Internal Medicine and Medical Specialties I

3rd Year Clinical Rotation: Internal Medicine I Page 1

Edward Via College of Osteopathic Medicine

3rd Year Clinical Rotation: Internal Medicine I

ROTATION SYLLABUS

I. Rotation Description

As clinicians, teachers, and researchers, our internal medicine faculty members are committed to the college's mission to provide medical education and research that prepares globally minded, community-focused physicians and to improve the health of those most in need. Over 300 strong and growing, the Internal Medicine clinical faculty are practicing in affiliated teaching hospitals for VCOM. The Internal Medicine faculty are passionate about medicine and medical education. The Internal Medicine faculty include those practicing primary care internal medicine, hospital medicine, and those who practice in the full range of sub-specialties. Sharing the college's mission, and leading by

Teresa Kilgore, D.O., FACOI

Chair, Internal Medicine Carolinas Campus

Phone: 864-237-9817 [email protected]

Donald Langley, D.O. Chair, Internal Medicine

Auburn Campus Phone: 334-442-4011

[email protected]

Peter Recupero, D.O., FACP, FACOI

Co-Chair, Internal Medicine Virginia Campus

Phone: 540-231-0013 [email protected]

Megan Thomas, D.O., FAAP, FACP,

FACOI Chair, Internal Medicine

Virginia Campus Phone: 540-231-0375

[email protected]

mailto:[email protected]




3rd Year Clinical Rotation: Internal Medicine I Syllabus Page 2 of 18

example, members of our faculty provide volunteer care for the under-served in regional free clinics, and on international medical missions. During the third year internal medicine rotations, students expand their knowledge of adult health and wellness, preventative, primary, secondary and tertiary care. They learn about the treatment of acute and chronic medical conditions, palliative and end of life care and gain the ability to apply this knowledge in the clinical setting. The curriculum is taught through on-line interactive SIMPLE cases, assigned readings, bedside and clinic teaching, journal clubs, tumor boards, grand rounds, and through one-on-one student-preceptor experience in caring for patients in the clinical setting.

Students are expected to complete their assignments for both internal medicine and the longitudinal OMM course. The Core Internal Medicine rotations include inpatient and outpatient exposure, as well as general internal medicine and medical sub-specialty exposure. The practice of internal medicine occurs in the private, public and governmental clinic settings, in long-term care facilities, in inpatient institutional settings and in the emergency departments of hospitals and institutions. Due to the variety of practice opportunities and formats in internal medicine rotations, students should review their specific site instructions for a more detailed description of their specific practice setting.

II. Course Goals and Objectives A. Goals of the Course

To acquire the knowledge, skills and competencies that are required to evaluate and treat patients with acute and chronic medical conditions commonly found in the adult at a level consistent with a graduating generalist medical student.

To develop the physical examination and clinical skills required of a graduate medical student in general internal medicine practice, including the ability interpret information relative to normal and abnormal structure, function and physiology.

To apply historical and clinical information for problems solving to advance the health of the patient.

To develop the psycho-social and communication skills and competencies that are required to communicate with, and treat a wide diversity of patients in acute, outpatient and institutional settings.

To develop the ability to research medical literature and scientific resources for information that affects the patient’s condition, treatment and outcomes and the ability to evaluate and apply scientifically valid information to maximize the outcome of the patient.

To develop knowledge, skill application and understanding of the indications, contraindications and application of medical procedures and therapies common to the specialty, including but not limited to ordering and interpretation of diagnostic studies, utilization of pharmacological agents, psychological and nutritional therapies, incorporation of osteopathic principles and practices into the patient’s care, and clinical procedures such as central line placement, lumbar punctures, intubation, management of ventilators, etc.

B. Clinical Performance Objectives

While the end-of-rotation exam is derived from the didactic curriculum and objectives described above in the “Clinical Modules – Required Curriculum” section, the end-of-rotation evaluation completed by your family medicine preceptor is based on clinical core competencies. These core competencies reflect student performance in 6 key areas: communication, problem solving, clinical skills, medical knowledge, osteopathic medicine and professional and ethical considerations. Your end-of-rotation evaluation from your preceptor will be based directly on your performance in these 6 core competencies as described below.

http://intranet.vcom.edu/clinical/Login/index.cfm?fuseaction=LoginInfo&LoginPage=IM


1. Communication - the student should demonstrate the following clinical communication skills:

a. Effective listening to patient, family, peers, and healthcare team b. Demonstrates compassion and respect in patient communications c. Effective investigation of chief complaint, medical and psychosocial history specific

to the rotation d. Considers whole patient: social, spiritual & cultural concerns e. Efficiently prioritizes essential from non-essential information f. Assures patient understands instructions, consents & medications g. Presents cases in an accurate, concise, well organized manner

2. Problem Solving – the student should demonstrate the following problem solving skills: a. Identify important questions and separate data in organized fashion organizing

positives & negatives b. Discern major from minor patient problems c. Formulate a differential while identifying the most common diagnoses d. Identify indications for & appliy findings from the most common radiographic and

diagnostic tests e. Identify correct management plan considering contraindications & interaction

3. Clinical Skills - the student should demonstrate the following problem solving skills: a. Assesses vital signs & triage patient according to degree of illness b. Perform good auscultory, palpatory & visual skills c. Perform a thorough physical exam pertinent to the rotation

