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Internal medicine clerkship syllabus

Internal Medicine Clerkship Syllabus
2014-2015
Clerkship Directors
Karen Szauter, M.D. (UTMB)
Bernard Karnath, M.D. (UTMB)
Sherine Salib, M.D. (Austin)
Barry Zeluff, M.D. (St. Luke's)
Lary Kupor, M.D. (St. Joseph's)
Johanna Clewing, M.D. (Methodist)

Coordinators

Antoinette Hickerson (UTMB)
Candice Russell (Austin)
Fran Dawe (Houston)
Jennifer Thomas (St. Luke's)
Marivel Lozano (St. Joseph's)
Michelle Henderson (Methodist)

I. Overview

Each student will spend three months on the Internal Medicine Clerkship.
Galveston students
On the Galveston campus, each student will spend one month on a general internal medicine
inpatient service (John Sealy medicine, TDCJ medicine or Geriatrics), one month on a
subspecialty service (cardiology, nephrology, infectious diseases), and one month on an
ambulatory/consultative service depending on your preference sheets. A subspecialty
consult/ambulatory rotation in the community may be requested only as a substitute for the
UTMB-based ambulatory/consult month. All such rotations must have prior approval by the
Clerkship Director at least 4 weeks prior to beginning the clerkships.
Austin students
On the Austin campus, each student will spend two months on a general internal medicine
inpatient service and one month at a community general internal medicine practice. Students
will be oriented to specific clinical responsibilities by Dr. Sherine Salib (site director in Austin)
or his designee. A subspecialty consult/ambulatory rotation may be requested only as a
substitute for the community-based ambulatory month. All such rotations must have prior
approval by the Associate Clerkship Director in Austin.

Houston students
On the Houston campus, each student will spend one month on a general internal medicine
inpatient service, one month at a community general internal medicine practice, and one
month on a subspecialty service or general internal medicine inpatient service. Students will
be oriented to specific clinical responsibilities by Dr. Barry Zeluff at St. Luke's Hospital, Dr.
Lary Kupor at St. Joseph's Hospital and Dr. Jose Perez at the Methodist Hospital. A
community-based ambulatory month will be required for Houston students.
Community Rotation
Each student may spend 4 weeks on an ambulatory outpatient rotation in the community.
Criteria for Community Rotation:
1. The 4 week block must be a full-time experience - meaning at least 20 days out of the 28 with at least 8 hours per day. 2. The preceptor/attending must be a faculty at UTMB and/or have their credentials reviewed and approved by the local AHEC and course director. 3. The attending physician must agree to the policies and procedures of the clerkship a) give mid-month feedback to the student b) return their evaluation form within 3-4 days of the end of the rotation c) be familiar with and teach towards the learning objectives 4. The student proposing the new rotation must ensure the new attending understands these parameters and agrees that s/he has the time and willingness to take a student for the specified time period. Documentation will be by the signed request form. II. Goals and Objectives
The third year is an exciting year for students. This is when all the learning that has been
occurring in the first two years begins to make sense. This is when students begin to move
from mostly abstract learning to real patients in real situations. This is when students take on
responsibility, when what they do matters to their patients and the healthcare team, and they
take it on in pace with their gaining of skills.
In this year, students will move from thinking about patients piecemeal or in artificial
situations, to interacting with real patients having real problems, usually multiple problems
ranging from psychosocial to organ system damage. Students will begin to learn how to apply
their basic skills to true situations, integrate them with real patient issues in real situations,
and watch their skills grow as they become competent physicians. Students will learn how to
gather information in difficult settings (e.g. how to obtain a history and examine a patient with
dementia), develop appropriately thoughtful and defensible differential diagnoses (e.g.
develop a rational differential diagnosis for a patient with chest pain who has historical and
physical exam findings suggestive of both coronary artery disease and musculoskeletal
causes), and learn basic diagnostic and therapeutic plans (e.g. criteria for admission to the
hospital, urgent treatment of a gastrointestinal bleed, and diagnostic work-up for atypical
chest pain).
A. Goals .
 Gain knowledge of common medical problems: pathophysiology, presentation, natural history/complications of disease, basic treatment - acute and chronic, and diagnostic work-up.  Gain the knowledge and skills to gather appropriate information on an adult patient with medical problems, recognize abnormal physical findings, interpret basic lab, x-ray and ECG findings, to develop a defensible differential diagnosis  Be able to present relevant patient information in written format (e.g. H&P and daily progress notes), and verbally (e.g. full H&P, daily patient rounds, and focused visits or consults)  Be able to recommend basic therapeutic plans for common medical problems (e.g. appropriate classes of medication for the treatment of hypertension and why one class would be better than another in different patient situations and rational choices of antimicrobials for specific infectious diseases).  Be able to recommend basic diagnostic work-ups for common medical problems (e.g. when to do a non-invasive cardiac test for atypical angina and the most appropriate work-up for abdominal pain).  Be able to communicate instructions/education, difficult information and provide support to patients.  Understand and be able to act in a professional manner in different clinical situations. B. Objectives .
Knowledge:

 Be able to demonstrate a fund of knowledge in basic science essential to the understanding of disease processes and therapeutics  Specific learning objectives by discipline and subject are listed below.  Be able to demonstrate knowledge of chest x-ray and ECG interpretation  Be able to demonstrate the appropriate knowledge of basic patient education for common medical problems and counseling techniques  Be able to demonstrate knowledge of psychosocial issues and their impact on health  Be able to demonstrate knowledge of medicolegal and ethical issues, and their impact on the practice of medicine  Be able to perform a competent (i.e. relevant, complete, accurate) history and physical examination on a patient with an acute or chronic problem  Be able to gather the appropriate information for a focused problem/visit, consultation, or hospital admission.  Be able to generate an appropriate differential diagnosis for a patient's problem(s).  Be able to generate a plan for a patient problem(s) - basic therapeutic and diagnostic  Be able to write an appropriately focused (e.g. for consult or ambulatory visit) and an appropriately comprehensive (e.g. hospitalized patient) H&P; be able to write an appropriate (clear, concise, accurate) daily progress note.  Be able to verbally present both complete history and physical examinations and focused/problem-oriented history and physical examinations.  Demonstrate appropriate clinical reasoning (problem-solving) skills including the ability to: * integrate basic science information into the assessment of the patient's problems/presentation * prioritize a patient's signs and symptoms * identify patient risks or likelihood of disease * identify the pertinent positive and negative information in developing a differential diagnosis * develop an appropriate, prioritized differential diagnosis * discuss the logical rationale behind the diagnostic rationale * recommend appropriate disease screening, health maintenance, and health promotion * recommend and discuss appropriate management for common acute and chronic diseases  Be able to demonstrate appropriate interpersonal and communication skills to provide patient education and information. This would include breaking bad news and discussing end-of-life issues.  Be able to perform basic procedures, i.e. breast exam, rectal exam including stool Attitude:
 Be able to demonstrate appropriate regard for patients (e.g. respect patient belief systems, autonomy, financial situation, education level, self-discipline abilities, etc.)  Be able to demonstrate respect for the health care team, colleagues and the medical  Be able to demonstrate appropriate professionalism, i.e. appropriate work responsibilities, civility with colleagues and patients, and ethical behavior (e.g. understand, practice and promote honesty and integrity in the care of patients and interactions with colleagues) III. Required Textbooks for Comprehensive Reading

Harrison's Textbook of Internal Medicine (Available online) Dale Dubin's Rapid Interpretation of EKGs Note: see learning objectives in Appendix D to help guide your studies. It is also helpful to utilize review books with board style questions for your preparation and review for the NBME shelf examination. MKSAP for Students is highly recommended for Board Exam preparation. IV. Course Policies
A. Discipline .
Students will be governed by the academic rules of UTMB while on the clerkship. Any act of
academic dishonesty including recording, transmitting, giving or receiving exam questions or
answers, or plagiarism, will result in a report to the Associate Dean for Student Affairs and will
be dealt with according to the regulations of the University.

B. Absence Policy .


Any planned absence for examinations only must be approved in advance by the Associate
Dean for Student Affairs. All other planned absences from the clerkship MUST have prior
approval by the clerkship office (see the attached student absence policy). Unexpected
absences (e.g., illness) must be reported as soon as possible that day or the next to the
clerkship office, the student's attending and resident. Absences that are not approved or that
are not reported in a timely manner will be considered "UNEXCUSED". Any unexcused
absence from the clerkship or an examination will result in a FAILING grade for the clerkship.
If a student arrives late to an examination he/she will not be given extra time to complete the
examination. Excused absences totaling four or more days will generally result in a grade of
"INCOMPLETE"(I) and the student will be required to spend additional time on the clerkship.

C. Days Off Policy .


Each student will receive the weekend off in between rotations. For inpatient rotations, it is
recommended that students take off one weekend day per week during the month (this
includes three day holiday weekends). Each student will receive most weekends off during
outpatient and consult rotations. Days off may vary for AHEC sites depending on the practice.
The first two rotations will end at 5:00pm on the last Friday. The last rotation will end at
5:00 PM on the last Thursday.

In the event that a call day falls on a Saturday and a post-call day falls on a Sunday, it is
recommended that students ask their resident for a compensation day off. Students are
strongly encouraged to participate on all call days and post-call days within the confines of the
rotation. Weekdays off are strongly discouraged except in the scenario mentioned above
involving a weekend call.
NOTE Per the School of Medicine Academic Calendar: Holiday schedules for Year 3 and
Year 4 students with clinical responsibilities are determined by each School of Medicine
department. Students may be required to attend clinical responsibilities during listed holiday
periods. Please check with the clerkship office and your attending physician.

D. Examination Policy .

Students are excused from clinical duties on the day of the Shelf exam. Students are excused
from call and clinical duties the evening before the shelf examination.

