The Department of Medicine at the University of North Carolina at Chapel Hill provides an integrated, progressive experience for residents in their 36- month training period. The goal of our curriculum is to prepare residents to be well- trained general internists. We believe this type of training not only prepares our residents for careers in General Internal Medicine but also provides the necessary foundations for further training as a subspecialist.
The curriculum in the Department of Medicine changes greatly from the PGY 1 year to the PGY 3 year. The PGY 1 year consist of 9 months of inpatient rotations and 3 months of ambulatory medicine. During the second and third years, residents spend an increasing amount of time in the outpatient setting, so that by the time a resident is in the PGY 3 year, a majority of rotations occur in ambulatory medicine. The curriculum will be specifically described for each of the 3 year of training.
Patient Care- medical interviews, physical examinations, review of data, procedural skills, diagnostic and therapeutic decision making
Medical Knowledge- basic and clinical science, evidence- based medicine, literature searching
Practice Based Learning and Improvement- evaluation of own performance, incorporation of feedback, use of technology for patient care and self improvement
Interpersonal and Communication Skills- establishment of relationships with patients and families, education and counseling of patients, team skills with colleagues
Professionalism- demonstration of respect, compassion, integrity, and honesty, commitment to self assessment, acknowledges errors, considers needs of patients and colleagues
System Based Practice- ability to utilize resources, use a systematic approach to reduce errors and improve patient care
These competencies are reviewed with all residents and the faculty and serve as the foundation for monthly evaluation. The evaluation tool includes a description of each of the core competencies and a scale of evaluation for each from 1-9. A copy of the evaluation took is included in Section ___.
Communicates with the patient and ward team regarding daily progress
Enters a history and physical and daily progress notes into the patient record
Develops a diagnostic and therapeutic plan for each patient
Enters a discharge summary in to the patient record</li></ul>Cardiology -consists of 32 beds covered by four teams. Each team is made up of one upper level resident and one PGY 1 resident. One faculty member and one subspecialty fellow are assigned to each team to assist in patient management and to conduct teaching rounds. Didactic teaching rounds and bedside teaching occur daily. Also, there is a weekly core curriculum lecture series that is case- based.<br />A copy of the Cardiology Curriculum is included in Section 2. Common diagnoses of patients admitted to the cardiology service included myocardial infarction, arrhythmias, and chronic heart failure. Residents follow patients in the CCU (12 beds) and the general floor (20 beds). Residents on service place central lines including Swan Ganz catheters and perform arterial blood gases and thoracenteses. <br />ICU- Consist of 19 beds in a MICU. There are 4 teams, each team consisting of one upper level resident and one PGY 1 resident. One faculty member serves as the attending in the MICU. There is also a Critical Care Fellow. Teaching rounds include didactic presentations (30 min/day, 6 days/week), bedside teaching(2hours/day, 7days/week), and x-ray teaching (30 minutes/day,6days/week). There is a designated curriculum (Section 2). Patients admitted commonly have the following diagnoses: GI bleeding, septic shock, drug overdose, s/p cardiopulmonary arrest, DIC, COPD exacerbation, cystic fibrosis exacerbation, rejection s/p lung transplant, and acute renal failure. Residents perform all procedures. <br />Inpatient General Internal Medicine - consists of 2 general medicine services. For each service, there is one attending, one upper level resident, and two PGY 1 residents. Teaching rounds occur for one hour, five times per week covering a number of topics described in the Inpatient General Medicine curriculum (see Section 2). Patients admitted have a variety of problems including: community acquired pneumonia, COPD exacerbation, diabetic complications, and lupus complications. Residents perform all procedures. <br />Also, residents rotate at Wake Hospital, a community hospital in Raleigh, NC. There are four teams consisting of one attending, one upper level resident, and one PGY 1 resident. Teaching rounds occur for one hour five times per week covering topics in General Internal Medicine. Residents perform all procedures. <br />Inpatient Subspecialty Wards- <br />Service#beds<br />Medicine A-Geriatrics20<br />Medicine B- Nephrology20<br />Medicine E- Hematology/Oncology40<br />Medicine G- Pulmonary20<br />Medicine K- Infectious Disease20<br />For each service there is one attending, one upper level resident, and two PGY 1 residents. Each of these services has daily work rounds and attending rounds. Each service has designated reaching time occurring at a minimum of five hours per week. During teaching time a series of topics pertinent to each service are reviewed. A copy of each curriculum is included in Section 2. Residents perform all procedures on these services. <br />The PGY 1 Curriculum also includes the following rotations: <br />Emergency Medicine- 1 month<br />Same Day Clininc-1 month<br />Continuity Care/Ambulatory Elective- 1 month<br />Emergency Room – faculty from the Department of Emergency Medicine supervise PGY 1 residents. PGY 1 residents have a generic experience seeing medical, surgical, and obstetrics/gynecology patients. There are four hours of didactic teaching per week, which cover a wide variety of topics. Examples of monthly topics are included in Section 3.<br />Same Day Clinic- This is a walk in clinic for the established IM patients and also serves as an Urgent Care clinic. Faculty in the Division of General Internal Medicine supervise PGY 1 residents. A variety of outpatient problems are encountered. Didactic teaching takes place daily for 30 minutes. Subjects covered in the curriculum are included in Section 3. <br />Continuity Care/Ambulatory Elective- PGY 1 residents spend one month in the General Medicine clinics working with Faculty from the Division of General Medicine. Some of the modules include enhanced care in anticoagulation, diabetes, pain management, and travel medicine. Each resident also undertakes a CQI project. PGY 1 residents may also rotate on a subspecialty service of the Department of Medicine. Consultations are done on inpatients and outpatients and patients are also seen in subspecialty clinics. Division faculty provide supervision. Curricula for each rotation are included in Section 3.<br />Teaching Conferences<br />PGY1 residents attend a series of Departmental Conferences. The daily work schedule is set up to allow PGY 1 residents to attend the conferences (Table 1).<br />Table 1<br />UNC Department of Medicine- Schedule of Daily Activities<br />TimeMondayTuesdayWednesdayThursdayFriday0700Pre RoundsPre RoundsPre roundsPre RoundsPre Rounds073001000Work RoundsWork RoundsWork RoundsWork RoundsWork Rounds1000Residents ReportResidents ReportResidents ReportResidents ReportResidents Report1100Attending RoundsAttending RoundsAttending RoundsAttending RoundsAttending Rounds1200Core CurriculumCore CurriculumIntern ConferenceGrand Rounds/ Morbidity and Mortality ConferenceEBM Conference<br />Residents are expected to attend all conferences. The conferences are as follows:<br />Monday- Resident Core Curriculum Conference 1 hour<br />Tuesday- Resident Core Curriculum Conference 1 hour<br />Wednesday- Interns Conference 1 hour<br />Thursday- Grand Rounds 1 hour<br />Friday – EBM Conference 1 hour <br />The content of some of these conferences is briefly described. Lecture topics are included in Section 4.<br />Monday and Tuesday- Residents Conference- Faculty in the Department of Medicine presents a series of lectures covering focused topics. <br />Wednesday- Interns Conference- A lecture series o f Emergency Medicine Topics mixed with case based group discussion. <br />Thursday- Grand Rounds <br />Thursday- Mortality and Morbidity- The morbidity and mortality conference centers on a subject relating to patient care in the department. The Vice Chair of the department conducts this lecture.<br />Friday- Evidence Based Medicine Conference- An evidence based medicine discussion of selected literature by both faculty and residents.<br />The PGY 2 Year<br />Each PGY 2 resident must demonstrate competence in the following:<br />Patient Care<br />Medical Knowledge<br />Practice Based Learning and Improvement<br />Interpersonal and Communication Skills<br />Professionalism<br />System Based Practice<br />Competency is defined as outlined above for PGY 1 residents and is used for monthly evaluations of PGY 2 residents<br />The PGY 2 year is composed of a series of monthly rotations coupled with Departmental teaching conferences.<br />The monthly inpatient rotations for a PGY 2 resident are as follows:<br /><ul><li>MICU- 1month
Night Float- 2-3 2 week blocks</li></ul>On inpatient rotations the role of the PGY 2 resident is to be in charge of the ward team. In this role the PGY 2 resident:<br /><ul><li>Performs a history and physical examination on each new patient
Reviews the treatment plan for each new patient with the PGY 1 resident
