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Updated 5/23/19 MRE
INTERNAL MEDICINE CLERKSHIP
LEARNING OBJECTIVES
Abdominal Pain:
1. Describe the pathophysiology of the principle types of abdominal pain: parietal, visceral, vascular,
and referred.
2. Generate a prioritized differential of important and most likely causes of a patient’s abdominal
pain by recognizing specific history, physical exam, and laboratory findings that distinguish
between the various conditions.
3. List symptoms and signs indicative of an acute/surgical abdomen.
4. Recommend a basic management plan for diverticulitis.
5. Recommend a basic management plan for pancreatitis.
6. Explain the indications and utility of hepatobiliary imaging studies including MRCP and ERCP.
(Note overlap with the Liver Function Tests objectives)
References:
Aquifer Case 9
Aquifer Case 12
Harrison’s Principles of Internal Medicine, 20e. Chapter 12: Abdominal Pain
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?bookid=2129§ionid=192010958#1155941479
Harrison’s Principles of Internal Medicine, 20e. Chapter 321: Diverticular Disease and Common
Anorectal Disorders
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192282719&bookid=2129&jumpsectionid=192282730&
Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 341: Acute and Chronic Pancreatitis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192284191&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 151: Pancreatitis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558976&bookid=1820&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 37: Abdominal Pain
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127554383&bookid=1820
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 3: Abdominal Pain
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?bookid=1088§ionid=61696569
Updated 5/23/19 MRE
Acid-Base Disorders:
1. Identify and discuss the normal homeostatic mechanisms which maintain pH in the normal range.
2. Describe the principles of the Henderson-Hesselbach equation.
3. Describe the effect on pH of:
a. Metabolic acidosis.
b. Metabolic alkalosis.
c. Respiratory acidosis.
d. Respiratory alkalosis.
4. Discuss the renal and/or respiratory adaptation to the abnormalities in (3) above.
5. Calculate the anion gap and explain its relevance to determining the cause of a metabolic
acidosis.
6. Define and describe the pathophysiology of:
a. Simple and mixed acid-base disorders.
b. Respiratory acidosis and alkalosis.
c. Metabolic acidosis and alkalosis.
7. Discuss presenting signs and symptoms of the above disorders.
8. List the differential and identify the most common causes of respiratory acidosis, respiratory
alkalosis, non-anion gap metabolic acidosis, anion gap metabolic acidosis, and metabolic
alkalosis.
9. Discuss how altered mental status can contribute to electrolyte disorders.
10. Discuss tests to use in the evaluation of fluid, electrolyte, and acid-base disorders.
11. Predict acid-base abnormalities from the clinical picture.
12. Identify acid-base abnormalities that medicines can cause.
13. List and discuss indications for obtaining an arterial blood gas (ABG).
References:
Lecture: Acid-base disorders
Aquifer Case 26
Harrison’s Manual of Medicine, 19e. Chapter 1: Electrolytes/Acid-Base Balance
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127553582&bookid=1820&Resultclick=2#1128781609
Harrison’s Principles of Internal Medicine, 20e. Chapter S1: Fluid and Electrolyte Imbalances and
Acid-Base Disturbances: Case Examples
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192509786&bookid=2129&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 4: Acid-Base Abnormalities
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?bookid=1088§ionid=61696804
Acute Renal Failure:
1. Compare and contrast the distinction between the three major pathophysiologic etiologies for
acute renal failure (ARF) based on history, urinalysis, urine studies, and radiological imaging:
a. Decreased renal perfusion (prerenal)
Updated 5/23/19 MRE
i. Hypovolemia.
ii. Decreased cardiac output.
iii. Systemic vasodilation.
iv. Renal vasoconstriction.
a. Intrinsic renal disease (renal)
i. Vascular lesions.
ii. Glomerular lesions.
iii. Interstitial nephritis.
iv. Intra-tubule deposition/obstruction.
v. Acute tubular necrosis (ATN).
b. Acute renal obstruction (postrenal)
i. Ureteral (e.g. tumors, calculi, clot, sloughed papillae, retroperitoneal fibrosis,
lymphadenopathy).
ii. Bladder neck (e.g. tumors, calculi, prostatic hypertrophy or carcinoma,
neurogenic).
iii. Urethral (e.g. stricture, tumors, obstructed indwelling catheters).
2. Describe the metabolic consequences of significant reductions in renal function.
3. Describe the indications for dialysis.
4. Calculate the fractional excretion of sodium and/or the fractional excretion of urea and apply it to
distinguish between pre-renal and intrinsic renal disease causes of acute renal failure.
5. Develop an appropriate initial management plan for acute renal failure including volume
management, dietary recommendations, drug dosage alterations, electrolyte monitoring, and
indications for dialysis.
6. Interpret a urinalysis, including microscopic examination for casts, red blood cells, white blood
cells, and crystals. (Note overlap with the Renal Tests objectives)
7. Calculate the anion gap and generate a differential diagnosis for metabolic acidosis. (Note
overlap with the Acid-Base Disorders objectives)
8. Identify risk factors for contrast-induced nephropathy and recommend steps to prevent this
complication.
References:
Case Discussion: Acute Renal Failure
Aquifer Case 33
Harrison’s Principles of Internal Medicine, 20e. Chapter 304: Acute Kidney Injury
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=186950567&bookid=2129&Resultclick=2#1157019087
Harrison’s Manual of Medicine, 19e. Chapter 138: Acute Renal Failure
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558544&bookid=1820&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 28: Kidney Injury, Acute
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?bookid=1088§ionid=61700156
Updated 5/23/19 MRE
Anemia/Complete Blood Count:
1. Be able to define and describe the classification of anemia based on red cell size:
a. Microcytic
i. Iron deficiency.
ii. Thalassemic disorders.
iii. Sideroblastic anemia.
iv. Lead toxicity/poisoning.
v. Anemia of chronic disease.
b. Normocytic
i. Acute blood loss.
ii. Hemolysis.
iii. Anemia of chronic disease (e.g. infection, inflammation, malignancy).
iv. Chronic renal insufficiency/erythropoietin deficiency.
v. Bone marrow suppression (e.g. bone marrow invasion, aplastic anemia).
vi. Hypothyroidism.
vii. Testosterone deficiency.
viii. Early presentation of microcytic or macrocytic anemia (e.g. early iron deficiency
anemia).
ix. Combined presentation of microcytic and macrocytic anemias.
c. Macrocytic
i. Ethanol abuse.
ii. B12 deficiency.
iii. Folate deficiency.
iv. Drug-induced.
v. Reticulocytosis.
vi. Liver disease.
vii. Myelodysplastic syndromes.
viii. Hypothyroidism.
2. Discuss the potential usefulness of the white blood cell count and platelet count when attempting
to determine the cause of anemia.
3. Discuss the meaning and utility of various components of the hemogram (e.g., hemoglobin,
hematocrit, mean corpuscular volume, and red cell distribution width).
4. Classify anemia into hypoproliferative and hyperproliferative categories using the reticulocyte
count/index.
5. Use information regarding the diagnostic utility of the various tests for iron deficiency (e.g., serum
iron, total iron binding capacity, transferring saturation, ferritin) when selecting a lab evaluation for
iron deficiency.
6. Identify key historical and physical exam findings in the patient with anemia.
7. Recognize common morphologic changes on a peripheral blood smear.
8. Develop a further evaluation and management plan for a patient with anemia.
9. Incorporate the complete blood count with the history and physical exam to prioritize a differential
diagnosis and management plan for a patient with anemia.
References:
Lecture: CBC / Anemia
Aquifer Case 19
Updated 5/23/19 MRE
Harrison’s Principles of Internal Medicine, 20e. Chapter 59: Anemia and Polycythemia
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192014145&bookid=2129&Resultclick=2#1160011310
Harrison’s Manual of Medicine, 19e. Chapter 45: Anemia and Polycythemia
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127554643&bookid=1820&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 6: Anemia
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=61697176&bookid=1088&Resultclick=2#1102643095
Asthma:
1. Discuss the etiology, pathophysiology, and pathology of asthma.
2. Discuss the epidemiology, risk factors, symptoms, signs, and typical clinical course of asthma.
3. Prioritize common causes of acute exacerbations of asthma, allergic and non-allergic, including:
a. Acute infectious bronchitis.
b. Pneumonia.
c. Pulmonary edema.
d. Poor air quality (e.g. ozone, pollutants, tobacco smoke).
e. Occupational exposures.
f. Medical noncompliance.
g. Grass and tree pollen.
h. Animal dander.
i. Cockroaches.
j. Dust mites.
k. Allergic rhinitis/post-nasal drip.
l. Acute/chronic infectious sinusitis.
m. Exercise.
n. Anxiety/stress.
o. Smoking.