4. Osteopathic Manipulative Medicine - the student should demonstrate the following skills in regards to osteopathic manipulative medicine

a. Apply osteopathic manipulative medicine successfully when appropriate b. Perform and document a thorough musculoskeletal exam c. Utilize palpatory skills to accurately discern physical changes that occur with various

clinical disorders d. Apply osteopathic manipulative treatments successfully

5. Medical Knowledge – the student should demonstrate the following in regards to medical knowledge

a. Identify & correlate anatomy, pathology and pathophysiology related to most disease processes

b. Demonstrate characteristics of a self-motivated learner including demonstrating interest and enthusiasm about patient cases and research of the literature

c. Are thorough & knowledgeable in researching evidence based literature d. Actively seek feedback from preceptor on areas for improvement e. Correlate symptoms & signs with most common disease

6. Professional and Ethical Behaviors - the student should demonstrate the following professional and ethical behaviors and skills:

a. Is dutiful, arrives on time & stays until all tasks are complete b. Consistently follows through on patient care responsibilities c. Accepts & readily responds to feedback, is not resistant to advice d. Assures professionalism in relationships with patients, staff, & peers e. Displays integrity & honesty in medical ability and documentation f. Acknowledges errors, seeks to correct errors appropriately g. Is well prepared for and seeks to provide high quality patient care h. Identifies the importance to care for underserved populations in a non-judgmental &

altruistic manner


III. Rotation Design A. Educational Modules

Educational modules using lectures, cases, and other forms of delivery are used for third year curriculum. Each student must complete a post-rotation exam to assure that the expected basic content or medical knowledge has been acquired during the rotation. In addition to the experiences received in the clinical training sites, students are expected to read the content of the assigned textbooks and on line materials in order to complete the entire curriculum assigned for the clinical module.

B. Formative Evaluation Student competency based rating forms are used by the preceptor to evaluate each student’s clinical skills and the application of medical knowledge in the clinical setting. These forms are only completed by the clinical faculty member or preceptor. Performance on rotations will be evaluated by the primary clinical faculty member precepting the student. VCOM uses a competency based evaluation form which includes the osteopathic core competencies. These competencies evaluated include:

a. Medical knowledge; b. Communication; c. Physical exam skills; d. Problem solving and clinical decision making; e. Professionalism and ethics; f. Osteopathic specific competencies; and g. Additional VCOM values.

Student competency is judged on clinical skill performance. Each skill is rated as to how often the

student performs the skill appropriately (i.e. unacceptable, below expectation, meets expectation, above expectation, exceptional).

C. Procedure Log Students are required to maintain a log to identify the procedures performed, and the number of

essential patient encounters. The faculty member will verify the information at the end of the rotation either online using a password signature, or by signing the log.

IV. Credits 5 credit hours

V. Course Texts A. Required Textbooks

The American College of Physicians. (2015). IM essentials text. Author. ISBN-13: 978-1938921094 Electronic format is available only if purchased or if hard copy of text is purchased.

Kuchera, M. & Kuchera, W. (1994). Osteopathic considerations in systemic dysfunction (Rev 2nd ed.). Dayton, OH: Greyden Press. ISBN: 978-1570741548

American Osteopathic Association, & Chila, A. Foundations of osteopathic medicine (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins. ISBN: 978-0781766715 Available in electronic format on the VCOM Library – on LWW Osteopathic Medicine Collection


VI. Course Grading and Requirements for Successful Completion

A. Requirements Attendance according to VCOM and preceptor requirements as defined in the College Catalog

and Student Handbook. Completion of all Clinical Modules in the required curriculum. Completion of a minimum of 10 Aquifer Internal Medicine SIMPLE cases from the Required

Curriculum. Ten (10) cases must be completed during the IM 2 rotation (the Introductory case does not count as one of your cases). Please note: To get full credit for each case you complete, please be sure to click to the page at the end of the case that states “Summary of Your Case Session” in the upper left hand corner. The color of each case shown in the list of cases you complete shows the level of engagement. You must have a green color (good) to get credit for the case. You will not get credit for any cases that have a yellow color (moderate) or a red color (low) level of engagement. If you have a case with a yellow or red color, you can either choose a different case to work through or you can contact Clinical Affairs to reset the original case for you to work through again.

o Register for the Aquifer cases:

Go to https://www.aquifer.org

If you are a first-time user:

Click “Sign in” in the top right corner.

Enter your institutional email address in the email box. Then click on the “Register” button at the bottom of the page.

You will be sent an email with a link to complete registration. Upon receipt of the registration email, click on the link “Click Here“. You will then be brought to the profile setup page. An email will be sent to you. Follow the instructions in the email to setup your account.

You will be asked to fill in your profile information and set up a password (8 character minimum).Once you have completed your user profile and created a password, you will receive a welcome email with links to useful information and guides. You would also be logged into the Aqueduct learning management system.

Once your profile is completed successfully, you will be brought to your institution’s Course page.

You will also receive a “Thank you for registering with Aquifer” email with links to tools, resources, and Aquifer news.

If you are a returning user:

Click “Sign in” in the top right corner.

Please log in with your institutional email and account password and click “Sign In”.

Procedure Log:

o Please submit completed procedure logs electronically on the VCOM Portal by the last day of the rotation.

o Please print out a copy of the procedure log. o During the rotation, keep track of the number of each procedures you perform or

witness. o At the end of the rotation, your preceptor must review and sign the procedure log. o Input the number of each procedure into the electronic log on the Portal once

rotation has been completed. Please see the website at:

http://www.vcom.edu/handbooks/catalog/index.html


https://www.aquifer.org/

http://www.vcom.edu/academics/clinical-procedure-logs


www.vcom.edu/sites/default/files/clinical/files/On-line%20Procedure%20Logs%20Instructions.pdf for instructions. Note: Once this information is submitted, you cannot re-enter the log on the Portal.

o Keep the signed paper copy for your records. (It does not need to be turned into the site coordinator or VCOM.)