Supervises all procedures</li></ul>On night float the PGY 2 resident reports at 7pm and until 7 am. They are responsible for the primary evaluation and management of all non intensive care patients admitted to the Department of Medicine. At 7am the care of those patients goes to the incoming team on call. The Attending Physician of the service provides supervision. <br />Cardiology/ICU/Inpatient General Medicine Wards/Inpatient Subspecialty Wards - <br />These have been previously described under the PGY 1 resident. The role of the PGY 2 resident on these services is supervisory. The PGY 2 resident evaluates all patients on service and the PGY 2 resident is integral in constructing a plan of care, which is carried out by the PGY 1 resident. Another major responsibility is teaching. The PGY 2 resident teaches and supervises medical students on these services.<br />The PGY 2 curriculum also includes the following rotations:<br />Ambulatory General Internal Medicine- 2-3 months<br />Subspecialty Consultation- 2-3 months<br />Ambulatory General Internal Medicine – PGY 2 residents can choose from several month blocks focusing on outpatient skills of the generalist. Some of the choices are:<br />Wake Hospital Ambulatory Rotation<br />Siler City- PGY 2 residents spend the month in a community setting supervised by general internists. <br />Subspecialty Consultation- PGY 2 residents can choose among any subspecialty in the Department of Medicine. Consultations are done on inpatients. Patients are also seen in subspecialty clinics. Division faculty provides supervision. Curricula for each rotation are included in Section 3. <br />Teaching Conferences<br />Like PGY 1 residents, PGY 2 residents attend a series of conferences, which are integrated with the daily work schedule. Some have been described previously including Monday Resident Core Curriculum, Tuesday Core Curriculum, Thursday Grand Rounds and Friday Evidence Based Medicine. In addition, PGY 2 residents attend Morning report. This is case- based with residents presenting unknown patients to their peers. The presenting resident completes his /her presentation with a review of a particular subject. This review like all presentations is posted on the internet so that residents may review these at their leisure. These conferences are coordinated by the Chief Residents. The curriculum is set by the chief residents; a list of topics discussed is included in Section 4. <br />The PGY 3 Year <br />ACGME Competencies <br />Each PGY 3 resident must develop competency in the following:<br />Patient Care<br />Medical Knowledge<br />Practice Based Learning and Improvement<br />Interpersonal and Communication Skills<br />Professionalism<br />Systems Based Practice <br />Competency is defined as outlined above for the PGY 1 and PGY 2 residents and is used in monthly evaluation. <br />In many ways the PGY 3 year is similar to the PGY 2 year in that the residents function as described previously under the PGY 2 year, include teaching conferences. The rotations however, are different and are as follows:<br /><ul><li>Wake Med- 1 month
Night Float- 2-3 2 week blocks</li></ul>Inpatient General Internal Medicine Wards/ Inpatient Subspecialty Ward- The role of the PGY 3 resident is identical to that described previously for the PGY 2 resident.<br />Same Day Clinic- The role of the PGY 3 resident is identical to that of the PGY 1 resident<br />Ambulatory General Internal Medicine- PGY 3 residents can choose from several month blocks including those described for PGY 2 residents. There are additional choices as follows:<br />General Medicine Consults/Hospitalist Service- PGY 3 residents see patients on other services, providing General Medicine Consultations. Also a small number of inpatients are cared for. Supervision is provided by faculty from the Division of General Internal Medicine Hospitalist group.<br />Geriatric Medicine- PGY 3 residents are exposed to management of this population. Faculty trained in Geriatrics provide supervision <br />Subspecialty Consultations- The role of the PGY 3 resident is the same as described for the PGY 2 resident on those rotations.<br />Special Electives- These rotations are designed to enhance individual training. Residents pick a faculty mentor to conduct clinical or basic research. Rotations at other institutions or international rotations can also be done. <br />SECTION 2<br />INPATIENT CURRICULUM<br />Cardiology<br />Intensive Care Unit<br />General Medicine<br />Geriatrics<br />Nephrology<br />Hematology/Oncology<br />Pulmonary<br />Infectious Diseases<br />Endocrinology <br />Section 2<br />Inpatient Curriculum<br />General <br />Each inpatient service has designated teaching time, previously described in Section 1. It is the responsibility of the division faculty when on service to review a series of topics during the monthly rotation. The division faculty generates these topics with input from residents as well as data supplied to each division from preceding In-Training Examination. A dominant theme for these conferences is to review material a general internist must know about each discipline. The curricular goal for each resident is to have a working knowledge of these subjects. <br />Cardiology Inpatient Curriculum<br />Objective 1. Takes a history<br />Demonstrates knowledge necessary to obtain an orderly history on patients suspected of having cardiovascular diseases and recognizes the importance of <br /><ul><li>Dyspnea ( resting, exertional, nocturnal, positional)
Chest pain ( specifically, what constitutes “typical” angina)
Claudication</li></ul> Objective 2. Performs a physical examination<br />Demonstrates knowledge necessary for performing an orderly, systematic and adequate physical examination of patients with cardiovascular problems and recognizes the importance of <br /><ul><li>Arterial System &Jugular Venous Pulse
Reports and demonstrates the correct method of measuring arterial blood pressure
Is familiar with difficulties in measuring arterial blood pressure accurately:
Variation between extremities, position, and level of extremity
Exercise testing with and without perfusion scintigraphy. Including an understanding of the meaning of sensitivity and specificity with regards to the latter test in the diagnosis if coronary disease
Tomographic imaging techniques, including MRI and CT
Basic knowledge of methodology involved in performing coronary angiography, left ventricular hemodynamic assessment and electrophysiologic testing; Understands the indications and risks of invasive diagnostic procedures </li></ul>Objective 4. Understands the pathophysiology, natural history, clinical presentation, diagnostic work up and management of common cardiac disorders.<br /><ul><li>Heart Failure
Altered myocardial hemodynamics as well as abnormal neuroendocrine responses
Precipitating causes of worsened heart failure
Mechanisms and importance of diastolic dysfunction
Therapy including relative values and limits of diuretics, digoxin, vasodilators, beta blockers, inotropes, fluid restriction, and other pharmacologic and non-pharmacologic therapies
Diagnosis, history and physical of the adult with congenital heart disease espically for the diagnosis of :</li></ul> a. Atrial septal defect<br />b.Ventricular septal defect<br />c.Aortic stenosis<br />d.Pulmonic stenosis<br /> e.Coarctation of the aorta<br />2. Basic understanding of the adult with partially corrected congenital heart disease and post op complications of the more common repair procedures such as:<br /><ul><li>Transposition of the great vessels
Asses preoperative risk for non cardiac surgery </li></ul>Objective 5. Develops treatment plan for common cardiac problems<br /><ul><li>For each major disease of the cardiovascular system indentifies the appropriate therapeutic approach
Understands the indications for and can perform the following:
Cardiopulmonary resuscitation and advanced life support
Recognizes the possible need, and request medical consultation, for the performance of the following therapeutic procedures:</li></ul>a. Transvenous pacemaker<br /> b.Pericardiocentesis<br /> c. Swan-Ganz catheter insertion<br /><ul><li> d. Elective cardioversion
For each of the treatments and drug types listed below identifies indications, dose, mechanism of action, main effects, side effects, adverse reactions, interactions, cost, efficacy, and appropriate follow-up:
Practice and system based improvements: protocols and data monitoring </li></ul>General Medicine Inpatient Curriculum<br /> Likelihood Ratios; testing<br />Community Acquired Pneumonia<br />Pulmonary Emboli<br />Chest Pain Evaluation; CAD<br />Diabetic ketoacidosis, complications<br />Meningitis<br />Venous Stasis Ulcers<br />Peripheral Vascular Disease<br />W/U of Diarrhea<br />COPD, acute exacerbation<br />Depression, mood disorders <br />Stroke, endarterectomy <br />Hypertension Emergencies<br />Common Biliary tract diseases, cholecystitis, cholangitis<br />Dementia<br />Delirium<br />Diverticulitis<br />Avitaminoses<br />Peripheral Neuropathy<br />Cellulitis<br />Pulmonary Nodule <br />Anemia of chronic disease, liver disease<br />Pancreatitis<br />Poisonings- ethylene glycol, arsenic<br />Geriatrics Inpatient Curriculum<br /> Current requirements from the Residency Review Committee for Internal Medicine, as outlined by the Accreditation Council for Graduate Medical Education, specify that “Residents must have formal instruction and assigned clinical experience in geriatric medicine. The curriculum and clinical experience should be directed by an ABMS- certified geriatrician. These experiences may occur at one or more specifically designated geriatric inpatient units, geriatric consultation services, long-term facilities, geriatric ambulatory clinics,, and/ or in home care settings.”<br />The Department of Medicine at the University of North Carolina at Chapel Hill currently has a separate Division of Geriatric Medicine with faculty and fellows in graduate medical training who are dedicated to the education of medical students and residents.<br />Currently residents receive training in the care of geriatric patients in both inpatient and outpatient settings.<br />Inpatient Geriatric Curriculum:<br />UNC currently has a Geriatric Inpatient Service that is always staffed by one of the faculty from the Division of Geriatric Medicine. Internal Medicine residents who rotate on this service work closely with the Geriatrics Faculty Attending in the care of older adults with acute medical illnesses. <br />Based upon the guidelines as outlined by the AGS Education Committee in 2004, resident trainees on this rotations will meet the following goals in attitudes, knowledge and skills required for the appropriate care of older patients.<br /><ul><li>Attitudes: This training program encourages respect for older people and their autonomy. The rotation on the inpatient service promotes compassionate, high quality care. Residents gain an appreciation for the heterogeneity in older people in respect to functional status, health, values and personal preferences. The resident learns the skills needed to negotiate the goals of care with the patients and family. Our inpatient service offers a truly multidisciplinary experience and the resident learns the importance of this approach to caring for older patients. The residents on our service work closely with a Geriatric Nurse Practitioner, Recreational Therapist, Physical Therapy service, social worker and specialized nurses interested in the care of older adults. The resident on this service truly gains an appreciation for the fact that the maintenance of function and quality of life may be more the goal than cure.