4. Discuss the etiology, pathogenesis, evaluation, and management of hypoxemia and hypercapnia
in the context of asthma.
5. Discuss therapies for asthma, noting advantages, disadvantages, and side effects, for the
following:
a. Beta-agonist bronchodilators.
b. Anticholinergic bronchodilators.
c. Leukotriene inhibitors.
d. Mast cell stabilizers.
e. Theophylline.
f. Inhaled corticosteroids.
g. Systemic corticosteroids.
h. Antimicrobial agents.
i. Supplemental oxygen.
j. Immunotherapy.
6. Identify the indications for and the efficacy of influenza and pneumococcal vaccines in patients
with asthma.
Updated 5/23/19 MRE
References:
Case Discussion: Asthma
Harrison’s Principles of Internal Medicine, 20e. Chapter 281: Asthma
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=186950288&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 129: Asthma
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127554643&bookid=1820&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 33: Wheezing and Stridor
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?bookid=1088§ionid=61701006
Atrial Fibrillation:
1. Identify risk factors for atrial fibrillation.
2. Identify atrial fibrillation on an electrocardiogram.
3. Identify other supraventricular arrhythmias that may resemble atrial fibrillation.
4. Compare and contrast the differences, including etiologies, between paroxysmal, persistent, and
chronic atrial fibrillation.
5. Describe the hemodynamic consequences of new onset atrial fibrillation.
6. Develop a framework for management focusing on the three main therapeutic goals:
anticoagulation, rate control, and rhythm control.
7. Compare and contrast the role of a rate control versus rhythm control strategy in atrial fibrillation.
8. Define the risk of stroke for the patient with persistent or paroxysmal atrial fibrillation.
9. Define the relative and absolute risk reduction of stroke for coumadin and aspirin.
10. Choose an appropriate anticoagulation strategy for patients with atrial fibrillation.
11. Identify the different classes of antiarrhythmics, noting their advantages and disadvantages.
12. Describe the roles of nonpharmacologic therapies such as ablation and device therapy.
13. Develop a plan for safe, elective cardioversion in a patient with atrial fibrillation of unknown or
greater than forty-eight hours duration.
References:
Case Discussion: Atrial Fibrillation
Aquifer Case 3
Harrison’s Principles of Internal Medicine, 20e. Chapter 246: Atrial Fibrillation
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192028757&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 123: Tachyarrhythmias
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558091&bookid=1820
Updated 5/23/19 MRE
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 15: Dyspnea
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=61698418&bookid=1088&jumpsectionid=61698478&Re
sultclick=2
Cardiac Clinical Correlation:
1. Be able to define and describe the mechanism of generation, clinical significance, and best
listening areas on the chest of the following sounds:
a. S1 & S2 – including etiologies for increased and decreased intensities.
b. S2 splitting patterns – including normal, wide, fixed, paradoxical.
c. S3 & S4.
d. Ejection clicks – early and mid (including mitral valve prolapse).
e. Opening snap.
2. Describe the grading system for heart murmurs (I-VI/VI).
3. Compare and contrast the location, pattern of radiation, timing, pitch, shape, quality, and
response to common physiologic maneuvers and any associated change in carotid waveform
with the following murmurs:
a. Aortic stenosis.
b. Mitral stenosis.
c. Aortic regurgitation.
d. Mitral regurgitation.
e. Hypertrophic cardiomyopathy.
f. Ventricular septal defect.
g. Atrial septal defect.
h. Mitral valve prolapse.
i. Pericardial rub.
4. Integrate the cardiac examination with the history to formulate a prioritized differential diagnosis.
References:
Lecture: Cardiac Clinical Correlation
Harrison’s Principles of Internal Medicine, 20e. Chapter 234: Physical Examination of the
Cardiovascular System
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=186950064&bookid=2129&jumpsectionid=196914061&
Resultclick=2
Chest Pain:
1. Organize and prioritize a differential diagnosis of acute chest pain based on specific historical and
physical exam findings including the following:
a. Symptoms and signs of chest pain due to gastrointestinal disorders such as:
i. Esophageal disease (GERD, esophagitis, esophageal dysmotility).
ii. Biliary disease (cholecystitis, cholangitis).
iii. Peptic ulcer disease.
iv. Pancreatitis.
b. Symptoms and signs of chest pain due to pulmonary disorders such as:
Updated 5/23/19 MRE
i. Pneumonia.
ii. Spontaneous pneumothorax.
iii. Pleurisy.
iv. Pulmonary embolism.
v. Pulmonary hypertension/cor pulmonale.
c. Symptoms and signs of chest pain due to musculoskeletal causes such as:
i. Costochondritis.
ii. Rib fracture.
iii. Myofascial pain syndromes.
iv. Muscular strain.
v. Herpes zoster.
d. Symptoms and signs of chest pain due to psychogenic causes such as:
i. Panic disorders.
ii. Hyperventilation.
iii. Somatoform disorders.
e. Symptoms and signs of chest pain due to angina pectoris.
f. Symptoms and signs of chest pain due to other cardiac causes such as:
i. Atypical or variant angina (coronary vasospasm, Prinzmetal angina).
ii. Cocaine-induced chest pain.
iii. Pericarditis.
iv. Aortic dissection.
v. Valvular heart disease (aortic stenosis, mitral valve prolapse).
vi. Non-ischemic cardiomyopathy.
vii. Syndrome X.
2. Describe the physiologic basis and/or scientific evidence supporting each type of treatment,
intervention, or procedure commonly used in the management of patients who present with chest
pain.
3. Define and discuss the pathogenesis, signs, and symptoms of the acute coronary syndromes
including unstable angina and acute myocardial infarction.
4. List the cardiovascular risk factors and methods of primary and secondary prevention of ischemic
heart disease by reducing these risk factors (e.g. controlling hypertension and dyslipidemia,
aggressive diabetes management, avoiding tobacco, and aspirin prophylaxis). (Note overlap with
the Coronary Artery Disease objectives)
5. Develop an appropriate diagnostic and treatment plan, including recommended lifestyle
modifications, for a patient presenting with acute coronary syndrome.
6. Categorize the patient’s symptoms as angina pectoris, atypical angina, or non-cardiac chest pain.
7. Order appropriate laboratory and diagnostic studies based on patient demographics and the most
likely etiologies of chest pain.
8. Prescribe appropriate anti-anginal medications when indicated and identify potential adverse
reactions. (Note overlap with Coronary Artery Disease objectives)
References:
Aquifer Case 1
Aquifer Case 2
Harrison’s Principles of Internal Medicine, 20e. Chapter 11: Chest Discomfort
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192010902&bookid=2129&Resultclick=2
Updated 5/23/19 MRE
Harrison’s Manual of Medicine, 19e. Chapter 31: Chest Pain
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127554272&bookid=1820&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 9: Chest Pain
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=61697579&bookid=1088&Resultclick=2
Chronic Obstructive Pulmonary Disease:
1. Be able to describe and define the common clinical presentations and diagnostic criteria for
emphysema.
2. Describe and define the etiology, pathophysiology, and pathology for COPD.
3. Recommend appropriate laboratory evaluation for a suspected COPD exacerbation.
4. Prioritize common causes of acute exacerbations of COPD including:
a. Acute infectious bronchitis.
b. Pneumonia.
c. Pulmonary edema.
d. Poor air quality (e.g. ozone, pollutants, tobacco smoke).
e. Occupational exposures.
f. Medical noncompliance.
5. Discuss the etiology, pathogenesis, evaluation, and management of hypoxemia and hypercapnia
in the context of COPD.
6. Describe and define therapies for COPD, noting advantages, disadvantages, and side effects for
the following:
a. Beta-agonist bronchodilators.
b. Anticholinergic bronchodilators.
c. Leukotriene inhibitors.
d. Mast cell stabilizers.
e. Theophylline.
f. Inhaled corticosteroids.
g. Systemic corticosteroids.
h. Antimicrobial agents.
i. Supplemental oxygen.
j. Immunotherapy.
k. Smoking cessation.
7. Describe and define the role of influenza and pneumococcal vaccines in the care of patients with
obstructive airway disease.
References:
Case Discussion: Chronic Obstructive Pulmonary Disease
Aquifer Case 28
Harrison’s Principles of Internal Medicine, 20e. Chapter 276: Chronic Obstructive Pulmonary Disease
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192031379&bookid=2129&Resultclick=2
Updated 5/23/19 MRE
Harrison’s Manual of Medicine, 19e. Chapter 131: Chronic Obstructive Pulmonary Disease
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558359&bookid=1820&Resultclick=2
Congestive heart failure:
1. Be able to describe and define the terms preload, contractility, and afterload and how these are
affected in the heart with systolic dysfunction.