E. Grading Policy .
Grades in Internal Medicine are determined as follows:

Clinical Performance Evaluations: NBME Shelf Exam: Logbooks, H&P's, EBM Write ups, and CRI's: Challenges in Medicine Essay: EKG and Test interpretation Appeals Process: consistent with SOM policy, the student who wishes to appeal an
examination, evaluation or course grade/score must notify the course director in writing within
five workdays of the posting of the examination, evaluation or course grade/score. The course
director will decide the most appropriate action to take in hearing the student's appeal, which
may include, but is not limited to: acting on the appeal directly, requesting the grading or
course committee to review the appeal, or asking from input from other faculty and
administrators. Appeals of a failing clinical performance or final clerkship grade will be
reviewed by an independent committee consisting of no less than 3 faculty members
knowledgeable in education and assessment. The appeals committee will only review relevant
information to the student's performance on the clerkship
. After the appropriate
committee or individual has heard the appeal, the student will be notified of their decision with
in 3-5 working days. Once a final decision has been rendered, the student may appeal to the
Academic Review Committee as per School of Medicine policies.

Clinical Evaluations: (40%)

The attending faculty and supervising resident/fellow will complete written evaluations on
students for all three months. (see appendix D) These evaluations, student write ups and
presence at all required activities are reviewed by the Course Committee and a clinical grade
is assigned. The Committee also takes into account verbal or written information, both positive
and negative constructive criticism, about a student's performance while on the clerkship from
any professional source; for example the Chief Residents in preparing students to present at a
CPC conference, nursing service comments, and/or course coordinator comments. This
committee also takes into account any issues of professional behavior or absenteeism. They
assign a grade based on these items. Written comments from the faculty evaluations are
edited and submitted to the Office of Student Affairs for inclusion in the Dean's Letter.
A student's clinical performance is the most important part of her/his evaluation for
competency for the clerkship. It is only here that all the clinical skills are assessed, i.e. data
collection, communication, problem-solving, knowledge and professional behavior. This is the
key assessment of a student having obtained competency in the required skills. Because of
this the Course Committee assigns the scores for this component. The members carefully
review ALL the information on the evaluation forms from both the faculty and the residents.
No single item checked on the form outweighs the other information. In some cases, the
faculty or resident may be asked to provide further information that will also be included in the
Committee's deliberations.
It is also very important to recognize that the highest standards of professional behavior are expected from all members of the health care team. Information on professional behavior is part of the clinical evaluation and significant irregularities in behavior may result in a failing clinical score, outweighing other positive demonstration of clinical skills. After failures have been determined, the students scores will be curved based on the mean and standard deviation of the cohort's raw scores. NBME Shelf Exam: (30%)
Students will take the NBME shelf exam for Internal Medicine at the end of the rotation. The lecture series given during the clerkship and the reading material should prepare the students adequately for passing this exam. The Course Committee will determine the passing score and curve, if applicable, for the examinations. In order to be eligible for a curved score, a student must be at or above the 5th percentile nationally. A score below the 5th percentile nationally is considered a failing score. Please see the Grade Determination section below in regards to "Partial Competency." After failures have been determined, the students scores will be curved based on the mean and standard deviation of the cohort's raw scores. Patient Logbook, H&P's, EBM write ups, and CRI's: (15%)
Comprehensive Patient Evaluation:
All students will be required to complete 6 H&P's during the clerkship. One H&P (within the
first two months) must be written on a patient > 65 years of age. Each H&P must be
reviewed (please submit your H&P to your faculty with the evaluation form provided on our
website and signed by your attending physician. (See also page 22 of syllabus). It should
also be noted that some consult attending physicians require comprehensive write ups. See
appendix C for Sample write up. All H&P's must be uploaded into the assignments section of
our website upon completion.

Preventive Healthcare

Preventive Health (information provided by Dr. Laura Rudkin)
You must include a discussion of Preventive Health in all 6 of your H&P's.
Must include the general healthcare prevention guidelines for the patient based on age and
sex. Must also include a discussion of disease-specific screening recommendations for the
specific patient

Primary Prevention: Health Promotion
Documentation of recommended lifestyle changes (e.g., diet, physical activity, tobacco use, alcohol or other substance abuse, sleep patterns, stress reduction) Primary Prevention: Specific Protections
Documentation of recommended immunizations (age specific) Documentation of other recommended specific protections (e.g., injury prevention, STD prevention, protection from environmental or occupational exposures) Secondary Prevention: Screening and Monitoring
Documentation of recommended blood work (based on age) Documentation of other recommended screening tests (based on age and FH, e.g., Pap smear, mammogram, colonoscopy, other) Tertiary Prevention: Disease Management
Discussion of patient's disease specific preventive health recommendations (e.g., eye care, foot care in diabetes, etc.) Provide source (references) for information cited above (journal-based sources recommended or use of published clinical guidelines such as guidelines.gov) Evidence of synthesis (e.g. overall organization) Background Materials: The Public Health and Prevention Theme is integrated into the
medical curriculum to prepare students to: Think Prevention, Practice Prevention, and Partner
for Prevention
. In years 1 and 2 of the curriculum, students learn the basic concepts and
strategies of preventive medicine and are expected to think prevention in the clinical
encounter. During the clerkships and electives, students have opportunities to practice
prevention
in both clinical and community settings and learn to partner for prevention by
collaborating with public health and other entities to promote population health.
Students unfamiliar with the framework of preventive strategies may choose to view
information on the Levels of Prevention (through and a
The purpose of these materials is to familiarize students with the range
of disease prevention strategies used in clinical medicine and public health.
Prevention in clinical and population health is often focused on how to keep healthy people healthy through health promotion, specific protection, and screening activities. In your medical school training, a major focus has been how to restore an unhealthy person to health through treatment and interventions. The reality facing health care and public health, however, is that a large number of people are living with chronic diseases and the focus of our efforts becomes how to maximize the health of an unhealthy person through disease management. Regardless of the patient's reason for visiting the clinic (specific complaint, well visit, disease management), opportunities for prevention will be present. A health care provider who is thinking prevention will gather information in the patient interview that will suggest appropriate clinical preventive interventions (e.g., immunizations, screenings, counseling for behavior change). In patients with diagnosed chronic conditions and diseases, effective prevention strategies can reduce the likelihood of complications and loss of function. Based on the patient's age, gender, family history, past medical history, social history, etc., consider the following: How healthy is the patient's lifestyle? Can healthy behaviors and lifestyles be reinforced? Can unhealthy lifestyles be changed? Diet, physical activity, tobacco use, alcohol and substance abuse, sleep patterns, stress levels, etc. Are there opportunities to change risk behaviors and exposures to prevent injury or disease? Sexual risk taking, violence, driving behaviors, protective gear, occupational and environmental exposures, etc. Which screening tests have been done recently? Which tests are due? Published guidelines are often based on age, gender, and perhaps family history. Patients with specific chronic diseases may require screening patterns that differ from the guidelines for the general population. In a patient already diagnosed with a specific condition or disease, what factors place them at elevated risk for complications or other diseases? Which health promotion, specific protection, and screening activities are especially important for these patients? Are there comorbidities present? How do these comorbidities influence your choice of prevention strategies? A recent Institute of Medicine report focused on strategies to maximize the health and function of people living with chronic diseases, including those with multiple comorbidities. (IOM. 2012. A Call for Public Health Action. Washington, DC: The National Academies Press.) That report emphasized the range of factors that influence individual and population health and the various groups that may contribute to health improvement through policies and programs. The report stated: "A chronic disease or illness, in general terms, is a condition that is slow in progression, long in duration, and void of spontaneous resolution and it often limits the function, productivity, and quality of life of someone who lives with it." The committee recognized that chronic diseases differ on several important dimensions:  Stage  Chronicity/time course (episodic, stable, progressive)  Severity of symptoms  Level of functional impairment or disability  Self-management burden  Burden to others The preventive and treatment strategies employed will vary depending upon these factors. Evidence-Based Medicine (EBM) supplemental write ups:
Student selects and critically reviews an article relevant to the diagnosis or treatment of
his/her patient. Articles should be from the current literature, and from peer reviewed medical
journals.

EBM addendums are linked to a specific H&P and relates to the care of the patient (You must
turn in 2 supplemental Evidence-Based Write ups).
These are to be an addendum to two
of your H&Ps. These are graded by the Clerkship Directors. Literature References must be
included. Limit the addendum to 1 or 2 pages. You must have a literature review supporting
the Assessment and Plan of the patient's primary problem. Reference your assessment and
plan with literature from current journals. Consider how your literature review has impacted
the care of your patient. Limit the addendum to 1 or 2 pages. Please include journal-based
references.
Note that 2 of the 6 H&P's should include an evidence-based supplemental write up
as above. These 2 supplements are to be uploaded into the assignments section of
our website along with your H&P's. You must turn in your 1st EBM supplemental
write up by the end of month 1 and the 2nd EBM supplemental write up by the end of
month 2 of the clerkship.