Knowledge: Internal Medicine residents who complete a rotation in the inpatient service will know:
Principles of kidney transplantation </li></ul>Hematology/Oncology Inpatient Curriculum<br /> Goals: This rotation should acquaint you with the general principles of diagnosing and treating Hematologic and Oncologic diseases. The inpatient services are divided into one that focuses on patients with malignant hematologic disease such as leukemias (E1) and lymphomas and the other (E2) on the rest of oncology. While there is some overlap in the services, we suggest that you focus your reading on the service you were assigned to. Every effort will be made for you to do the other service at least once during your residency. A case based teaching program to supplement your reading that combines patients from both services is done from 11:00-12:00 on Mondays, Tuesdays, Wednesdays, and Fridays. <br /><ul><li>Acute Leukemia
Febrile Neutropenia and infected catheters</li></ul>Mermel LA et al: Guidelines for the management of intravascular catheter related infections. Clin Infect Dis 32:1249,2001<br /><ul><li>Thrombotic Disorders
Quality of life in breast cancer survivors</li></ul>Fisher B et al: Twenty year follow up of a randomized trail comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation of the treatment of invasive breast cancer. N Engl J Med 347: 1233, 2002<br />Wong ZW, Ellis MJ: First- line endocrine treatment of breast cancer: Aromatase inhibitor or antiestrogen? Br J Cancer 90:20, 2004<br />Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15 year survival: an overview of the randomized trials. Lancet 2005; 365, 1687<br />Ravdin PM et al: Computer program to assist in making decision about adjuvant therapy for women with early breast cancer. J Clin Oncol 2001;19:980 m<br /><ul><li>Colorectal Cancer
Post resection surveillance in colorectal cancer
Management of patients with metastatic colorectal cancer</li></ul>Baron J et al: A randomized trial of aspirin to prevent Colorectal adenomas. N Engl J Med 348:391, 2003<br />Walsh JME, Terdiman JP: Colorectal cancer screening: JAMA 289:1288, 2003<br /><ul><li>Lung Cancer
Small cell lung cancer</li></ul>American College of Chest Physican: Diagnosis and management of lung cancer: ACCP evidence based guidelines. Chest, 123: 1S, 2003<br /><ul><li>Cancer of Unknown Primary Site
Squamous cell carcinoma of unknown primary sire
Poorly differentiated carcinoma of unknown primary site</li></ul>Hainsworth JD, Greco FA: Management of patients with cancer of an unknown primary site. Oncology 14:563,2000<br /><ul><li>Lymphadenopathy, lymphoma and Multiple Myeloma </li></ul>Diehl V et al: Hodgkin’s lymphoma – Diagnosis and treatment. Lancet Oncol 5;19, 2004<br />Barlogie B et al: Treatment of multiple myeloma. Blood 103:20, 2004<br /><ul><li>Prostate Cancer
Mechanical Emergencies ( Spinal Cord Compression, SVC, Pericardial Effusion and Tamponade)</li></ul> Strewler GJ: The parathrid hormone-related protein. Endocrine Metab Clin. North Amer 29:629,2000<br />Yim BT et al: Rasburicase for the treatment and prevention of hyperuricemia. Ann Pharmacotherapy 37: 1047, 2003<br /><ul><li>Chemotherapy, biotherapy, and hematopoietic colony stimulat ing factors: </li></ul> American Society of Clinical Oncology: Update of recommendations for use of hematopoietic colony stimulating factors: Evidence based clinical practice guidelines. J Clin Oncol 2000:3558-85<br /><ul><li>Antimetics</li></ul>Wisner, W. Practical management of chemotherapy – induced nausea and vomiting oncology 2005;5 : 637-45<br /><ul><li>Pain Management</li></ul>Levy MH: Pharmacologic treatment on cancer pain. N Engl J Med 335:1124, 1996<br />Pulmonary Inpatient Curriculum<br /><ul><li>Pulmonary Physiology
Lymphangioleiomyomatosis</li></ul>Resident Activities while on the Pulmonary Inpatient Rotation<br /><ul><li>Each resident will be expected to prepare a minimum of three 20-30 minute, informal lectures to be given to the rest of the team throughout the month.
Houseofficers are expected to attend Chest X-Ray rounds Monday, Wednesday, and Fridays at 2:30
The medical houseofficers are encouraged to attend the pulmonary lectures and conferences ( conference schedule enclosed).</li></ul>Med G Syllabus Journal Articles<br /><ul><li>ASPIRATION PNEUMONIA</li></ul>Aspiration Pneumonia. Lung Abscess, and Emphysema<br /><ul><li>ASTHMA</li></ul>Review Article- Asthma<br />The Assessment and Management of Adults with Status Asthmaticus<br /><ul><li>COMMUNITY ACQUIRED PNEUMONIA</li></ul>American Thoracic Society clinical guidelines for the initial management of adults with community acquired pneumonia<br />Current concepts- community acquired pneumonia<br />ATS guidelines for the initial management of adults with community acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobrial therapy<br /><ul><li>COPD
Management of Chronic Obstructive Pulmonary Disease
Current Concepts management of chronic obstructive pulmonary disease
Infectious Disease Inpatient Curriculum</li></ul>Antibiotics I ( antibacterials)<br />Antibiotics II ( antivirals and antifungals)<br />HIV I<br />HIV II<br />Sepsis<br />Endocarditis<br />Skin and Soft Tissue Infection (Including osteomyelitits)<br />Diarrhea<br />Urinary Tract Infection<br />FUO<br />New and unusual infections, including Lyme disease and RMSF<br />Endocrine Inpatient Curriculum<br />Residents will work on a daily basis with the endocrinology team to include an attending (Dr. O’Connell and/or Dr. DeCherney), an endocrine fellow, an endocrine nurse practitioner and possibly a diabetes educator during their rotation. Other attendings with special interest will be invited to rounds periodically when interesting cases are seen( i.e. Dr. Sharpless for interesting pituitary cases, Dr. Rubin for interesting bone cases, etc.)<br />The resident will participate in the care of a wide variety of endocrine disorders seen in the hospital. Inpatient diabetes management will be a major focus. <br />The residents will see patients one half day per week ( Tuesday mornings) in the endocrine outpatient clinic ( High gate Specialty Center) under the supervision of an attending.<br />The residents will learn from their interactions with the team members, managing complex endocrine patients and from teaching while at the bedside. The endocrine curriculum will be provided and topics selected for teaching on a daily/weekly basis reflecting the patient material encountered. We will coordinate these teaching activities with the General Medicine Inpatient and Outpatient curriculum. Additionally, the residents will have the oppturnity to attend the Endocrine Division’s weekly conferences held Thursday afternoons from 3-5:30 in 2020 Bondurant. These sessions include a 3-4 pm didactic lecture given on an array of topics by attendings from multiple departments ( nuc med, pathology, ophthalmology, Endocrine, ect.) From 4-5 is journal club or a research presentation and from 5-5:30 is a case presentation by one of the fellows.