2. Be able to define and describe compensatory mechanisms of heart failure: cardiac remodeling,
activation of endogenous neurohormonal systems, cytokine systems, adrenergic nervous system,
renin angiotensin-aldosterone system, endothelin, tumor necrosis factor, and vasopeptides.
3. Interpret neck vein findings for jugular venous distention and abdominal jugular reflux.
4. Identify and translate auscultatory findings of the heart including rate, rhythm, S3/S4, and
murmurs in a patient with heart failure. (Note overlap with the Cardiac Clinical Correlation
objectives).
5. Compare the differing etiologies and signs of left-sided vs right-sided heart failure.
6. Be able to define and describe the types of processes that cause systolic vs. diastolic dysfunction
and how treatment is different.
7. Be able to define and describe the importance of age, gender, and ethnicity on the prevalence
and prognosis of heart failure.
8. Identify and explain the factors leading to symptomatic exacerbation of heart failure, including
ischemia, arrhythmias, valvular disease, anemia, hypertension, thyroid disorders, non-
compliance with medications, dietary restrictions, and use of nonsteroidal anti- inflammatory
drugs.
9. Interpret B-type natriuretic peptide results.
10. Be able to define and describe the staging system for heart failure:
a. Stage A: high risk for heart failure but no structural heart disease is present.
b. Stage B: structural heart disease is present but never any symptoms.
c. Stage C: past or current symptoms associated with structural heart disease.
d. Stage D: end-stage disease with requirements for specialized treatment.
11. Assign a risk and prognosis to patients in NYHA Class I, II, III, and IV without vasodilator blocker
or beta blocker therapy.
12. Be able to define and describe the physiological basis and scientific evidence supporting each
type of treatment, intervention, or procedure commonly used in the management of patients who
present with heart failure.
13. Compare and contrast ACE inhibitors, angiotensin receptor blockers, and aldosterone inhibitors.
14. Outline a treatment plan and assign a risk reduction for patients with compensated or
decompensated congestive heart failure including pharmacologic management: diuretics, digoxin,
vasodilators, and beta blockers.
References:
Case Discussion: Congestive Heart Failure
Aquifer Case 4
Harrison’s Principles of Internal Medicine, 20e. Chapter 252: Heart Failure: Pathophysiology and
Diagnosis
Updated 5/23/19 MRE
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192028958&bookid=2129
Harrison’s Principles of Internal Medicine, 20e. Chapter 253: Heart Failure: Management
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192029052&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 124: Heart Failure and Cor Pulmonale
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558108&bookid=1820&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 17: Edema
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?bookid=1088§ionid=61698622#1102644542
Coronary Artery Disease:
1. Identify risk factors for the development of coronary heart disease:
a. Age and gender.
b. Family history of sudden death or premature CAD.
c. Personal history of peripheral vascular or cerebrovascular disease.
d. Smoking.
e. Lipid abnormalities (includes dietary history of saturated fat and cholesterol).
f. Diabetes mellitus.
g. Hypertension.
h. Obesity.
i. Sedentary lifestyle.
j. Cocaine use.
k. Estrogen use.
l. Chronic inflammation.
2. Be able to define and describe the 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).
(Note overlap with Chest Pain objectives)
3. Identify factors that may be responsible for provoking or exacerbating symptoms of ischemic
chest pain by:
a. Increasing myocardial oxygen demand.
b. Tachycardia or tachyarrhythmia.
c. Hypertension
d. Increased wall stress (aortic stenosis, cardiomyopathy)
e. Hyperthyroidism
f. Decreasing myocardial oxygen supply
g. Anemia
h. Hypoxemia
4. Be able to define and describe the pathogenesis, signs and symptoms of the acute coronary
syndromes:
a. Unstable angina
b. Non-ST-elevation myocardial infarction (NSTEMI)
c. ST-elevation myocardial infarction (STEMI)
Updated 5/23/19 MRE
5. Be able to define and describe the typical clinical course of the acute coronary syndromes.
6. Be able to define and describe the atypical presentations of cardiac ischemia/infarction. (Note
overlap with Chest Pain objectives)
7. Be able to define and describe the ECG findings and macromolecular markers (myoglobin, CK-
MB, troponin-I, troponin-T) of acute ischemia/MI.
8. Be able to define and describe the utility of echocardiography in acute MI.
9. Be able to define and describe the importance of monitoring for and immediate treatment of
ventricular fibrillation in acute MI.
10. Be able to define and describe the therapeutic options for acute MI and how they may differ for
NSTEMI and STEMI, including:
a. Aspirin
b. Morphine
c. Nitroglycerine
d. Oxygen
e. Heparin
f. Antiplatelet agents (glycoprotein IIb/IIIa inhibitors)
g. Beta-blockers
h. ACE-I/ARB
i. HMG-CoA reductase inhibitors
j. Thrombolytic agents
k. Emergent cardiac catheterization with percutaneous coronary intervention
11. Be able to define and describe the pathogenesis, signs and symptoms of the complications of
acute MI, including arrhythmias, reduced ventricular function, cardiogenic shock, pericarditis,
papillary muscle dysfunction/rupture, acute valvular dysfunction, and cardiac free wall rupture.
12. Symptoms and signs of chest pain that are characteristic of angina pectoris. (Note overlap with
Chest Pain objectives)
13. Symptoms and signs of chest pain due to other cardiac causes such as: (Note overlap with Chest
Pain objectives)
a. Atypical or variant angina (coronary vasospasm, Prinzmetal angina)
b. Cocaine-induced chest pain
c. Pericarditis
d. Aortic dissection
e. Valvular heart disease (aortic stenosis, mitral valve prolapse)
f. Non-ischemic cardiomyopathy
g. Syndrome X
References:
Case Discussion: Coronary Artery Disease
Aquifer Case 1
Aquifer Case 2
Harrison’s Principles of Internal Medicine, 20e. Chapter 267: Ischemic Heart Disease
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192029847&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 121: Chronic Stable Angina
Updated 5/23/19 MRE
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558044&bookid=1820
Harrison’s Manual of Medicine, 19e. Chapter 119: ST-Segment Elevation Myocardial Infarction
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127557971&bookid=1820
Harrison’s Manual of Medicine, 19e. Chapter 202” Cardiovascular Disease Prevention
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127560598&bookid=1820
Diabetes Mellitus:
1. Define and discuss diagnostic criteria for impaired fasting glucose and impaired glucose
tolerance.
2. Define and discuss diagnostic criteria for type I and type II diabetes mellitus, based on a history,
physical examination, and laboratory testing.
3. Define and discuss pathophysiology, risk factors, and epidemiology of type I and type II diabetes
mellitus.
4. Define and discuss presenting symptoms and signs of type I and type II diabetes mellitus.
5. Define and discuss presenting symptoms and signs of diabetic ketoacidosis (DKA) and nonketotic
hyperglycemic (NKH).
6. Describe pathophysiology for the abnormal laboratory values in DKA and NKH including plasma
sodium, potassium, and bicarbonate.
7. Identify precipitants of DKA and NKH.
8. Identify major causes of morbidity and mortality in diabetes mellitus (coronary artery disease,
peripheral vascular disease, hypoglycemia, DKA, NKH coma, retinopathy, neuropathy -
peripheral and autonomic, nephropathy, foot disorders, infections).
9. Identify laboratory tests needed to screen, diagnose, and follow diabetic patients including:
glucose, electrolytes, blood urea nitrogen/creatinine, fasting lipid profile, HgA1c, urine
microalbumin/creatinine ratio, urine dipstick for protein.
10. Compare and contrast non-pharmacologic and pharmacologic drugs and side effects noting
advantages and disadvantages of treatment of diabetes mellitus to maintain acceptable levels of
glycemic control, prevent target organ disease, and other associated complications.
11. Identify the specific components of the American Diabetes Association (ADA) dietary
recommendations for type I and type II diabetes mellitus.
12. Identify basic management of diabetic ketoacidosis and nonketotic hyperglycemic states,
including the similarities and differences in fluid and electrolyte replacement.
13. Describe basic management of blood glucoses in the hospitalized patient.
14. Outline the fundamental aspects of the American Diabetes Association (ADA) clinical practice
recommendations and how they encourage high quality diabetes care.
