osteoporosis. 2. Describe the clinical findings of osteoporosis. 3. Describe prevention and treatment measures* for osteoporosis. *Note: details of the pharmacologic treatment options will be tested in the Patient Management course. Genitourinary Genitourinary Required Readings I. GU Lab Tests Current Chp. 22 Mosby’s Manual of Diag. And Lab tests (look up individual studies) Noble Chp. 144 II.. III Urinary Tract Infections, Stones, and Hematuria
  • Current Chp. 23 Noble Chp. 146, 147 IV, V, VI Fluid & Electrolytes, Renal Diseases, and Proteinuria Current Chp. 21, 22, 23 Noble Chps. 145, 148, 149 VII. Male GU Problems Current Chp. 23 Noble Chp. 150, 151, 152, 153, 155 Genitourinary Genitourinary Objectives I. Diagnostic Testing and Assessment of Renal Function 1. Describe the general utilization of each of the following laboratory tests in evaluating patients with suspected urinary tract disease. urinalysis (both dipstick and microscopic exam; know the significance of RBC and WBC casts) urine culture BUN, creatinine glomerular filtration rate (GFR) 2. Identify the advantages and disadvantages of each of the following imaging techniques of the urinary tract. ultrasound (US) intravenous pyelogram (IVP) CT and MRI 3. Briefly identify the indications, contraindications, and complications of renal biopsy. II. Urinary Tract Infections (UTIs) 1. Define or distinguish between the following terms: uncomplicated vs. complicated UTIs, lower UTIs vs. upper UTIs, acute urethral syndrome, asymptomatic bacteriuria. 2. Identify predisposing factors for UTI. 3. Identify common uropathogens. 4. Identify three routes of infection for UTI.
  • 5. Describe classic signs and symptoms of lower vs. upper tract UTI. 6. Describe the use of each of the following in diagnosing out-patient UTI: urinary nitrate, urinary leukocyte esterase, pyuria and bacteriuria, urine culture. 7. Identify patients who should have urologic evaluation following UTI. 8. Identify other causes of dysuria that should be considered in the differential diagnosis of UTI. 9. Describe the approach to treatment for low-risk, uncomplicated UTI. 10. Distinguish between relapse and reinfection in recurrent UTI. 11. Describe the role of prophylactic antibiotics in recurrent UTI. 12. Describe an approach to evaluation and management of acute urethral syndrome. 13. Describe the syndrome of asymptomatic bacteriuria, and the differing approach to evaluation and management in elderly vs. pregnant patients. 14. Identify which patients with acute pyelonephritis should be hospitalized vs. which can receive outpatient treatment. 15. Describe the typical management approach for outpatient treatment of acute uncomplicated pyelonephritis. III. Nephrolithiasis 1. Describe the classic clinical syndromes associated with kidney stones, particularly renal colic. 2. Describe the general approach to diagnosis and management of a patient with an acute stone episode, including when to consult a urologist or nephrologist. 3. Identify obstruction and infection as common complications of kidney stones. 4. Identify dietary modification, increased fluid intake, and/or pharmacologic treatment as the basis of prevention of recurrent stone formation. IV. Fluid and Electrolyte Disorders 1. Identify common causes of each of the following:
  • metabolic acidosis, metabolic alkalosis, hypokalemia, hyperkalemia, hyponatremia, hypernatremia. 2. Describe signs and symptoms of hypokalemia and hyperkalemia, including EKG changes. 3. Describe signs and symptoms of hyponatremia and hypernatremia. V. Renal Disease 1. Identify important areas to cover in the history and physical examination of a patient with suspected renal disease. 2. Identify laboratory studies and diagnostic procedures that might be obtained to evaluate renal disease. 3. Define oliguria, azotemia, and uremia and recognize their association with renal failure. 4. Distinguish between prerenal causes, postrenal causes, and intrinsic causes of acute renal failure, and list or recognize common examples of each. 5. Identify important systemic diseases associated with renal insufficiency. 6. Identify general principles of treatment of acute renal failure. 7. Identify general principles of management of chronic renal failure, including criteria for the initiation of dialysis. VI. Hematuria and Proteinuria 1. Identify hematuria as an important sign of renal disease, urinary tract disease, or hematologic disorder. 2. Identify common causes of hematuria in particular the association of hematuria with renal cancer and bladder cancer. 3. Describe an approach to working up a patient with hematuria. 4. Define proteinuria, and recognize its association with virtually all kidney diseases as well as certain functional disorders.