Geriatric Focused Write-Up:
One H&P (within the first two months) must be written on a patient > 65 years of age.
(details below)
Geriatric Write-up:
Geriatric patients often have multiple, chronic illnesses which may present with atypical
symptoms. Management strategies need to take into account the effects of aging on multiple
organ systems and socioeconomic factors faced by older adults. Students are encouraged to
identify and discuss the relevant symptom or disease presentations and how these may
present atypically in the elderly patient.
1. Cardiovascular disease 7. Cerebrovascular disease 3. Substance abuse 4. Thyroid disease 10. Fluid and electrolyte disturbances 11. Constipation 6. Acute abdomen Students should also address any issues that are common in the older adult including: 7. Falls/gait and balance problems 8. Incontinence 3. Sleep disturbance 9. Dementia / delirium 10. Pressure ulcers 11. Hearting and visual impairment 6. Weight loss / failure to thrive / malnutrition
Patient Logbook:

Student expectations will be to perform a history, physical examination, and clinical reasoning
concerning diagnosis and/or management on the selected patient. These patient issues do not
have to be the presenting complaint; they can be issues that have developed during
hospitalization or are a secondary issue where a clinical reasoning activity (e.g., rounds
discussion) took place and utilized student data collection. Interaction can occur in any clinical
care area. See appendix A for the educational requirements checklist.
Clinical Reasoning Instrument:
You must complete one Clinical Reasoning Instrument per week. The form must
be signed by faculty weekly. You will turn these in at the end of each rotation. The
goal of this activity is to provide a structure for you to practice oral presentation
skills and clinical problem solving. All Clerkships will use the same form.
 After you see a patient and you should use the front page of the Clinical
Reasoning Instrument as a "post encounter" note to record your data from the
interview and pertinent physical exam. The purpose of page one will be for you
to record information for personal use—basically to gather your thoughts and
organize yourself.
 On page 2 of the Clinical Reasoning Instrument, you will then be expected to
record what you believe to be the appropriate diagnoses; ranking from the most to the least likely. You will then be instructed to list up to three items from the history, physical exam and other available information to support the diagnoses listed in this section.  Finally, you will be expected to record up to 5 diagnostic tests or procedures that would be indicated to help you rule in or rule out their suspected diagnoses.
Challenges in Medicine Essay Assignment: (10%)

As part of the experience on Internal Medicine, we would like you to take some time to reflect
on some of the challenges of patient care.
Essay structure: there are many issues that challenge us in the care of our patients. We
would like you to select a topic from the list below
1. Rationing healthcare
2. Truth-telling
3. Decision–making capacity
4. Impaired colleague
5. End-of-life decisions
6. Informed consent
7. Other as pre-approved by clerkship directors [must propose a topic and get
email approval from Dr. Karnath or Dr. Szauter]
The essay should be 3-4 typed pages (double spaced; 12 point font; 1.25 inch margins)
The first paragraph should describe a specific patient situation to frame your discussion. This
should be a patient that you cared for, or was on your team during the internal medicine
rotation. You do not need to present all of the details of the patient's medical problems; limit
the introductory comments to provide enough information as to why this patient's situation
prompted you to reflect on one of the above listed issues. The remainder of the essay should
explore your selected topic, and what you learned from the patient interaction or situation
surrounding the care of the patient. Please reflect on the topic and explain how this patient
interaction has shaped your thoughts about the issue.
You should include at least 2-3 references from the current literature.
This essay will be 10% of your final clerkship grade. The essays will be graded by the
internal medicine clerkship committee (UTMB faculty).
The deadline for your essay is the 2nd Monday of the 3rd month of the clerkship.

You must pass all components to pass the clerkship!!!

Failure of the NBME alone results in a "PC"
Failure of any of the written components will result in a "PC"
Failure of clinical performance evaluations results in a "Fail"
Overall clerkship grade < 70% will result in a "Fail"

Written components include: Essay, Addendums, CRIs, H&P's, Logbook.
Honors = a final clerkship grade of 91 and in the top 15% of cohort grades.
High Pass = a final clerkship grade of 86 to the cut point for honors.
Pass = a final clerkship grade of 70 to 85 with all components passed.
Note: to qualify for honors, you must have a score of at least 85 in each component.
V. Appendix

A. Educational Requirements
B. Sample Progress Notes
C. Sample Medicine Comprehensive H&P

D. Theme-Based Write up Criteria
E. Sample Evidence-Based Medicine Write up

F. Clinical Performance Evaluation Form
G. Suggested Study Guide for Internal Medicine


Appendix A

Internal Medicine Clerkship
Educational Requirements
Must have patient problems (i.e., the primary student actively caring for the patient under the
guidance of faculty and/or house staff). Student expectations will be to perform a history,
physical examination, and clinical reasoning concerning diagnosis and/or management on the
selected patient. These patient issues do not have to be the presenting complaint; they can
be issues that have developed during hospitalization or are a secondary issue where a clinical
reasoning activity (e.g., rounds discussion) took place and utilized student data collection.
Interaction can occur in any clinical care area.
General areas to be covered
Management of new acute condition with an emphasis on diagnosis (4) Management of new acute condition with an emphasis on treatment (4) Management of a chronic condition (2) Management of an exacerbation of a chronic condition (4) Management of a psychosocial issue as significant issue of the interaction, e.g. difficulty with placement post discharge or depression/anxiety playing a significant part of the patient's healthcare management (2) Behavioral counseling of a patient for lifestyle change (4) (Tobacco cessation, substance use cessation, diet change) Caring for a patient from a culture not your own (1) Caring for a patient with limited access to care (1) Caring for an elderly patient (1)
Topic specific areas to be covered


Evaluation of a patient with a symptom, sign or abnormal lab value:

Altered mental status Fluid / Electrolyte abnormality Acid-Base disorder Gastrointestinal bleeding Joint Pain / Arthralgia Skin eruption / rash
Patient Presenting with a Known Condition

Acute coronary syndrome Acute Renal failure Chronic Kidney disease Common cancers (breast, colon, lung) COPD/Obstructive Airways disease Diabetes Mellitus Immunocompromised state (includes HIV) Nosocomial infections Pneumonia / Respiratory infection Autoimmune disease Venous thromboembolism
Must perform 2 of each of the following

ECG interpretation CXR interpretation
Patient encounter cards should be used to help you track your patients.
Please enter the data in New Innovations often. Do not wait until the end of the
clerkship to enter data into the New Innovations Logbook.

------------------------------------------------
Patient Encounter Card
Patient Encounter Card
Reason(s) for admission or clinic visit
Reason(s) for admission or clinic visit
Diagnosis/co-morbidities
Diagnosis/co-morbidities
Patient Encounter Card
Patient Encounter Card
Reason(s) for admission or clinic visit
Reason(s) for admission or clinic visit
Diagnosis/co-morbidities
Diagnosis/co-morbidities
Appendix B: Sample Progress Note Content
Student Progress Note
SOAP format
Ms. Rogers describes no chest pain in the last 24 First comment is an update of chief complaint; hours. She walked around the nursing station for circumstances of stability or instability are described. 20 minutes on three occasions yesterday without Positive findings related to complaint are described and limitation. She noted a brief (5 second) episode of chest fluttering at rest after dinner without Relevant negative ROS included here. associated pain, dizziness or other complaints. She describes no dyspnea, cough, nausea or vomiting Always start with vital signs BP 132/80 P 72-regular R-12 T 37.2 Character of pulse relevant here. Include relevant CV exam Neck: No visible JV pulsations
Chest: RRR with no murmurs, gallops, rubs
Lungs: Clear without crackles or wheezes
No cyanosis, edema Labs relevant to problem; list all values (1730 yesterday; after palpitations) NSR without ectopy or ST changes List time of ECG, associated symptoms Normal; unchanged from admission Not immediately relevant; summarized Chest Pain
Character of previous episodes strongly List primary problem first; if DX of ischemic heart suggestive of angina pectoris. She has disease is firmly established, this problem could be remained pain free for 72 hours on her labeled ischemic heart disease instead of chest pain. current medications Describe degree of stability. This is her first mention of this complaint. A new complaint; discuss possible etiologies specific for Other symptoms suggestive of ischemic this patient, in order of likelihood. heart disease (angina) raise question of a dysrhythmia, but she manifests no other signs of continuing ischemia. Important, relevant lab abnormality Hypokalemia
Discuss in relation to other problems May be related to diuretic use, and may contribute to #2 above. Include your rationale for each intervention Include continuation of major management steps, as well Continue anti-anginal medications (ISDN, as new interventions. nifedipine). Indication: Ischemic heart Continue HCTZ Indication: Hypertension Add KCL 40 meg po BID Indication: Addition of new medication. A list of current meds should be posted prominently in the chart for you to Recheck K level in 48 hours Indication: Hypokalemia If not written early in the day, it must be updated as Await evaluation by cardiology Indication: warranted by new information or changes in the patient's Possible cardiac catheterization Sample Progress Note in EPIC Format

Sample Progress Note in EPIC

Please take the time to format your progress notes in EPIC.
You may use pre-existing templates or create your own.

STUDENT:
XXXXX

PATIENT: XXXXXX (000000P) J7C 13
NOTE: PROGRESS NOTE

DATE OF SERVICE: 7/10/2014
SUBJECTIVE:
Hospital day # 3. No acute problems overnight. Patient says he feels better everyday.
However, patient says his cough has gotten worse and is again producing green sputum.
CURRENT HOSPITAL MEDICATIONS:
MEDICATION

FREQUENCY
Dextromethorphan-guaifenesin (ROBITUSSIN DM) 10-100 mg/5 ml 5 ml Oral Q6HPRN Hydrocodone-acetaminophen (NORCO 5) 5-325 mg 1 Tab Oral Q6HPRN (TYLENOL) tablet 650 mg 1 Tab Oral Q6HPRN Levofloxacin in D5W (LEVAQUIN) 750 mg Albuterol-ipratropium (COMBIVENT) 18-103 mcg inhaler 2 Puff Inhalation QID
OBJECTIVE:
PHYSICAL EXAM:
T max: 39.3 T current: 37.0 Pulse:105-126/min Resp: 20/min BP: 100-130/ 62-93 mmHg
General: pt alert and oriented and in no apparent distress
Lungs: Decreased breath sounds in LLL, clear to auscultation on right
Chest: chest tube in place with only 50 cc of drainage overnight.
Cardiac: tachycardic with normal S1 and S2; no murmurs, rubs or gallops
Abdomen: soft; non-tender; non-distended; normoactive bowel sounds
Extremities: No edema

Laboratory:

Range: 4.0-10.0 /CMM Range: 3.90-5.30 /CMM Range: 11.5-15.5 G/DL Range: 34.0-45.0 % Range: 80.0-96.0 FL Range: 27.0-32.0 PG Range: 31.0-37.0 % Range: 11.6-14.0 % Range: 150-400 /CMM Range: 40.0-73.0 % Range: 18.0-53.0 % Range: 4.0-12.0 % Range: 0.0-6.0 % Range: 0.0-2.0 % SPUTUM SAMPLE RECEIVE DATE: 07/09/08
GRAM STAIN: FEW GRAM NEGATIVE BACILLI
RARE POLYMORPHONUCLEAR LEUKOCYTES
BODY FLUID CULTURE COLLECT DATE:07/08/08
SOURCE: PLEURAL FLUID RECEIVE DATE: 07/08/08
PLEURAL FLUID START DATE: 07/08/08
GRAM STAIN: NO ORGANISMS OBSERVED
NUMEROUS PMN'S, RARE MONONUCLEAR CELLS (LYMPHOCYTES, MONOCYTES)
PRELIMINARY REPORT: NO GROWTH AT 24 HOURS
AFB CULTURE -STERILE BODY SITE COLLECT DATE :07/08/08
SOURCE: ASPIRATE RECEIVE DATE: 07/08/08
ASPIRATE START DATE: 07/08/08 1
AFB STAIN: NO ACID-FAST BACILLI OBSERVED ON SMEAR.
BLOOD CULTURE: NO GROWTH AT 72 HOURS
FUNGAL CULTURE IN PROGRESS
ASSESSMENT/PLAN:
XXXXX is a 60 year old man admitted to the hospital with chest pain.
1) CHEST PAIN
Chest pain was pleuritic in nature CP has resolved and was likely due to LLL pneumonia. 2) COMMUNITY ACQUIRED PNEUMONIA
Continue with IV Levaquin 750 mg daily day # 3. Blood cultures are negative. Sputum cultures negative. 3) LEFT PLEURAL EFFUSION
Exudative effusion per laboratory evaluation. Chest tube might be removed as it is no longer draining effusion. Will call Radiology for re-evaluation of chest tube today 4) PRODUCTIVE COUGH
Change dosage of Robitussin DM to q4h as cough has worsened. Re-submit sputum for gram stain as his cough is now productive. 5) DYSPNEA
Educate patient on use of Combivent inhaler. O2 per protocol. Monitor O2 saturations.
XXXXX, MSIII
Pager: 643-XXXX

Appendix C
Sample Comprehensive Medicine H&P

SAMPLE MEDICINE WRITE-UP

Chief Complain: "Chest pain with excessive sweating and nausea"
History of Present Illness: Mrs. A.L. is a 50-year old white female who presented
to the UTMB Emergency Room at 8:00 this morning with the chief complaint of
"chest pain, nausea, and sweating" upon waking 1 ½ hours earlier. She describes the
pain, which was constant for the 1.5 hours, as "squeezing". The pain diffusely
spread over her upper anterior chest wall. She rates the pain 8/10 with radiation to
her left jaw and left arm. She has never experienced this type of pain before. She
noted no other associated signs or symptoms other than sweating and nausea and
denies dyspnea, tachypnea, and fever. Although nothing relieved the pain at the
time, exertion made the pain worse. She denied any previous history of chest pain,
orthopnea, paroxysmal nocturnal dyspnea, or edema. Pertinent cardiovascular risk
factors include a 45-pack-year smoking history, a family history of premature
myocardial infarction, and being menopausal. Her mother and father both suffered
MI's before age 50. This patient does report occasional brief palpitations, chronic
dyspnea on exertion, and wheezing with overexertion. Pertinent social history
includes a one year history of depression and stress due to the illness and death of
her ex-husband.
Past Medical History:
Childhood Illnesses:
Recurrent ear infections. Appendicitis at age 10. Chickenpox
and measles.
Medical Illnesses: Dyspepsia for the past 3 years.
Injuries: Stabbed with a pencil in the abdomen in 1990. She was treated surgically
to close wound, no complications.
Surgeries:
Appendectomy (1962), no complications Ob/Gyn History:
G3P3 ABO LC3, all vaginal deliveries, no complications Menarche at age 10 Menopause at age 48 Psych Hx: Depression since menopause, treated with Prozac by her PCP for the past
year.
Other Hospitalizations: none
Medications: Prozac 20 mg PO daily. Multivitamin daily. Antacids prn dyspepsia.
Drug allergies: Penicillin (causes diffuse rash)
Blood transfusion/donation: none
Toxic Exposure: not aware of any
Preventive Care: She sees her family doctor annually and as needed. She receives
annual mammograms and pap smears. Patient has not completed colonoscopy yet.
Immunizations: Td was given 3 years ago and patient received influenza vaccine last
fall.
Family History:
Father passed away at age 46 from an MI. He had his first MI at age 35.
Mother, 75 has heart disease (MI at age 45)
46 yo sister with Type 2 diabetes mellitus
42 yo sister with Type 2 diabetes mellitus
40 yo sister in good health
Daughters: 24, 27 and Son: 29, all in good health
Significant family history for Type 2 diabetes mellitus with maternal grandmother
and 2/3 maternal aunts afflicted. No family history of hypertension or cancer.

Social History:
She lives at home with her husband in Galveston and works as a secretary at a local
insurance company. Her lifestyle is sedentary, as she works a desk job and does not
exercise. Mrs. A. L. was married at 18 and divorced at 28. All three of her children
are from that marriage. She remarried at 30 to her current husband and has a good
relationship with him. The major stressor in her life is the death of her ex-husband
recently. She did not want to elaborate further but mentioned that they were on bad
terms when he passed away and she feels guilt. Her social support network is mainly
through her husband and friends at church. She also gets stress relief from visiting
her children who all reside in Austin. Mrs. A.L. has smoked 1.5 packs a day for 30
years (45-pack-year) and denies any alcohol or drug use. In terms of diet, she eats
mainly fried foods and pork but has recently switched to turkey and chicken over the
last 3 months.
Review of Systems:
General:
She has lost 10 pounds over the past year due to diet.
Denies fever, chills, night sweats.
Skin: Denies other pruritus, rashes, change in hair, or skin changes.
HEENT: Nearsighted since youth, vision corrected with glasses. Denies headaches or
vision changes. No hearing loss, ear pain, or tinnitus. Denies epistaxis, nasal
discharge, sinusitis, dental problems, mouth ulcers, or sore throats.
No hoarseness, neck pain, or stiff neck.
Breasts: No breast sores, masses, pain, or discharge
Respiratory: Other than the HPI, patient has non-productive cough associated with
smoking. She denies hemoptysis.
Cardiovascular: Other than the HPI, she denies claudication or syncope.
GI: Minor heartburn for the past 3 years, primarily after meals and lasts about an
hour. Patient takes antacids as needed but has not had the problem evaluated
further. No anorexia, hematemesis, vomiting, dysphagia, odynophagia, abdominal
pain, hematochezia, melena, constipation or other changes in bowel habits.
GU: No dysuria, nocturia, or hematuria, or pelvic pain. Patient's age at menarche
was 10 and she has been menopausal since January 2001. No vaginal discharge,
bleeding, or sexual dysfunction.
Neurologic: No past history of seizures, muscle weakness, sensation change,
incoordination, or headache.
Musculoskeletal: Denies joint stiffness, pain, swelling, or backache.
Hematologic: Denies bleeding, easy bruising, infections, or swollen nymph nodes.
Endocrine: No history of heat/cold intolerance, excessive sweating, diabetes,
polyphagia, polydipsia, polyuria. Denies vasomotor flushing.
Psychiatry: Depression over the past year since menopause associated with the
illness/death of her ex-husband. Denies anxiety, sleep disturbance, or suicidal
ideation.
Physical Examination:
Vital Signs:
Temp. 37C. Ht. 64", Wt. 170 lbs. (BMI=29.2)
BP, left arm sitting, 110/57 mmHg Pulse: 68/min, regular Respirations: 17/min General:
Well-developed white female who appears stated age in mild distress. Appropriately dressed and groomed. Few hyperpigmented macules on anterior chest. Few flat pinkish-white skin discolorations on the dorsum of both hands. Lesions are not raised or fluid-filled when palpated. No other skin abnormalities on the back, upper/lower extremities, or scalp. Hair has normal texture. Visual acuity reduced without glasses. Patient did not have glasses with her to test corrected vision. Pupils equally round and reactive to light and accommodation. Extraocular muscles intact. Sclerae anicteric and eyelids without lesions. Conjunctiva non-injected. Fundi-discs sharp. Vessels without hemorrhages or exudates on funduscopic exam. Hearing intact, bilaterally. External auditory canal patent, free of cerumen. Auricles without lesions. Tympanic membrane appears intact with visible, landmarks, and cone of light. Nares patent and nasal mucosa appears pink. Teeth, lips, and gums without lesions. Oral mucosa without lesions. Posterior pharynx without erythema or exudate. Full range of motion. Thyroid non-palpable. Trachea in midline. No masses or lymph nodes palpable. Breasts:
Respirations without retractions or use of accessory muscles. Symmetrical in thoracic expansion. No deformities on posterior chest wall. Lungs resonant to percussion and clear to auscultation bilaterally, without adventitious sounds. Prolonged expiratory phase. No deformities on anterior chest wall. PMI is in the 5th ICS, mid-clavicular line, 1-2 cm diameter. Regular rhythm, with normal S1, single S2. 2/6 systolic ejection murmur heard best at left midsternal border without radiation. No S3, S4, or rub. No JVD. Carotids 2+ bilaterally without bruits. Femoral arteries 2+ bilaterally without bruits. Dorsalis pedis and posterior tibial 2+ bilaterally. Abdomen: Well-healed surgical scars in RLQ and midline. Bowel sounds
normoactive. Abdomen non-tender, without guarding or rebound tenderness to deep palpation. Liver span 9 cm in the mid-clavicular line. Spleen and kidneys not palpable. No hernias palpable. Rectal exam deferred. (Stool was guaiac negative in the Emergency Room.) Psychiatric: Patient alert, oriented to person, place, and time. Intact memory for
remote and recent events. Mood normal and appropriate. Patient able to interpret proverbs (abstraction intact). Neurologic: Cranial nerves II-XII intact. Muscle bulk is appropriate in upper/lower
extremities. Motor strength is 5/5 in upper (biceps and triceps) and lower extremities (quadriceps, hamstrings, and ankles). Sensation intact to light touch, temperature, and pinprick. DTR's 2+ in the biceps, triceps, quadriceps, and ankles. Babinski responses downgoing bilaterally. Gait normal. Romberg negative. Extremities Full range of motion of shoulders, elbows, wrists, fingers, hips, knees,
and ankles. No joint deformity, tenderness, or swelling. No cyanosis, clubbing, or edema in the extremities. Lymphatic: No palpable lymph nodes in the neck, axilla, or inguinal region.
Laboratory:
Range: 135-145 MMOL/L Range: 3.5-5.0 MMOL/L Range: 98-108 MMOL/L Range: 23-31 MMOL/L Range: 7-23 MG/DL Range: 70-110 MG/DL Range: 0.50-1.04 MG/DL Range: 33-194 U/L Range: High: <0.030 ng/mL
Problem List:
1. Chest pain 2. Nausea 3. Diaphoresis 4. Tobacco abuse 5. Dyspnea on exertion 6. GERD/Dyspepsia 7. Depression 8. Penicillin allergy 9. Post-menopausal 10. Family Hx of premature cardiovascular disease 11. Family HX of diabetes mellitus 12. Obesity (BMI=29.2, Wt=170, Ht=64 in) 13. Prolonged expiratory phase
Assessment:

1. Chest Pain: Based on history and physical exam, the patient's chest pain is
most likely unstable angina. The onset with constant "squeezing" chest pain for 1.5 hours with radiation to the left arm and jaw, quality of the pain, and presence of risk factors (pertinent family history, smoking, menopause, and obesity) are consistent with this etiology. Further laboratory evaluation with ECG, CK-MB, and troponin-I can rule out myocardial infarction. Until proven otherwise, this patient would benefit from beta-blockers, heparin, aspirin, and telemetry monitoring. Other differential diagnoses to consider in a patient with chest pain would include esophageal spasms/GERD, aortic aneurysm, pulmonary embolus, and costochondritis. Aortic aneurysms typically present with pain in the center of the back. This condition can be suggested by chest x-ray/imaging. This patient does not have the classic symptoms for PE: dyspnea, tachypnea, and pleuritic chest pain. Since pulmonary emboli usually impair arterial oxygen saturation, determination of arterial PO2 in addition to radiographic imaging can make this differential less likely. Pneumonia is less likely since the patient's lungs are clear to auscultation and she does not have fever. Lastly, diffuse esophageal spasms (DES)/GERD often present with more epigastric pain or dysphagia (in DES). However, this patient has had recent onset of heartburn, and further evaluation with upper endoscopy or imaging may be necessary. 2. Obesity/Family Hx of Diabetes/Smoking: With BMI of 29.2, this patient
is considered obese. Since obesity is a risk factor for several illnesses including coronary artery disease, hypertension, and diabetes, she should be counseled to lose weight with exercise and diet. Additionally, patient should be closely monitored/educated for diabetic symptoms (polyuria, polydipsia, polyphagia), especially considering her family history. Smoking cessation should be encouraged as she is at risk for cardiovascular, pulmonary, and neoplastic diseases. She might benefit from nicotine patches, which may facilitate her quitting smoking. 3. GERD/Heart Burn: The patient has had recurring episodes for the past 3
years. Further evaluation may be warranted as she may benefit from more effective drugs such as proton pump inhibitors/H2 blockers. She may also be counseled on avoiding foods that exacerbate symptoms. She may later need evaluation with upper GI endoscopy or imaging. 4. COPD: The history of dyspnea on exertion, wheezing, and tobacco abuse
along with the physical exam finding of prolonged expiratory phase suggest that she has developed COPD. She should be counseled on smoking cessation. Consider PFT evaluation later as an outpatient to quantify pulmonary function. 5. Depression: The patient has a history of depression and states that she is
currently controlled with Prozac. She should continue follow-up with her PCP. 6. Post-Menopausal: The patient has been post-menopausal for one year and
has not been taking estrogen replacement. Recent studies have raised concerns over the safety of HRT in women with recent coronary events and in women taking HRT for greater than 5 yrs. The patient should be counseled about osteoporosis prevention or perhaps be screened for osteoporosis at a later time. 7. Health Maintenance:
Immunizations: Td was given 3 years ago and patient was given the influenza vaccine last fall. See below for pneumococcal vaccine. Consider Varicella Zoster Vaccination at age 60. Cancer screening: Mammogram was obtained this year and patient will continue with annual screening. Patient does not perform self-breast examination. Her last Pap smear was 2 years ago and patient receives her Pap smear screening every 3 years. She has never had an abnormal Pap smear. Patient is at average risk for colorectal cancer. She is considering colonoscopy and will continue in discussion with her primary care physician as outpatient. Patient should also consider annual FOBT. Disease specific: Lung cancer prevention with smoking cessation. Offer nicotine replacement therapy. Patient would benefit from nicotine patch while in hospital. Screen for hyperlipidemia given patient's presentation with chest pain, it is import to assess further risk for cardiac disease. Will evaluate for COPD and consider pneumococcal vaccine if patient has COPD. Otherwise, the pneumococcal vaccine is given at age 65. May also consider DEXA bone density study to screen for osteoporosis given patient's smoking history and possible COPD. Plan:
Diagnostic Evaluation:

1. ECG 2. Chest X-Ray 3. CK (with CK-MB fraction), Troponin Enzymes 4. Telemetry monitoring 5. CBC/with differential, Chemistry w/Lipids 6. Cardiology consultation if rules in for MI 7. Echocardiography to assess ejection fraction and wall motion 8. Consider cardiac stress after evaluation with cardiac enzymes.
Pharmacologic/Therapeutic (In Confirmed Myocardial Infarction):

1. O2 2 l/min per nasal cannula 2. Beta-blocker to reduce myocardial oxygen demand 3. Aspirin/anti-platelet drugs to reduce platelet coagulation 4. Heparin until results of cardiac enzymes rule out MI 5. Proton Pump Inhibitor/H2 antagonist for GERD 6. HMG CoA Reductase Inhibitor, if dyslipidemia is present
Patient Education/Counseling:

1. Education on Smoking Cessation 2. Education on diet/weight management and looking for diabetic symptoms 3. Education on osteoporosis prevention 4. Education on anti-reflux measures 5. Education on Ambulation/Cardiac Rehabilitation 6. Schedule follow-up visit 7. Primary Care Physician to consider outpatient Pap smear, colonoscopy, mammogram, DEXA bone density. Other preventive measures as discussed in Health Maintenance. Reference: Coons JC, Battistone S. 2007 Guideline update for unstable angina/non-ST-segment elevation myocardial infarction: focus on antiplatelet and anticoagulant therapies. Ann Pharmacother. 2008;42:989-1001. Comprehensive Write up Evaluation Form
H&P # 1 2 3 4 5 6 Needs Significant Help On Target Well Above Expectations
History:
History of Present Illness:
CC: Concise, Uses quotations appropriately
HPI Patient identifiers
Time prior to admission Duration, Frequency, Location, Radiation, Comments:
Alleviating, Aggravating Factors, Severity, etc… Associated Symptoms, relevant PMH e.g. Pt. Denies possible associated symptoms etc… Easy to read, starts with ID and CC Logical sequence PMH, SH, FH and ROS:
Dose, frequency, correctly spelled Type of reaction Hospitalizations Dates and reason Dates and reason Comments:
Medical illnesses Duration or date of diagnosis Living arrangements, with whom Single, married, partnered, divorced, widowed Amount, frequency, type Physical Examination:
Duration and amount FH Ages and illnesses of relatives
ROS Must have 3 (+) or (-) per system or refer to HPI
Comments:
Physical Examination:
Blood pressure, Pulse, Respirations, Temperature General: Describes patient and mental status Skin: Rashes, Scars, Tattoos, Piercings etc…. Head and Neck: HEENT, Neck Exam, Thyroid Clinical Thinking:
Cardiac: Auscultation, PMI, Pulses Lungs: Auscultation and Percussion Abdomen: Inspection, Auscultation, Percussion, and Palpation Genitourinary: As indicated for pelvic and rectal examination Extremities: Joints, ROM, Edema Comments:
Neurological: CN, Motor, DTR's, Sensation Lymph nodes: Presence or absence Laboratory Data: Labs formatted and clearly labeled
Clinical Thinking:

Overall Impression:
Problem list
Most important first All major active medical problems, risk factors Assessment
Comments:
Most important first Incorporates history and PE data Appropriately justified Plan
Diagnostic
Justifies reason based on differential Dose, route, duration Risk reduction, Counseling etc… Prevention Preventive Health Maintenance:
Adult Immunizations, Cancer Screening
Disease specific recommendations
Evidence Evidence-Based Medicine: (Journal article cited)
Appendix D
Theme-Based Supplements (Evaluation Criteria)

Evidence-Based Medicine
You must complete 2 EBM addendums.
 Clearly discusses the topic in the assessment and plan.
(addendum restates the key issues to be discussed)  Article selected is from a well-recognized, peer reviewed journal (article clearly relates to the assessment and plan)  Key relevant findings of the article are documented in the review (evidence-based discussion relates to the assessment and plan)  Application in the care of the patient is documented (how did the article impact the approach to the care of the patient?)
Preventive Health
You must include a discussion of Preventive Health in all 6 of your H&P's
Primary Prevention: Health Promotion
 Documentation of recommended lifestyle changes (e.g., diet, physical activity, tobacco use, alcohol or other substance abuse, sleep patterns, stress reduction)  Primary Prevention: Specific Protections
 Documentation of recommended immunizations (age specific)  Documentation of other recommended specific protections (e.g., injury prevention, STD prevention, protection from environmental or occupational exposures)  Secondary Prevention: Screening and Monitoring
 Documentation of recommended blood work (based on age)  Documentation of other recommended screening tests (based on age and FH, e.g., Pap smear, mammogram, colonoscopy, other) Tertiary Prevention: Disease Management
 Discussion of patient's disease specific preventive health recommendations (e.g., eye care, foot care in diabetes, etc.) Provide source (references) for information cited above (journal-based sources recommended or use of published clinical guidelines such as guidelines.gov) Evidence of synthesis (e.g. overall organization) Appendix E
Sample Evidence-Based Medicine Addendum