<br />The goal of the inpatient endocrine service is to improve care of admitted patients with endocrine disease. It is the hope of the Endocrine Division that the medicine residents will find this rotation an enjoyable and educational experience and that after the rotation, they will be better prepared to manage endocrine patients in both the inpatient and outpatient settings. <br />Section 3<br />Ambulatory Curriculum<br />Emergency Room<br />Same Day Clinic<br />Cardiology<br />Endocrinology<br />Hematology/Oncology<br />Pulmonary Disease<br />Digestive Disease<br />Infectious Disease<br />Rheumatology<br />Nephrology<br />Adolescent Medicine<br />Geriatric Medicine<br />PGY -1 Continuity Elective<br />PGY- 2/3 Continuity Elective<br />Enhanced Care Elective<br /> <br />Section 3<br />Ambulatory Curriculum<br />General<br />Each rotation has designated teaching times. The responsibility for teaching is given to the respective department or a division in the Department of Medicine. The topics are generated by the faculty with input from the Department of Medicine. These curricula are designed for consultation as well as direct patient care. <br />Emergency Medicine Curriculum<br />UNC Department of Emergency Medicine<br />The Emergency Department (ED) attendings work 8 hour shifts, 7a-3:00p, 1p-9p, 10 a-6p, 3p-11p, 6p-2a, and 11p-7a. Two attendings are on duty, with the exception of the time period from 2a to 10a when one attending is on duty.<br />The ED has 3 main areas. The Acute Care area has 24 beds including 2 cardiac rooms and 3 trauma rooms. Team C is an adjacent area with 8 beds. Team C is open 9a to midnight daily. Pediatric Acute Care is a separate unit staffed by Pediatric attending and residents. Pediatric Acute Care is open from 9a-2a daily. After those hours, pediatric patients (age 15 and below) are treated in the main ED. During your rotation, you will be assigned shifts in both the Acute Care area of the ED and the Minor Trauma area.<br />Guidelines for House officers<br />Introduction and General Principles<br />Welcome to the Department of Emergency Medicine! During this rotation, you will learn skills that are essential to your medical education. You will be supervised by faculty members who are Board Certified or Board Eligible in Emergency Medicine. Our faculty have practiced in a variety of institutions and settings, and thus, your experience here will be enhanced by exposure to different styles of practice. <br />Emergency Medicine differs in many respects from the inpatient and clinic settings. During this rotation, you will see a broad spectrum of illnesses ranging from the most trivial complaints to life-threatening diseases. It is important to remember that all patients come to the ED for a reason. Many present to the ED early in the course of their illness, therefore a serious disease may initially present to you as an apparently benign compliant. Many may present with complaints that could be handled elsewhere. It is our role to ensure our patients receive our best efforts to guide them through the increasing complex healthcare system as well as to diagnose and treat acute care conditions. Remember the Emergency Department is an important portal of entry into the hospital and provides a strong impression of the institution to patients, their families, and referring physicians from other medical centers.<br />House Officer Requirements for Successful Completion of Emergency Medicine Rotation<br /><ul><li>Completion of the Online Orientation Module
Each house officer must complete the online orientation course and exam before starting their Emergency Medicine rotation. The orientation module is available online at www.med.unc.edu/wrkunits/2depts/emergmed.
Be prompt for your assigned shifts. If you are ill or must miss an assigned shift, you need to contact:
Your Chief Resident. Chief Residents from each rotating department will be responsible for providing replacement coverage for their individual department residents who are unable to fill an assigned shift.
The ED attending physician working at the time your shift begins( 966-4721)</li></ul>In order to successfully complete the ED rotation as required by your residency, you must complete all assigned shifts. Illnesses are only excused if verified by your personal physician (not a resident physician) or your residency director.<br /><ul><li>Resident Conferences
In order for the Department of Emergency Medicine, Medicine, Surgery, Family Medicine and OB/GYN to meet the requirements of the Residency Review Committee, weekly attendance at our Emergency Medicine Conferences is MANDATORY. These conferences are held on Wednesday mornings from 7a to noon. The schedule of topics is available monthly. Emergency Medicine interns/residents are required to attend conferences 5 hours per week. Off service interns/residents are required attend 3 hours per week. During your rotation, you will likely be scheduled in the ED on one or more Wednesday mornings. On these mornings you should attend sign out rounds and check in with the ED attending prior to departing for conference. When you are not scheduled to work in the ED, you should attend at least part of the Wednesday morning conference. Attendance will be taken at these conferences and reported to individual residency directors at the end of each rotation along with your final evaluation.
Although you will be quiet busy at times, make sure you speak to any family members or visitors who may be in the waiting room after you have finished your evaluation. It is important to let them know how well the patient is doing and give them an estimate of the anticipated length of stay. Always overestimate the length of stay. Things may take longer than you think.
Laboratory studies and X-Rays are ordered only if they impact on acute treatment, immediate decision making, or are essential for the provision of follow up care. The Emergency Department is not the place to begin an extensive workup of non-critical problems.
Every patient should be given instructions for follow up care and referred to a follow up physician, no matter how trivial the problem may seem. ( see documentation and charting guidelines)
You should be able to arrive at a reasonable clinical diagnosis on most patients. If you lack a definitive diagnosis, you must have formulated a clear differential diagnosis and have ruled out all possible life treating conditions before the patient can be discharged safely.
Information concerning patients seen or discussed in the ED is confidential. It should not be discussed anywhere else, other than medical conference setting. This means you must not discuss patient information in the hallways, nor elevators, nor in downtown restaurants, etc. You are a professional and must conduct yourself as such.
All patients who are seen in the Emergency Department are the ultimate responsibility of the attending emergency physician. Consequently, THE EMERGENCY DEPARTMENT ATTENDING MUST SEE EVERY PATIENT AND SIGN EVERY CHART PRIOR TO THE PATIENTS DISCHARGE, ADMISSION OR TRANSFER.
Some patients have such serious illness at the time of presentation that they may decompensate in a very short period of time. Because of this, there are certain circumstances when it is vital for you to notify the attending physician of the patient’s condition IMMEDIATELY AND POSSIBLY BEFORE YOU HAVE FINISHED YOUR INTIAL EVALUATION. (You will find a list of these circumstances attached in this handout.) If you think a particular patient is unstable, alert the attending on duty.
T System: All ED patients are tracked on a computer system called T System. When you arrive in the ED, you will be instructed how to use this system to sign up as the provider for the patients you are evaluating. In order to access this system, you must have a valid UNC Hospital code and password.