  • 5. Describe the finding of isolated proteinuria and its apparent relation to postural factors. 6. Describe an approach to working up a patient with proteinuria discovered during a random urine examination VII. Male GU Problems 1. Identify the typical clinical manifestations of benign prostatic hyperplasia (BPH). 2. Describe the routine history, physical exam, and laboratory assessment of patients with BPH. 3. Describe the medical and surgical options for treatment of BPH. 4. Describe the typical clinical presentation, diagnostic tests, and general principles of treatment of prostate cancer. 5. Describe the different types of prostatitis. 6. Describe the typical presentation, diagnostic evaluation, and general principles of treatment (if any) of each of the following: testicular torsion, epididymitis, hydrocele, varicocele, spermatocele. (Note: you may wish to review the illustrations in Bates, pp. 379-380) 7. Describe the typical age and clinical presentation of patients with testicular tumors. Identify the role of cryptorchidism as a risk factor. Note that there are different cell types of testicular cancer, but you do not have to know any of the details about the differences between them. 8. Describe a primary care approach to male sexual problems of impotence and erectile dysfunction. Alcoholism Alcoholism Required Readings I. Alcoholism Current Chp. 25 Noble Chp. 51
  • Alcoholism Alcoholism Objectives I. Alcoholism 1. Define "alcoholism." 2. Cite male sex and a family history of alcohol abuse as two major risk factors for alcoholism. 3. List clues in the history that may suggest the diagnosis of alcoholism. 4. List common abnormalities on the physical exam and laboratory studies which may suggest alcoholism. 5. Describe several strategies you might use to overcome an alcoholic's resistance to accepting his or her diagnosis and the need for treatment. Your strategies should recognize: a) the patient's denial and potential hostility b) the need for family involvement c) the role of support groups, such as AA d) the health care provider's role in providing factual information about the disease. 6. Describe the pros and cons of use of disulfiram (Antabuse) in the treatment of alcoholism. 7. Define "Delirium Tremens" 8. Describe the most common presentation of delirium tremens. 9. Given a classic case presentation of delirium tremens be able to a. identify delirium tremens b. develop an appropriate treatment plan Dermatology Dermatology Required Readings I. A. Dermatology Anatomy, Physiology and Terminology Review your dermatology objectives from week 10 of Basic Clinical Skills. II. Common Dermatologic Problems Current Chp. 6 Noble Chps 82-95 Look up specific topics
  • Fitzpatrick Various sections* Dermatology Dermatology Objectives I. Objectives for Common Derm Problems Our dermatology readings cover a great many diseases, including some rarities. For the exam, concentrate on only the following common, representative dermatologic conditions from your reading, which should also be discussed (at least briefly) in class. On the exam, be able to recognize each of the following by classic history and physical appearance. You should also be able to answer very general questions about treatment, (i.e., not specific drugs and dosages, but general principles like whether something is typically treated with antibiotics, topical steroids, antihistamines, liquid nitrogen, antifungals, excision, referral, etc.). Urticaria Warts Furuncle Herpes zoster Acne vulgaris Eczema Impetigo Allergic contact dermatitis Scabies Pediculosis Atopic dermatitis (eczema) Psoriasis Seborrheic dermatitis Pityriasis rosea Herpes simplex Pityriasis versicolor Tinea pedis Tinea cruris Tinea corporis Tinea capitis Onychomycosis Folliculitis (infectious) Cellulitis Lipoma Seborrheic keratosis Skin cancers: basal cell, squamous cell, and malignant melanoma; precursor lesions (actinic keratoses, leukoplakia, and nevi); Kaposi's sarcoma l Be sure to review the color photos and descriptions in Fitzpatrick ‘s and/or Noble page 787-801. Obesity Required Readings IV. Obesity Current Chp. 26, Chp. 29 Noble Chp. 58 Obesity Obesity Objectives
  • 1. Describe social, psychologic, and genetic factors that contribute to the onset and perpetuation of obesity. 2. Identify the medical conditions associated with obesity. 3. Describe the history, physical exam, and lab tests which would be appropriate for an obese patient. 4. Describe the approach you would take in counseling and supporting an obese patient in your practice who needs to lose weight. 5. Describe the role of each of the following in the medical management obesity. balanced calorie dieting very-low-calorie diets exercise behavioral modification drug therapy surgical procedures Nutrition Nutrition Required Readings I. Nutrition Current Chp. 29 Noble look up individual topics Mosby’s Manual Look up individual topics A helpful resource for your Nutrition objectives can be found at: ap/medex/lectures/nutrition.html Another useful resource is the Harvard School of Public Heath web site: I. Nutrition Nutrition Objectives 1. Describe the medical significance of increased or decreased serum levels of sodium, potassium, calcium, iron, zinc, chromium and iodine. 2. Explain the importance of phytochemicals, antioxidants and fiber in our diets. 3. Describe the functions and medical significance of the fat soluble vitamins, A, D, E, and K.