Addendum Evidence-Based Medicine #1
H&P #1: Mrs. DRG is a 74-year-old Caucasian female with PMH of HTN, AS, CAD
s/p PCI stent in 2008, who presents with complaints of dizziness and loss of
consciousness. Patient has been experiencing similar episodes for the last 6 months,
progressively increasing in number of episodes per day that has limited her ADLs. Her
history is positive for SOB, DOE, negative for seizures disorder or signs of stroke. TTE
done in 9/11 showed moderate to severe AS with valve area of 0.71 cm2 and peak valve
gradient 36.9 mmHg.
Clinical Question: In an elderly patient with symptoms of aortic stenosis, would a
transcatheter aortic valve replacement offer better 1 year survival outcome when compare
to traditional surgical approach?
Background: The most common symptom of AS is dyspnea, which results from
diastolic dysfunction and inability of the left ventricle to increase the cardiac output
during exertion because of stiff aortic valve obstructing the flow. Average survival after
the onset of these symptoms is only two to three years, with a high risk of sudden death.
There is currently no effective medical treatment for symptomatic AS. Surgical
replacement of the aortic valve is the only effective treatment1. Patients with advanced
age and poor LV function are at risk for operative complications or death, in which a less
invasive procedure may be desirable.
Methods: A multicenter recruitment of 699 high risk patients, having NYHA class II or
worse, with severe AS, define as aortic valve area < 0.8 cm2 plus either mean valve
gradient of at least 40 mmHg or peak velocity at least 4.0 m/s were recruited for the
study. 650 patients were needed to achieve a power greater than 85%. Patients were
deemed to be high risk for operative complications or death based on the basis of
coexisting conditions. Exclusion criteria were bicuspid or noncalcified valves, CAD
requiring revascularization, aortic annulus < 18 mm or > 25 mm, severe mitral or aortic
regurgitation, recent neurologic event, and severe renal insufficiency. Patients were
randomized to either transcatheter aortic valve replacement/implantation (TAVI)
with a balloon expandable bovine pericardial valve or surgical replacement. The
hypothesis was that TAVI is not inferior to surgical treatment and the primary endpoint
was death from any cause at 1 year. Secondary endpoints include death from
cardiovascular sources, NYHA functional class, repeat hospitalization because of valve
or procedure related hospitalization, MI, stroke, AKI, valvular complication, bleeding, 6
minute walk distance and valve performance.
In this study, 244 patients in the transcatheter group were assigned to undergo
transfermoral placement and 104 were assigned to undergo transapical placement. A
total of 351 patients were assigned to undergo surgical treatment, in which 248 were
assigned as control group to the transfemoral group and 103 assigned as control group to
transapical placement. Baseline characteristic were similar between the two study
groups. 42 patients (4 in transcatheter and 38 in the surgical group) did not undergo
assigned procedure due to withdrawal from the study and a decision to not undergo
surgical therapy.
Results: For the primary outcome, an intention-to-treat analysis revealed no significant
difference between the rates of death from any cause at 1 year in the transcatheter group
(24.2%) when compared to the surgical group (26.8%, P=0.44). Similar there are no
difference between the transfermoral cohort when compared to the surgical group (22.2%
vs 26.4%, P=0.25). The rate of death from any cause was significantly different at 30
days, with3.4% in the transcatheter group and 6.5% in the surgical group (P=0.07). Rates
of all neurologic events from strokes and TIA were significantly higher in the
transcatheter group when compared to the surgical group at 30 days (5.5% vs 2.4%,
P=0.004) and at 1 year (8.3% vs 4.3%, P=0.04). There were no significant difference in
the rate of stroke between the transcatheter group vs. surgical group in 30 days (3.8% vs.
2.1%, P=0.20), however there is significantly higher rate of stroke (5.1% vs. 2.4%,
P=0.07) in the transcatheter group.
Secondary outcome comparison at 30 days revealed significantly higher rate of major
vascular complication in the transcatheter group than the surgical group (11.0% vs 3.2%,
P=0.001) but lower rate of major bleeding event (9.3% vs. 19.5%, P=0.001) and new
onset atrial fibrillation (8.6% vs 16.0%, P =0.0006). Patients in the transcatheter group
also had a greater reduction of symptoms to NYHA class II or lower when compared to
those in the surgical group (P=0.001).
Conclusion: TAVI provides the benefit of a shorter hospital stay and better NYHA
functional class post procedure compared to traditional open heart surgery. Patients
experienced a higher frequency of stroke with TAVI, however, death from any cause of
stroke remain the same between the 2 groups. As expected, open surgery results in
higher major bleeding postoperatively and so results in a higher incidence of new onset of
atrial fibrillation. Both procedures were associated with similar mortality at 30 days and
1 year duration2.
Mrs. DRG had an EF of 55-60%, currently without any coexisting conditions that would
put her with a high risk of death 30 days after the procedure. Her valve measurements
put her at moderate to severe AS. Both procedures have been shown to have similar
mortality postoperatively, however she would benefit from reduction of symptoms with
offered by TAVI. The risk and benefits of both procedures would need to be discussed
with the patient in order to find out which is best for her.
References:
1. Freeman RV, Otto CM. Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies. Circulation 2005; 111:3316. 2. Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. PARTNER Trial Investigators. New England Journal of Medicine. 2011;364:2187-98. Appendix F
Clerkship Student Evaluation Form

A. Interview & Examination Skills
Obtained pertinent data relevant to patient problem Obtained accurate Hx and PE information Performs PE maneuvers appropriately Able to distinguish normal from abnormal PE findings B. Verbal Presentation Skills
Uses proper medical terminology Presents data in appropriate, logical sequence w/o commentary C. Writing Skills
Writes complete, thorough, well organized H&P Incorporates pertinent positive/negative information Daily notes are accurate, up-to-date, legible D. Clinical Reasoning
Appropriate knowledge of common problems Incorporates basic science knowledge Focus assessment on patient problems Suggests appropriate diagnostic & therapeutic management Incorporates team thinking into ongoing care E. Professional Behavior
Arrives prepared, on time, participates on rounds Accepts responsibility and criticism Demonstrates concern for patient. Conducts self professionally Works well with team/staff
The following scale will be used for each section above
Un-

Note: Comments from your evaluator should be provided for each section.
Please review your evaluation during the last week of each rotation with
your attending physician and resident.

Appendix G
Suggested Study Guide for Internal Medicine
Cardiology

How to diagnose and manage a patient with CHEST PAIN:
Distinguish cardiac from non-cardiac chest pain from history, physical examination and appropriate diagnostic studies.
How to diagnose and manage a patient with CAD:
Understand the spectrum of presentation of angina pectoris Know when a patient with angina should be hospitalized, Distinguish angina from myocardial infarction Know the pathophysiology of CAD and MI Know basic treatment regimens for CAD and MI – both inpatient and outpatient treatment plans – both pharmacological and non-pharmacological – including mechanisms of action, side effects, etc. Define risk factors for CAD and MI How to diagnose and manage a patient with HEART FAILURE (HF):
Understand the pathophysiology of heart failure, e.g. diastolic and systolic dysfunction and their causes; Starling's curve, preload, afterload and contractility Recognize symptoms and findings characteristic of HF Know basic treatment regimens for HF – pharmacological and non-pharmacological – including mechanisms of action, side effects, etc. How to diagnose and manage a patient with a HEART MURMUR:
Recognize clinical findings, historical and physical examination data, in aortic and mitral valve heart disease, including distinguishing stenotic from regurgitant valvular disease Recognize complications of aortic and mitral valvular heart disease Understand basic treatment regimens; understand the role of surgery in management of valvular heart disease
How to diagnose and manage a patient with PALPITATIONS:
Recognize the causes of palpitations, cardiac and non-cardiac Recognize common atrial and ventricular arrhythmias, including risk factors Distinguish benign from potentially lethal arrhythmias Know basic treatment regimens
Know how to read EKG's:
Recognize basic EKG electrical complexes, e.g. QRS, P waves Recognize basic arrhythmias – atrial and ventricular Recognize ischemic changes
Pulmonary

How to diagnose and manage a patient with pulmonary causes of DYSPNEA
Distinguish major patterns of obstructive and restrictive lung disease, i.e.
pathophysiology, clinical presentation, risk factors and diagnostic testing; including
Asthma, Emphysema, Chronic Bronchitis (COPD)
Understand pulmonary function tests, recognize the flow-volume loop profile of obstructive and restrictive diseases Understand the diagnostic value of arterial blood gases (ABG's); select treatment options in a patient with hypoxemia Be able to describe basic treatment regimens for common causes of dyspnea, i.e. basic treatment regimens for obstructive and restrictive disease Recognize features of impending respiratory failure Identify the pathologic process that can lead to respiratory failure Recognize the clinical and laboratory features and treatment of pulmonary embolus
How to diagnose and manage a patient with pulmonary causes of COUGH
Be able to describe the common causes of cough and distinguish non-pulmonary from pulmonary causes by clinical presentation and diagnostic testing Be able to describe basic treatment regimens for pulmonary causes of cough
How to diagnose and manage a patient with a respiratory disorder of ACID-BASE BALANCE
Recognize patterns of acute and chronic respiratory acidosis Recognize patterns of acute and chronic respiratory alkaloses Select treatment options in patients with hypercapnia
How to diagnose and manage a patient in with PULMONARY HYPERTENSION
Recognize disease processes that can lead to pulmonary hypertension Identify physical examination findings characteristic of pulmonary hypertension Select diagnostic tests in patients with suspected pulmonary hypertension Select treatment options for patients with suspected pulmonary hypertension
How to diagnose and manage a patient with a PLEURAL EFFUSION
Identify risk factors and physical exam findings in patients with pleural effusion Know how to evaluate a patient with a pleural effusion Distinguish transudative and exudative effusions Select treatment options in patients with pleural effusion
Gastroenterology