As patients enter the Emergency Department, they are triaged by the nursing staff. The triage designations are : </li></ul> ESI-1ESI-2ESI-3ESI-4ESI-5Stability of vital functionsUnstableStableStableStableStableLife-threat or organ-threatObviousReasonably likelyUnlikely (possible)NoNoSevere pain or severe distressImmediatelySometimesSeldomNoNoExpected resource intensityMaximum: staff at bedside continuously; mobilization of outside resourcesHigh: multiple, often complex diagnostic studies; frequent consultation; continuous (remote) monitoringMedium: multiple diagnostic studies; or brief observation; or complex procedureLow: one simple diagnostic study; or simple procedureLow: exam onlyMed/staff responseImmediate team effortMinutesUp to 1 hrCould be delayedCould be delayedExpected time to disposition1.5 hr4 hr6 hr2 hr1 hrExamplesCardiac arrest, intubated/hypotensive trauma patient, acute (<3 hr) MI or strokeMost chest pain, stable trauma (MOI concerning), elderly pneumonia patient, altered mental status, behavioral disturbanceMost abdominal pain, dehydration, esophageal food impaction, hip fractureClosed extremity trauma, simple lac, simple cystitis, typical migraineSore throat, minor burn, recheck<br />In general, patients should be seen in the order in which they arrive in the ED, however patients triaged as “1” or “2” should be evaluated before those designated “3-4-5”. If you are unsure which patient you should evaluate next, ask the attending or a senior resident to direct you.<br />SCHEDULE<br />Housestaff will be assigned to one section of the department and will report ONLY to the attending staffing that section. <br /> <br />RESPONSIBILITIES<br /> Role of the Emergency Department Attending<br />The ED attending is primarily responsible for patient flow and consultation. The ED attending will be responsible for the supervision of all medical students and house officers. Housestaff cannot sign student orders.<br /> <br />Role of the PGY-III Resident<br />The PGY-III Emergency Medicine Resident has three main responsibilities in the ED:<br />1. Directly evaluate patients as the primary physician, with particular attention to critically ill or injured patients.<br />2. Ensure that patient flow in the ED is maintained.<br />3. Supervise one or more PGY-I residents who are working in the ED.<br />4. Perform or supervise procedures required for patient care.<br />5. At times, these residents may take a turn at being “in charge” of the ED under the supervision of the attending.<br />.<br /> <br />Role of the PGY-I and PGY-II Residents and Medical Students<br />The PGY-I resident and medical student are primarily responsible for patient evaluation and management. Remember that you are here to learn and that specific questions are expected. It is better to ask and ask early!<br /> <br />PATIENT CARE AND CASE PRESENTATION<br />It will be the responsibility of the EM PGY-III resident, all PGY-I residents, and medical students to pick up new patients as they are added to the board by the triage nurse. Patients are to be seen according to their time of entry into the ED unless another patient with a potentially life-threatening complaint has not yet been evaluated. Patients with life-threatening complaints are designated by a triage classification of “1” (in red) and should be seen promptly. If you are not certain whether a particular patient is to be seen, ask the attending physician or triage nurse.<br />The residents will see and evaluate the majority of patients. This initial evaluation is to consist of a history and physical examination, which may be “directed” if the patient has an obviously isolated problem (such as a minor extremity injury). All other patients should have a complete history and physical examination including social and family history, medications and allergies. This evaluation should take no longer than 5 to 10 minutes to complete. <br /> <br />ANY PATIENT WITH A CONDITION WHICH MAY DETERIORATE PRECIPITOUSLY MUST BE CALLED TO THE ATTENTION OF THE ED ATTENDING IMMEDIATELY, EVEN IF THE INITIAL EVALUATION IS NOT COMPLETED. A list of such conditions is listed in this handout.<br />After formulating a differential diagnosis and treatment plan, but before writing orders, the intern is to present the patient to the ED attending. At that time, an evaluation and treatment plan can be formulated and orders written. No verbal orders are acceptable.<br /> <br />After all ancillary studies have been completed; the house officer is to present the case to the ED attending again, this time noting the results of laboratory values, X-rays, etc. At this time a disposition will be made and the patient will be either be discharged, admitted or transferred to a different institution. <br /> <br />TYPES OF PATIENTS SEEN<br />Adult patients with a wide variety of complaints are seen in the Acute Care area of the ED. In addition to evaluating and treating patients with general medical and surgical problems, you will gain experience with patients whose complaints include the following:<br />Psychiatric - Our responsibility is medical clearance; be especially careful with elderly patients or those with confounding medical problems; some psychiatric patients will be seen directly by the Psychiatric consultants.<br />OB-Gyn - Women at 20 weeks or greater gestation are transferred directly to Labor and Delivery. The exceptions to this are if they have any type of trauma or a complaint totally unrelated to pregnancy. All women between ages10-60 should be assumed to be pregnant until proven otherwise by a negative urine or serum pregnancy test.<br />Trauma - Major trauma patients, as determined by criteria, are seen by the Trauma team, EM Attending and Senior Emergency Medicine Residents. Patients with lesser trauma are evaluated and treated by the general ED staff.<br />Pediatrics (ages 15 and below) - These patients are seen directly by a Pediatric resident, either in Pediatric Acute Care (9a-11p) or in the Acute Care ED at other times.<br /> <br />ANCILLARY SERVICES<br />Laboratory Studies<br />1. Laboratory studies are ordered in writing on the order sheet. <br /> 2. Laboratory reports results can be obtained on the computer. Be sure to check the computer frequently for results so the patient can receive disposition in a timely manner<br /> 3. All laboratory studies must be documented on the chart, including those that are pending at the time of disposition.<br />Radiologic Studies<br />1. If a patient needs an X-ray or other imaging study, write the order on the order sheet and give the order sheet to the clerk. You need to write a reason for the X-ray study, i.e. chest pain or SOB. The X-ray orders are entered into the computer by the nursing staff.<br />2. Look at the patient’s X-rays even though the radiologist’s interpretation is available. Remember that you have the advantage of knowing the patient’s clinical presentation and thus may notice something the radiologist might have misses.<br /> 3. If you have any questions regarding the interpretation of a particular radiograph, you may consult the radiology attending or resident by dialing 68850.<br /> 4. All radiologic studies must be documented on the chart!<br /> <br />MEALS<br />Housestaff are encouraged to briefly leave the ED for nutrition breaks as patient flow permits, but only after notifying the attending that they are leaving.<br /> <br />DOCUMENTATION STANDARDS<br /> It is your responsibility to see that these standards are met on every chart. Charts will be returned to you for completion if documentation standards are not met.<br /> <br />DISCHARGE INSTRUCTIONS AND FOLLOW-UP<br />All patients are to receive a discharge instruction sheet prior to leaving the Emergency Department. There are specific items that must be included on the discharge form. <br /> <br />PATIENTS LEAVING THE EMERGENCY DEPARTMENT AGAINST MEDICAL ADVICE (AMA)<br />All patients who threaten to leave the Emergency Department against medical advice (AMA) must be seen by the ED attending immediately. The patient is required to sign an AMA form on the back of the chart and must be properly informed of the risks of departing AMA.<br /> <br />SECURITY AND PARKING<br />Escorts to the parking decks are available 24 hours a day. USE THEM!! Use the Point to Point Service (962-7867) or have hospital security accompany you! You cannot park in the ED patient parking lot.<br /> <br />DRESS CODE AND IDENTIFICATION<br />Name badges must be worn at all times. Housestaff are expected to look and act like professionals at all times. Scrub suits are acceptable for wear in the Emergency Department provided they are clean and in good condition. Jeans, shorts, sweats and T-shirts are not permitted.<br /> <br /> WHEN YOUR SHIFT ENDS<br />You must turn your patients over to an intern or resident on duty in the ED. If your patient is nearing completion of their evaluation – please fill out the chart completely including the discharge form if appropriate. If the evaluation is in progress, please have a clear plan to pass on to the next doctor.<br /> <br /> <br />Medical Conditions RequiringImmediate Attending Physician Notification<br /> <br />The following is a list of conditions that require immediate notification of the Emergency Department attending physician, regardless of your level of training. This list does not cover all possible situations, and you should feel free to notify the attending immediately if you have a patient you feel may deteriorate precipitously or if you are uncomfortable given your present level of training.<br /> <br />1. Any patient who presents with or develops acute cardiopulmonary arrest.<br /> 2. Any patient with a complete or partially obstructed airway.<br /> 3. Any patient who presents with or develops a significant cardiac arrhythmia, whether stable or not.<br /> 4. Any patient with acute onset Alteration of Mental Status (AOMS). This includes any patient presenting with this as the chief complaint or any patient whose mental status deteriorates while in the ED.<br /> 5. Any patient with significant hypotension or hypertension. For these purposes, significant hypotension will be defined as blood pressure of less than 100 mmHg systolic and significant hypertension will be defined as a blood pressure of greater than or equal to 180 mmHg systolic or hypertension associated with acute alteration of mental status.