15. Discuss basic management of hypertension and hyperlipidemia in the diabetic patient.
References:
Case Discussion: Diabetes Mellitus
Aquifer Case 7
Aquifer Case 8
Updated 5/23/19 MRE
Diabetes Standards of Care Guidelines, 2019.
http://care.diabetesjournals.org/content/42/Supplement_1
Harrison’s Principles of Internal Medicine, 20e. Chapter 396: Diabetes Mellitus: Diagnosis,
Classification, and Pathophysiology
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Harrison’s Principles of Internal Medicine, 20e. Chapter 397: Diabetes Mellitus: Management and
Therapies
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Harrison’s Principles of Internal Medicine, 20e. Chapter 398: Diabetes Mellitus: Complications
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Harrison’s Manual of Medicine, 19e. Chapter 173: Diabetes Mellitus
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 12: Diabetes
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Deep Vein Thrombosis/Pulmonary Embolism:
1. Define and describe risk factors for developing DVT, including:
a. Prior history of DVT/PE.
b. Immobility/hospitalization.
c. Increasing age.
d. Obesity.
e. Trauma.
f. Smoking.
g. Surgery.
h. Cancer.
i. Acute MI.
j. Stroke and neurologic trauma.
k. Coagulopathy.
l. Pregnancy.
m. Oral estrogens.
2. Define and describe genetic considerations predisposing to venous thrombosis.
3. Define and describe the symptoms and signs of DVT and PE.
4. Discuss the diagnostic evaluation of DVT and PE.
5. Generate a prioritized differential diagnosis of DVT/PE based on specific physical findings using
pre-test probability tools.
6. Describe the indications for and utility of various diagnostic tests and describe their interpretation
including but not limited to spiral CT, V/Q scan, lower extremity dopplers, and d-dimer.
Updated 5/23/19 MRE
7. Define and describe the differential diagnosis of DVT including the many causes of unilateral leg
pain and swelling:
a. Venous stasis and the post-phlebitic syndrome.
b. Lymphedema.
c. Cellulitis.
d. Superficial thrombophlebitis.
e. Ruptured popliteal cyst.
f. Musculoskeletal injury.
g. Arterial occlusive disorders.
8. Define and describe and describe the differential diagnosis of PE including the many causes of
chest pain and dyspnea (Note overlap with Chest Pain objectives):
a. MI/unstable angina.
b. Congestive heart failure.
c. Pericarditis.
d. Pneumonia/bronchitis/COPD exacerbation.
e. Asthma.
f. Pulmonary hypertension.
g. Pneumothorax.
h. Musculoskeletal pain (e.g. rib fracture, costochondritis).
9. Define, describe, and develop an appropriate management plan for DVT/PE including but not
limited to the following:
a. Unfractionated heparin
b. Low-molecular-weight heparin
c. Warfarin
d. Thrombolytics
e. Novel oral anticoagulants
1. Direct thrombin inhibitors
2. Anti-Xa agents
10. Define and describe the risks, benefits, and indications for inferior vena cava filters.
11. Define and describe the long-term sequelae of DVT and PE.
12. Define and describe methods of DVT/PE prophylaxis, their indications, and their efficacy,
including:
a. Ambulation.
b. Graded compression stockings.
c. Pneumatic compression devices.
d. Unfractionated heparin.
e. Low-molecular-weight heparin.
f. Warfarin.
g. Novel oral anticoagulants
1. Direct thrombin inhibitors
2. Anti-Xa agents
13. Identify the appropriate duration of anticoagulation therapy in a patient with DVT and PE based
on the clinical picture.
14. Identify the appropriate thrombophilia evaluation in a patient with DVT and PE based on the
clinical picture.
References:
Case Discussion: Deep Venous Thrombosis / Pulmonary Embolism
Updated 5/23/19 MRE
Aquifer Case 30
Harrison’s Principles of Internal Medicine, 20e. Chapter 273: Deep Venous Thrombosis and
Pulmonary Thromboembolism
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Harrison’s Manual of Medicine, 19e. Chapter 133: Pulmonary Thromboembolism and Deep-Vein
Thrombosis
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 15: Dyspnea
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Dyspnea:
1. List the major pathologic states which cause dyspnea.
2. Describe the common causes of tachypnea.
References:
Aquifer Case 22
Harrison’s Principles of Internal Medicine, 20e. Chapter 33: Dyspnea
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Harrison’s Manual of Medicine, 19e. Chapter 33: Dyspnea
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 15: Dyspnea
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Fever:
1. Define the criteria for fever of unknown origin (FUO).
2. Compare and contrast etiologies of fever in normal hosts and in special populations (e.g. patients
with human immunodeficiency virus (HIV), transplant patients, immunosuppressed states, recent
travel or immigration, intravenous drug use).
3. Obtain and present an age-appropriate patient history that helps differentiate among likely
etiologies for fever.
4. Prioritize certain diagnostic and laboratory tests for fever.
5. Develop an appropriate treatment plan for a patient with fever of unknown origin.
References:
Updated 5/23/19 MRE
Aquifer Case 35
Harrison’s Principles of Internal Medicine, 20e. Chapter 15: Fever
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Harrison’s Principles of Internal Medicine, 20e. Chapter 17: Fever of Unknown Origin
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Harrison’s Manual of Medicine, 19e. Chapter 28: Fever, Hyperthermia, and Rash
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Gastrointestinal Bleed:
1. Define hematemesis, melena, and hematochezia.
2. Define, describe, and prioritize the common causes for and symptoms of upper and lower GI
blood loss, including:
a. Esophagitis/esophageal erosions.
b. Mallory Weiss tear.
c. Peptic and duodenal ulcer disease.
d. Esophageal/gastric varices.
e. Erosive gastritis.
f. Arteriovenous malformations.
g. Gastrointestinal tumors, benign and malignant.
h. Diverticulosis.
i. Ischemic colitis.
j. Hemorrhoids.
k. Anal fissures.
3. Define and describe the distinguishing features of upper versus lower GI bleeding including but
not limited to the following:
a. Recognize melena (usually indicating an upper GI source) is the most frequent cause of
major GI bleeding, but all black stools are not melena.
b. Recognize hematochezia is usually a manifestation of lower GI bleeding but can be a
manifestation of severe upper GI bleeding.
c. Recognize the most common cause of major upper GI bleeding is peptic disease.
d. Recognize diverticulosis is a common cause of major lower GI bleeding.
4. Recommend laboratory and diagnostic tests to evaluate GI bleeding, which include (when
appropriate): stool and gastric fluid tests for occult blood, CBC, PT/PTT, endoscopy, and
colonoscopy.
a. Recognize that upper endoscopy (EGD) is the initial diagnostic test and therapeutic
modality of choice in upper GI bleeding and has predictive value of rebleeding.
b. Recognize that colonoscopy (after cessation of bleeding and colonic cleansing) is the test
of choice in lower GI bleeding.
c. Identify the role of capsule endoscopy and arteriogram studies.
5. Develop an appropriate evaluation and treatment plan for patients with a GI bleed that includes:
a. Protecting the airway.
Updated 5/23/19 MRE
b. Establishing adequate venous access.
c. Administering crystalloid fluid resuscitation.
d. Ordering blood and blood product transfusion.
e. Determining when to obtain consultation from a gastroenterologist for upper endoscopy.
6. Define and describe the role of contributing factors in GI bleeding such as H. pylori infection,
NSAIDs, alcohol, cigarette use, coagulopathies, and chronic liver disease.
References:
Case Discussion: Gastrointestinal Bleed
Aquifer Case 10
Harrison’s Principles of Internal Medicine, 20e. Chapter 44: Gastrointestinal Bleeding
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Harrison’s Manual of Medicine, 19e. Chapter 41: Gastrointestinal Bleeding
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 19: GI Bleed
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HIV:
1. Define and describe symptoms and signs of acute HIV seroconversion.
2. Define and describe CDC AIDS case definition.
3. Define and describe specific tests for HIV (e.g. HIV ELISA, confirmatory western blot, quantitative
PCR) and their operating characteristics.
4. Define and describe the relationship of CD4 lymphocyte count to opportunistic infections as well
as relationship between CD4 lymphocyte count and viral load to overall disease progression.
5. Define and describe the basic principles of highly active antiretroviral therapy (HAART), including
the different classes of antiviral medications and their use, as well as common side effects and
drug-drug interactions.
6. Define and describe basics of post-exposure prophylaxis.
7. Define and describe the marked importance of antiretroviral medication adherence and the
potential consequences of erratic or poor adherence.
8. Define and describe vaccination recommendation for patients infected with HIV.
9. Define and describe indications for and utility and risks of prophylaxis of HIV-related opportunistic
infections.