Rotation Evaluations: o Student Site Evaluation: Students must complete and submit at the end of rotation. See

the VCOM website at: http://intranet.vcom.vt.edu/clinical/Login/index.cfm?fuseaction=LoginInfo&LoginPage=ViewStudentSchedule to access the evaluation form.

o Third-Year Preceptor Evaluation: It is the student's responsibility to ensure that all clinical evaluation forms are completed and submitted online or turned in to the Site Coordinator or the Clinical Affairs Office at the completion of each rotation. Students should inform the Clinical Affairs Office of any difficulty in obtaining an evaluation by the preceptor at the end of that rotation. See the VCOM website at: www.vcom.edu/academics/clinical-forms to access the evaluation form.

o Mid-Rotation Evaluation: The mid-rotation evaluation form is not required but highly recommended. See the VCOM website at: www.vcom.edu/academics/clinical-forms to access the mid-rotation evaluation form.

Successful completion of the end-of-rotation written exam. The end-of-rotation exam questions

will be derived directly from the specific objectives presented in each of the below modules.

B. Grading Students must pass both the "module" and "rotation" portions of the course. All rotations have a clinical rotation grade and clinical modules/exam grade. The clinical rotation grade uses the Honors, High Pass, Pass, Fail system; these grades are not calculated in the GPA. The rotation modules are assigned an exam grade.

Clinical Grading Scale and GPAs

OMS 3 End-of-Rotation Exam Grades

OMS 3 AND OMS 4 Clinical Rotation Grades

Other Grades

A 90-100 4.0 H Honors IP In Progress

B+ 85-89 3.5 HP High Pass INC Incomplete

B 80-84 3.0 P Pass CP Conditional Pass

C+ 75-79 2.5 F Fail R Repeat

C 70-74 2.0 Au Audit

F <70 0.0

B. Remediation

Students who fail one or more rotations or one or more end-of-rotation exams twice will be referred to the Promotion Board. If a student fails the professionalism and ethics portion of the evaluation he or she may be removed from the rotation and referred to the Professionalism and Ethics Standards Board. No grade will be changed unless the Office of Clinical Affairs certifies to the Registrar, in writing, that an error occurred or that the remediation results in a grade change.

Failure of an End-of-Rotation Exam Students must pass each end of rotation exam with a C (70%) or better to receive a passing grade for the clinical medical knowledge module. Students who fail an end of rotation exam but

http://www.vcom.edu/sites/default/files/clinical/files/On-line%20Procedure%20Logs%20Instructions.pdf

http://www.vcom.edu/sites/default/files/clinical/files/On-line%20Procedure%20Logs%20Instructions.pdf

http://intranet.vcom.vt.edu/clinical/Login/index.cfm?fuseaction=LoginInfo&LoginPage=ViewStudentSchedule

http://intranet.vcom.vt.edu/clinical/Login/index.cfm?fuseaction=LoginInfo&LoginPage=ViewStudentSchedule

http://www.vcom.edu/academics/clinical-forms



pass the clinical rotation evaluation component have a second opportunity to pass the exam within 30 days of notification. If the student passes the remediation exam, the remediated exam grade will be the grade recorded on the transcript and be GPA accountable. If the student fails the second attempt at the end-of-rotation exam, an F is recorded for the exam grade, and the student will be brought before the Promotion Board.

Failure of a Rotation The student who does not receive a satisfactory evaluation for a clinical rotation in the second semester will receive a failing grade for the rotation and will be brought before the Promotion Board. If the student is allowed to repeat the rotation, all components of the rotation must be repeated. In this case, the “F” grade remains the permanent grade for the first rotation and the student will receive a new grade for the repeated rotation. The grade will be recorded in a manner that designates that it is a repeated rotation (eg. R-pass).

Failure to Make Academic Progress Repeated poor a failing performance in a specific competency area on the evaluation form across more than one rotation may also be a reason for a required remediation at the discretion of the Associate Dean for Clinical Affairs in consultation with the clinical chair and the preceptor, and the Promotion Board. In general, rotations should show a progression of improvement in clinical performance. Those students who continually score in the "unsatisfactory" category or repeated "performs some of the time, but needs improvement" and who do not improve over time may be deemed as not making academic progress and, as a result, may be referred to the Promotion Board and be required to complete additional curriculum. Poor ratings on the clinical rotation evaluation in the professional and ethical areas of the assessment are addressed by the Associate Dean for Clinical Affairs. The Associate Dean may design a remediation appropriate to correct the behavior or if needed may refer the student to the Professionalism and Ethics Board. In the case of repeated concerns in a professional and/or ethical area, the Associate Dean for Clinical Affairs may refer the student to the Campus Dean for a Behavioral Board or Promotion Board hearing. The Campus Dean will act upon this referral depending on the severity and the area of the performance measure. Poor ratings in this area will include comments as to the exact nature of the rating.

VII. Academic Expectations Grading policies, academic progress, and graduation requirements may be found in the College Catalog and Student Handbook at: http://www.vcom.edu/handbooks/catalog/index.html A. Attendance