<br /> 6. Any patient with severe respiratory distress. For these purposes, significant respiratory distress will be defined as a respiratory rate greater than 30 breaths/minute, any patient with a pulse oximeter reading of less than or equal to 90 mmHg, any patient with an acute elevation of pCO2 greater than or equal to 60 mm Hg, any patient with a complaint of shortness of breath accompanied by diaphoresis, use of accessory muscles of respiration, cyanosis, alteration of mental status, bradycardia, or any other signs consistent with imminent respiratory failure.<br /> 7. Any patient with significant tachycardia or bradycardia. For these purposes, significant tachycardia is defined as a heart rate greater than or equal to 150 beats/minute and significant bradycardia is defined as a heart rate less than or equal to 60 beats/minute.<br /> 8. Any patient with a significant cardiac arrhythmia.<br /> 9. Any patient with either clinical or EKG evidence of acute myocardial infarction.<br /> 10. Any patient with a fever greater than 105 degrees Fahrenheit, any patient with significant alteration of mental status associated with a fever, or any patient with a fever and a potentially immunocompromised state (e.g. HIV disease, cancer patients, transplant patients, etc.) <br />11. Any patient with significant hypothermia. For these purposes, significant hypothermia is defined as a rectal temperature less than or equal to 95 degrees Fahrenheit.<br /> 12. Any patient with severe abdominal pain or abdominal pain associated with peritoneal signs.<br /> 13. Any female with abdominal pain and a positive pregnancy test.<br /> 14. Any patient with significant upper or lower GI bleeding (whether hypotensive or not).<br /> 15. Any patient who develops seizure activity while in the Emergency Department.<br /> 16. Any patient with significant abnormality of any laboratory value (e.g. hypo/hypernatremia, hypo/hyperkalemia, symptomatic hypercalcemia, hematocrit less than 28, etc.).<br /> 17. Any patient with a history of significant trauma.<br /> 18. Any patient with a pregnancy and sign/symptoms of a precipitous delivery.<br /> 19. Any patient with an overdose of prescription or over-the-counter medications.<br /> 20. Any patient or visitor who gives evidence of becoming significantly agitated, violent, or suicidal.<br /> 21. Any patient with a blood sugar of less than 70 mg/dL.<br /> 22. Any patient with a snake bite.<br /> 23. Any patient with significant bleeding, or bleeding associated with hemophilia (blood dyscrasias).<br /> 24. Any patient with a significant allergic reaction.<br /> 25. ANY PATIENT WHO YOU FEEL IS BEYOND YOUR PRESENT CAPABILITIES AS A RESIDENT, OR WHO YOU THINK MAY DETERIORATE SUDDENLY. <br /> <br /> <br />Documentation Standards<br />The following information is required on all charts for all Emergency Department patients for legal and billing purposes. Please review this in conjunction with the copy of the chart included in this packet.<br /> <br />1. The Emergency Department uses the T System for charting. Please complete the T System training module before starting your first shift.<br /> 2. For all patient charts, documentation should reach a “level 5” by the standards of the T System Documentation System. Please confirm this before signing your chart.<br /> <br />3. It is important to write a short summary of your assessment and plan in each chart..<br />Based on the differential problem list that you have established, it should be obvious by reviewing the chart how you distinguished among the possibilities and came to your final diagnosis. Some examples: GI cocktail given, patient with complete relief; Phenergan 25mg IV given, nausea relieved and patient tolerating PO well.<br /> <br />If you make a clinical diagnosis without any work-up, you need to explain that. For example: 20 year old white female with reproducible chest wall pain, no risk factors for CAD and no associated symptoms, likelihood of cardiopulmonary disease as the underlying etiology is very low. We will treat her with NSAID’s. Patient knows to return if symptoms change or worsen.<br /> <br />4. You need to list the medications the patient is taking and any drug allergies the patient has.<br /> <br />5. If the patient is in the Emergency Room for a significant length of time waiting for disposition or a bed, you need to make note that you reevaluated the patient during this time. For example: 2:45 pm Patient now afebrile and tolerating oral fluids well. Many conditions such as respiratory distress, chest pain and abdominal pain require frequent reevaluation, and you need to document it.<br /> <br />6. If you call a consultant to see the patient, record the time and who you talked with. For example: 6 pm Discussed case with Dr. Smith (General Surgery) who will evaluate patient. “Curbside” consultations are not official. If there is really a question, the patient must be seen by the consultant.<br /> <br />7. Record a procedure note for all procedures done on the patient including laceration repairs, lumbar punctures, central lines, etc<br />.<br />8. Please select a disposition and diagnosis (often more than 1diagnosis) for each patient.<br /> <br />DISCHARGE INSTRUCTIONS<br />The T system has standard discharge instructions for many different diagnoses as well as medications Every discharged patient should receive 1 or more of these instruction sets. <br /> <br />All patients should receive Follow-Up. Follow-up options include but are not limited to:<br /> <br />Follow-up with their own doctor (MUST BE NAMED) for a specific period of time. If the patient is unable to identify an MD, a referral should be given. <br /> <br />UNC Clinic Appointment: <br />Options for obtaining this are:<br />* You can call and get an appointment for the patient (Mon-Fri 8a-5p)<br />* Fill out a clinic referral sheet available in the ED; these are faxed to a central office where appointments are made,<br />* You can give the patient the phone number for a specific clinic (listed in the T system discharge instructions) BUT, keep in mind, it may be several months before a patient can get an appointment.<br />Welcome!From the Nurses in the Emergency Department<br /> <br />The following handout details survival skills for your emergency department rotation. We hope that it may be helpful to you.<br /> <br />The ED is divided into several sections:<br />1. Triage<br />2. Acute Area<br />3. Team C<br />4. Pediatric Acute Care<br /> <br />The nursing staff is assigned by “team.” One or two nurses are assigned to the triage area. These nurses are responsible for screening all patients and prioritizing their care. The Acute Area is divided into Team A and Team B. Two or more nurses are assigned to cover each of these teams.<br /> There are three trauma bays, including a pediatric resuscitation bay. There are two cardiac resuscitation rooms. The Acute Area is divided into the A and B teams which are each responsible for ½ the acute area of the department. Team C is a separate area that usually evaluates ESI score 4 and 5 patients (see above).<br /> A charge nurse is assigned to coordinate the care of the ED patients. At various times, the charge nurse will also have a patient care assignment. Two nurses are assigned to the trauma team. If there is a trauma in progress and the nurse assigned to a certain area becomes unavailable, refer all questions to the charge nurse.<br /> Remember, if you are busy, so is the nursing staff!This is a team-oriented department. Help us and each other!<br />General Information<br /> <br /> It is mandatory that you wear your name tag! <br /> Familiarize yourself with the clean and dirty utility rooms on your first day. You will find this invaluable. Most of the equipment you need is located in these areas. Equipment is secured in the PYXIS.<br /> Tidy up after yourself after completing an exam or procedure. There are trash cans located at each patient care bedside. (This includes the lounge!)<br /> The ED staff is a life form in itself. The nursing assistants, clerks, nurses, and social worker can be great resources for the inside scoop on usual routines, community resources, etc.<br /> Clerks can help you with phone calls and paging. Clerks answer the phones, even if you have paged someone. Listen to the intercom for your name or the person you have paged. The key staff in the ED has assigned intercom cell phones.<br />Nursing Assistants can perform the following:<br />1. simple wound preps<br />2. crutch set-up<br />3. lab transport<br />4. patient transport (excluding monitored patients)<br />5. room set-up<br />6. assist with procedures<br /> <br />Remove all needles and sharps from trays and dispose of them in the sharps box!<br /> If a laceration needs sutures, anesthetize the wound prior to wound prep. The department’s infection rate has been consistently 0% because the NA’s do an excellent job.<br /> RN’s<br />1. Unless the patient is acutely ill, please allow the RN to triage the patient prior to beginning your exam or Gathering information<br />.<br /> 2. ED nurses will assess the acuity of patients and institute treatment and diagnostic procedures prior to you seeing the patient. For example: monitoring, IV access. Orders still need to be written for the patient.