10. Define and describe pathogenesis, symptoms, signs, typical clinical course, and management of
HIV-related opportunistic infections with a recognition of which are most common:
a. Pneumocystis jiroveci.
b. Candidiasis (oral, esophageal, vaginal).
c. Cryptococcus neoformans.
d. Cryptosporidium parvum.
e. Cytomegalovirus infection (gastrointestinal, neurologic, retinal).
Updated 5/23/19 MRE
f. Varicella-zoster virus.
g. Isospora belli.
h. Microsporidiosis.
i. Mycobacterium avium complex.
j. Mycobacterium tuberculosis.
k. Toxoplasma gondii.
11. Define and describe symptoms and signs of the following HIV-related malignancies:
a. Kaposi’s sarcoma.
b. Non-Hodgkin’s lymphoma.
c. Cervical carcinoma.
12. Define and describe common skin and oral manifestations of HIV infection and AIDS:
a. Molluscum contagiosum.
b. Cryptococcus neoformans.
c. Viral warts.
d. Lipodystrophy.
e. Herpes zoster.
f. Seborrheic dermatitis.
g. Buccal candidiasis.
h. Oral hairy leukoplakia.
13. Distinguish between common etiologies of fever of unknown origin (FUO) in immunocompetent.
patients and those infected with the human immunodeficiency virus (HIV). (Note overlap with
Fever objectives)
14. List appropriate diagnostic tests for an HIV-positive patient presenting with fever.
References:
Case Discussion: HIV
Aquifer Case 20
Harrison’s Principles of Internal Medicine, 20e. Chapter 197: Human Immunodeficiency Virus
Disease: AIDS and Related Disorders
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Harrison’s Manual of Medicine, 19e. Chapter 105: HIV Infection and AIDS
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 5: AIDS/HIV Infection
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Hyponatremia:
1. Define and describe the effect of hyponatremia on the brain and the resultant presenting signs
and symptoms.
2. Define and describe the importance of total body water distribution and its relationship to
hyponatremia.
Updated 5/23/19 MRE
3. Discuss the approach to a patient with hyponatremia including pseudohyponatremia
associated with hyperlipidemia or paraproteinemias.
4. Discuss hyponatremia associated with hyperglycemia or mannitol administration.
5. Define and describe the concept of free water clearance by the kidney.
a. Define and describe the differential diagnosis and treatment of hyponatremia in the setting of
volume depletion, euvolemia, and hypervolemia associated with:
a. Over-hydration – CHF, nephrotic syndrome, or cirrhosis with ascites.
b. Dehydration –
i. High urinary sodium – Addison’s disease, diuretic use, salt-losing nephropathies,
cerebral salt wasting.
ii. Low urinary sodium – extra-renal sodium and water loss.
c. Euhydration – SIADH, hypothyroidism, psychogenic water drinking, sick cell syndrome,
beer potomania, Tea and Toast syndrome, and exercise-induced hyponatremia.
6. Define and describe the risks of too rapid or delayed therapy for hyponatremia.
References:
Lecture: Hyponatremia
Aquifer Case 7
Aquifer Case 25
Harrison’s Principles of Internal Medicine, 20e. Chapter 49: Fluid and Electrolyte Disturbances:
Hyponatremia
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Harrison’s Manual of Medicine, 19e. Chapter 1: Electrolytes/Acid-Base Balance: Hyponatremia
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 24: Hyponatremia and Hypernatremia
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Infectious Disease Basics:
1. Define the concepts of bacteriostatic, bactericidal, MIC, and MBC.
2. Define the classes of antibiotics and know some specific antibiotics within each class.
3. Define the classes of organisms that are commonly associated with the following organ systems:
HEENT, pulmonary, cardiac, abdomen, lymph node, skin, bone, and genitourinary.
4. List reasons why a particular antibiotic regimen may fail.
5. Define the concept of antibiotic synergy.
6. Identify infectious diseases that are potentially life threatening.
7. Define and describe the epidemiology, pathophysiology, microbiology, symptoms, signs, typical
clinical course, and preventive strategies for the most common nosocomial infections, including:
a. Urinary tract infection.
Updated 5/23/19 MRE
b. Pneumonia.
c. Surgical site infection.
d. Intravascular device-related bloodstream infections.
e. Skin infections.
f. Healthcare associated diarrhea.
8. Define and describe the general clinical risk factors for nosocomial infection, including:
a. Immunocompromise.
b. Immunosuppressive drugs.
c. Extremes of age.
d. Compromise of the skin and mucosal surfaces secondary to
i. Drugs.
ii. Irradiation.
iii. Trauma.
iv. Invasive diagnostic and therapeutic procedures.
v. Invasive indwelling devices (e.g. intravenous catheter, bladder catheter,
endotracheal tube, etc.).
9. Define and describe empiric antibiotic therapy for the most common nosocomial infections
recognizing resistance patterns.
10. Define and describe the epidemiology, pathophysiology, microbiology, symptoms, signs, typical
clinical course, and preventive strategies for colonization or infection with the following
organisms:
a. Vancomycin-resistant enterococci.
b. Clostridium difficile.
c. Methicillin-resistant Staphylococcus aureus (MRSA).
d. Multidrug-resistant gram-negative bacteria.
11. Describe the clinical presentation of sepsis syndromes.
12. Develop an appropriate treatment plan for patients with fever including the selection of an initial,
empiric treatment regimen for patients with life-threatening sepsis.
13. Recommend appropriate empiric therapy based on an understanding of urinary tract infection
pathogenesis and resistance patterns.
14. Interpret a urinalysis. (Note overlap with Renal Tests objectives, Acute Renal Failure objectives)
15. Demonstrate knowledge of cerebrospinal fluid analysis and its interpretation.
16. Define and describe the major routes of nosocomial infection transmission, including:
a. Contact.
b. Droplet.
c. Airborne.
d. Common vehicle.
References:
Lecture: Infectious Disease 101
Aquifer Case 21
Aquifer Case 24
Harrison’s Principles of Internal Medicine, 20e. Chapter 115: Approach to the Patient with an
Infectious Disease
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Updated 5/23/19 MRE
Harrison’s Principles of Internal Medicine, 20e. Chapter 139: Treatment and Prophylaxis of Bacterial
Infections
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Harrison’s Principles of Internal Medicine, 20e. Chapter 297: Sepsis and Septic Shock
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Harrison’s Principles of Internal Medicine, 20e. Chapter 137: Infections Acquired in Health Care
Facilities
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Harrison’s Manual of Medicine, 19e. Chapter 78: Infections Acquired in Health Care Facilities
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Harrison’s Manual of Medicine, 19e. Chapter 12: Sepsis and Septic Shock
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 25: Hypotension
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Immuno Tests:
1. Define and describe indications for performing an arthrocentesis and the results of synovial fluid
analysis.
2. Describe the diagnostic approach to:
a. Rheumatoid arthritis.
b. Spondyloarthropathies (reactive arthritis/Reiter’s syndrome, ankylosing spondylitis,
psoriatic arthritis).
c. Systemic lupus erythematosus.
d. Systemic sclerosis.
e. Raynaud’s syndrome/phenomenon.
f. Sjogren’s syndrome.
g. Temporal arteritis and polymyalgia rheumatica.
h. Other systemic vasculitides.
i. Polymyositis and dermatomyositis.
j. Fibromyalgia.
3. Recommend and interpret diagnostic and laboratory tests, both prior to and after initiating
treatment, based on the differential diagnosis. Laboratory and diagnostic tests should include,
when appropriate:
a. CBC with differential.
b. Synovial fluid analysis (Gram stain, culture, crystal exam, cell count with differential, and
glucose).
c. Uric acid.
Updated 5/23/19 MRE
d. ESR/CRP.
e. Rheumatoid factor/anti-CCP.
f. Antinuclear antibody test (ANA) and anti-DNA test.
References:
Lecture: Rheumatologic Disease / Immuno Test
Harrison’s Principles of Internal Medicine, 20e. Chapter 355: The Spondyloarthritides
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Harrison’s Principles of Internal Medicine, 20e. Chapter 356: The Vasculitis Syndromes
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Harrison’s Principles of Internal Medicine, 20e. Chapter 366: Fibromyalgia
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Harrison’s Principles of Internal Medicine, 20e. Chapter 365: Gout and Other Crystal-Associated
Arthropathies
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Harrison’s Manual of Medicine, 19e. Chapter 158: Systemic Lupus Erythematous, Rheumatoid
Arthritis, and Other Connective Tissue Diseases
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Harrison’s Manual of Medicine, 19e. Chapter 159: Vasculitis
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Harrison’s Manual of Medicine, 19e. Chapter 164: Gout, Pseudogout, and Related Diseases
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Liver Disease:
1. Develop an approach to the patient with clinical jaundice.
2. Recognize the five serologic types of hepatitis (A, B, C, D and E), their serologic markers for
active, acute, and chronic disease, their primary mode of transmission, that only B, C and D can
culminate in chronic hepatitis, and that liver biopsy is essential in establishing the diagnosis of
chronic disease.