Attendance for all clinical rotations is mandatory. Students are required to work a minimum of 20 days in a four week rotation period but should not work greater than 12 out of every 14 days or more than 12 hours daily exclusive of call assignments. Students may be required to work up to 24 days in a 4 week period or 25 days in a one month rotation including call and weekends at the discretion of the clinical faculty member providing the educational experience. For those rotations consisting of shift work such has Emergency Medicine or Hospitalist services, students should work a minimum of 160 and up to 200 hours for the month as required by the clinical site. It should be noted that preceptors will have final determination of the distribution of hours, which may vary from this policy but should not in general be less than 160 hours. Students must complete an Excused Absence Clinical Rotations Approval form. Forms are available at: www.vcom.edu/academics/clinical-forms . The Office of Clinical Affairs requires that the medical student complete and submit this form for any time "away" from clinical rotations. The student must




have this form signed by their preceptor and others designated on the form to obtain an excused absence. The form must be completed prior to the beginning of the leave. If an emergency does not allow the student to submit this prior to the absence, the “Excused Absence Clinical Rotations Approval” form must be submitted as soon as the student is physically able to complete the form. In addition to completion of the form, students must contact the Department of Clinical Affairs by 8:00 AM of the day they will be absent due to an illness or emergency and contact the Site Coordinator and preceptor(s). No excused absence will be granted after the fact except in emergencies as verified by the Associate Dean for Clinical Affairs. Regardless of an excused absence, students must complete a minimum of 160 hours. OMS 3 students who have any unexcused absences will be referred to the Promotion Board and/or Professional and Ethics Standards Board as determined by the Associate Dean. Clinical site coordinators and preceptors document attendance on the student’s rotation evaluation form. This information is reviewed by the Director of 3rd Year Clinical Rotations and the Associate Dean for Clinical Affairs. A student is expected to arrive on time to all clinical rotations. If a student is late, he or she must notify the site coordinator and the preceptor prior to or at the time they are scheduled arrive. Students must have a reason for being late such as illness or vehicle issues and it is not anticipated that this would occur more than one occasion AND it is important the student call in prior to being late. Repeated tardiness is a reason for a referral to the Promotion Board and/or Professional and Ethics Standards Board as determined by the Associate Dean. Any time missed must be remediated during the course of the month for credit to be issued. Students may remediate up to four missed days or 48 hours missed during any rotation period by working on normal days off.

VIII. Professionalism and Ethics It is advised that students review and adhere to all behavioral policies including attendance, plagiarism, dress code, and other aspects of professionalism. Behavioral policies may be found in the College Catalog and Student Handbook at: http://www.vcom.edu/handbooks/catalog/index.html A. VCOM Honor Code

The VCOM Honor Code is based on the fundamental belief that every student is worthy of trust and that trusting a student is an integral component in making them worthy of trust. Consistent with honor code policy, by beginning this exam, I certify that I have neither given nor received any unauthorized assistance on this assignment, where “unauthorized assistance” is as defined by the Honor Code Committee. By beginning and submitting this exam, I am confirming adherence to the VCOM Honor Code. A full description of the VCOM Honor Code can be found in the College Catalog and Student Handbook at: http://www.vcom.edu/handbooks/catalog/index.html

IX. Clinical Modules

1. Acute Coronary Syndrome Reading Assignment:

IM Essentials Text o Chapter 1 (Cardiovascular Medicine: Approach to Chest Pain) o Chapter 3 (Cardiovascular Medicine: Acute Coronary Syndrome)

Online Case: Aquifer SIMPLE Case 1 Learning Objectives:

i. Create a differential diagnosis of acute chest pain and narrow the differential based on specific physical exam and history findings.





ii. Define and discuss the pathogenesis, signs, and symptoms of the acute coronary syndromes. iii. List cardiovascular risk factors iv. Predict the primary and secondary prevention of ischemic heart disease. v. Develop an appropriate diagnostic and treatment plan—including recommended lifestyle

modifications—for a patient presenting with acute coronary syndrome

2. Ischemic Heart Disease Reading Assignment: IM Essentials Text: Chapter 2 (Cardiovascular Medicine: Chronic Stable Angina) Online Case: Aquifer SIMPLE Case 2 Learning Objectives:

i. Identify the symptoms and signs of chest pain characteristic of angina pectoris. ii. Categorize the patients’ symptoms as angina pectoris, atypical angina, or non-cardiac chest pain. iii. Obtain, document, and present an appropriately complete medical history that differentiates

among the common etiologies of chest pain. iv. Obtain a history of a patient with chest pain that contains information about those clinical

characteristics that are typical of angina pectoris and includes risk factors of coronary heart disease.

v. Perform a physical exam that includes identifying the presence of dyspnea and anxiety, obtaining accurate vital signs, and performing heart, lung, and vascular exams.

vi. Order appropriate laboratory and diagnostic studies based on patient demographics and the most likely etiologies of chest pain.

vii. Recommend primary and secondary prevention of ischemic heart disease through the reduction of cardiovascular risk factors (e.g. controlling hypertension and dyslipidemia, aggressive diabetes management, avoiding tobacco, and aspirin prophylaxis)

viii. Prescribe appropriate anti-anginal medications when indicated and communicate potential

3. Arrhythmias & Disorders of Cardiac Output Reading Assignment:

IM Essentials Text o Chapter 4 (Cardiovascular Medicine: Conduction Blocks and Bradyarrythmias) o Chapter 5 (Cardiovascular Medicine: Supraventricular Arrhythmias) o Chapter 6 (Cardiovascular Medicine: Ventricular Arrhythmias) o Chapter 40 (General Intern Medicine: Approach to Syncope)


i. List the common causes of syncope. ii. Determine the important aspects of the history and physical exam in a patient with syncope. iii. Discuss the approach to the evaluation and treatment of a patient with syncope. iv. Identify atrial fibrillation on an electrocardiogram. v. List the common causes of atrial fibrillation. vi. Discuss the approach to the evaluation and treatment of a patient with atrial fibrillation

(including stroke risk scoring). vii. Explain how atrial fibrillation and mitral stenosis may lead to syncope. viii. List indications for permanent pacing. ix. Identify a bundle branch block on electrocardiogram. x. Define SA node disease. xi. Discuss management of a left bundle branch block xii. Define Long QT syndrome and its risk factors xiii. Predict treatment regimens for ventricular tachycardia (including torsades de pointes)