<br /> <br />Educational Conferences<br />Emergency Medicine conferences are held Wednesday from 7:00 am to noon. All PGY1 residents assigned to the Emergency Department each month will be expected to attend. <br />Scheduling in the Emergency Department<br /> PGY-1 Medicine Interns will work 12 hour shifts beginning at 7 am, 10 am, or 7pm. These times will rotate throughout the month. <br />Same-Day Clinic CURRICULUM<br />Low Back Pain<br />Monoarticular Arthritis<br />Approach to Arthritis<br />Musculoskeletal Syndromes of the Neck and Arm<br />Depression<br />Initial Diagnosis and Management of Hypertension<br />Initial Diagnosis and Management of Type II Diabetes<br />Bronchitis<br />Rhinitis/Sinusitis<br />Headache<br />Pharyngitis/Mononucleosis<br />PID<br />Chest Pain<br />STD’s<br />This curriculum is taught each day from 8:00-8:30am by the faculty member who is attending for the 8-12 shift. The format is case based with significant participation by the residents assigned to the Same Day Clinic. <br />CARDIOLOGY AMBULATORY CURRICULUM<br /> Consultations including preoperative evaluations will be handled by internal medicine residents, cardiology fellows and faculty. When the residents is not involved with patient work-ups, he or she can see patients in faculty clinics, participate in exercise stress testing, read EKG’s from teaching files and/or ACC patients. The following subjects will be reviewed on the month rotation<br />1. Evaluation of arrythmias in the post-operative patient<br />2. Pre-operative risk assessment for the patient with known cardiac disease<br />3. Evaluation and management of malignant hypertension<br />4. Use of thrombolytic therapy<br />5. Evaluation and management of shock in the post-operative patient<br />6. Endocarditis prophylaxis<br />7. Evaluation and management of lipid abnormalities<br />8. Evaluation and management of peripheral vascular insufficiency<br />9. Recognize common EKG abnormalities<br />10. Recognize common echocardiographic abnormalities<br />11. Evaluation and management of patients with left ventricular dysfunction<br />Endocrinology and Metabolism Curriculum<br />Dear Residents and Students,<br /> The Endocrine Division is delighted that you will be taking our Endocrinology and Metabolism Elective. Our clinic is located in Durham near Southpoint Mall off of Hwy 54 (Highgate Specialty Center, 5316 Highgate Dr, Suite 125, Durham NC, 27713. 919-484-1015). The majority of your time will be spent in the clinic working with various attendings and seeing a variety of Endocrine patients. On rare occasions, when too many residents/students are assigned to Endocrinology, you may be asked to spend a few days with the inpatient team.<br /> Clinic Operations<br />Highgate Specialty Center opens at 7:30am and closes by 5:30pm. Please arrive by 8:30 each morning and look for Dr. O’Connell who will help coordinate the attending with whom you will work (usually Dr. O’Connell the first day and any day that other attendings are not available). We will try to have you work with almost every attending during your two weeks so you can see a wide variety of patients and styles. Dr. O’Connell is never at Highgate on Thursdays so if your first day is Thursday, simply come and introduce yourself to another attending that is present that day. Dr. Ontjes is usually there on Thursdays and is always amenable to working with residents and students.<br />The clinic is closed most Thursday afternoons to allow everyone to attend Thursday afternoon Endocrine Conferences.<br /> <br />Conferences<br />Thursday afternoon Endocrine conferences as described below are from 3 pm to 5:30 pm. You are expected to attend these while on your Endocrine rotation. They are located in the GCRC conference room, 3rd floor bedtower.<br />3pm: Fellows conference: a faculty member will give a didactic lecture to the fellows/residents<br />4pm: Endocrine Journal Club:<br />5pm: 30 minute case presentation and discussion by one of the fellows<br />Evaluations<br />Please give your evaluation form (students) to the Elective Director, who will then distribute it to the fellows and faculty in the division. Evaluations (students and residents) are compiled by the Elective Director after input from other members of the division.<br />We appreciate your attention to these matters and hope that you find your rotation with us to be educational and enjoyable. Please bring any concerns to our immediate attention.<br /> <br />Sincerely,<br /> <br />Tom O’Connell, MD (pager 216-6359)<br />Resident Elective Director<br />Endocrinology and Metabolism <br />Thomas_oconnell@med.unc.edu<br />Hematology/Oncology Curriculum<br />Overview:<br />This is a 1month block of time designed to expose medical residents to some of the breadth of outpatient oncology or hematology patients. We suggest that the resident choose either the Oncology block or the Hematology Block and not make a combined block of the various clinics. This will enable the resident to get a good spectrum of one part of this broad field. The resident will see patients along with the attending physician and will be responsible for obtaining histories and examinations, dictate or type consult notes and progress notes, follow up on calls and tests. In many cases there will be a reading list to master. This can be discussed with the attending for each clinic. Residents are also encouraged to participate in the Division conferences and when possible, present at the Case of the month program. Participation at Case of the month should occur if this is offered during the resident’s rotation (The division can let the resident know ahead of time.). <br />Outpatient Rotation Oncology<br />MondayTuesdayWednesdayThursdayFriday7:30 am Head and Neck Conference GI Clinic with Dr. O’Neil and Dr. BernardBreast Cancer Clinic with Dr Carey** Thoracic Oncology GU ClinicCheck12:30 Monday Lectures Divison lectures.*Multidisciplinary Thoracic Oncology conference. Breast Conference 10:30 to 12 1:15 GU tumor board. Breast Cancer Clinic with Dr CareyThoracic OncologyBreast Oncology GU clinic <br /> ** If Dr Carey’s clinic does not take place go to head and neck clinic. Head and Neck Conference on Friday is optional but encouraged if you have seen these patients. <br />***Beginning in 1/2008, Fellows’ Conference is switching to Tuesdays. <br />Outpatient Rotation Hematology<br />MondayTuesdayWednesdayThursdayFriday7:30 am Fellows’ Conference 7:30 am Fellows’ Conference) **7:30 am Fellows’ Conference. Hemophilia Clinic with Dr Key and Ma Sickle Cell ClinicHeme Malignancy Clinic with Drs VanDeventer and Voorhees Parker conference at 11am Heme clinic, Dr Ma12:30 Monday Division Lectures * 1PM Heme conferenceCoagulation Clinic with Dr Moll Sickle Cell Clinic Heme clinic, Dr Ma<br />Check with the Division re the Conference on Mondays for titles and place<br />**Beginning in 1/2008, Fellows’ Conference is switching to Tuesdays. <br />Check with Dr Ma. She may be moving her clinic to Thursdays. When that happens the clinic will be off site and you will not need to go to Parker Conferences. <br />PULMONARY DISEASES AMBULATORY CURRICULUM<br />In overview, the medical resident’s activities will mirror the responsibilities of the Pulmonary consult Fellow, i.e., evaluation of inpatient and outpatient referrals and interpretation of standard pulmonary function tests. The resident will interact closely with the Pulmonary consult Fellow and Attending.<br />The overall educational goals will be accomplished through several formats:<br />1.Daily inpatient consults on all non—ICU pulmonary referrals (we average 1.5 consults per day).<br />2.Interpretation of pulmonary function tests and review of tests with the Attending physician. We perform about 600 individual pulmonary function tests per month. Specific attention will be focused on interpretation of blood gases and spirometric parameters. Understanding the indication for lung volume and DLCO tests will be a goal for the resident’s experience.<br />3.Work—up of a new pulmonary outpatient referral and follow—up of selected patients in each Wednesday’s day—long clinic. In conjunction with the consult fellow and clinic attending, this will involve selecting and interpreting appropriate pulmonary function tests.<br />4.Evaluation of sleep clinic outpatient referrals on Friday mornings and review of sleep apnea studies in conjunction with a senior Fellow and the Attending. The goal will be to better define for the resident indications for obstructive sleep apnea studies.<br />5.Evaluation of outpatient “walk—in” referrals or outpatient consults who need to be “added on” and seen on days other than Wednesday. We see 2—4 new patients per week by this route.<br />6.Presentation and discussion of cases at the weekly medicine— radiology—chest surgery—oncology conference (1 hour).<br />7.Three didactic conferences (1 hour each) per week related to critical care medicine, clinical topics, and review of research papers. These presentations draw on faculty and fellows from Pulmonary, Infectious Disease, Radiology, Critical Care Surgery, Anesthesiology, & etc.<br />8.The weekly pulmonary division clinical—pathologic “work” conference (2 hours) that involves presentation of difficult, complex, and/or interesting cases. Pathophysiologic concepts are emphasized.<br />9.Although the consult service performs a number of procedures, we will not emphasize the technical aspects of those studies except for aspects of the thoracentesis and/or pleural biopsy. The opportunity to observe decision—making about bronchoscopic procedures, and to visualize endobronchial anatomy during bronchoscopy, will contribute to the resident’s appreciation for the role of this procedure in the evaluation of pulmonary disease.<br />In summary, the medical resident will enjoy an integrated experience of inpatient and outpatient evaluations, learn the indications and interpretation of pulmonary functions tests, have exposure to patients referred for sleep—apnea studies (and perhaps learn some indications for these referrals), better appreciate the role of fiberoptic bronchoscopy in evaluation of pulmonary disease, and expand their pulmonary physiologic concepts. Overall, this resident rotation complements the resident’s ICU and inpatient exposure to pulmonary diseases. It provides an experience that will be useful for most internal medicine physicians because pulmonary disease is a common cause for clinic visits to the internists.<br />DIGESTIVE DISEASES AMBULATORY CURRICULUM<br />On the Digestive Diseases Consultation Service, residents have the opportunity to see patients with gastroenterology as well as hepatology disorders. The following subjects will be reviewed on the month rotation.