3. Recognize that active and passive immunization is available for hepatitis A and B only.
4. Recognize that treatment of chronic B and C disease is available with interferon and several oral
agents.
5. Recognize some of the indications for hepatic transplantation.
Updated 5/23/19 MRE
6. Define and describe the symptoms, signs, and complications of portal hypertension.
7. Define and describe the pathophysiology and common causes of ascites.
8. Identify causes of portal hypertension unrelated to liver disease.
9. Complete an abdominal exam, including evaluation for presence of ascites.
10. Define and describe the pathophysiologic manifestations, symptoms, signs, treatment, prognosis,
and complications of alcohol-induced liver disease including but not limited to:
a. Spontaneous bacterial peritonitis.
b. Hepatic encephalopathy.
c. Hepatorenal syndrome.
11. Define and describe the analysis of ascitic fluid and its use in the diagnostic evaluation of liver
disease including analysis of the serum to ascites albumin gradient (SAAG).
12. Define and describe the epidemiology, pathophysiology, symptoms, signs, and typical clinical
course of cholelithiasis and cholecystitis.
13. Define and describe the clinical syndrome of “ascending cholangitis” including its common causes
and typical clinical course.
14. Describe the pathophysiology of conjugated and unconjugated hyperbilirubinemia. (Note overlap
with Liver Function Tests objectives)
15. Describe the common types of liver diseases and their risk factors (including inherited and
acquired).
16. Recognize when to order laboratory tests for evaluation of liver disease and when a liver biopsy
might be indicated. (Note overlap with Liver Function Tests objectives)
17. Define and describe genetic considerations in liver disease (e.g. hemochromatosis, Wilson’s
disease, alpha-1 antitrypsin deficiency, Gilbert’s syndrome).
18. Discuss the CAGE screening tool for alcohol abuse.
References:
Case Discussion: Liver Disease
Aquifer Case 11
Aquifer Case 36
Harrison’s Principles of Internal Medicine, 20e. Chapter 329: Approach to the Patient with Liver
Disease
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Harrison’s Principles of Internal Medicine, 20e. Chapter 335: Alcoholic Liver Disease
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Harrison’s Principles of Internal Medicine, 20e. Chapter 336: Nonalcoholic Fatty Liver Diseases and
Nonalcoholic Steatohepatitis
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Harrison’s Principles of Internal Medicine, 20e. Chapter 332: Acute Viral Hepatitis
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Updated 5/23/19 MRE
Harrison’s Principles of Internal Medicine, 20e. Chapter 334: Chronic Hepatitis
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Harrison’s Principles of Internal Medicine, 20e. Chapter 45: Jaundice
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Harrison’s Principles of Internal Medicine, 20e. Chapter 339: Diseases of the Gallbladder and Bile
Ducts
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Harrison’s Manual of Medicine, 19e. Chapter 154: Cirrhosis and Alcoholic Liver Disease
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Harrison’s Manual of Medicine, 19e. Chapter 152: Acute Hepatitis
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Harrison’s Manual of Medicine, 19e. Chapter 153: Chronic Hepatitis
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Harrison’s Manual of Medicine, 19e. Chapter 333: Toxic and Drug-Induced Hepatitis
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Harrison’s Manual of Medicine, 19e. Chapter 179: Hemochromatosis, Porphyrias, and Wilson’s
Disease
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Harrison’s Manual of Medicine, 19e. Chapter 42: Jaundice and Evaluation of Liver Function
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Harrison’s Manual of Medicine, 19e. Chapter 150: Cholelithiasis, Cholecystitis, and Cholangitis
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 26: Jaundice and Abnormal Liver Enzymes
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Symptom to Diagnosis: An Evidence-Based Guide, 3e. 17: Edema
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Updated 5/23/19 MRE
Liver Function Test Interpretation:
1. Define and describe the biochemical/physiologic/mechanistic approach to and common causes of
hyperbilirubinemia, including:
a. Increased production.
b. Decreased hepatocyte uptake.
c. Decreased conjugation.
d. Decreased excretion from the hepatocyte.
e. Decreased small duct transport (intrahepatic cholestasis).
f. Decreased large duct transport (extrahepatic cholestasis, obstructive jaundice).
2. Define and describe the use of serum markers of liver injury (e.g. AST, ALT, GGT, alkaline
phosphatase) and function (e.g. bilirubin, albumin, PT/INR) in the diagnostic evaluation of
hepatobiliary disease.
3. Define and describe the clinical significance of asymptomatic, isolated elevation of AST/ALT,
GGT, and/or alkaline phosphatase.
4. Define and describe the common pathologic patterns of liver disease and their common causes,
including:
a. Steatosis (fatty liver).
b. Hepatitis.
c. Cirrhosis.
d. Infiltrative.
e. Intrahepatic cholestasis.
f. Extrahepatic cholestasis (obstructive jaundice).
5. Define and describe the epidemiology, symptoms, signs, typical clinical course, and prevention of
viral hepatitis. (Note overlap with Liver Disease objectives)
6. Define and describe the distinctions between acute and chronic hepatitis. (Note overlap with Liver
Disease objectives)
7. Define and describe the epidemiology, symptoms, signs, and typical clinical course of
autoimmune liver diseases such as autoimmune hepatitis, primary biliary cirrhosis, and primary
sclerosing cholangitis.
8. Define and describe common causes of drug-induced liver injury.
9. Define and describe genetic considerations in liver disease (i.e. hemochromatosis, Wilson’s
disease, alpha-1 antitrypsin deficiency, Gilbert’s syndrome).
10. Define and describe the epidemiology, pathophysiology, symptoms, signs, and typical clinical
course of cholelithiasis and cholecystitis. (Note overlap with Liver Disease objectives)
11. Define and describe the clinical syndrome of “ascending cholangitis” including its common causes
and typical clinical course. (Note overlap with Liver Disease objectives)
12. Define the indications for and utility of hepatobiliary imaging studies, including:
a. Ultrasound.
b. Nuclear medicine studies.
c. CT.
d. MRI.
e. Magnetic resonance cholangiopancreatography (MRCP).
f. Endoscopic retrograde cholangiopancreatography (ERCP).
References:
Lecture: Liver Function Test Interpretation
Updated 5/23/19 MRE
Harrison’s Principles of Internal Medicine, 20e. Chapter 329: Approach to the Patient with Liver
Disease
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192283281&bookid=2129&Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 335: Alcoholic Liver Disease
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192283757&bookid=2129&Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 336: Nonalcoholic Fatty Liver Diseases and
Nonalcoholic Steatohepatitis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192283783&bookid=2129&Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 332: Acute Viral Hepatitis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=159214492&bookid=2129&Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 334: Chronic Hepatitis
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com.archer.luhs.org/content.aspx?sectionid=159214653&bookid=2129
Harrison’s Principles of Internal Medicine, 20e. Chapter 45: Jaundice
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com.archer.luhs.org/content.aspx?sectionid=192013000&bookid=2129
Harrison’s Principles of Internal Medicine, 20e. Chapter 339: Diseases of the Gallbladder and Bile
Ducts
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192284017&bookid=2129
Harrison’s Manual of Medicine, 19e. Chapter 154: Cirrhosis and Alcoholic Liver Disease
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Harrison’s Manual of Medicine, 19e. Chapter 152: Acute Hepatitis
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Harrison’s Manual of Medicine, 19e. Chapter 153: Chronic Hepatitis
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Harrison’s Manual of Medicine, 19e. Chapter 333: Toxic and Drug-Induced Hepatitis
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Harrison’s Manual of Medicine, 19e. Chapter 179: Hemochromatosis, Porphyrias, and Wilson’s
Disease
Updated 5/23/19 MRE
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127559930&bookid=1820&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 42: Jaundice and Evaluation of Liver Function
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127554546&bookid=1820
Harrison’s Manual of Medicine, 19e. Chapter 150: Cholelithiasis, Cholecystitis, and Cholangitis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558904&bookid=1820&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 26: Jaundice and Abnormal Liver Enzymes
https://accessmedicine-mhmedical-com.archer.luhs.org/content.aspx?bookid=1088
Lung Cancer/Pulmonary Nodule:
1. Define and describe the risk factors for lung cancer.
2. Define, describe, and discuss characteristics of a pulmonary nodule(s) on CXR or CT that makes
it more or less likely to be malignant.