4. Congestive Heart Failure Reading Assignment:

IM Essentials Text o Chapter 7 (Cardiovascular Medicine: Heart Failure) o Chapter 8 (Cardiovascular Medicine: Valvular Heart Disease) o Chapter 90 (Pulmonary Medicine: Approach to Dyspnea)


i. Interpret neck vein findings for jugular venous distention (JVD) and abdominal jugular reflux. ii. Identify and translate auscultatory findings of the heart including rate, rhythm, S3/S4, and

murmurs. iii. List the major pathologic states that cause dyspnea. iv. Compare the differing etiologies and signs of left-sided vs. right-sided heart failure. v. Utilize the staging system for heart failure. vi. Discuss the factors leading to symptomatic exacerbation of HF, including ischemia, arrhythmias,

anemia, hypertension, thyroid disorders, non-compliance with medications and dietary restrictions, and use of non-steroidal anti-inflammatory drugs (NSAIDS).

vii. Interpret B-type natriuretic peptide (BNP) results. viii. Recommend pharmacologic management of heart failure. ix. Define grading of the intensity of cardiac murmurs. x. Describe the murmur, etiology and treatment of aortic stenosis xi. Predict the etiology, diagnosis and therapy of mitral stenosis

5. Diabetes Mellitus Reading Assignment:

IM Essentials Text o Chapter 13 (Endocrinology and Metabolism: Diabetes Mellitus) o Chapter 14 (Endocrinology and Metabolism: Diabetic Ketoacidosis and Hyperglycemic)


i. Discuss the definition and differential diagnosis of hypotension, including how to use orthostatic signs and symptoms.

ii. Utilize the American Diabetes Association (ADA) and the U.S. Preventive Task Force (USPTF) recommendations to screen for diabetes, including recognizing risk factors for diabetes.

iii. Discuss the pathogenesis of Type 1 and Type 2 diabetes. iv. Diagnose type 2 diabetes mellitus using the four accepted criteria, as well as know the diagnostic

criteria for impaired fasting glucose and impaired glucose tolerance. v. Calculate anion gap, osmolar gap, and corrected sodium to distinguish hyponatremia from

pseudohyponatremia. vi. Define hyperosmolar hyperglycemic state (HHS), including nonketotic coma. vii. Recognize precipitants and presenting symptoms and signs of HHS and diabetic ketoacidosis

(DKA), as well as discuss the pathophysiology for the abnormal laboratory values of each. viii. Describe the basic management of diabetic ketoacidosis and nonketotic hyperglycemic states,

including the similarities and differences in insulin therapy and fluid and electrolyte replacement. ix. List the ADA-recommended targets for glycemic control for adults. x. Understand the differences between types of insulin and the indications for their use. xi. Counsel diabetic patients appropriately on dietary measures and exercise. xii. Recognize precipitants and presenting symptoms and signs of hypoglycemia, as well as basic

management.




6. GI Bleed Reading Assignment:

IM Essentials Text o Chapter 17 (Gastroenterology and Hepatology: Dyspepsia) o Chapter 18 (Gastroenterology and Hepatology: Gastroesophageal Reflux Disease) o Chapter 19 (Gastroenterology and Hepatology: Peptic Ulcer Disease) o Chapter 27 (Gastroenterology and Hepatology: Approach to Gastrointestinal Bleeding) o Chapter 42 (General Internal Medicine: Approach to Involuntary Weight Loss) o Chapter 54 (Hematology: Transfusion Medicine) o Chapter 83 (Oncology: Colorectal Cancer)

Online Cases: Aquifer SIMPLE Case 10 Learning Objectives:

i. Perform medication reconciliation upon admission and discharge. ii. Identify the common causes for and symptoms of upper and lower gastrointestinal blood loss,

including recognizing the distinguishing features of each. iii. Define hematemesis, melena, and hematochezia. iv. Examine the role of contributing factors in gastrointestinal bleeding such as Helicobacter pylori

infection, non-steroidal anti-inflammatory drugs, alcohol, coagulopathies, and chronic liver disease.

v. Demonstrate the indications for, contraindications to, and complications of blood transfusion, including describing system errors that produce transfusion reactions.

vi. Identify and manage transfusion reactions. vii. Describe the difference between adverse events and medical errors. viii. Develop an appropriate evaluation and treatment plan for patients with a gastrointestinal bleed

that includes: 1. Establishing adequate venous access 2. Administering crystalloid fluid resuscitation 3. Ordering blood and blood product transfusion 4. Determining when to obtain consultation from a gastroenterologist for upper

endoscopy. ix. Distinguish among the types of shock and their presentations. x. Discuss the common causes for and symptoms of lower gastrointestinal (GI) blood loss. xi. List elements of physical exam in patient with suspected GI bleed. xii. Recommend laboratory and diagnostic tests to evaluate GI bleeding. xiii. Understand the physician’s role when a patient is no longer capable of making medical decisions. xiv. Utilize clinical history and appropriate diagnostic tests to diagnose GERD xv. Discuss treatment for GERD and indications for EGD xvi. Cite the strategy for diagnosis and treatment H. pylori

7. Abdominal Pain Reading Assignment:

IM Essentials Text o Chapter 16 (Gastroenterology and Hepatology: Approach to Abdominal Pain) o Chapter 25 (Gastroenterology and Hepatology: Approach to Diarrhea) o Chapter 26 (Gastroenterology and Hepatology: Inflammatory Bowel Disease)


i. List symptoms and signs indicative of an acute/surgical abdomen. ii. Approximate a likelihood ratio of the common causes of abdominal pain based on pain pattern,

the quadrant the pain is located and abdominal exam findings.




iii. Generate a prioritized differential of the most important and likely causes of a patient’s abdominal pain and recognize specific history, physical exam, and laboratory findings that distinguish between the various conditions.

iv. Recommend a basic management plan for diverticulitis. v. Define irritable bowel syndrome. vi. Utilize history and clinical presentation to create a differential for infectious and non-infectious

diarrhea vii. Utilize common diagnostic tests for diarrhea to determine a diagnosis. viii. Differentiate ulcerative colitis from Crohn’s disease.