  • 4. Describe the functions and medical significance of the water soluable vitamins: Metabolic B Vitamins (niacin, riboflavin, thiamin), Building B vitamins (folic acid, pantothenic acid, biotin, B6, B12), Vitamin C. 5. Describe functions of carbohydrates, protein and fats in foods in the diet. Neurology Neurology Required Readings I. Acute CNS Problems: Cerebrovascular Disease and CNS Infections Current Chp. 30 Noble Chp. 165 II. Chronic CNS Problems: Movement Disorders, Seizures, and Multiple Sclerosis Current Chp. 24 Noble Chp. 159, 163, 169, 171 III. Headaches Current Chp. 24 Noble Chp. 160 IV. Alterations in Mental State Current Chp. 4 Noble Chp. 157 and 158 Bates Chp. 16 Neurology Neurology Objectives I. Meningitis and Encephalitis 1. Identify Streptococcus pneumoniae and Neisseria meningitidis as the two most common causes of acute bacterial meningitis in adults. 2. Describe or recognize the classic clinical picture seen in a patient with acute bacterial meningitis. 3. Describe or recognize the typical CSF findings seen in acute bacterial meningitis; identify the WBC with differential and blood cultures as important additional studies to be obtained. 4. Describe the importance of obtaining CT scan, when possible, prior to lumbar puncture if there is any suspicion of a space-occupying lesion.
  • 5. Since antibiotic choices change rapidly, you will not be ask ed to learn specific recommendations for this. Be aware that you may have to make empiric antibiotic choices based on patient's age, clinical circumstances, etc., before a definitive bacterial pathogen can be identified. 6. Identify the need for prophylaxis of close contacts of patients with meningitis caused by Neisseria meningitidis and Hemophilus influenzae type b. 7. Describe or recognize the typical clinical syndrome of acute aseptic (viral) meningitis, including CSF findings. 8. Describe the usual clinical course and lack of neurological sequelae seen in most cases of acute viral meningitis. 9. Identify tuberculosis and fungi as common causes of subacute and chronic infectious meningitis. 10. Identify cryptococcal meningitis as a common cause of CNS infection in AIDS patients. 11. Describe or recognize the typical clinical syndrome of acute viral encephalitis. 12. Identify acute viral encephalitis as an important cause of substantial mortality and serious neurological morbidity in survivors. 13. Identify herpes simplex encephalitis as presenting with focal neurological signs, requiring differences in diagnosis (e.g., MRI, CT, or possible brain biopsy) and treatment (e.g., IV acyclovir). III. Cerebrospinal Fluid Examination 1. Be able to describe the typical cerebrospinal fluid findings in the normal patient and in a patient with: a. Community acquired bacterial meningitis b. Mycobacterial or fungal meningitis c. Spirochetal meningitis d. Aseptic or viral meningitis and meningoencephalitis e. Neighborhood reaction (brain abcess, vertebral osteomyelitis, epidural abcess, subdural empyema, bacterial sinusitis or mastoiditis) IV. Seizure Disorders 1. Distinguish between the following major categories of seizures. partial seizures: simple partial seizures (focal)
  • complex partial seizures (aka: psychomotor or temporal epilepsy) generalized seizures: absence, or petit mal tonic-clonic, or grand mal status epilepticus 2. Identify the main elements of the history, physical examination, and diagnostic tests which are obtained in working up a patient with seizure disorder. 3. Identify each of the following as a common cause of acute or recurrent seizure disorder. idiopathic epilepsy metabolic and toxic encephalopathies posttraumatic epilepsy (especially penetrating head injuries) CNS neoplasms cerebrovascular disease intracranial infection 4. Read the material about treatment of seizure disorders, but pharmacology questions will be deferred to the Patient Management course. V. Multiple Sclerosis 1. Identify multiple sclerosis (MS) as the most common chronic neurologic disease of young adults. 2. Recognize that the most popular current theory of MS is that it is an autoimmune, inflammatory demyelinating disorder of the CNS resulting in the delay, dispersion, and blockage of electrical impulses. 