How to diagnose and manage a patient with ACID-PEPTIC DISEASES
Recognize the clinical features of peptic ulcer disease; distinguish peptic ulcer disease
from GERD and esophagitis clinical features; be able to describe common
complications and their manifestations
Be able to describe the common causes or predisposing factors for each syndrome Be able to describe appropriate diagnostic testing for each Be able to describe basic treatment plans for each syndrome
How to diagnose and manage a patient with JAUNDICE / CHOLESTASIS
Distinguish a hepatocellular from a cholestatic process Recognize clinical manifestations of liver dysfunction Recognize risk factors that contribute liver and biliary tract disease Identify common causes of drug induced cholestasis Identify common metabolic / systemic causes of cholestasis
How to diagnose and manage a patient with HEPATITIS

Recognize common causes of acute and chronic hepatitis Recognize the clinical manifestation of acute and chronic hepatitis Understand the viral etiologies of hepatitis Know how to interpret viral serology in acute and chronic liver disease Understand distinguishing features of alcohol induced liver disease Understand common causes of drug induced hepatocellular / cholestatic injury
How to diagnose and manage a patient with CIRRHOSIS

Be able to describe the pathophysiology of cirrhosis and its complications Be able to diagnose cirrhosis Be able to describe common causes of cirrhosis and how to evaluate a patient for these causes Be able to describe the clinical presentation of cirrhosis How to diagnoses and manage a patient with GASTROINTESTINAL BLEEDING
Distinguish upper from lower gastrointestinal bleeding. Recognize risk factors that predispose to upper or lower gastrointestinal bleeding Distinguish signs of acute and chronic gastrointestinal bleeding Be able to describe the appropriate diagnostic testing for GI bleeds, including work-up of guaiac positive stools Be able to describe appropriate management of a patient with GI bleeding How to diagnose and manage a patient with ACUTE ABDOMINAL PAIN
Understand distinguishing features of abdominal pain Understand pertinent physical findings Understand appropriate use of diagnostic tests for abdominal pain
How to diagnose and manage a patient with DIARRHEA
Understand the clinical presentation of Acute and Chronic Diarrhea; understand the
definition that distinguishes one from the other
Be able to describe the clinical presentation and tests that differentiates osmotic from secretory diarrhea; understand the pathophysiology for both Be able to describe the common causes of Acute and Chronic Diarrhea and how to
diagnose them
Be able to describe basic treatment regimens for common causes of diarrhea How to diagnose and manage a patient with NAUSEA AND VOMITING
Be able to describe the common causes for acute and chronic nausea and vomiting and
their clinical presentations
Be able to describe an appropriate diagnostic work-up for each Be able to describe basic treatment plans for common causes of nausea and vomiting
How to diagnose and manage a patient with DYSPHAGIA
Be able to describe the clinical presentation of common causes of dysphagia Be able to describe an appropriate diagnostic work-up and basic treatment plan for common causes of dysphagia Understand the pathophysiology of common causes of dysphagia
Endocrinology
Diagnosis and management of a patient with HYPERGLYCEMIA
Describe the clinical presentation, pathophysiology and diagnosis of diabetes; describe
the common complications and end organ damage associated with diabetes; describe the
risk or predisposing factors for diabetes
Describe the basic treatment regimens for diabetes, including pharmacological and non-
pharmacological
Describe the roles of physicians (primary care, endocrinology, ophthalmology, nephrology), nurses, dietitians, podiatrists, and other healthcare providers in optimizing the health outcomes for patients with diabetes Describe the pathogenic abnormalities that cause diabetic ketoacidosis (DKA) and non-
ketotic hyperosmolar state (NKHOS)
; describe the metabolic derangement that occurs
in patients with DKA; describe the clinical presentations of DKA and NKHOS and
common precipitating factors of DKA and NKHOS
Discuss the diagnosis, treatment and monitoring of patients with DKA and NKHOS
Diagnosis and management of a patient with HYPERCALCEMIA
Describe the homeostatic control of calcium and phosphorus metabolism Discuss the pathophysiologic mechanisms of causes of hypercalcemia Describe the clinical symptoms and findings in patients with hypercalcemia Discuss the pros and cons of available treatment options in patients with hypercalcemia
Diagnosis and management of a patient with ADRENAL INSUFFICIENCY
Describe the regulation of the hypothalamic-pituitary-adrenal axis Describe the clinical presentation of primary and secondary adrenal insufficiency Describe the general principles of management of patients with adrenal insufficiency
Diagnosis and management of a patient with THYROID DISEASE
Know how to interpret thyroid function tests Describe the clinical presentations, common causes and pathophysiology of
hypothyroidism and hyperthyroidism
Describe the basic treatment options for hypothyroidism and hyperthyroidism
Describe the clinical presentation, diagnostic work-up and basic treatment options for
thyroid nodules

Diagnosis and management of a patient with DYSLIPIDEMIAS
Describe the pathophysiology of common dyslipidemias Describe the work-up and basic treatment options (pharmacological and non-pharmacological) for common dyslipidemias Describe the common complications of dyslipidemias, e.g. pancreatitis, atherosclerotic diseases
Diagnosis and management of a patient with OSTEOPOROSIS
Describe the pathophysiology of osteoporosis Describe the diagnosis, screening, clinical presentation, pathologic versus natural aging, and basic treatment plans How to diagnose a patient with SECONDARY HYPERTENSION (HTN):
Understand the pathophysiology and epidemiology of secondary causes of HTN Know the various causes of secondary hypertension (e.g. pheochromocytoma, hyperaldosteronism, renal artery stenosis).
Nephrology
How to diagnoses and manage a patient with HYPONATREMIA / HYPERNATREMIA
Recognize the clinical findings in patients with hypo/ hypernatremia Understand the major causes of hypo/ hypernatremia Understand the classification of hypo / hypernatremia based on volume status Know how to evaluate a patient with hypo / hypernatremia Select proper therapy for patients with hypo/ hypernatremia
How to diagnoses and manage a patient with HYPOKALEMIA/ HYPERKALEMIA
Recognize the clinical findings of patients with hypo/ hyperkalemia Understand the major causes of hypo/hyperkalemia Understand the classification system for hypo/hyperkalemia Know how to evaluate a patient with hypo / hyperkalemia Select proper therapy for patients with hypo/ hyperkalemia
How to diagnose and manage a patient with metabolic disorders of ACID-BASE BALANCE
Recognize the clinical findings of patients with metabolic acidosis and alkalosis Recognize the major causes of metabolic acidosis and alkalosis Understand the clinical evaluation of a patient with an acid / base disorder Distinguish causes of normal and elevated anion gap metabolic acidosis Select proper therapy for patients with metabolic acidosis and alkalosis
How to diagnoses and manage a patient with ELEVATED BUN/CREATININE
Recognize clinical features of patients with acute or chronic renal failure; be able to
distinguish between them; be able to define either acute or chronic renal failure
Understand risk factors and causes for development of acute or chronic renal failure
Distinguish pre-renal, renal and obstructive causes of acute renal failure
Distinguish glomerular from tubulointerstital disease in patients with renal failure
Recognize common complications seen in patients with renal failure – acute or chronic
Be able to describe indications for dialysis in the management of renal failure; be able to
describe basic management of acute or chronic renal failure.

How to diagnose a patient with NEPHROTIC or NEPHRITIC syndromes
Recognize the clinical features of each syndrome; be able to define each syndrome Be able to describe the causes or predisposing factors for each syndrome Be able to describe basic diagnostic testing for each Be able to describe basic management issues for each
How to recognize and diagnose a patient with RENOVASCULAR HYPERTENSION
Recognize the clinical features of renovascular hypertension
Be able to describe the causes or predisposing factors for this disease Be able to describe basic diagnostic testing
How to diagnose and manage a patient with NEPHROLITHIASIS
Recognize the clinical features of patients with acute stone disease Be able to describe the natural history and epidemiology of stone disease Be able to describe the basic diagnostic and management work-up of a patient with stone disease Be able to describe basic treatment of a patient with stone disease
Geriatrics
How to diagnose and manage a patient with DELIRIUM or DEMENTIA
Recognize delirium or dementia in elderly patients
Obtain relevant historical information in a patient with delirium or dementia
Develop a differential diagnosis for delirium or dementia
Distinguish delirium from dementia and other related conditions
How to diagnose and manage a patient who FALLS
Obtain relevant historical information in a with a history of falls Recognize the complications of falls Develop a differential diagnosis for the causes of falls Recruit ancillary services for the treatment of a patient with falls How to diagnose and manage a patient with PRESSURE SORES
Recognize preventive measures to avoid pressure sores Understand different treatment modalities for pressure sores Identify the complications of pressure sores How to diagnose and manage ACUTE URINARY INCONTINENCE
Distinguish between acute and established urinary incontinence Understand the causes of acute urinary incontinence Appreciate the appropriate treatment of acute urinary incontinence How to diagnose and treat CONSTIPATION
Recognize preventive measures to avoid constipation Identify the complications of constipation How to coordinate DISCHARGE PLANNING
Understand the importance of functional ability of patients to be discharged Identify appropriate resources and social supports for patients to be discharged Recognize the need for convalescent care for patients to be discharged
Infectious Diseases