8. Liver Disease Reading Assignment:

IM Essentials Text o Chapter 20 (Gastroenterology and Hepatology: Approach to Liver Chemistry Tests) o Chapter 21 (Gastroenterology and Hepatology: Hepatitis) o Chapter 22 (Gastroenterology and Hepatology: Cirrhosis)


i. Understand pathophysiology of conjugated and unconjugated hyperbilirubinemia. ii. Describe the common types of liver diseases and their risk factors (including inherited and

acquired). iii. Obtain an appropriate history to elicit risk factors for viral hepatitis. iv. Know when to order laboratory tests for evaluation of liver disease and when a liver biopsy

might be indicated. v. Know the signs, symptoms, and complications of portal hypertension. vi. Describe the presenting signs and symptoms of spontaneous bacterial peritonitis (SBP). vii. Complete an abdominal exam, including evaluation for presence of ascites. viii. Understand the indications for paracentesis and how to analyze the ascitic fluid using the serum

to ascites albumin gradient (SAAG). ix. Describe the components of obtaining informed consent. x. Become familiar with the indications for hepatic transplantation referral in end stage liver

disease. xi. Utilize history and patterns in liver function tests to diagnose hepatitis. xii. Utilize hepatitis B serologies to determine the stages of infection xiii. Utilize clinical history to create a differential for liver diseases, such as hemochromatosis,

nonalcoholic fatty liver disease, alcoholic liver disease, autoimmune hepatitis, hepatitis A, hepatitis B, etc.

xiv. List the goals of therapy for cirrhosis

9. Pancreatic Disease Reading Assignment:

IM Essentials Text o Chapter 16 (Gastroenterology and Hepatology: Approach Abdominal Pain) o Chapter 20 (Gastroenterology and Hepatology: Approach to Liver Chemical Tests) o Chapter 23 (Gastroenterology and Hepatology: Diseases of the Gall Bladder and Bile Ducts) o Chapter 24 (Gastroenterology and Hepatology: Acute Pancreatitis)


i. Describe the pathophysiology of the principle types of abdominal pain: parietal, visceral, vascular, and referred.

ii. Determine when to consult a surgeon regarding abdominal pain. iii. Explain the indications and utility of hepatobiliary imaging studies including MRCP and ERCP.




iv. Utilize liver function tests and clinical history to create a differential for cholestatic liver disease. v. Discuss common etiologies of pancreatitis in the US. vi. Predict general treatment plan for pancreatitis. vii. Utilize clinical history such as painless jaundice and risk factors to diagnose pancreatic cancer.

10. Substance Abuse Reading Assignment: IM Essentials Text: Chapter 38 (General Internal Medicine: Substance Abuse) Online Cases: Aquifer SIMPLE Case 11 Learning Objectives:

i. Be familiar with the CAGE and AUDIT screening tools for alcohol abuse. ii. Take a substance abuse history and provide counseling in a non-judgmental manner. iii. Recognize the clinical presentations of substance abuse and recommend treatment. iv. Apply diagnostic criteria for alcohol abuse, dependence, and addiction. v. Recommend basic prevention and treatment for alcohol withdrawal.

11. Acute Renal Failure Reading Assignment:

IM Essentials Text o Chapter 66 (Nephrology: Approach to Kidney Disease) o Chapter 70 (Nephrology: Acute Kidney Injury)


i. Compare the pathophysiology of major etiologies of acute renal failure including decreased renal perfusion (pre-renal), intrinsic renal disease, and acute renal obstruction (post renal).

ii. Utilize the fractional excretion of sodium and apply it to distinguish between pre-renal and intrinsic renal disease.

iii. Utilize common diagnostic tests, including UA, BMP to determine likely etiology of acute renal failure.

iv. Develop appropriate initial management plan for acute renal failure including volume management, dietary recommendations, drug dosage alterations, electrolyte monitoring, and indications for dialysis.

v. Identify risk factors for contrast-induced nephropathy and recommend steps to prevent this complication.

vi. Interpret a urinalysis, including microscopic examination for casts, red blood cells, white blood cells, and crystals.

vii. Differentiate nephrotic syndrome and nephritic syndrome. viii. Create a differential diagnosis for acute kidney injury based on clinical history and basic

diagnostic studies.

12. Chronic Kidney Disease Reading Assignment:

IM Essentials Text o Chapter 31 (General Internal Medicine: Hypertension) o Chapter 66 (Nephrology: Approach to Kidney Disease) o Chapter 68 (Nephrology: Calcium and Phosphorus Metabolism) o Chapter 71 (Nephrology: Chronic Kidney Disease)

Online Case: Aquifer SIMPLE Case 23 Leaning Objectives:

i. List the most common causes of chronic kidney disease (CKD). ii. Utilize clinical history and diagnostic tests to diagnose etiologies of chronic kidney disease. iii. Describe pathophysiology and clinical signs of uremia.





iv. Tell about the pathophysiology of hyperkalemia, hypocalcemia, and hyperphosphatemia in the setting of CKD.

v. Educate patients about the significance of proteinuria in CKD. vi. Appropriately recommend the use of angiotensin converting enzyme (ACE)-inhibitors and

angiotensin receptor blockers (ARBs) in the management of CKD. vii. Outline treatment with phosphate binders and calcium replacement. viii. Summarize the staging of CKD based on glomerular filtration rate (GFR). ix. Define hypertension, hypertensive emergency, and hypertensive urgency. x. List indications for antihypertensive drug classes. xi. Define the stages of chronic kidney disease. xii. List the indications for dialysis.