3. Define and describe the general approach, both short-term and long-term, to the evaluation and
management of a solitary pulmonary nodule including FNA, bronchoscopy, CT-guided biopsy,
PET scan, open lung biopsy, and lobectomy.
4. Define and describe paraneoplastic syndromes related to primary lung cancer.
5. Define and describe general treatment options for lung cancer.
6. Define and describe minimal pulmonary function requirements for lung cancer resection.
7. Define and describe the basic principles and general prognosis for patients with various stages of
lung cancer.
References:
Case Discussion: Lung cancer and management of solitary nodule
Harrison’s Principles of Internal Medicine, 20e. Chapter 74: Neoplasms of the Lung
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192015508&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 69: Lung Cancer
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127555440&bookid=1820&Resultclick=2
The MD Anderson Manual of Medical Oncology: Chapter 17: Small Cell Carcinoma of the Lung:
Paraneoplastic Syndromes
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=121898203&bookid=1772&jumpsectionid=121898327&
Resultclick=2
Mental Status Changes:
Updated 5/23/19 MRE
1. Define or describe mental status changes and the syndromes of dementia and delirium (acute
confusional state) as well as psychiatric illnesses that may present as changes in mental status.
2. Define and describe the major points of differentiation between dementia, delirium, and
depression on history, physical examination, and mental status testing.
3. Define or describe the differential diagnosis for dementia, the major causes of dementing
illnesses, and the evaluation for dementia.
4. Define and describe the major causes of delirium (acute confusional states) and the diagnostic
evaluation of the delirious patient.
5. Recognize that mental status changes are a common pathway of a variety of illnesses in older
patients and that older people should not be assumed to be demented when they present with
mental status changes.
6. Recognize 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.
7. Discuss the pathophysiology, symptoms, and signs of the most common and most serious
causes of altered mental status, including:
a. Metabolic causes (e.g. hyper/hyponatremia, hyper/hypoglycemia, hypercalcemia,
hyper/hypothyroidism, hypoxia/hypercapnia, B12 deficiency, hepatic encephalopathy,
uremic encephalopathy, drug/alcohol intoxication/withdrawal, and Wernicke’s
encephalopathy).
b. Structural lesions (e.g. primary or metastatic tumor, intracranial hemorrhage, subdural
hematoma).
c. Vascular (e.g. cerebrovascular accident, transient ischemic attack, cerebral vasculitis)
d. Infectious etiologies (e.g. encephalitis, meningitis, urosepsis, endocarditis, pneumonia,
cellulites).
e. Seizures/ post-ictal state.
f. Hypertensive encephalopathy.
g. Low perfusion states (e.g. arrhythmias, MI, shock, acute blood loss, severe dehydration).
h. Miscellaneous causes (e.g. fecal impaction, postoperative state, sleep deprivation,
urinary retention).
8. Develop a management plan for the most common causes of altered mental status including a
diagnostic evaluation.
9. Recognize the importance of thoroughly reviewing prescription medications, over-the-counter
drugs, and supplements and inquiring about substance abuse.
10. Identify nonpharmacologic measures to reduce agitation and aggression, including:
a. Avoiding the use of physical restraints whenever possible.
b. Using reorientation techniques.
c. Assuring the patient has his or her devices to correct sensory deficits.
d. Promoting normal sleep and day/night awareness.
e. Preventing dehydration and electrolyte disturbances.
f. Avoiding medications which may worsen delirium whenever possible (e.g.
anticholinergics, benzodiazepines, etc.).
11. Identify the risks of using physical restraints.
12. Define and describe the risk and benefits of using low-dose high potency antipsychotics for
delirium associated agitation and aggression.
Updated 5/23/19 MRE
13. Recognize that mental status changes are a common event in the care of patients with HIV-
related illness.
14. Identify indications, contraindications, and complications of lumbar puncture.
References:
Case Discussion: Mental Status Change
Aquifer Case 25
Aquifer Case 26
Harrison’s Principles of Internal Medicine, 20e. Chapter 24: Confusion and Delirium
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192011608&bookid=2129&Resultclick=2#1160872259
Harrison’s Principles of Internal Medicine, 20e. Chapter 25: Dementia
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192011639&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 182: Dementia
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127560025&bookid=1820&Resultclick=2
Poisoning and Drug Overdose: Section 1: Comprehensive Evaluation and Treatment: Altered Mental
Status
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=177337821&bookid=2284&jumpsectionid=177337848&
Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 11: Delirium and Dementia
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=61697830&bookid=1088&Resultclick=2
Pneumonia:
1. Define and describe the epidemiology, pathophysiology, symptoms, signs, and typical
clinical course of community-acquired, nosocomial, aspiration pneumonia, and pneumonia in the
immunocompromised host.
2. Define and describe the conceptualization of “typical” and “atypical” pneumonia and its limitations.
3. Define and describe common pneumonia pathogens (viral, bacterial, mycobacterial, and fungal)
in immunocompetent and immunocompromised hosts.
4. Identify patients who are at risk for impaired immunity.
5. Define and describe indications for hospitalization and ICU admission of a patient with
pneumonia.
6. Define and describe the antimicrobial treatments (e.g. antiviral, antibacterial, antimycobacterial,
and antifungal) for community-acquired, nosocomial, aspiration pneumonia, and pneumonia in
the immunocompromised host.
7. Define and describe the implications of antimicrobial resistance.
8. Define and describe the pathogenesis, symptoms, and signs of the complications of
Updated 5/23/19 MRE
acute bacterial pneumonia including: bacteremia, sepsis, parapneumonic effusion, empyema,
meningitis, and metastatic microabscesses.
9. Define and describe the indications for and efficacy of influenza and pneumococcal vaccinations.
10. Define and describe the Centers for Medicine and Medicaid Services (CMS) and the Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO) quality measures for
community-acquired pneumonia treatment.
11. Recognize bronchial breath sounds, rales (crackles), rhonchi, wheezes, signs of pulmonary
consolidation, and pleural effusion on physical exam.
12. Recommend when to order diagnostic laboratory tests, including complete blood
counts, sputum gram stain and culture, blood cultures, pleural effusion analysis, and arterial
blood gases, how to interpret these tests, and how to recommend treatment based on these
interpretations.
References:
Case Discussion: Pneumonia
Aquifer Case 22
Harrison’s Principles of Internal Medicine, 20e. Chapter 121: Pneumonia
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=184041853&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 132: Pneumonia, Bronchiectasis, and Lung Abscess
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558380&bookid=1820&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 97: Mycoplasma pneumoniae, Legionella species, and
Chlamydia pneumoniae
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127556736&bookid=1820&Resultclick=2
Fishman’s Pulmonary Diseases and Disorders, 5e. Chapter 123: Pulmonary Infection in
Immunocompromised Hosts
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=81198646&bookid=1344
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 10: Cough, Fever, and Respiratory Infections
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com.archer.luhs.org/content.aspx?sectionid=61697703&bookid=1088
Pulmonary Tests:
1. Distinguish between the various mechanisms of hypoxia.
2. Describe how to calculate the A-a gradient.
3. Describe and discuss the interplay between oxygen content, delivery, and extraction.
4. Identify the principles determining one’s CO2.
5. Describe the concept of Dead Space Ventilation.
Updated 5/23/19 MRE
6. Interpret pulmonary function tests (PFTs) recognizing obstruction, restriction, and diffusion
impairments, and use them to recommend appropriate therapy.
7. Accurately interpret arterial blood gases. (Note overlap with Acid-Base Disorders objectives)
8. List major pathologic states causing dyspnea. (Note overlap with Dyspnea objectives)
9. Relate the utility of supplemental oxygen and the potential dangers of overly aggressive oxygen
supplementation.
10. Recognize the various oxygen delivery devices.
References:
Lecture: Pulmonary Tests
Aquifer Case 28
Harrison’s Principles of Internal Medicine, 20e. Chapter 36: Hypoxia and Cyanosis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192012521&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 1: Electrolytes/Acid-Base Balance
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127553582&bookid=1820&Resultclick=2#1128781609
Harrison’s Principles of Internal Medicine, 20e. Chapter S1: Fluid and Electrolyte Imbalances and
Acid-Base Disturbances: Case Examples
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192509786&bookid=2129&Resultclick=2
Fishman’s Pulmonary Diseases and Disorders, 5e. Chapter 33: Pulmonary Function Testing
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=81187235&bookid=1344&Resultclick=2#1122357559
Principles and Practice of Hospital Medicine, 2e: Chapter 138: Acute Respiratory Failure: Oxygen
Supplementation and Oxygen Flow Devices
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=146980188&bookid=1872&jumpsectionid=146980231&
Resultclick=2#1137614278
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 15: Dyspnea
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=61698418&bookid=1088
Renal Tests:
1. Interpret a urinalysis, including microscopic examination for casts, red blood cells, white blood
cells, and crystals. (Note overlap with Acute Renal Failure objectives)
2. Define and describe the distinction between the three major pathophysiologic etiologies for acute
renal failure (ARF) based on urinalysis, urine studies, and radiological imaging:
a. Decreased renal perfusion (prerenal).
b. Intrinsic renal disease (renal).