How to diagnose and manage a patient with FEVERS
Describe the pathophysiology of fevers, definition of pathologic fever, common treatments of fever. Know the basic workup for fever
How to select ANTIMICROBIALS
Recognize clinical signs of infection requiring antimicrobial use Distinguish signs and symptoms of bacterial, viral, and fungal infection Know the antimicrobial activity of the major classes of Know the toxicity of the major antibiotic classes Know basic treatment options for common infections or infectious presentations
How to diagnose a patient with MENINGITIS OR ENCEPHALITIS
Know the most common organisms that cause meningitis encephalitis (i.e. bacterial vs. viral), including risk or predisposing factors for different micro-organisms Know distinguishing features of aseptic meningitis vs. bacterial meningitis Know the clinical features and presentation of meningitis or encephalitis, including risk or predisposing factors Know the basic diagnostic work up for meningitis or encephalitis Know basic treatment regimens for both meningitis and encephalitis How to recognize infections with IMPARED IMMUNE RESPONSE
Know the definition and classification system for HIV infection Know the T cell and B cell defects that occur in HIV infection Know the initial work-up of an HIV positive patient Know the most important causes of pneumonia, intracranial infection and retinitis in patients with AIDS Know the most likely organisms that cause infection in patients with humoral deficiencies, neutropenia and deficiencies in cellular function Know the approach to evaluation and therapy of a febrile neutropenic patient How to manage a patient with INFECTIVE ENDOCARDITIS (IE)
Know the pathogenesis of IE: turbulence, endothelial damage, nonbacterial thrombus formation Know the valvular abnormalities that predispose to IE Know the most common organisms that cause native valve and prosthetic valve endocarditis Know the common physical examination findings and clinical complications that are associated with IE Know the diagnostic value of echocardiography and blood cultures in IE Know the general principles of antimicrobial therapy in patients with IE Know the common indications for antimicrobial prophylaxis of IE in susceptible individual
How to diagnose and manage a patient with TUBERCULOSIS
Recognize screening tests and populations at risk for infection Recognize clinical presentation of disease Recognize treatment options and indications for adverse effects of drug therapy
How to diagnose and manage a patient with SOFT TISSUE AND BONE INFECTIONS
Recognize populations as risk for infection Know microbiology and pathophysiology of disease Recognize clinical presentation of disease, especially for cellulitis and osteomyelitis,
common diagnostic tests
Recognize basic treatment/management plans How to diagnose and manage a patient with LOWER RESPIRATORY TRACT INFECTIONS
Be able to describe the clinical presentation, diagnosis, predisposing factors,
pathophysiology and microbiology of bronchitis and pneumonia
Be able to describe basic treatment regimens bronchitis and pneumonia

Rheumatology

How to diagnose and manage a patient with ARTHRITIS
Be able to describe the clinical presentation, pathophysiology and diagnosis of
osteoarthritis, rheumatoid arthritis and infectious arthritis
Be able to discuss how to evaluate patients with musculoskeletal complaints Be able to describe basic treatment regimens for the above diseases
How to diagnose and manage a patient with a CYRSTALLINE ARTHRITIS
Be able to describe the clinical presentation, pathophysiology and diagnosis of gout
versus pseudogout

Be able to describe basic treatment regimens for the above diseases
How to diagnose and manage a patient with an AUTOIMMUNE DISEASES
Recognize the clinical features and complications of systemic lupus erythematosus
Recognize the clinical features and complications of scleroderma
Recognize the clinical features and complications of polymyositis/dermatomyositis

How to appropriately order IMMUNOLOGIC TESTS
Understand the appropriate use of immunologic tests Understand the clinical utility of specific immunologic tests Hematology/Oncology

How to diagnose and manage a patient with abnormal BLEEDING
Distinguish disorders of primary hemostasis (e.g. dysfunctional platelets, thrombocytopenia) vs. secondary hemostasis (e.g. clotting factor deficiencies, hemophilia) Understand the coagulation cascade and the rational use of lab studies in the diagnosis of bleeding disorders Recognize clinical features of bleeding disorders Understand the blood components available for blood transfusion Understand the potential complications of transfusion of blood and the appropriate clinical management
How to diagnose and manage a patient with ANEMIA
Recognize common clinical and laboratory findings in patients with anemia Classify anemia by blood count indices and reticulocyte counts Distinguish hypoproliferative and hyperproliferative anemia Determine appropriate therapies for anemia
How to diagnose and manage a patient with a MYELOPROLIFERATIVE or
LYMPHOPROLIFERATIVE DISORDER

Be able to recognize the common diseases of Leukemia, Lymphoma and Multiple
Myeloma
– clinical presentation, pathognomic features, general pathophysiology, basic
diagnostic work-up and general approaches to therapy

How to diagnose COMMON MALIGNANCIES
Be able to describe the clinical presentations of common malignancies, i.e. breast, lung
and colon cancer

Be able to describe appropriate diagnostic testing for lung nodule, breast nodule/mass, guaiac positive stools
How to diagnose and manage COMPLICATIONS OF CANCER
Recognize the common complications and their presentations of cancer including malignant pleural effusion, cord compression, tumor lysis syndrome, hypercalcemia, superior vena cava syndrome – Be able to recognize the clinical presentations of oncologic emergencies - SVC cord compression, hypercalcemia Recognize the general therapeutic to treatment of common cancer complications How to provide a cancer patient with SUPPORTIVE CARE
Understand the principles of effective pain management in patients with cancer Understand obstacles to effective pain management in patients with cancer Understand the skills needed to cope with quality of life and end-of-life issues in cancer patients and their families General Internal Medicine

How to diagnose and manage a patient with ESSENTIAL HYPERTENSION (HTN):
Understand the pathophysiology and epidemiology of HTN Know the definition of HTN and the common causes and risk factors Know basic treatment regimens, pharmacological and non-pharmacological; know basic classes of agents mechanism of action and side effects How to diagnose and manage a patient with TYPE 2 DIABETES
Describe the clinical presentation and pathophysiology of type 2 diabetes
Describe the common complications and end organ damage associated with type 2
diabetes
Describe the risk or predisposing factors for type 2 diabetes
Describe the basic treatment regimens for type 2 diabetes, including pharmacological
and non-pharmacological
Describe the roles of physicians, nurses, dietitians, podiatrists, and other healthcare providers in optimizing the health outcomes for patients with diabetes How to provide health maintenance screenings for the general adult population:
Know the differences between the American Cancer Society and United States Preventative Services Task Force guidelines for cancer screening for the commonly screened malignancies (e.g. colorectal cancer, breast cancer, prostate cancer, and cervical cancer). Know the risks and benefits of cancer screening. Know the indications for early screening for osteoporosis
How to provide routine immunizations for the general adult population:
Know the guidelines for providing routine immunizations for the general adult population (e.g. influenza vaccine, pneumococcal vaccine, tetanus vaccine, and Zoster vaccine). How to conduct a preoperative evaluation and assess for cardiac risk
Know the ACP and AHA guidelines on preoperative cardiac risk assessment. Know the indications for a preoperative cardiac work up.
How to provide general medical care to the hospitalized patient:
Know how to prevent DVT's in hospitalized patients. Know the indications for intravenous fluids. Be able to describe the various intravenous fluids available and their common indications (e.g. volume expansion in the hypotensive patient) Ethical and Professional Issues
How to provide medical care in an ethically responsible manner Understand and describe the basic principles behind informed consent, patient autonomy, right to refuse treatment, patient confidentiality, breaking bad news, end of life discussion and advance directives Demonstrate ability to obtain appropriate informed consent, including understanding role of surrogate decision makers, determination of decisional capacity, and ability to maintain patient confidentiality. Demonstrate ability to participate with the team in treatment decisions including DNR decisions, the use of advance directives and palliative care. How to behave in an acceptably professional manner Understand the elements of professional behavior, e.g. demonstrating integrity and accepting responsibility, respecting patients and other members of the healthcare team, and accepting criticism Demonstrate professional behavior, e.g. accepts responsibility for actions and information, accepts feedback and makes positive changes, demonstrates compassion for patients and family. How to effectively communicate with patients and family Demonstrates ability to establish rapport with family and patients Understands key concepts in effective communication with a variety of patients, e.g. angry, seductive, non-compliant. Note: The learning objectives should provide a strong format for your NBME shelf exam preparations. It is also recommended that you take practice quizzes provided in many standardized board review books. This syllabus was prepared by Clerkship Directors Karen Szauter M.D. (UTMB Galveston) Bernard Karnath M.D. (UTMB Galveston) Toni Hickerson Last Edited on 6/22/2014

Source: https://som.utmb.edu/Educational_Affairs/OCE/Documents/IMClerkshipSyllabus.pdf

mpmo.gc.ca

PROJECT AGREEMENT FOR THE QUEBEC LITHIUM SPODUMENE MINE IN PREAMBLE WHEREAS the Government of Canada is committed to improving the efficiency of the federal environmental assessment (EA) and regulatory review processes for major resource projects to enable a more effective assessment and mitigation of potential environmental effects, while protecting the health and safety of Canadians and promoting innovation and competitiveness within the Canadian resource industry sectors; AND WHEREAS the Government of Canada is committed to undertaking a process of early, effective and meaningful consultation with Aboriginal groups, including Treaty First Nations, Non-Treaty First Nations, Métis and Inuit people, concerning contemplated federal Crown (Crown) conduct with respect to, among other things, major resource projects that may adversely affect established or potential Aboriginal and treaty rights under Section 35 of the Constitution Act, 1982; AND WHEREAS the Government of Canada has created the Major Projects Management Office (MPMO) for the purpose of overseeing and tracking the federal review, which includes the EA, regulatory reviews and Aboriginal consultation activities for major resource projects; AND WHEREAS Quebec Lithium Inc. (the Proponent) has submitted a project description in support of its proposed 3,800 tonnes per day open-pit spodumene mine located about 60 km north of Val-d'Or, 38 km south-east of Amos and 15 km south-west of Barraute, Quebec; AND WHEREAS the Canadian Environmental Assessment Agency (CEA Agency) has commenced a comprehensive study pursuant to the former Canadian Environmental Assessment Act (CEAA)1; AND WHEREAS the CEA Agency and Fisheries and Oceans Canada (DFO) have regulatory and statutory duties in relation to the proposed project; AND WHEREAS nothing in this Project Agreement (the Agreement) fetters the powers, statutory authorities and functions of federal departments/agencies and their respective Ministers; NOW THEREFORE the signatories (the Parties) to this Agreement commit to work together to facilitate an effective, accountable, transparent, timely and predictable federal review in relation to the proposed project and to contribute to fulfilling the Crown's duty to consult with Aboriginal groups.

azen.com.sg

Information and Recommendations for the Engineer Fan Bearing Maintenance & Troubleshooting LubricationProper lubrication and maintenance are essential for long possible, the proper level with the fan on must be bearing life. An adequate supply of clean lubricant must marked on the level also. Oil can be blown out of bear- be present at all times to prevent damaging, metal-to-