13. Acid-Base Disorders Reading Assignment: IM Essentials Text: Chapter 69 (Nephrology: Acid-Base Disorders) Online Case: Aquifer SIMPLE Case 26 Learning Objectives:

i. Calculate anion gap, osmolar gap, and correct sodium to distinguish hyponatremia from pseudohyponatremia.

ii. Discuss the pathophysiology of SIMPLE and mixed acid- base disorders. iii. Calculate the anion gap and explain its relevance to determining the cause of a metabolic

acidosis. iv. List the differential of anion-gap metabolic acidosis. v. Calculate the anion gap and generate a differential diagnosis for metabolic acidosis

14. Pneumonia Reading Assignment:

IM Essentials Text o Chapter 35 (General Internal Medicine: Approach to Cough) o Chapter 65 (Infectious Disease Medicine: Health Care-Associated Infections) o Chapter 57 (Infectious Disease Medicine: Community-Acquired Pneumonia) o Chapter 90: (Pulmonary Medicine: Approach to Dyspnea)

Online Case: Aquifer SIMPLE Case 22 Suggested Online Resource: Infectious Disease Society of American Community-Acquired Pneumonia and Hospital-Acquired Pneumonia Guidelines Learning Objectives:

i. Discuss the common causes of acute dyspnea, their pathophysiology, symptoms, and signs. ii. List the common pneumonia pathogens (viral, bacterial, mycobacterial, and fungal) in

immunocompetent and immunocompromised hosts. iii. Describe radiographic findings associated with specific pathogens. iv. Identify bronchial breath sounds, rales (crackles), rhonchi, and wheezes, signs of pulmonary

consolidation, and pleural effusion on physical exam. v. Recognize the most common complications of pneumonia. vi. Recommend when to order diagnostic laboratory tests—including complete blood counts,

sputum gram stain and culture, blood cultures, and arterial blood gases—how to interpret those tests, and how to recommend treatment based on these interpretations.

vii. Select an appropriate empiric antibiotic regimen for community-acquired, nosocomial, immunocompromised-host, and aspiration pneumonia, taking into account pertinent patient features.

viii. Discuss the Centers for Medicare and Medicaid Services (CMS) and Joint Commission’s quality measures for smoking cessation advice and vaccination against pneumonia and influenza in patients with pneumonia and other pulmonary disorders.

ix. Create a differential diagnosis for chronic cough.



http://www.idsociety.org/Organ_System/%23Lower/Upper%20Respiratory

http://www.idsociety.org/Organ_System/%23Lower/Upper%20Respiratory


x. Define hospital-acquired and ventilator-associated pneumonia. xi. Predict empiric antibiotic treatment for HAP and VAP. xii. Discuss risk factor modification for the prevention of HAP and VAP. xiii. Create a differential diagnosis for acute and chronic dyspnea.

15. Chronic Lung Disease Reading Assignment:

IM Essentials Text o Chapter 81 (Oncology: Lung Cancer) o Chapter 89 (Pulmonary Medicine: Interpretation of Pulmonary Function Tests) o Chapter 90 (Pulmonary Medicine: Approach to Dyspnea) o Chapter 92 (Pulmonary Medicine: Asthma) o Chapter 93 (Pulmonary Medicine: Chronic Obstructive Pulmonary Disease) o Chapter 95 (Pulmonary Medicine: Diffuse Parenchymal Lung Diseases)


i. Accurately interpret arterial blood gas. ii. Explain pulmonary function test (PFT) results and use them to recommend appropriate

therapy. iii. List major pathologic states causing dyspnea. iv. Relate the utility of supplemental oxygen and the potential dangers of overly aggressive oxygen

supplementation. v. Describe the indications for, benefits of, and side effects of therapies for chronic obstructive

pulmonary disease (COPD) including: beta-agonists, anticholinergics, methylxanthines, and inhaled and systemic corticosteroids.

vi. Recommend appropriate laboratory evaluation for suspected COPD exacerbation. vii. Describe the benefits of immunizing adults with COPD against influenza and pneumococcal

infection. viii. Identify paraneoplastic syndromes associated with lung cancer. ix. Recognize basic treatment protocols for lung cancer based on stage. x. Differentiate obstructive and restrictive lung disease using pulmonary function tests. xi. Utilize history and clinical examination to diagnose diffuse parenchymal lung diseases. xii. Utilize diagnostic tests (imaging and laboratory) in a work-up of acute and chronic dyspnea. xiii. Diagnose asthma and initiate treatment based on asthma severity. xiv. Classify COPD by stages and predict treatment based on severity. xv. Create a differential diagnosis for diffuse parenchymal lung diseases.