Updated 5/23/19 MRE
c. Acute renal obstruction (postrenal).
3. Define and describe the significance for proteinuria in chronic kidney disease (CKD).
4. Define and describe the most common etiologies of chronic kidney disease (CKD) based on:
a. Diabetes Mellitus.
b. Hypertension.
c. Glomerulonephritis.
d. Polycystic kidney disease.
e. Autoimmune diseases (e.g. systemic lupus erythematosus).
f. The staging scheme for CKD.
5. Define and describe the pathophysiology of anemia in chronic kidney disease (CKD).
References:
Lecture: Renal Tests
Aquifer Case 23
Harrison’s Principles of Internal Medicine, 20e. Chapter 304: Acute Kidney Injury
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=186950567&bookid=2129&Resultclick=2#1157019087
Harrison’s Principles of Internal Medicine, 20e. Chapter 305: Chronic Kidney Disease
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=186950702&bookid=2129&Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 93: Iron Deficiency and Other
Hypoproliferative Anemias: Anemia of Chronic Kidney Disease
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com.archer.luhs.org/content.aspx?sectionid=192017034&bookid=2129&jumpsectionid=196889076&
Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 308: Glomerular Diseases
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com.archer.luhs.org/content.aspx?sectionid=192281295&bookid=2129
Harrison’s Principles of Internal Medicine, 20e. Chapter 309: Polycystic Kidney Disease and Other
Inherited Disorders of Tubule Growth and Development
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192281464&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 138: Acute Renal Failure
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com.archer.luhs.org/content.aspx?sectionid=127558544&bookid=1820&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 139: Chronic Kidney Disease and Uremia
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com.archer.luhs.org/content.aspx?sectionid=127558560&bookid=1820&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 142: Glomerular Diseases
Updated 5/23/19 MRE
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558609&bookid=1820
Harrison’s Manual of Medicine, 19e. Chapter 143: Renal Tubular Diseases: Polycystic Kidney
Disease
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127558668&bookid=1820&jumpsectionid=127558690&
Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 28: Kidney Injury, Acute
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?bookid=1088§ionid=61700156
Rheumatological Diseases:
1. Define and describe a systematic approach to joint pain based on an understanding of
pathophysiology to classify potential causes.
2. Define and describe the effect of the time course of symptoms on the potential causes of joint
pain (acute vs. subacute vs. chronic).
3. Define and describe the difference between and pathophysiology of arthralgia vs. arthritis and
mechanical vs. inflammatory joint pain.
4. Define and describe the distinguishing features of intra-articular and periarticular complaints (joint
pain vs. bursitis and tendonitis).
5. Define and describe the effect of the features of joint involvement on the potential causes of joint
pain (monoarticular vs. oligoarticular vs. polyarticular, symmetric vs. asymmetric, axial and/or
appendicular, small vs. large joints, additive vs. migratory vs. intermittent).
6. Define and describe the indications for performing an arthrocentesis and the results of synovial
fluid analysis.
7. Define and describe the pathophysiology and common signs and symptoms of:
a. Osteoarthritis
b. Crystalline arthropathies
c. Septic arthritis
8. Define and describe the basic pathophysiology of autoimmunity and autoimmune diseases.
9. Define and describe typical clinical scenarios when systemic rheumatologic disorders should be
considered:
a. Diffuse aches and pains
b. Generalized weakness/fatigue
c. Myalgias with or without weakness
d. Arthritis with systemic signs (e.g. fever, weight loss)
e. Arthritis with disorders of other systems (e.g. rash, cardiopulmonary symptoms,
gastrointestinal symptoms, eye disease, renal disease, neurologic symptoms)
10. Discuss and describe the typical clinical and laboratory findings of rheumatoid arthritis, systemic
lupus erythematosus (SLE), dermatomyositis, and systemic vasculitis. (Note overlap with Immuno
Tests objectives)
11. Compare and contrast the various causes of inflammatory polyarthritis.
12. Define and describe the common signs and symptoms of and diagnostic approach to:
a. Rheumatoid arthritis
b. Spondyloarthropathies (reactive arthritis/Reiter’s syndrome, ankylosing spondylitis,
psoriatic arthritis)
Updated 5/23/19 MRE
c. Systemic lupus erythematosus
d. Systemic sclerosis
e. Raynaud’s syndrome/phenomenon
f. Sjogren’s syndrome
g. Temporal arteritis and polymyalgia rheumatica
h. Other systemic vasculitides
i. Polymyositis and dermatomyositis
j. Fibromyalgia
13. Define and describe indications for and effectiveness of intra-articular steroid injections.
14. Define and describe treatment options for gout (e.g. colchicine, NSAIDs, steroids, uricosurics,
xanthine oxidase inhibitors).
References:
Lecture: Rheumatologic Disease / Immuno Tests
Aquifer Case 31
Aquifer Case 32
Harrison’s Principles of Internal Medicine, 20e. Chapter 364: Osteoarthritis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192286042&bookid=2129&Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 355: The Spondyloarthritides
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192285312&bookid=2129
Harrison’s Principles of Internal Medicine, 20e. Chapter 356: The Vasculitis Syndromes
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192285458&bookid=2129&Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 366: Fibromyalgia
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192286180&bookid=2129&Resultclick=2
Harrison’s Principles of Internal Medicine, 20e. Chapter 365: Gout and Other Crystal-Associated
Arthropathies
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192286121&bookid=2129
Harrison’s Manual of Medicine, 19e. Chapter 163: Osteoarthritis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127559428&bookid=1820&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 158: Systemic Lupus Erythematous, Rheumatoid
Arthritis, and Other Connective Tissue Diseases
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127559269&bookid=1820&Resultclick=2#1128787294
Updated 5/23/19 MRE
Harrison’s Manual of Medicine, 19e. Chapter 159: Vasculitis
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127559341&bookid=1820&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 164: Gout, Pseudogout, and Related Diseases
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127559449&bookid=1820&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 47: Pain and Swelling of Joints
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127554699&bookid=1820&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 27: Joint Pain
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com.archer.luhs.org/content.aspx?bookid=1088§ionid=61699947
Substance Abuse:
1. Take a substance abuse history and provide counseling in a non-judgmental manner.
2. Recognize the clinical presentations of substance abuse and recommend treatment.
3. Apply diagnostic criteria for alcohol abuse, dependence, and addiction.
4. Recommend basic prevention and treatment for alcohol withdrawal.
5. Identify the presenting signs and symptoms of intoxication and overdose of common substances
of abuse.
6. Describe how homelessness can influence patient’s access to illicit substances and interfere with
ability to enable effective treatment.
References:
Aquifer Case 9
Harrison’s Principles of Internal Medicine, 20e. Chapter 445: Alcohol and Alcohol Use Disorders
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192534023&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 199: Alcohol Use Disorder
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127560547&bookid=1820&Resultclick=2
Behavioral Medicine: A Guide for Clinical Practice, 4e: Chapter 24: Alcohol and Substance Use
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=62688745&bookid=1116
The Color Atlas and Synopsis of Family Medicine, 3e. Chapter 246: Substance Abuse Disorder
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=206783152&bookid=2547&Resultclick=2
Syncope:
Updated 5/23/19 MRE
1. List the common causes of syncope.
2. Recognize the important aspects of the history and physical exam in a patient with syncope.
3. Explain the approach to the evaluation and treatment of a patient with syncope.
4. Explain how atrial fibrillation, aortic stenosis, and mitral stenosis may lead to syncope.
5. Identify atrial fibrillation on an electrocardiogram. (Note overlap with Atrial Fibrillation objectives)
References:
Aquifer Case 3
Harrison’s Principles of Internal Medicine, 20e. Chapter 18: Syncope
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=192011273&bookid=2129&Resultclick=2
Harrison’s Manual of Medicine, 19e. Chapter 50: Syncope
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?sectionid=127554812&bookid=1820&Resultclick=2
Symptom to Diagnosis: An Evidence-Based Guide, 3e. 31: Syncope
https://accessmedicine-mhmedical-
com.archer.luhs.org/content.aspx?bookid=1088§ionid=61700616