<br />Evaluation and treatment of diarrhea<br />Evaluation and treatment of jaundice<br />Inflammatory bowel diseases<br />Hepatitis - viral and non-viral<br />Diagnosis and management of peptic ulcer disease<br />Nutritional support - enteral and intravenous<br />Colonoscopy - indication and screening<br />Diagnosis and management of pancreatitis<br />Diagnosis of esophageal motility disorders<br />Evaluation and treatment of abdominal pain<br />Diagnosis and management of cirrhosis<br />Liver transplantation - indicators and outcomes<br />Diagnosis and management of GI bleeding<br />Appropriate use of radiologic studies of the gastrointestinal system<br />Evaluation and management of gallstones/gallbladder diseases<br />INFECTIOUS DISEASE AMBULATORY CURRICULUM<br />Role:<br />Residents play an important role on the consult service and in the clinic, where they help to manage outpatients with AIDS, chronic fatigue syndrome, and a variety of different infections including endocarditis and osteomyelitis. Residents are supervised by an attending physician.<br />Teaching Conferences:<br />Teaching conferences include a Wednesday clinical case conference at 8:30 a.m. and a Friday 8:30 a.m.conference which is didactic and/or research oriented.<br />Topics:<br />Topics covered through these conferences can be organized according to an organ system approach in Infectious Disease. These include 1) central nervous system infections, including meningitis and encephalitis; 2) infections of the eyes, ears, nose and throat; 3) infections of the upper and lower respiratory tracts; 4) infections of the cardiovascular system including endocarditis; 5) infections of the intestinal tract including infectious diarrhea and intra-abdominal catastrophe; 6) infections of the urinary tract, including sexually transmitted diseases; 7) systemic infections, including HIV; 8) infectious disease syndromes, including chronic fatigue syndrome. General lectures also include a) antibiotics, b) host defenses, c) microbial pathogenesis. Pathogenesis includes discussion of worms, protozoans, fungi, viruses and bacteria.<br />Resident’s Responsibilities<br />for Consults and Ward Service<br />Rounds will begin at 1:30 PM in the Clinical Microbiology lab with discussion of sterile fluid infection, review of new micro data and “unknown” case presentations from Microbiology faculty.<br />Consultations & Rounds:Residents are responsible for full evaluations of patients seen in consultation. Residents are responsible for following in-patients daily, presenting patients during rounds, discussing differential diagnoses with the attending, and writing appropriate notes in the medical record. The on-call schedule and sequence of assignments will be discussed by the Attending or the Fellow at the beginning of the rotation.<br />Conferences<br />The following conferences are held weekly by either the Division of Infectious Diseases or the Department of Medicine. All listed conferences are required.<br />Day/ConferenceTime Place<br />Wednesday:<br />Case Presentation8:30amOrthopedic Conference Room<br />Thursday:<br />Dept. of Medicine Grand Rounds12:00pmClinic Auditorium<br />Friday:<br />ID Didactic/Research Conference8:30amClinic B Conference Room<br />RHEUMATOLOGY AMBULATORY CURRICULUM<br />Welcome to the Division of Rheumatology and Immunology. Although rheumatologic and autoimmune disease are, in the aggregate, extremely common, physicians who miss this special opportunity for a rotation on a rheumatology service may never acquire the knowledge and skills required for caring for patients with these disorders. For this reason, emphasis during your rotation will be on learning “nuts and bolts” rheumatology:<br />a.signs and symptoms of the different arthritides<br />b.performance of a musculoskeletal history and exam<br />c.construction of common differential diagnoses<br />d.choice and interpretation of laboratory tests and x-rays<br />e.arthrocentesis and soft-tissue injection techniques<br />f.choice of therapy for commonly encountered conditions.<br />In addition, you will learn the basic elements of the pathogenesis and disease expression in rheumatologic disease.These educational objectives will be accomplished by seeing patients, clinical discussions with faculty and fellows, literature searches and reviews, various lectures and conferences, and Bob Berger’s “tool-kit.”<br />Rheumatology is largely an out-patient specialty, and the major block of your time will be spent in the Musculoskeletal Module in the ACC. This module houses rheumatology examining and consult rooms, facilities for physical therapy, occupational therapy, patient education, a library, and a special bone and joint x-ray suite. You will also see in-patient consults at UNCH. Scheduling of consult rounds, on-call responsibilities, your time in clinic, etc., will vary from month-to-month. Schedules and responsibilities will be discussed with you by the Attending and/or Fellow at the beginning of your rotation.<br />There are only four rules: 1) Be in clinic on time. Medicine residents and students should report to clinic at 9:00am. 2) If you are not called to see an urgent consult, be in the clinic. 3) Formal consult rounds will not be held until 3:30pm in order to minimize conflicts with your ambulatory care experience in the clinic. 4) Turn in the evaluation sheet and list of patients seen to me at the end of your rotation.<br />Resident’s Responsibilities for Clinics and Consults<br />Report to the musculoskeletal module, 1st floor, Ambulatory Care Center at 9:00 am. Meet for Consult Rounds at the film assembly desk (“cage “) in Radiology at the times designated by the Attending or Fellow.<br />Clinic Responsibilities:<br />Residents will perform complete evaluations of new patients and return patients, as assigned by the Attending. The nursing staff may also direct residents to do initial work-ups on patients. Residents will be responsible for presenting patients to the Attending, developing a therapeutic plan, discussing differential diagnoses with the attending, and completing a write-up for the medical record.<br />Consultations & Rounds:<br />Residents are responsible for full evaluations of patients seen in consultation. Residents are responsible for following in-patients daily, presenting patients during rounds, discussing differential diagnoses with the attending, and writing appropriate notes in the medical record. The on-call schedule and sequence of assignments will be discussed by the Attending or the Fellow at the beginning of the rotation.<br />Schedule<br />The following schedule is subject to some change. Please check with your attending on the first day of the rotation to confirm the following schedule.<br />Monday Tuesday -Friday8:30-3:30Clinic8:30-12Clinic10:00-11:00 Rheumatology Grand Rounds1:00-3:00Clinic12:00-1:00Immunology Journal Club3:30-5:00Clinic or Consult Rounds 2:00-3:00Research In progress3:30-5:00 Clinic or Consult Rounds <br />Please note that this schedule only includes required events. Optional conferences, etc. are listed separately.<br />•NOTE: Consult rounds are held 2-3 days per week. Days of week may vary in different months. Formal consult rounds will not be held earlier than 3:30. Scheduling of consult rounds far the month will be defined by the Attending at Fellow at the beginning of each rotation.<br />Conferences<br />The following conferences are held weekly by either the Division of Rheumatology and Immunology or the Department of Medicine. Please note that several are required for medical students and others are optional. For more in formation regarding speakers and titles, contact the Rheumatology Division Office in 3330 Thurston Building, (919) 966-4191.<br />Day/Conference Time Place Required/Optional<br />Monday<br />Immunology Journal Club10:00am3280 ThurstonOptional<br />Rheumatology Grand Rounds12:00noon3280 ThurstonRequired<br />Research-I n-Progress2:00pm3280 ThurstonOptional<br />Wednesday<br />Lecture:Program On Aging12:00 Noon Clinic AuditoriumOptional<br />Thursday<br />Dept. of Medicine Grand Rounds12:00 pm Clinic AuditoriumRequired<br />Friday<br />Ambulatory Care Conference12:00 Noon Clinic AuditoriumOptional<br />Nephrology Ambulatory Curriculum<br />Nephrology Consultation Service Resident Curriculum<br />Role of Resident<br />Evaluation and discussion of patients with kidney disease, hypertension, and disorders of fluid, and electrolyte and acid-base balance disorders in the consultative setting under the supervision of Nephrology faculty.<br />Consults<br />Residents will see both hospitalized and ambulatory patients in consultation on a daily basis, unless assigned to their continuity clinic. Patients with a wide range of renal diagnoses will be seen and discussed with the Nephrology Attending and fellow. Residents are expected to communicate consultative recommendations with the referring physicians, and to provide ongoing follow up while on the rotation. <br />Curriculum<br />Topics to be discussed during rounds as well as during formal didactic sessions will include the following:<br />Evaluation of kidney structure and function<br />Urinalysis<br />Measurement of GFR<br />Evaluation of proteinuria<br />Measurement of urinary electrolytes<br />Renal imaging techniques<br />Chronic kidney disease<br />Acute kidney injury<br />General principles of dialysis<br />Hemodialysis<br />Peritoneal dialysis<br />Continuous renal replacement therapies<br />Critical care nephrology<br />Metabolic acidosis<br />Metabolic alkalosis<br />Disorders of water metabolism (hyponatremia and hypernatremia)<br />Disorders of potassium and magnesium metabolism<br />Disorders of calcium, phosphorus and bone metabolism<br />Overview of evaluation and treatment of hypertension<br />Glomerular syndromes<br />nephritic syndrome<br />nephrotic syndrome<br />Diabetic nephropathy<br />Principles of kidney transplantation<br />Clinics<br />Participation in several Nephrology Subspecialty Clinics is available to residents interested in seeing patients with specific diagnoses and is optional. Residents will see patients under the direction of one of the Nephrology Attendings. <br />Monday PM Hypertension Clinic<br />Tuesday AM and PMTransplant Clinic<br />Thursday AM and PMVasculitis Clinic<br />Renal Conferences<br />Residents are encouraged to attend the following Divisional Educational Conferences during the rotation:<br /> Conference Time TopicLeader/Organizer<br />Hypertension2nd and 4thReview of literature related toDrs. RomuloJournal ClubMondayshypertensionColindres and Steven4-5 pm GrossmanTransplant 1st and 3rd Review of literature related to Dr. Randy DetwilerJournal Club Mondays kidney transplantation 4-5 PM FellowsTuesdayReview of topics in