16. Altered Mental Status Reading Assignment:

IM Essentials Text o Chapter 40 (General Internal Medicine: Approach to Syncope) o Chapter 67 (Nephrology: Fluid and Electrolyte Disorders) o Chapter 76 (Neurology: Altered Mental Status, Dementia, and Delirium)


i. List the common causes of syncope. ii. Determine the important aspects of the history and physical exam in a patient with syncope. iii. Discuss the approach to the evaluation and treatment of a patient with syncope. iv. Recognize that altered mental status in an older inpatient is a medical emergency and requires

that the patient be evaluated immediately. v. Differentiate among delirium, dementia, and depression. vi. Identify the risk factors for developing altered mental status, including:




a. Dementia b. Advanced age c. Substance abuse d. Comorbid physical problems such as sleep deprivation, immobility, dehydration, pain,

and sensory impairment e. ICU admission

vii. Thoroughly review prescription medications, over-the-counter drugs, and supplements, and inquire about substance abuse when evaluating delirium.

viii. Recognize the symptoms and signs of the most common and most serious causes of altered mental status, including metabolic causes, such as hyponatremia.

ix. Perform a thorough diagnostic evaluation of altered mental status. x. Manage the most common causes of altered mental status. xi. Describe the pathophysiology, presenting signs and symptoms, laboratory interpretation, and

the management of hyponatremia, including the risk of too rapid or too delayed therapy of hyponatremia.

xii. Write appropriate fluid and replacement orders for patients with common electrolyte and metabolic disturbances.

xiii. Identify the presenting signs and symptoms of intoxication and overdose of common substances of abuse.

xiv. Recognize the presenting signs and symptoms and list the differential diagnosis of hypernatremia.

xv. Understand how homelessness can influence patient’s access to illicit substances and interfere with ability to enable effective treatment.

xvi. Describe the pathophysiology of ethylene glycol toxicity. xvii. Evaluate for calcium oxalate crystalluria and relate the presence to ethylene glycol toxicity and

other disorders. xviii. List the differential of hypernatremia. xix. Manage ethylene glycol toxicity, including the use of the antidote fomepizole. xx. Describe how to correct hypernatremia.

17. Sepsis Reading Assignment:

IM Essentials Text o Chapter 60 (Infectious Disease Medicine: Urinary Tract Infections) o Chapter 64 (Infectious Disease Medicine: Sepsis Syndrome) o Chapter 73 (Neurology: Headache) o Chapter 74 (Neurology: Approach to Meningitis and Encephalitis)

Online Cases: Aquifer SIMPLE Cases 24 Recommended Reading: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) Learning Objectives:

i. Interpret a urinalysis. ii. Recommend appropriate empiric therapy for sepsis from a urinary sourse based on an

understanding of urinary tract infection pathogenesis and resistance patterns. iii. Discuss types of patient isolation precautions and their indications. iv. Describe indications for and contraindications and complications of lumbar puncture. v. Demonstrate knowledge of cerebrospinal fluid analysis and its interpretation. vi. Define and diagnose sepsis and septic shock. vii. Predict treatment principles of sepsis including early recognition, appropriate laboratory,

aggressive fluid resuscitation, early broad-spectrum antibiotic administration and vasopressor administration

viii. Predict treatment of urinary tract infections based on clinical history and risk factors.


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http://jama.jamanetwork.com/article.aspx?articleid=2492881


ix. Recognize “red flag” headache signs. x. Differentiate headaches based on clinical history and physical exam findings. xi. Differentiate bacterial from viral meningitis based off typical cerebrospinal fluid findings. xii. Predict empiric antibiotic treatment for meningitis based on age and clinical risk factors. xiii. Predict sepsis morbidity/mortality utilizing scoring tools such as SOFA. xiv. Associate elevated lactate and its role in sepsis management.

18. Hospital Acquired Infections Reading Assignment: IM Essentials Text: Chapter 65 (Infectious Disease Medicine: Health Care- Associated Infections Online Case: Aquifer SIMPLE Case 24 Suggested Online Resource: Infectious Disease Society of America (IDSA) Guidelines on Prevention of Healthcare-Associated Infections in Acute Care Hospitals and Clostridium Difficile Learning Objectives:

i. List risk factors for and precautions against the acquisition of nosocomial infection. ii. Utilize system-based practices to prevent health care-associated infections such as catheter-

related bloodstream infections, urinary tract infections and ventilator-associated pneumonia iii. Diagnose Clostridium difficile infection and predict treatment based on severity of the illness.

19. Venous Thromboembolism Reading Assignment:

IM Essentials Text o Chapter 9 (Cardiovascular Medicine: Vascular Disease) o Chapter 13 (Endocrinology and Metabolism: Diabetes Mellitus) o Chapter 53 (Hematology: Thrombophilia)


i. Describe indications for and methods of deep vein thrombosis prophylaxis. ii. List risk factors for the development of a deep vein thrombosis (DVT). iii. Recognize the signs and symptoms of DVT and pulmonary embolism (PE). iv. Generate a prioritized differential diagnosis of DVT/PE based on specific physical findings

using pre-test probability tools. v. Understand the indications for and utility of various diagnostic tests and describe their

interpretation. vi. Develop an appropriate management plan for DVT/PE, including appropriate use and

monitoring of heparin and warfarin vii. Diagnose congenital and acquired thrombophilia disorders utilizing clinical history and

diagnostic testing

20. Osteopathic Manipulative Medicine and Internal Medicine

A. Lower Respiratory Infections Reading Assignment:

Osteopathic Considerations in Systemic Dysfunction, Lower Respiratory Disorders, pp. 33-52.

Foundations of Osteopathic Medicine, Chapter 59: Difficulty Breathing, pp. 931-938. Learning Objectives:

i. Identify the structural areas affected by sympathetic viscerosomatic reflex ii. Define “Work of Breathing” as it pertains to the pulmonary system iii. Recognize the Osteopathic “Models” of treatment iv. Identify the structural areas which may play a role in Vagal nerve facilitation


http://www.idsociety.org/Organ_System/#Gastrointestinal (GI)





v. Identify the common rib dysfunctions found as a result of paroxysmal coughing vi. Describe the pulmonary effects of increased parasympathetic tone vii. Describe the pulmonary effects of increased acute sympathetic activation viii. Describe the pulmonary effects of increased chronic sympathetic activation ix. Identify the spinal segments most likely to become facilitated with lung dysfunction x. Identify the anterior Chapman’s points for lung dysfunction

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Internal Medicine and Medical Specialties I