3. Describe various clinical manifestations of MS, especially the following: visual disturbances: optic neuritis, nystagmus, diplopia, paresthesias/dysesthesias, spasticity, limb weakness, and ataxia, urinary urgency, frequency, or incontinence, disorders of mental function. 4. Recognize that the natural history of MS is very variable; identify factors which may precipitate symptoms or attacks. 5. Identify diagnostic tests which help confirm the diagnosis of MS. 6. Describe the role of corticosteroids and beta-interferon in the treatment of MS. VI. Movement Disorders: Parkinson's and Huntington's
  • 1. List or recognize the triad of tremor, rigidity, and bradykinesia which characterize Parkinsonism. 2. Identify idiopathic Parkinson's disease as tending to begin in the 50's – 60's age group. 3. Identify dopamine depletion and degeneration of the substantia nigra as the most characteristic pathophysiologic features of Parkinson's disease. 4. Identify levodopa (L-dopa) as the most common medication used for Parkinson's disease. 5. Identify chorea and dementia as the characteristic features of Huntington's disease. 6. Describe the typical age of onset, usual progressive nature, and ultimate prognosis of Huntington's disease. 7. Identify Huntington's disease as an autosomal dominant disorder and describe the implications for genetic counseling for patients with a family history of Huntington's disease. VII. Headache 1. Describe the history questions, physical exam, and possible lab tests that you would obtain in any of the common headache disorders. 2. Distinguish between new, acute headaches and chronic, recurrent headaches in your differential diagnosis and approach to the patient. 3. Recognize signs and symptoms of potential organic or serious disease in a headache patient. 4. Describe the major features of the history, physical exam, diagnosis and basic principles of treatment* for each of the following headache syndromes: tension headaches (aka: muscle contraction headaches), migraine with aura (aka: classic migraine), migraine without aura (aka: common migraine), cluster headaches. * For treatment, concentrate on patient education and non-pharmacologic therapy, appropriate use of analgesics, and avoiding drug dependence. For migraines, read carefully about prophylaxis, ergotamines, and sumitriptan. There has been alot of new treatment options recently, focus more on the presentations and characteristics of the various types of headaches and keep in mind that you will need to stay abreast of the current treatment options.
  • 5. Recognize the presentation of any of the following other causes of headaches by typical signs and symptoms. intracranial hemorrhage (especially subarachnoidhemorrhage) sinusitisheadache ocular headache (refraction error/glaucoma) temporal arteritis meningitis posttraumatic headache lumbar puncture headache intracranial neoplasm headache TMJ dysfunction/bruxismheadache of neck origin (cervical radiculopathy) VIII. Alterations in Mental State 1. Define Coma. 2. Describe the rapid assessment needed to determine the anatomic level of dysfunction in a comatose patient. 3. Describe the two major categories considered in the diagnosis of coma. 4. Describe the physical and laboratory exams that may be helpful in the differential diagnosis of the cause of coma. 5. Define brain death (according to the 1981 President's commission) 6. Define delirium (acute confusional state Noble pages 1468-1473). 7. Describe the common presenting clinical features of delirium. 8. Describe the initial laboratory work-up for a patient suffering from delirium. Note: There are many causes of delirium. Our main thrust here is that you know the major categories of etiologies. (e.g., injury by physical agents, infections, intoxications, etc.) 9. Define dementia. 10. Describe the most common causes of dementia. 11. Formulate a work-up for a patient presenting with dementia. 12. Compare and contrast the common presentations of delirium and dementia. 13. Given a patient presentation be able to differentiate between delirium and dementia.